meeting of the council of governors- 1 december 2016 paper 1 tony fox 5 action point register paper...

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Meeting of the Council of Governors

Agenda

Taunton Conference Centre, Wellington Road, Taunton, Somerset, TA1 5AX at 11.30hrs on Wednesday 17 May 2017 Chairman: Tony Fox, Chairman of the NHS Foundation Trust and Council of Governors

No Topic Format Presenter Timing

1 Welcome, Introduction & Apologies Verbal Tony Fox

11.30hrs

2 Declarations of Conflicts of Interest Verbal Tony Fox

3 A Patient’s Experience Verbal Torquil

MacInnes

4 Minutes of the Meeting of the Council of Governors - 1 December 2016

Paper 1 Tony Fox

5 Action Point Register Paper 2 Tony Fox

6 Report from the Chairman Paper 3 Tony Fox 11.40hrs

7 Performance Update from the Chief Executive Paper 4 Ken Wenman 11.55hrs

8 Update from the Non-Executive Directors Verbal 12.15hrs

9

Agenda and Minutes of the Trust Board Meetings:

29 September 2016 (Agenda and Minutes) William Thomas in attendance

24 November 2016 (Agenda and Minutes) Torquil MacInnes in attendance

26 January 2017 (Agenda and Minutes) No Governor in attendance

30 March 2017 (Agenda Only) Craig Holmes and Torquil MacInnes in attendance

Paper 5 Tony Fox 12.30hrs

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LUNCH 12.45hrs

10

Future Ways of Working

Session to achieve consensus on:

Meetings & Workshops – Items of Business, Number and Timings

Sub Groups or Task & Finish Groups

Seeking assurance: o NED attendance at CoG meetings o Receiving Board Minutes o Governor attendance at Board and

Committee Meetings

Proposals for Annual Members Meeting

Composition of the Council of Governors

Self-assessment against Service Level Agreement

Lead Governor Role & Responsibilities

Presentation Adrian Rutter 13.15hrs

BREAK 14:15hrs

11 Trust Membership and Engagement Paper 6 Robert Day 14:45hrs

12 Council of Governors Terms of Reference Paper 7 Marty McAuley 15:00hrs

13

Remuneration & Recommendations Panel

Terms of Reference

Appointments to the Panel

Paper 8 Marty McAuley 15:10hrs

14 Policy of Engagement Paper 9 Helen Braid 15:20hrs

15

Any Other Business

Items to be notified to the Trust Secretary three clear working days before the meeting.

Verbal Tony Fox 15:25hrs

Members of the Council of Governors:

Rae Care Public Governor, Bristol & B&NES William Thomas Public Governor, Cornwall Ray Foss Public Governor, Devon Phil Ford Public Governor, Devon David Pinder-White Public Governor, Devon Adrian Rutter Public Governor, Devon Robert Day Public Governor, Dorset Peter Lucas Public Governor, Dorset Craig Holmes Public Governor, Gloucestershire Steve Smith Public Governor, Gloucestershire John Hawkins Public Governor, Somerset

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Anthony Leak Public Governor, Somerset Simon Michell Public Governor, Somerset Torquil MacInnes Public Governor, Wiltshire & Swindon Dee Nix Public Governor, Wiltshire & Swindon David Shephard Staff Governor, A&E (Dorset and Somerset) Mark Stubbs Staff Governor, A&E (Bristol, B&NES, Gloucestershire,

North Somerset, South Gloucestershire, Swindon and Wiltshire)

Neil Hunt Staff Governor, Administration & Support Services Sandy Turner Staff Governor, Urgent Care Services Mark Norbury Staff Governor, Volunteers Doug Hellier-Laing Appointed Governor, Local Authorities Helen Richardson Appointed Governor, Acute Trusts Dr Blair Millar Appointed Governor, Clinical Commissioning Groups Dr Jon Hayes Appointed Governor, Clinical Commissioning Groups Professor Steve Waite Appointed Governor, NHS Mental Health Partnerships Paul Walker Appointed Governor, Fire & Rescue Services Officers: Ken Wenman Chief Executive Marty McAuley Trust Secretary Helen Braid Committees & Membership Manager Lucie Bennett Committees & Membership Officer Emma Mitchell Board & Committee Co-Ordinator

Council of Governors – Thursday 1 December 2016

Page 1 of 10

Minutes Council of Governors Meeting

Thursday 1 December 2016

Great Eastern Hall, SS Great Britain, Bristol, BS1 6TY

Chair: Heather Strawbridge OBE, Chairman Minutes: Helen Braid, Governance & Assurance Manager

No Agenda Item Action

1. Welcome, Introduction & Apologies for Absence

1.1 1.2 1.3

The Chairman welcomed John Hawkins to the meeting. Mr Hawkins was currently a Governor for Yeovil District Hospital and was interested to see how other Councils operated. Apologies for absence had been received from Terry Beale (Public Governor, Somerset), Robert Day (Public Governor, Dorset), Steve Frost (Staff Governor, UCS), Jeff Liddiatt (Public Governor, Somerset), Dee Nix (Public Governor, Wiltshire & Swindon), Alan Peak (Staff Governor, A&E North) and Paul Young (Public Governor, Devon). Apologies had also been received from the following Non-Executive Directors: Venessa James, Hugh Hood and Dr Ian Reynolds.

2. Declarations of Interest

2.1 None

3. A Patient’s Experience

3.1 3.2

The meeting heard two stories from patients who had used the Trust’s services. The Chairman reminded the meeting that hearing a patient’s experience, whether negative or positive, was a reminder as to why we did what we did. One patient experience was extremely positive, whilst the other highlighted the anxiety experienced by patients who have to wait for a clinician to arrive.


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3.3

It was noted that the complaint had been investigated, with all information relating to the incident in question being analysed and lessons learned at an individual and organizational level. What had been identified from this, and similar complaints made about delays, was the impact of patient perception and expectations. As a result, changes had been made to the statement made to patients by the call taker regarding the dispatch of an ambulance. Action: The re-worded statement regarding the dispatch of an ambulance to patients to be circulated to the Council.

JW

4. Minutes of the Meeting of the Council of Governors held on 15 September 2016

4.1 4.2

The minutes of the meeting of the Council of Governors held on 15 September 2016 were agreed and signed as a correct record. It was agreed that for future minutes would list attendees at the end of the minutes and apologies for absence within the body of the minutes.

5. Action Point Register

5.1 The Action Point Register was reviewed and progress noted.

6. Report from the Chairman and Chief Executive

6.1 6.2 6.2.1 6.2.2

The Chairman and Chief Executive introduced a report which provided an overview of recent Care Quality Commission activity, the Single Oversight Framework and performance exception overview. Governors sought assurance on a number of issues: CQC Inspection It was reported that following the June inspection, the Trust had received a rating of “requires improvement”. However, there were areas which had been rated as outstanding including the “caring” nature of staff and the Trust’s resilience. An action plan had been developed to address the issues highlighted in the report and a positive Quality Summit had been held to agree a way forward. Governors highlighted that the issue of consistency across the Trust’s operating area had been made a number of times in the report and asked how the Board would be addressing this, especially in light of the geographical spread and constantly evolving nature of the Trust.


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6.2.3 6.2.4 6.2.5 6.3

The Chairman confirmed that the consistent embedding of quality was one of the top three priorities identified as a result of the inspection, with the others being medicines management and the implementation of infection prevention and control procedures. Trust Charity The possibility of a Trust Charity being established was discussed. It was noted that many offers of thanks were received from grateful patients and families and whilst the Trust did have a charitable fund into which these could be paid, there was no active fund raising undertaken. Paramedic Re-Banding Governors sought assurance as to how the impact of the national Paramedic Re-Banding was being managed. It was noted that negotiations had been ongoing for two years and discussions had taken place with regard to job matching, retention, retirement, age and pay. The change in banding was a result of the autonomy to practice as an individual. A Band 6 job description had been published by NHS Employers and now the Trust would be required to match its own job descriptions against this template. No central resources had been made available to fund the upgrade and so the Trust needed to look to its own service provision and staffing arrangements; for example the removal of local agreements. The Council of Governors took assurance from the responses provided to their questions.

7. Board Agendas and Minutes

28 July 2016 (Agenda and Minutes)

29 September 2016 (Agenda only)

24 November 2016 (Agenda only)

7.1 The agenda and minutes of the Board meetings were received for assurance and no questions were asked.

8. Introducing the new Non-Executive Director – Gail Bragg

8.1

The recently appointed Non-Executive Director, Gail Bragg, introduced herself to the meeting and provided an overview of her background in organizational change and financial service.


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8.2 Gail also provided the meeting with an overview of her induction programme which had included meeting key officers, attending committee meetings and getting out and about across the Trust meeting staff.

9. Non-Executive Director Assurance Report

9.1 9.2

The Chairman and the other Non-Executive Directors (NEDs) provided an update on the work undertaken since the last meeting of the Council of Governors. The following was noted:

Staff engagement remained a priority for NEDs with visits to stations and third manning shifts being undertaken by all.

NEDs were all attending Serious Incident Panels to seek assurance as to how these are dealt with and how lessons are learned.

The focus of Board discussions had included financial management, social care pressures, ever increasing demand, operational planning and payband pressures.

Governors sought assurance on the following issues:

How the Board identified risks and horizon scanned, with it being noted that the Board Assurance Framework and Risk Register guided the Board as it was a dynamic document which included current and potential risks, both local and national. This was used to help inform operational planning, so that the Trust could mitigate where possible.

The impact that Brexit could have on the Trust and that we were less exposed than the social care sector due to lower levels of overseas recruitment.

10. Q&A with the Chairman and Non-Executive Directors

10.1 There were no additional questions from Governors as assurance had been gained during previous agenda items.

11. Work of Quality Committee

11.1

The Executive Director of Nursing & Governance made a presentation to the meeting about the work of the Quality Committee. The following points were highlighted:

The approach of the Committee was to have a very real discussion about the three domains of quality – patient experience, patient safety and clinical effectiveness – with assurance being tested across all domains.


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11.2

2016/17 had seen the introduction of extraordinary meetings of the Committee which focused on the delivery of the Regulatory Consolidated Action Plan which had been developed as a result of the CQC inspections carried out during the year. Areas for improvement included NHS111 staffing levels and the training and support available for call advisors. The Chairman of the Committee had visited the clinical hubs on a number of occasions to experience them first hand and speak to call advisors and other staff.

Recruitment for call advisor roles was a robust process as it was essential that the applicants were suitable for the environment and pressure of the work. Recent changes in contracts had also impacted on turnover rates.

The Trust encouraged reporting of incidents which was an indicator of a good safety culture. There was a high level of reporting, but low levels of harm.

The presentation was noted.

12. 2016/17 Quality Priorities Update

12.1 12.2 12.3 12.4

The Clinical Development Manager provided the meeting with an update on progress in delivering the Trust’s 2016/17 quality priorities and the following was highlighted: Patient Experience - Accessible Information

Progress included the commencement of engagement with patient groups and work with national ambulance colleagues. The Electronic Patient Clinical Record was also to be reviewed to establish how patient communication requirements could be recorded.

Patient Safety – Human Factors

The review of patient safety incidents to identify where telephone triage errors occurred is underway.

The Leadership Management Quality Human Factors Model had been identified as most appropriate for Trust to use as it focused on healthcare and was NHS recognised. This model will now be used to analyse the identified incidents.

Clinical Effectiveness – Cardiac Arrest

A resuscitation checklist had been developed and trialled. Feedback was informing the wider roll out of the checklist before the year end.

The whole call cycle had been subject to clinical audit, including time to recognitise cardiac arrest.


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12.5 12.6

The operational modelling work regarding the potential impact of regional cardiac arrest centres has been completed.

It was also noted that the clinical effectiveness priority would be reviewed by the Trust’s external auditors as part of the Quality Account process. The presentation was noted.

13. Dementia Strategy

13.1 13.2 13.3

The Clinical Development Manager made a presentation to the meeting which provided an overview of the national picture in relation to dementia, which included the implications for the individual dealing with the diagnosis as well as clinicians undertaking patient assessments. It was noted that whilst the Trust had previously focused upon incidents such as trauma and strokes, the focus was turning more and more to the changing demographics of patients and management of the presenting conditions of an aging population. The presentation was noted.

14. Membership and Governor Update

14.1 14.2

The Trust Secretary introduced a report which provided the meeting with an update on the Trust’s membership position and any changes that had occurred to the membership of the Council. The following points were highlighted:

o The changes reported in public membership levels were due to the data cleanses which had been undertaken in advance of the forthcoming elections.

o The future focus for membership would be on those members who had indicated that they wanted to become more engaged with the Trust, whether by attending events or taking part in consultation exercises, rather than trying to engage the entire membership.

o The new engagement team which had been established which would deliver the different types of engagement activities from attendance at PPE events through to working with focus groups.

The attendance tracker included in the report was discussed and it was agreed that this should be removed as it did not provide the whole picture by including work which went on behind the scenes or at sub group and Panel meetings.


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14.3 Action: Attendance tracker to be removed from future reports. MM

15. Appointments to the Council of Governors

15.1 15.2 15.3

The Trust Secretary introduced a report which sought agreement for the allocation of Appointed Governor seats with effect from 1 March 2017 onwards. The following was highlighted:

It was a statutory requirement that the Council had one Governor appointed by one or more of the Local Authorities within the area and that all other appointments were at the discretion of the Trust.

Consideration should be given to the number of seats allocated to Clinical Commissioning Groups and the future of the seat currently allocated to Police Forces.

Governors raised the following issues:

As Lead Commissioner for the Trust, Gloucestershire CCG should be represented on the Council;

The seat for Police Forces and that for Fire & Rescue Services should not be combined as they are very different organisations.

That there may be some advantage in current Governors raising the issue of vacant seats with the CCGs and Police Forces.

Agreed:

Dr Blair Millar to speak to colleagues in other CCGs to ask if they are happy for him to provide feedback as the only representative on the Council. If this is agreeable, then the additional CCG seat will be removed.

Chief Fire Officer Paul Walker to contact Chief Police Officers regarding the current vacancy and should they chose not to appoint, the seat be removed.

BM PW

16. 2017 Election Process

16.1 16.2

The Trust Secretary introduced a report which detailed the election process to be undertaken to ensure that all Public and Staff Governor seats were filled for the next phase of the Council of Governors. The following was highlighted:

The election process to be followed was in accordance with the Department of Health’s Model Rules for Election and that Electoral Reform Services would be carrying out the election on behalf of the Trust.


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16.3

The phased terms of office that had previously been agreed by the Council.

The proposal to amend the names of the A&E Staff Classes to ensure that they aligned with the Trust’s operating structure.

The communications plan developed to promote awareness of the elections and the two Information Events which were to be held for prospective Governors.

Agreed:

The three A&E Staff Classes to be re-named as follows: o Accident & Emergency (Devon and Cornwall) o Accident & Emergency (Dorset and Somerset) o Accident & Emergency (Gloucestershire, South

Gloucestershire, Swindon, Wiltshire, Bristol. Bath & North East Somerset and North Somerset)

Any Governors interested in attending the Information Events to contact the Trust Secretary.

HB

ALL

17. Feedback from Governors:

Wiltshire Game & Country Fair – Dee Nix, Rae - Care and Torquil MacInnes

Forest Showcase Food & Drink Festival – Rae Care and Craig Holmes

Restart a Heart Campaign – Jeff Liddiatt

Martock Women’s Institute – Mark Norbury

17.1 Governors provided an update on the engagement activity they had undertaken. The following issues were highlighted:

The criteria applied when selecting events to attend and whether this should be reviewed.

The support that was needed at events including literature, clinicians and demonstration vehicles.

Whether more events in the north of the region could be identified.

What Governors should be asking the public about at events.

Agreed:

Governors to inform the Engagement Team of any events which may be suitable for the Trust to attend.

Consideration be given to the specific role of the Governors attending each event.

18. Organisation and Venues for future Meetings of the Council of Governors

18.1

The Trust Secretary referred the meeting to conversations which had been taking place regarding where and when meetings for Governors


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18.2 18.3

were held. In light of the range of views on the subject, Governors were asked to volunteer to attend a meeting discuss how meeting locations and venues would be agreed in future as well as the content of meetings and a future programme of work. It was noted that Torquil MacInnes, Rae Care and Stephen Gough would be willing to take part in this meeting. All other Governors were asked to contact the Trust Secretary if they wished to be involved. Action: Ways of Working Meeting to be arranged and Governors to confirm their availability to attend.

LB/All

19. Any Other Business - Items to be notified to the Trust Secretary three clear working days before the meeting.

19.1 19.2

As this was the last meeting of the current Council of Governors, the Chairman thanked all Governors for their work. On behalf of the Council of Governors, Torquil MacInnes thanked the Chairman for her work in chairing the Council of Governors since its inception through to this meeting, which would be her last.

In Attendance: Chairman: Mrs H Strawbridge OBE (HS) Chairman of the NHS Foundation Trust Members of the Council of Governors: Mr J Christensen (JC) Appointed Governor, Air Ambulance Charities Mr P Walker (PW) Appointed Governor, Fire and Rescue Services Mr D Hellier-Laing (DHL) Appointed Governor, Local Authorities Professor S Waite (SW) Appointed Governor, Mental Health Partnerships Mr R Care (RC) Public Governor, Bristol B&NES Mrs S Hammond (SH) Public Governor, Cornwall Mr W Thomas (WT) Public Governor, Cornwall Mr P Ford (PF) Public Governor, Devon Mr A Rutter (AR) Public Governor, Devon Mr J Duffie (JD) Public Governor, Dorset Mr C Holmes (CH) Public Governor, Gloucestershire Mr J Pallister (JP) Public Governor, Gloucestershire


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Dr C Mills (CM) Public Governor, Isles of Scilly Dr A Leak (AL) Public Governor, Somerset Mr T MacInnes (TM) Public Governor, Wiltshire & Swindon Mr N Hunt (NH) Staff Governor, Admin & Support Mr D Shephard (DS) Staff Governor, A&E East Mr S Gough (SG) Staff Governor, A&E West Mr M Norbury (MN) Staff Governor, Volunteers Chief Executive and Executive Directors: Mr K Wenman (KW) Chief Executive Mrs J Winslade (JW) Executive Director of Nursing & Governance Non-Executive Directors: Mr T Fox (TF) Non-Executive Director and Senior Independent

Director Mr P Love (PL) Non-Executive Director and Chairman of the Audit Committee Mrs G Bragg (GB) Non-Executive Director Officers: Mr M McAuley (MM) Trust Secretary Mr D Partlow (DP) Clinical Development Manager Ms H Braid (HB) Governance and Assurance Manager Ms L Bennett (LB) Governance Support Manager Miss E Mitchell (EM) Committee & Events Manager

Signed: ______________________________________ (Chair)

Dated: ________________________________________

Date of MeetingMinutes

ReferenceAgenda Item (Topic) Action Allocated To Deadline Progress Date Completed

18.7.16 Public 8.2 Holding the NEDS to account

NEDs to share their activities with the Council of

Governors Admin team in order for an activity

paper to be produced for future meetings.

All NEDS

Way in which NEDs are

held to account to be

considered at meeting on

17.05.2017

ACTION COMPLETE

18.7.16 Public 14.2 Governor engagementRecord the area of events as well as when

events are attendedCP

Areas as well as dates of

events now recorded.

ACTION COMPLETE

01.12.16 Public 3.2 A Patient's Experience

The re-worded statement regarding the dispatch

of an ambulance to patients to be circulated to

the Council

LB

Callers are told "An

Ambulance is being

arranged" NOT that one is

on it's way.

ACTION COMPLETE

01.12.16 Public 14.2 Membership & Governor UpdateRemove the attendance tracker from future

reportsMM/HB

Attendance Tracker

Removed

ACTION COMPLETE

01.12.16 Public 15.3 Appointments to the Council of Governors

Speak with colleagues in other CCGs to agree

that BM will be the only representative, if this is

agreeable then the other CCG seat will be

removed

BM

Further CCG appointment

has been secured.

ACTION COMPLETE

01.12.16 Public 15.3 Appointments to the Council of Governors

Chief Fire Officer to contact Chief Police

Officers regarding the current vacancy and

should they chose not to appoint the seat will be

removed

PW

Police Forces have

confirmed that they will

not be making an

appointment.

Future of seat to be

considered at meeting on

17.05.2017

ACTION COMPLETE

01.12.16 Public 18.3Organisation and Future Venues for

Meetings of the Council of GovernorsWays of Working meeting to be arranged LB

Ways of Working Group

Meeting held on 27.02.17

ACTION COMPLETE

Council of Governors Action Point Register - 2016/17

At each Meeting meeting action points are recorded throughout the meeting to note items which need further development, additional work or raise other issues which need to be considered or discussed. This document

has been created to keep a record of these action points. This will be a yearly document and incomplete action points will be reported to each Meeting along with action points which have been completed since the last

meeting.

18.7.16 Public 12.3 Patient Engagement Provide an update on Makaton SC

Pre-Hospital

Communication Guide

(which includes Makaton)

now on every Trust

vehicle

ACTION COMPLETE

18.7.16 Public 14.2 Governor engagement

Trust to review powerpoint presentation for

Governors when they are talking on behalf of

the Trust.

MM/HB

Added to Governor Zone -

refreshed version to follow

ACTION COMPLETE

18.7.16 Conf 4.7 Governor engagement

Look into making the Board meetings more

accessible for the governors; teleconferencing

or videoing

HB/MM

Discussions ongoing as

part of future Ways of

Working.

ACTION ONGOING

18.7.16 Public 5.1 Governor engagementContact Governors when NED station visits are

arranged to coordinate joint visitsMM

NED visits being compiled,

send once completed

ACTION ONGOING

Public Council of Governors Meeting – 17 May 2017 Page 1 of 5

Public Council of Governors Meeting

Date: 17 May 2017

Paper Title: Report from the Chairman

Prepared by: Tony Fox, Chairman

Presented by: Tony Fox, Chairman

Action: Assurance

Recommendation:

The Council of Governors is recommended to take assurance from the first report of the Chairman which provides an overview of the first 100 days including the review of the way in which the Board of Directors operates including the Committee Structure and Non-Executive Director portfolios.

Executive Summary:

The first report from the Chairman, provides an overview of some of the issues considered during the first few weeks in office. During this time a review of the Trust Committee Structure has been undertaken as well as the portfolio arrangements for Non-Executive Directors. Key points of note:

Establishment of a People & Workforce Committee

Alignment of portfolios to Sustainability and Transformation Plan areas

Revision of committee memberships, including the incorporation of Deputy and Associate Directors as committee attendees

A themed approach to Board Seminars Work has also been undertaken with the Lead Governor and the Ways of Working Task & Finish Group on the future working arrangements for the Council of Governors.


Report from the Chairman

1. Introduction 1.1 On 1 March 2017 I became Trust Chairman following my appointment by the Council of

Governors. 1.2 During the first few weeks two key areas of focus have been the operation of the Board of

Directors and the Council of Governors and how this supports the Trust in meeting its aims and objectives.

1.3 I have worked with the Lead Governor and the Governor Ways of Working Group and the

recommendations from that work will be presented to you later in the agenda today. 1.4 This report focuses on the review of the way in which the Board of Directors and the

Committee Structure operate. Subsequent changes are reported to you to provide an overview of the portfolios of the Non-Executive Directors (NEDs) and the Committee decision-making structure, to support you in your duty of holding the NEDs to account.

2. Committee Structure and Membership 2.1 The revised committee structure below sees the introduction of a People & Workforce

Committee.

2.2 The revised membership of each committee is set out overleaf. Deputy and Associate

Directors are now incorporated as regular committee attendees to support their development and succession planning. It should be noted that the committee memberships were agreed prior to the most recent NED appointments and will be refreshed to ensure that they are fully aligned.


Meeting Frequency NED

Members Executive

Membership Non-Executive Membership

Board of Directors

6 7 All All

Quality Committee

4 4 Jenny Winslade

Dr Andy Smith

Venessa James (C)

Dr Ian Reynolds

New NED - clinical

Audit & Assurance Committee

5 4

Jennie Kingston

Jenny Winslade

Paul Love (C)

Venessa James

Gail Bragg

New NED – HR/OD

Finance & Investment Committee

5 3 +

Chairman

Ken Wenman

Jennie Kingston

Francis Gillen

Gail Bragg (C)

Paul Love

Tony Fox

Dr Ian Reynolds

New NED – HR/OD

Charitable Funds

Committee

2 1

Ken Wenman

Jennie Kingston

Neil Le Chevalier

Dr Ian Reynolds (C)

Tony Fox

Clinical NED

Remuneration Committee

1 All Ken Wenman All NEDS

People and Workforce Committee

Tbc 3

Emma Wood

Dr Andy Smith

Neil Le Chevalier

Hugh Hood / New NED HR/OD (C)

Venessa James

Clinical NED

3. Portfolio Arrangements 3.1 NEDs have been allocated a portfolio which covers a Sustainability and Transformation

Plan (STP) together with a number of areas of Trust business. Each will be supported by an Executive Lead.

3.2 NEDs will feedback to the Council of Governors on all of their work including their

committee and portfolios to provide assurance that their responsibilities as a NED are being discharged.

NED Lead Portfolios STP Engagement Area (oversight of plans only)

STP Lead Executive

Tony Fox

Procurement

Health and Safety

Logistics Environmental

Estates

Business Continuity

Devon Ken Wenman


NED Lead Portfolios STP Engagement Area (oversight of plans only)

STP Lead Executive

Dr Ian Reynolds

Charitable

Corporate Strategy Gloucestershire Emma Wood

Paul Love

Security and Fraud

Whistleblowing

Anti-Bribery

Finance and Accounting

Dorset Jennie Kingston

Gail Bragg

Commercial

Risk Management

Assurance

Change management

Bristol, North Somerset and South Gloucestershire

Jenny Winslade

Venessa James

Vice Chair

Senior Independent Director

Patient Safety

Patient Experience

Duty of Candour

Speak up Guardian

Somerset Jenny Winslade

Hugh Hood / Non-clinical

NED

HR, staffing and workforce

Health and Safety

Equality and Diversity

Training and OD

Digital / Technology

Cornwall & Isles of Scilly Francis Gillen

New clinical NED

Safeguarding

Clinical Care

Clinical Governance

Bath, Swindon and Wiltshire Dr Andy Smith

4. Board Seminars 4.1 The format of Board Seminars has been re-structured to enable the Board to focus on

strategic issues. Themes have been allocated to each Seminar to ensure better use of time and more relevant briefings aligned to Non-Executive Director portfolios.

Seminar Theme NED Lead Lead & Support

April 2017 Clinical Care, Medical and

Patient Safety and Experience

Venessa James Dr Andy Smith Jenny Winslade

Adrian South Sarah Thompson

June 2017 Corporate Direction and

Financial Planning

Gail Bragg

Dr Ian Reynolds

Jennie Kingston

Jonathan James

October 2017 Workforce Wellbeing and

People Management New NED Hr/od

Emma Wood

Amy Hanson

December 2017 Corporate Governance including fraud, bribery,

risk Paul Love

Jennie Kingston

Marty McAuley

February 2018 Strategic Direction and

enabling strategies (finance, estates, IT )

Tony Fox

Dr Ian Reynolds

Ken Wenman

Jess Hodgman


5. Recommendation 5.1 The Council of Governors is recommended to take assurance from the first report of the

Chairman which provides an overview of the first 100 days including the review of the way in which the Board of Directors operates including the Committee Structure and Non-Executive Director portfolios.

Tony Fox Chairman

Public Council of Governors Meeting – 17 May 2017

Page 1 of 5


Date: 17 May 2017

Paper Title: Performance Update from the Chief Executive

Prepared by: Marty McAuley, Trust Secretary

Presented by: Ken Wenman, Chief Executive

Action: Assurance

Recommendation:

The Council of Governors is asked to:

note further detail of the Trust’s performance contained within this report and the Integrated Corporate Performance Report; and

raise any questions with Non-Executive Directors.

Executive Summary:

The report provides the Council with information in respect of the CQC’s re-inspection of the NHS111 Services and also the performance exception report for March 2017. Key points:

The Trust’s CQC rating for its NHS111 services has improved from inadequate to requires improvement.

Category 1 Performance (ARP 2.2) in March 2017 showed further improvement and was above the performance target of 75%;

A&E (999) Activity levels (demand) in March 2017 were 7.7% below contracted volumes and 6.8% lower than actual activity levels in March 2016;

The staff turnover rate remains high, with the turnover rate varying between service lines;

Operational resource hours lost to chargeable handover delays (at acute hospitals) were 1,449 hours in March 2017. This equates to an average of 47 hours lost per day across the Trust;


Page 2 of 5

Performance Update from the Chief Executive

1. Care Quality Commission 1.1 On 27 April 2017, the CQC published its quality report following its re-inspection of the

NHS111 Service in December 2016. 1.2 The headline is that the Trust’s overall rating has moved from “Inadequate” to “Requires

Improvement”, with “Good” being achieved for safety, responsiveness and the caring nature of its 111 services.

1.3 Key findings from the report include:

The Trust had significantly improved their systems in place to mitigate safety risks across the NHS 111 service and was now aligned to the SWASFT vision with safety and quality.

The NHS 111 service was monitored against the National Minimum Data Set for NHS 111 services and adapted National Quality Requirements. Performance against indicators was improving but still below national targets.

Opportunities for learning from internal and external incidents were identified and discussed to support improvement. This included joint reviews with the NHS Pathways team for improvements in the assessment system.

Staff took action to safeguard patients and were aware of the process to make safeguarding referrals. Safeguarding systems and processes were in place to safeguard both children and adults at risk of harm or abuse, including frequent callers to the service.

Staff were trained to ensure they used the NHS Pathways safely and effectively.

Call audit activity had improved but still required further improvement to meet the NHS Pathways licence and to allow the service to identify areas of development and learning.

The Trust developed the operational staff knowledge and skills and recognised the need to continue with the programme of staff support. The appraisal programme had been revised and delivered and operational staff received more frequent supervision, support and training to perform their roles.

Patients using the service were supported effectively during the telephone assessment process. Consent to the assessment was sought and their decisions were respected.

The Trust responded effectively to complaints and to patient and staff feedback, although there was still a large number still being investigated.

Senior staff demonstrated a much improved understanding of governance. This included identification and management to safely mitigate risks.

The Trust demonstrated positive development of leadership and management systems to deliver significant progress in improving the NHS 111 service.

1.4 However improvements are still required, with the Trust being required to ensure that:

Systems are effective for patients to always access timely care and treatment.

All staff have the necessary skills and knowledge to undertake their roles.


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2. March 2017 – Performance Exception Overview 2.1 The Integrated Corporate Performance Report (ICPR) focuses on exceptional performance

and aims to provide the Trust with an early warning of deteriorating performance. The four reporting categories assigned to individual performance metrics contained within the ICPR are as follows:

Performance is in Line with Plan Performance in the reporting period is on or above target and there are currently no predicted risks to the Trusts quarterly or forecast year end performance;

Category 1 Performance (ARP 2.2) in March 2017 showed further improvement and was above (better than) the performance target of 75%;

Re-contact rates following treatment at scene were lower (better than) the local performance threshold;

Re-contact rates following telephone advice were lower (better than) the local performance threshold;

Ambulance calls closed with telephone advice are above (better than) local thresholds;

The percentage of A&E calls abandoned in March 2017 were lower (better than) the local threshold but remain above the threshold for the year to date;

ROSC following cardiac arrest was above (better than) local thresholds;

NHS 111 Call Abandonment - the percentage of calls abandoned in March 2017 was below (better than) than the national target of 5% in both Dorset and Cornwall;

Urgent Care Service QR12: In Dorset and Gloucestershire performance for Less Urgent Base Consultations were above (better than) the 95% performance target;

Tiverton UCC performance against the 4 hour treatment time was above the 95% target;

Information Governance Toolkit is RAG rated as Green as at 31 March 2017.

Early Warning Performance in the reporting period could be on or above target but there is evidence that performance is deteriorating or moving off trajectory AND/OR a metric has been escalated by a Directorate as part of the Trusts Performance Management arrangements. This indicates to the Trust that there is a perceived risk to performance regardless of whether this is evident in the reporting period. A&E (999) Activity levels (demand) in March 2017 were 7.7% below contracted volumes

and 6.8% lower than actual activity levels in March 2016;

The staff turnover rate remains high at 13.80% (excluding redundancies) at the end of March 2017. The turnover rate varies between service lines with significantly higher turnover rates in the Urgent Care Service Line (40.3% in NHS111 and 23.0% in Out of Hours). Within the A&E Service Line turnover for Qualified staff is currently 11.2% and 8.4% for Non-Qualified;

Staff Appraisal rates were below the internal KPI target of 85%. There are variances at Service Line level and information on these variances can be found within the Staff Metrics reports.


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Improvement is Expected Performance in the reporting period is below target but there is evidence that performance is improving AND/OR there is confidence in the action(s) being taken by the Trust. The forecast outturn position is therefore expected to be on or above plan if a performance metric is reported in this category.

Ambulance incidents managed without transport to A&E department are below (worse than) local thresholds but remain significantly above the national ambulance trust average;

Stroke patients receiving the appropriate care bundle was marginally below (worse than) the local threshold;

Outcome from STEMI PPCI, patients receiving primary angioplasty commencing within 150 minutes;

Outcome from Stroke, patients receiving thrombolysis at an hyper-acute centre within 60 minutes is below (worse than) local thresholds;

Acute STEMI patients receiving the appropriate care bundle was below the local threshold;

Outcome from cardiac arrest, survival to discharge rates, were marginally below the local thresholds;

NHS 111 Call Audit volumes are below (lower than) the target level at present but the Trust has internal improvement trajectories in place for both Hubs;

Urgent Care Service QR12: An improvement is expected for both the Gloucestershire and Dorset OOH performance for those measures where performance is below the national target levels;

Two PTS KPIs in the BNSSG contact are below contracted levels in March 2017, both of these metrics are also below contracted levels for the year to date. The PTS contract for the Bath, North Somerset and South Gloucester area ended on 31 March 2017 with the service being transferred to new providers;

Sickness levels across the Trust in March 2017 were 4.66%. Throughout 2016/17 sickness levels have been improving compared to last year but remain above the internal trust stretch target of 4%

Escalated Performance Issue Performance in the reporting period is significantly off plan and there is currently no action plan in place OR there is insufficient evidence of improvement as a result of actions already agreed and being taken by the Trust in order to improve performance. Operational resource hours lost to chargeable handover delays (at acute hospitals) were

1,449 hours in March 2017. This equates to an average of 47 hours lost per day across the Trust;

NHS 111 call answering performance is below (worse than) the 95% national KPI level in March 2017, but improvements in performance have been seen compared to both January and February 2017. Further improvements are expected in line performance improvement plans in the NHS 111 service


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Recommendation The Council of Governors is asked to:

(i) note further detail of the Trust’s performance contained within this report and the Integrated Corporate Performance Report; and

(ii) raise any questions on Board actions or decisions with Non-Executive Directors.

Marty McAuley Trust Secretary



Date: 17 May 2017

Paper Title: Board Agendas and Minutes

Prepared by: Marty McAuley, Trust Secretary

Presented by: Tony Fox, Chairman

Action: Assurance

Recommendation:

The Council of Governors is recommended to take assurance from the range of topics considered by the Board of Directors together with the feedback received from Governors who attended the meetings.

Executive Summary:

The Council of Governors has a statutory duty to hold the Non-Executive Directors of the Trust individually and collectively account for the performance of the Board of Directors. The Board of Directors is required to provide the agenda and minutes from their meetings to the Council of Governors. The following agendas and minutes are attached:

29 September 2016 (Agenda and Minutes)

24 November 2016 (Agenda and Minutes)

26 January 2017 (Agenda and Minutes)

30 March 2017 (Agenda Only)

Questions on the agendas and minutes will be taken by the Non-Executive Directors at the meeting.

Trust Public Board of Directors Meeting – 24 November 2016 Page 1 of 2

Agenda Trust Public Board of Directors Meeting

Date Thursday 29 September 2016 Time 10.00

Venue Boardroom, Trust HQ, Abbey Court, Eagle Way, Exeter EX2 7HY

Chair Mrs H Strawbridge OBE, Chairman

Members:

Mrs H Strawbridge OBE (HS), Mr K Wenman (KW), Mr T Fox (TF), Mr H Hood (HH) Mrs V James (VJ), Mr P Love (PL), Dr I Reynolds (IR), Mr F Gillen (FG), Mrs J Kingston (JK), Dr A Smith (AS), Mrs J Winslade (JW), Mrs E Wood (EW), Mrs G Bragg (GB)

Non Members:

Mr M McAuley (MM), Lord P Tyler (PT), Ms L Bowden (LB), Mr N Le Chevalier (NLC)

Circulation Mr C Nelson, Joint Branch Secretary, Unison, Ms J Fowles Joint Branch-Secretary, Unison, Council of Governors

Minutes Mrs J Smalley (JS)

Opening business

No Topic Format Presenter

1 Welcome, Introduction & Apologies Verbal HS

2 Declarations of Interest Verbal All

3 Patient Story Presentation HS

4 Report from the Chairman Verbal HS

5 Report from the Chief Executive Verbal KW

6 Questions from the Public Verbal HS

7 Minutes of Previous Meetings:

28 July 2016 Paper 1 HS

8 Action Point Register Paper 2 HS


Strategic Items for assurance

9 Integrated Corporate Performance Report Paper 3 KW

10 Corporate Risk Register and Board Assurance Framework Paper 4 JW

11 Patient Safety and Experience Report Paper 5 JW

12 Health and Safety Paper 6 JW

13 Communications Update Paper 7 LB

14 ACQIs Paper 8 AGS

15 Data Quality Report Paper 9 FG

Sub Committee reporting for assurance

16

Quality Committee Assurance Reports

30 June 2016

14 July 2016

Paper 10 VJ

17

Audit and Assurance Committee Assurance Report

18 August 2016 Audit and Assurance Committee Minutes

19 May 2016

Paper 11 PL

Closing business

18

Any Other Business

Identification of New Risks (incl. Health & Safety)

Identification of New Legislation

Verbal HS

Trust Public Board of Directors Meeting, 29 September 2016 10:00 hrs

Page 1 of 1616

Minutes Trust Public Board of Directors Meeting Thursday 29 September 2016, 10.00hrs Boardroom, Trust Headquarters, Abbey Court, Eagle Way, Exeter EX2 7HY Chair Mrs H Strawbridge OBE - Chairman Administration Mrs J Smalley – EA & Business Manager to Chairman and Chief Executive

Members: Mrs H Strawbridge OBE HS Chairman Mr K Wenman KW Chief Executive Mr P Love PL Non-Executive Director Mr T Fox TF Non-Executive Director Mr H Hood HH Non-Executive Director Mrs V James VJ Non-Executive Director Mr I Reynolds IR Non-Executive Director Mrs G Bragg GB Non-Executive Director Mr F Gillen FG Executive Director of IM&T Mrs J Kingston JK Deputy Chief Executive/Executive Director of

Finance Dr A Smith AGS Executive Medical Director Mrs J Winslade JW Executive Director of Nursing and Governance Mrs E Wood EW Executive Director of HR & OD Non Members: Mr N Le Chevalier NLC Director of Operations Lord P Tyler PT Adviser to the Trust Board of Directors Guests: Mrs T Dixon TD Programme Manager Mrs C Lukins CL Patient Speaker Mr W Thomas WT Deputy Lead Governor


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1.0 Welcome, Introduction & Apologies

1.1 1.2 1.3

HS welcomed Carol Lukins, Tineke Dixon, William Thomas and Gail Bragg to the meeting. HS introduced Gail Bragg as Non-Executive Director. Apologies were received from Paul Love, Louise Bowden and Marty McAuley.

2.0 Declarations of Interest

2.1 No declarations of interest.

3.0 Patient Story

3.1 3.2 3.3 3.4

Carol Lukins (CL) Incident Date: 2 March 2016 CL attended the Trust Board of Directors Meeting to provide them with her story following an incident when she contacted South Western Ambulance Service. CL’s 93 year old mother had vascular dementia and had carers visiting her in her home throughout the day. On 2 March 2016 the Carers left CL’s mother at 17:45 hours. CL telephoned her mother at 19:00 hours. Her mother said that her leg was not right and that she had fallen but managed to get to the sofa. She was otherwise well. When CL phoned her mother again 20 minutes later her mother was unable to move her leg and was distressed. CL kept her on the phone and contacted the care home. Her mother has planned routine care so this incident was not an immediate response from them. CL was concerned her mother may have fractured her hip. CL called 999 at 20:15 hours. The carers advised they would contact CL when the ambulance arrived. As CL lives 3.5 hours away she decided to stay where she was until her mother had been assessed. The carers contacted CL and advised her that they would not be able to stay with her mother after 21:00 hours. They agreed that if the ambulance did not arrive by then the carer would phone CL and stay on the phone until the ambulance arrived. CL did not receive a call back so made the assumption that the ambulance had arrived and did not rush to contact her mother again.


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3.5 3.6 3.7 3.8 3.9 3.10 3.11 3.12

CL received a phone call from the care home at 22:30 hours advising her that they were still awaiting an ambulance despite a further call made to the service. At midnight the night carer phoned the service and the Call Handler apologized for the wait. The Call Handler was unsure when the ambulance would arrive. At 01:45 hours a paramedic arrived with CL’s mother. The ambulance would not be available for a further three hours. At 05:00 hours CL’s mother was taken to Bristol Royal Infirmary. CL advised the Trust Board that she is not calling into question the care her mother received by all staff as they were compassionate and caring. She has concerns about the length of time the ambulance took to respond. HS thanked CL for sharing her experience and advised that the Trust wants to learn from this. KW thanked CL and noted that he had felt moved by her story and was disappointed by the Trust response. He advised CL that the Trust is involved in a trial with NHS England around response times. This aim of the trial is to enable the Trust to provide patients with the most appropriate response. Stage 3 of the trial commences in October 2016. The evidence from the trial so far is showing that the ambulance service should have fewer cars and more ambulances for patients. The Trust has started to increase the number of ambulances. Unfortunately, responses to less life threatening calls do get compromised when incidents outstrip the number of ambulances available. JW stated that these incidents are always very tragic. JW acknowledged that the complaint process had not provided CL with the timeliness of response she should expect and therefore the expected outcome to her complaint. . There is a National impetus around learning from complaints and incidents. KW explained that there had been attempts to get the ambulance to the care home. Where patients are in a safe place their priority can be reduced. There could be several calls waiting for the same ambulance but if a patient is in a care home or even with a relative they may not get the same priority as a patient in the street. This case is unusual as every time the Trust attempted to respond to CL’s mother another call came in with a higher priority and the ambulance was diverted. The ambulance services need more resources. JW acknowledged that there had been a second welfare call made to the


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3.13 3.14 3.15

care home but this had gone to answerphone and was not escalated by the service. KW advised that the Trust has been able to increase the frontline ambulance fleet by 16 double crewed ambulances (DCAs). As the trial continues the definitive number of DCAs required is not known. KW reported as part of the Stage 3 of the trial Dr A Smith, Executive Medical Director and a team of Medical Directors across the country will be looking at the types of response. It is likely that the Trust will need to increase from 63% of DCAs to 80% over a period of time. KW reported that a DCA costs £130k and a rapid response car costs £30k. This includes the cost of the vehicle and moving from a single person in a car to two people on an ambulance. HS and KW had met with CL on a previous occasion. CL agreed that there is work to be done educating and making sure the public make the most appropriate use of the ambulance service so that it is there for the people, like her mother, who need it. HS advised that the Trust Comms Team and Governors try to get those messages out to the public. HS advised that this is linked to the work that the Trust undertakes with Hear and Treat and making sure the public know who to contact with their specific needs. HS, on behalf of the Trust, apologised to CL and her mother for the delayed ambulance response and thanked CL for attending the meeting.

4.0 Report from the Chairman

4.1 4.2 4.3

HS reported that TF has been appointed as Vice Chairman at the Council of Governors. Adrian Rutter has been re-appointed as the Lead Governor for another year. William Thomas was re-appointed as the Deputy Lead Governor for another year. HS congratulated them. Since the last Trust Board Meeting HS had attended the Health Overview and Scrutiny Committee Meetings in Somerset and Wiltshire to give presentations with NLC and Paul Birkett-Wendes, Head of Operations North Division. The feedback was that the councilors had been respectful of the service the Trust provides and they fully understand and appreciate the issue of not having enough resources. The Trust continues to looking at partnership working with councils to introduce more community defibs and first responders. HS reminded the Trust Board that there are three Trust Community First Responder Award Ceremonies between October and November 2016,


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4.4

one in each of the Divisions. HS looked forward to recognizing the support for the volunteers. HS had attended the recent Open Day at Taunton Ambulance Station. The next one is in Shepton Mallet on 22 October 2016. HS encouraged the Trust Board to attend.

5.0 Report from the Chief Executive

5.1 5.2 5.3 5.4

KW commended the Research Team for being nominated for an HSJ Award. KW advised that the Ambulance Response Programme (ARP) update would be given during the Confidential Section of the Trust Board Meeting. He reported that Stage 3 of the trial commences in October 2016. There will be a number of important upgrades and initiatives to roll out prior to Stage 3. The Trust Board of Directors noted that the initiatives and Stage 3 of the trial had been approved by Dr Jonathan Benger, National Clinical Director for Urgent Care, NHS England. KW stated that the CQC Report has been finalized but is embargoed until 5 October 2016. The CQC will release a press statement on 5 October 2016. Stakeholders will receive the final report on 4 October 2016. KW noted that some members of the Trust Board would be attended the CQC Quality Summit on 30 September 2016 arranged by NHS Improvement and NHS England. Stakeholders will be in attendance. 30 September 2016 is a significant day for the Trust as the Devon NHS 111 contract ends. On the same day the Cornwall 111 service moves to the East Clinical Hub. The Dorset 999 service remains with the Trust and moves to the Trust HQ in Exeter, staff have been redeployed.

6.0 Questions from the Public

6.1 6.2

There were no formal questions from the Public. WT requested the dates of the Ambulance Station Open Days. ACTION: MM to ensure that the dates are included in the Governors Newsletter.

MM

7.0 Minutes of the Previous Meeting – 28 July 2016

7.1 The Minutes of the previous meeting of 28 July 2016 were approved as a correct record of proceedings.


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8.0 Action Point Register

8.1 The Action Point Register was updated and would be circulated to the Trust Board of Directors.

9.0 Integrated Corporate Performance Report

9.1 9.2 9.3 9.4 9.5 9.6 9.7

KW presented the Integrated Corporate Performance Report. KW reported that that National position for performance is challenging. No Ambulance Trust is delivering the current performance standards. Measuring performance has been difficult during the ARP trial. KW confirmed that trial sites are achieving 69-70% for red responses. KW reported that only this Trust and one other Ambulance Trust has not reported a deficit position at the end of year which is a significant achievement. The Trust activity is down on contract by 1%. The Trust saw a reduction in activity in August which is unusual as this usually increases during the summer months. Year on year the Trust has seen a rolling average of an upward trend. However, 3% below activity level has been predicted for this year. The Trust is closely monitoring activity. KW asked the Trust Board of Directors to be mindful that the ARP trial sites (South Western, Yorkshire and West Midlands) are being measured against performance standards which are indicative but not what will be set when the trial is complete. The new standards are likely to be set by Government in April 2017. As part of the trial the sites are focusing at the tail calls where it takes longer to get them an ambulance response. EW provided the Trust Board of Directors with a brief on the Rota Review. The Rota Review has working groups of staff who will meet four times. The Rota Review will provide an overview of demand. The review is encouraging staff to come up with their own rota within the financial envelope available. Staff and the Union have been highly engaged with the process. By end of the fourth meeting at the end of November 2016 every station and clinical hub should be realigned to the demand with new rotas commencing by the end of the financial year. Following a discussion about lack of resources HS advised that there have been numerous demonstrations provided to the Trust Board of Directors within the ORH Reports. KW stated that the latest reports identified the need for £22m and 402 extra staff. Redefining rota will assist but would


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9.8 9.9 9.10 9.11 9.12 9.13 9.14

not meet the need. Activity has increased by 6% in the last 10 years. KW reported that 1800 hours had been lost to handover delays in August 2016. This is an upward trend given winter is coming. Commissioners had held a local area workshop where pledges were made by acute trusts to improve handovers but performance is still concerning. The Trust is assisting CCGs on operational plans involving hospitals to try to reduce handover delays. Tiverton Urgent Care Centre is performing well by meeting and exceeding the 95% target. The Trust will be withdrawing from the Gloucestershire Out of Hours Service on the 31st May 2017. NHS 111 Devon has delivered improved performance during September . JW responded to a question from HS about how the Trust could improve NHS 111 call backs in Dorset. JW reported that Dorset is fully recruited for clinicians according to funded establishment. The Trust ensures that it follows national best practice for call backs. The Trust is below national average, particularly in Dorset. The NHS 111 Services for Dorset and Cornwall and the Out of Hours Service and Single Point of Access will all be in one building from October 2016 and there will be focus on clinical call backs. In order to resource up to offer 10 minute call backs the Trust will need to present a business case to the CCG’s to present a case for funding additional clinicians in the service to achieve an improvement in this target. . The service for Devon has performed better as the service streamed calls to Devon Doctors. JW reported that these issues actions are on the RCAP. JW advised that there is a Business Case with the Finance Team for review and it is hoped this will be progressed soon. KW reported to the Trust Board of Directors that in the future the Trust will have no compromise on contracts. VJ confirmed that at the June 2016 Quality Committee there was a dip test on patient safety information. There were no patient safety issues. JW also confirmed that there had also been a thorough risk assessment on risk to service users and patient safety provided to the Risk Assurance Group.

10.0 Corporate Risk Register and Board Assurance Framework

10.1 JW BAF provided the Risk Register in the format requested by the Trust


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10.2 10.3 10.4 10.5 10.6 10.7 10.8

Board of Directors with chronological risks by level of severity. JW highlighted that there are nine risks with a score of 20. These are as follows; Performance Targets Red (ARP) 111 Call Handling (Call Answering Performance, Waiting and Abandonment) NHS 111 Devon Contract Operational Resources (UCS) Commissioner Affordability Call Stacking (A&E) National Position on Paramedic Bandings Service Line Financials (A&E) Reputation The Internal Audit Report of the BAF recommended that the Board of Directors receive a deep dive on risks that sit below the highest level risks on a rotational basis. For this meeting JW had provided a deep dive on Health and Safety – Strategic Oversight as this relates to the Health and Safety Executive Inspection findings. JW confirmed that no new risks had been added to the risk register since it was last presented in July 2016. The next Risk Assurance Group will consider a financial and workforce risk assessment around TUPE. Board Assurance - Deep Dive: 111 Call Handling (Call Answering Performance, Waiting and Abandonment) JW reported that this risk had been consolidated to provide clarity. The risk now addresses all the following actions in one risk ; 111 call handling, 111 demand and 111 abandonment. This accounts for the need consolidate and review the risks as Devon 111 moves to a new provider and the 111 services are consolidated in the East Hub . Controls from actions are being updated and recommended to the Trust Board of Directors as a new way of looking at 111 risks. By December 2016 the Trust will start to see a change with the risks in call waiting and abandonment. Abandonment is now below 5% national rate. HS thanked JW and the team for providing an improved oversight of the work going on with NHS 111 services. HS acknowledged that work in the RCAP and with changes and improvements made the consequences of these risks are not as great as they were. HS noted that the forecast


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10.9 10.10 10.11 10.12 10.13 10.14

remains the same with the consequence as being serious. JW reported that given where the Trust had been with the Devon contract and the warning notice earlier in the year it was not right to reduce the forecast risk at that time. This will be reviewed with regard to recruitment and workforce. There will be new wording for improvements made and the forecast to show a reduction in consequences. ACTION: JW to ensure there is new wording for improvements made and the forecast to show a reduction in consequences. JW to feed this back to the Risk Assurance Group. HS requested that the Corporate Risk Register has definitions of what serious is. HH noted it was important to look forward at the mitigated risk. Board Assurance – Deep Dive: Reputation JW would expect a review of this risk with potential reduction with more positive media attention around 999 and the change with the Devon 111 contract moving to a new provider. Board Assurance – Deep Dive: Health and Safety – Strategic Oversight This Deep Dive was undertaken on the recommendation of Internal Audit. It was recorded that the Trust Board of Directors had undertaken Health and Safety Training in September 2016 and that for assurance there is a Health and Safety Improvement Plan. JW noted that this is a new and emerging risk but the score should reduce with controls in place. Board Assurance – Deep Dive: Ops Resources (UCS) GB noted that this risk had moved from likely to unlikely and asked what actions had led to the reduction in the risk score. JW advised that with the NHS 111 recruitment into Cornwall and if the recruitment trajectory proves successful this would reduce the risk of resourcing in UCS. HS noted that this is where the panel has taken account of the forecasting. Board Assurance – Deep Dive: NHS 111Devon Contract. HS noted that the NHS 111 Devon Contract ends on 30 September 2016 and that the forecast is there for quality performance issues. Acknowledging there are finance issues HS asked what the timescale would be for this. EW advised that the risks would be ongoing for TUPE, reputational risks because of the TUPE concerns and financial risks. The residual risk may remain for a further six to twelve months. The Trust Board of Directors accepted the longer term risk that remains with the Trust for the NHS 111 Devon Contract.


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10.15

The Trust Board of Directors took assurance from the Board Assurance Framework and Risk Register.

11.0 Patient Safety and Experience Report 1 July 2016 to 31 August 2016

11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8

JW presented the Patient Safety and Experience Report which provides an update on patient safety and experience issues reported during the period 1 July 2016 to 31 August 2016. JW reported that across both service lines the Trust is continuing to see a rise in complaints which in the main relate to delays in particular in the 999 service line. The Trust is also continuing to see a rise in reported incidents by staff. This is a positive increase as it demonstrates that staff are comfortable to report these to the organisation. JW advised there continue to be themes throughout service lines of delayed response . NHS 111is volatile in terms of demand. The ICPR demonstrates the demand issues in A&E. For Out of Hours the demand has increased. There are a multitude of reasons subject to system pressures from both NHS 111 and walk-ins. The Trust takes patients who cannot get access to primary care. The service is the end point for patients to seek help. JW noted that the Welfare Call Policy has been revised to ensure that this meets the needs of the patients and this is monitored. The main themes throughout the report are clinicians completing high quality records, communication issues, drug bags and telephone triage. JW reported that the backlogs of incidents are being worked through in both service lines. JW noted that the closure of incidents is related to the availability of investigating officers and their availability is impacted by demand as well. At this point HS asked that the Trust Board of Directors note the final version of the report rather than the draft report originally circulated. JW noted that one of the actions from the Trust Board of Directors in July 2016 (10.11) was for a review of any incidents that are considered significantly overdue. JW confirmed that there are 135 incidents over 12 months old in UCS and 2 for A&E. The oldest in A&E going back to 24 July 15 related to a hospital raising an issue about an RRV taking a patient to hospital. For UCS the old risk dated


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11.9 11.10 11.11 11.12 11.13

back to May 2014. All risks are under patient investigation. All have been reviewed and most are not classified as patient safety issues; they are all communication or process issues. ACTION: JW to provide the number of adverse incidents overdue by 12 months in the November Board report. Complaints were discussed and the second highest increase in complainant feedback related to perceptions of staff attitude. Year to date the Trust had received 106 complaints in respect of this matter compared to 70 in 2015/16. JW advised that the Quality Development Forum looks at particular issues and what the Trust can do about them. There is direct impact on communication, looking at support for crews around comms skills and in particular for those who have had a complaint against them. This is embedded for new staff in their preceptorship. There are difficulties for staff around violence and aggression, particularly in the hubs where they have abusive calls from members of the public. HS asked whether out of the 106 have any individual members of staff had more than one against them for their attitude. JW advised that this would be picked up by the Operational Officer and the member of staff would have either an assessment of practice by an LDO or in extreme circumstances they would have restriction of practice. ACTION: JW to provide an update for the Trust Board Meeting on 24 November 2016 on how many of the 106 incidents were where staff had been involved more than once for their attitude. Clinical Team Roadshows were discussed. AGS advised that these are linked to work rolling out nationally. The Clinical Team attends a lot of the LMCs. There are frequently asked questions about how to get the best from the ambulance station. ACTION: AGS to provide a programme for the roadshows. AGS noted that LMCs are bi-monthly, and there is availability for the Trust to be on their Agenda. Learning from experience was discussed and noted to be working well. JW confirmed no cases upheld by the PHSO in this period. JW highlighted to the Trust Board of Directors that following a Serious Investigation, the level of clinical support required in the NHS 111 Service is continually reviewed. A review of the clinical rota has been undertaken and all periods where there is no clinician cover in the hub will result in the Call Advisors ceasing to accept calls unless an alternative clinician is available. HS asked whether this situation had arisen. JW confirmed that it had not. ACTION: HS requested that a statement is added to the RCAP to demonstrate that clinical cover is carefully monitored and

JW JW AGS JW


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that to date due to the diligence and commitment of the clinical staff there has always been cover provided. VJ advised that the Quality Committee received a report in June 2016 with regard to specific incidents in NHS 111 and the usual report in July 2016 with no matters arising that required to be reported to the Trust Board of Directors. The Trust Board of Directors took assurance from the Patient Safety and Experience Report. They noted that the RCAP would be updated to include the statement on clinical cover and there would be a full report on overdue incidents. AGS would provide a programme for the clinical roadshows.

12.0 Health, Safety and Security Report

12.1 12.2 12.3 12.4 12.5 12.6 12.7

JW presented the Health, Safety and Security Report. JW noted that this was a new report following the Health and Safety inspection. JW advised that all actions following the inspection are within the plan with good contribution from all Directorates. All actions are being progressed. The report included a deep dive into stress related incidents. The Health and Safety Team are working with the Staying Well Service to support staff. The new process for Health and Safety inspections was noted. Adrian South, Deputy Clinical Director and JW are working closely with their teams. There will be joint Health and Safety and Infection control inspections on an annual basis. This joint process has been implemented following good engagement with staff side. ACTION: JW to review and decide whether the inspections should be unannounced. JW commended Unison for training a number of staff to be work place representatives for Health and Safety. JW confirmed that the next report will include a deep dive on manual handling. TF is the Non-Executive Director Lead for Health and Safety. ACTION: JW to ensure TF is included in all Health and Safety Plans. It was noted that members of the Trust Board of Directors who missed the recently Health and Safety Training will be invited to attend another session.

JW JW


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Following the training JW had received a suggestion about looking at Health and Safety KPIs in the same way as the ICPR. ACTION: JW to report the Health and Safety KPIs in the ICPR format and split into the service line format. The Trust Board of Directors took assurance from the Health, Safety and Security Report and noted the above actions to be taken.

JW

13.0 Communications Update

13.1 13.2 13.3 13.4

LB presented the Communications Update providing information on media coverage activity since the last meeting. LB advised that the team have been monitoring the content of all press releases during August 2016 and confirmed that just over 6% had been positive, 90% neutral and less than 2% had been negative. It was noted that there has been good media coverage raising the profile about incidents against staff. The Trust Board of Directors took assurance from the Communications Update.

14.0 ACQIs

14.1 The ACQI Report was not received on this occasion.

15.0 Data Quality Report

15.1 15.2 15.3 15.4

FG presented the Data Quality Report providing the Trust Board of Directors with an update on key data quality activities for the period April to September 2016. FG noted that the monthly data quality returns are reviewed in terms of completeness and ongoing actions and issues. There were five areas highlighted where adjustments had been made. Highlights of these are as follows; Post event messaging and messages to GP services after a 111 call. These had been under reported by 45%. The figures have now been revised. As part of ARP Stage 2 C3 CAD calculation of the Red Transport target it was noted that this included transport responses for instances where


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15.5 15.6 15.7 15.8 15.9 15.10 15.11

patients were not conveyed in the calculations. A CAD change is pending to correct this figure with a materiality of approximately 1% year to date. Telephony abandonment figures for 999 included re-presentation of BT operators, rather than patient disconnect. These have now been removed from ACQI returns post April 2016. Post the move to the single C3 CAD there are a number of matters under review in respect to non-conveyance destinations in the North of the Trust. IM&T are working through all alternative destinations with the Right Care Team to ensure end-end accuracy of locations The major areas of focus going forward will be programme alignment, application of ACQI guidance and assurance. FG reported that there is focus on increasing the governance associated with license management and compliance. This is being reported to the Audit Committee and the Directors Group. HH had attended the Data Quality Meeting in March 2016. ACTION: FG to invite HH to attend another meeting in the near future. HS commended IM&T for the good reporting and work undertaken nationally. The Trust Board of Directors took assurance from the Data Quality Report.

16.0 Quality Committee Assurance Reports

30 June 2016

14 July 2016

16.1 16.2 16.3 16.4

VJ presented the Quality Committee Assurance Reports for June and July 2016. June 2016 VJ advised that June 2016 was an Extraordinary Meeting focusing on NHS 111 and the RCAP. Key issues were in relation to Devon contract and ARP. Three Policies and SOPs were approved. The Committee received five assurances around NHS 111 call audit, risk assessments, pathways licence compliance assessment, varying themes and incidents and NHS 111 call dip test.


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16.5 16.6 16.7 16.8 16.9 16.10 16.11 16.12

The RCAP had been reviewed in detail. The Committee had received the summary of incidents and complaints, pathways policy, license compliance assessment and themes and trends. The Quality Committee in June 2016 had no matters that required to be raised with the Board. July 2016 The Quality Committee approved 3 policies and took assurance from 16 solid reports. The Quality Committee reviewed 2 key documents; the Quality Strategy before consultation and Quality Management of Risk. This will be received by the Trust Board of Directors for ratification having been approved by the Quality Committee. The Quality Committee in July 2016 had no matters that required to be raised with the Board. It was noted that the issue of Deep Cleaning of Vehicles had been referred to the Directors Group. HS noted that the Assurance Report from the Quality Committee in August 2016 had not been received. ACTION: JW to ensure that all reports are received in a timely manner for further meetings. The Trust Board of Directors took assurance from the Quality Committee Assurance Reports.

JW

17.0 Audit and Assurance Committee Assurance Report

18 August 2016

17.1 17.2

JK presented the Audit and Assurance Committee Assurance Report on behalf of PL. Internal Audit: Quarter 1 Audit Plan Review. As part of the Audit and Assurance Committee Work Programme there had been a mid-year review of the Work Programme to ensure that it was still fit for purpose and reflected the risks for assurance in the BAF process. This had been brought forward and reviewed in August. This was prompted as Audit South West had increased their prices. They had been through their own governance and committees. The Committee is reworking the programme without compromising this and ensuring that it remains within budget. This work has now been undertaken and will be ratified at the Audit and Assurance Committee Meeting in October 2016.


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17.3 17.4

The Trust Board of Directors took assurance from the Audit and Assurance Committee Report. The Trust Board of Directors noted the Audit and Assurance Minutes from 19 May 2016.

18.0 Any other business

Identification of New Risks (incl. Health and Safety)


18.1 18.2 18.3

No further business was discussed. There was no identification of new risks. There was no identification of new legislation.

Signed: (Chair)

Dated:

A final, signed copy of the minutes are available from the meeting administrator on request



Date Thursday 24 November 2016 Time 10.00



Members:

Mrs H Strawbridge OBE (HS), Mr K Wenman (KW), Mr T Fox (TF), Mr H Hood (HH) Mrs V James (VJ), Mr P Love (PL), Dr I Reynolds (IR), Mr F Gillen (FG), Mrs J Kingston (JK), Dr A Smith (AGS), Mrs J Winslade (JW), Mrs E Wood (EW) Ms G Bragg (GB)

Non Members:

Mr M McAuley (MM), Lord P Tyler (PT), Ms L Bowden (LB), Mr N Le Chevalier (NLC) Mr A South (AS)

Circulation Mr C Nelson, Joint Branch Secretary, Unison, Ms J Fowles Joint Branch- Secretary, Unison, Council of Governors

Administration Mrs J Smalley (JS)

Opening business







6 Questions from the Public - None Verbal HS

7 Minutes of Previous Meeting – 29 September 2016 Paper 1 HS







12 Information Governance YTD Report 2016/17 Paper 6 FG


Items for approval

14 Health and Safety Report and KPI’s Paper 8 JW

15 Security Management Strategy Paper 9 JW

16 CQC Action Plan and TOR for the Quality Development Group

Paper 10 JW

17 Procurement Policy Paper 11 JK


18

Quality Committee Assurance Report

Monday 17 October Quality Committee Minutes

Wednesday 24 August

Paper 12

VJ

19

Audit Committee Assurance Report

Thursday 13 October Audit Committee Minutes

Thursday 18 August

Paper 13

PL

Closing business

20

Any Other Business



Verbal

HS

Trust Public Board of Directors Meeting - 24 November 2016

Page 1 of 19

Minutes Trust Public Board of Directors Meeting Thursday 24 November 2016, 09.30 hours Boardroom, Trust Headquarters, Abbey Court, Eagle Way, Exeter EX2 7HY Chair: Mrs H Strawbridge OBE - Chairman Administration: Mrs J Smalley – EA & Business Manager to Chairman and Chief Executive

Members: Mrs H Strawbridge OBE HS Chairman Mr K Wenman KW Chief Executive Mr P Love PL Non-Executive Director Mr T Fox TF Non-Executive Director Mrs V James VJ Non-Executive Director Mr I Reynolds IR Non-Executive Director Mrs G Bragg GB Non-Executive Director Mrs J Kingston JK Deputy Chief Executive/Executive Director of

Finance Mr F Gillen FG Executive Director of IM&T Mrs J Winslade JW Executive Director of Nursing and Governance Mrs E Wood EW Executive Director of HR & OD Non Members: Mrs L Bowden LB Acting Head of Marketing, PR and Communications Mr N Le Chevalier NLC Director of Operations Lord P Tyler PT Adviser to the Trust Board Ms J Fowles JF Union Representative Mrs N Casey NC Head of Governance Guest: Mr B McInerney BM Member of the Public Mr G Nicholas GN Zoll Mr G Lewis GL Ferno UK Mr T MacInnes TM Public Governor for Wiltshire



1.1 Apologies were received from Hugh Hood, Marty McAuley and Dr Andy


Page 2 of 19

Smith.

2.0 Declarations of Conflict of Interest

2.1 No declarations of interest were declared.

3.0 Patient Stories

Update on Joshua’s Story

3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

Patient Stories JW read a plaudit received from the wife of a patient who praised the crew for the care they gave when her husband suffered a tear in his aorta. VJ read a complaint from the wife of a patient who made three calls to the ambulance service when her husband’s condition was deteriorating. The wife also advised that the Call Advisor had blamed the government for the lack of response. The following issues were highlighted from the investigation undertaken by the Trust: There had been an increase in demand over the expected levels. It was noted that the condition the patient was suffering from required a double crewed ambulance (DCA) and there was no DCA available at the time of the initial call. One hour after the call the Clinical Desk phoned the patient and the priority remained the same with the requirement of a DCA. If the call had been given a response level of ‘Red/Amber’ the grade of crew could have been lowered to Technician to provide a quicker response. Review of the call did not show that the Call Advisor had entered into a conversation about the government being to blame but the call was not handled in the most appropriate way. The investigation also noted that the phrases used as standard in the hub may cause some confusion to the public. Phrases such as ‘help has been arranged’ may be misleading at the member of the public might think that an ambulance is on its way to them. The caller then became angered on the latter calls due to having made this assumption. The complaint was upheld as the ambulance attendance was outside of the benchmark target of 19 minutes. Following the verbal feedback the complainant did not require any additional feedback.


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3.9 3.10 3.11 3.12 3.13 3.14

ACTION: HS requested that more background details are added to future stories for the Trust Board of Directors so that if the stories are taken to other forums such as the Council of Governors the detail required would be included. JW to take this action forward. Update on Joshua’s Story Bren McInerney BM had attended the Trust Board of Directors Meeting previously to talk about the launch of Joshua’s Story. BM attended this meeting to update the Trust Board of Directors on how the story had been received in other Trusts. BM passed on thanks to SWASFT from James Titcombe, Joshua’s father who had written the book, for the Trust welcoming the learning the Trust had taken forward. HS advised that it is the Trust who thanks James because without the sharing of such experiences the Trust is not able to take on the learning and make things better for others. HS advised that the key message has been the openness of the Trust. BM advised that he is in liaison with Duncan Selbie, Chief Executive Public Health England who will be emailing all Trust Chief Executives to provide full feedback and information where this crosses over between Trusts. JW advised that she had met with James and it had been valuable to spend time with him.

JW


4.1 4.2 4.3 4.4

HS noted that the Trust Community First Responder Award Ceremonies had taken place. These ceremonies recognize the huge contribution made by the volunteers across the Trust. HS announced to the Trust Board of Directors that the Research Team had won a national award presented by the Health Service Journal. HS commended the team for their work and achievement. HS has been presenting the Awards for SWASFT in Bloom. There had been a good number of entries to the competition and feedback from staff was very positive. The winners were Taunton Ambulance Station, North Bristol Operations Centre and Marlborough Ambulance Station. This year’s Trust Christmas Raffle is raising money for SANDS the stillbirth charity.


Page 4 of 19


5.1 5.2

Ambulance Response Programme Update KW reported that the new Ambulance Response Programme Coding set had been introduced since last Trust Board Meeting in October 2016. The Trust has already seen some improvements an update would be provided during the Integrated Corporate Performance Report Agenda Item. KW noted that today is the first of the annual round of Trust Staff Meetings. The meetings commence with Devon today and the Executive Team will be attending meetings in Cornwall, Wiltshire, Somerset, Avon, Gloucester and Dorset. All staff welcome. A Clinical Session has been arranged at the beginning of the meeting for CPD and two of the meetings will have Basic Life Support training for non-clinical staff. Staff have been asked in advance for questions and the meeting will follow a number of themes to provide staff with information and updates.


6.1 There were no questions received from the public.

7.0 Minutes of the Previous Meeting – 29 September 2016

7.1 JW advised that she had some amendments to make to the Minutes of 29 September 2016 before approval could take place. ACTION: JS to work with JW on the amendments to the September 2016 Minutes and they will be represented to the January 2017 Trust Board of Directors for final approval.

JS


8.1 The Action Point Register was reviewed. The Trust Board of Directors noted that all current actions had been completed.

9.0 Integrated Corporate Performance Report (ICPR) October 2016

9.1 9.2

KW presented the ICPR which reports by exception and focuses on actions being taken by the Trust to address off plan performance. ARP and Performance KW provided an update on the Ambulance Response Programme (ARP). The three trial sites involved in the programme are this Trust, Yorkshire Ambulance Service (YAS) and West Midlands Ambulance Service (WMAS). The programme is led by NHS England and the Department of


Page 5 of 19

9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10

Health. The programme has brought about complex changes over the last 18 months. Changes have been made to the coding set and how the service triages calls. The Trust is now seeing more accurate responses to triage and the decision on what resource to send to the patient. The target for Category 1 calls is 70%. The Trust achieved 72.5% last month exceeding the target. The Trust is the only trial site to have achieved this. Performance for the other targets are as follows: For Category 2 calls the Trust achieved 72%. For Category 3 calls the Trust achieved 72%. For Category 4 calls the Trust achieved 67%. KW and the Director of Operations met with Councillors in Gloucester recently and feedback was positive on the Trust achieving 75% in the Gloucester area. The Trust has seen a 1.9% increase on activity last year. This is below contract. The Trust is the only ambulance service seeing an activity level lower than the contracted activity. Hear and Treat will be a future measurement under ARP. The Trust is achieving between 12.5% and 17% on average which is double to the achievements of other ambulance services. The Trust is at 35% for See and Treat. Collectively 52% of patients dealt with through the 999 service stayed at home. HS advised that she met James Heappey MP for Wells at the Ambulance Station Open Day at Shepton Mallet and the message about providing patients with the right care is good. This will be part of the solution for some of the challenges facing the NHS. KW reported a slight increase in See and Convey and noted that as the weather changes this leads to more complex conditions for patients and they require admission into Emergency Departments. KW has been engaging with Chief Executives and noted that any change to Emergency Department attendances has a knock on effect to Acute Trusts. There has been an increase in calls from NHS 111 to the 999 service. This is currently at 20.7% and is usually around 16%. There is a dichotomy as the Trust wants patients to telephone NHS 111 before dialing 999 for some conditions. When the 999 service receives the calls from NHS 111 and Red calls are coded as life threatening there is no re-


Page 6 of 19

9.11 9.12 9.13 9.14 9.15 9.16

triage allowed of the call and the resource is sent. There has been a change seen since 1 October 2016 with the other category calls being re-triaged. There is a new NHS 111 provider for Devon and on Saturday 19 November 2016 the Trust had 46% of calls coming from that provider. The Trust is in discussions with NEW Devon CCG with regard to the new provider of the service and how this can be improved. KW provided a positive update on ARP with regard to the Trust average response to an incident. KW confirmed that the number of resources sent to each incident has decreased to 1.28 resources per incident, previously the average was 2. There is less need to send a car and an ambulance. The Trust requires more ambulances. The vehicle fleet demographic has too many cars. More patients are receiving an ambulance to convey them to hospital and this is working well. The handover delay issue has been raised by NHS Improvement. NHS Improvement is putting more emphasis on work on handover delays. KW noted that this is welcomed by the service as the control total has released the burden of penalties for handover delays. In future the Trust will be unable to charge for handover delays. The Trust Board of Directors noted that handover delays had led to1,849 operational resource hours were lost to chargeable handover delays at acute hospitals in October 2016. KW advised that the Trust sends in liaison officers to look after patients in the Emergency Departments to release crews and the Acute Trusts value this assistance. KW reported that 999 call answering is now above average which is an improvement on the delays in call answering reported in July 2016. VJ noted that the Council of Governors (CoG) took assurance from a paramedic Governor who informed the CoG at the last meeting that when and where it is possible ambulance crews double up on the handling of patients in order to release ambulance resources back into active service to reduce risk in patients in need in the community. The systemic issue is the key one to address. GB asked if the Acute Trusts match the clinicians the Trust sends in to reduce handover delays. KW advised that joint managing of the queue is welcomed and that this does take place in some areas. KW noted that 62.8% of patients that the ambulance service take to hospital do get admitted which is commendable and is a very high percentage when compared to national data. This reflects very positively on the staff of the Trust. KW advised that the Ambulance Association of Chief Executives


Page 7 of 19

9.17 9.18 9.19 9.20 9.21 9.22 9.23

has paid for HES data so that Trusts can check these figures more regularly. PL noted that with the successes the Trust has with Hear and Treat and See and Treat this is not resonating with the Commissioners who are now withdrawing funding for Right Care 2. JK advised that the Commissioners recognize the work but are unable to afford to pay for it. JK stated that there is good coverage for the Ambulance Service in the National Audit Office (NAO) Report which will be released to the public shortly. The report makes the point about how the ambulance sector can have a positive impact on health systems in productivity and savings to the systems. ACTION: KW recommended that the staff receive the summary of the NAO report and the Trust Board of Directors. Staff turnover was discussed and KW advised that all Ambulance Services have high levels of attrition. The Trust is working hard to meet the workforce plan. The Trust holds monthly Graduate Welcome Days. EW reported that the biggest risk with recruitment and retention for the Trust is that of Primary Care Services who have recognised how useful the qualified paramedics are. They can pay more and offer day time shifts. NHS 111 NHS 111 was discussed and JW reported an improving position. The Trust will be fully recruited to the NHS 111 Service in Cornwall by the end of December 2016. Call Audits were discussed and JW advised that the Call Audit Report will be presented in the Confidential section of the Trust Board Meeting. JW did report that the Trust has seen an improving position between July and September 2016. The position should improve again in November but October 2016 had been challenging. The Operations Directorate has offered assistance over the coming months. The Trust is not resourced to provide call audit compliance. A Business Case will be presented to take to the CCGs. The Non-Executive Directors have been visiting the Urgent Care Service/NHS 111 Hub in St Leonards and this has been encouraging for staff. The Trust will be investing money into some refurbishments in the hub at St Leonards to improve the working environment. There will be new carpets and decorating taking place over the next few weeks. PTS

KW


Page 8 of 19

9.24 9.25 9.26 9.27 9.28 9.29

PTS was discussed. KW advised that the PTS contract is out to tender. On 14 December 2016 the Trust will receive notification of who the new provider will be. The Trust may be asked to extend the contract. If this occurs it will be the fifth extension to the contract. The Trust will be applying the No Compromise Rule. The Trust may be asked to extend for two months to assist the new provider to take over the service. The Trust would agree to this on the same terms as have agreed before. The Chief Executive, Director of Operations, Head of PTS and HR Business Manager have monthly meetings with PTS staff. There have been improvements made on the PTS Action Plan following the CQC Inspection. The Trust Board of Directors will be kept updated on progress with the action plan. Out of Hours Service Gloucester Out of Hours Service: JW reported an improvement in the Gloucester Out of Hours Service in terms of targets. The Trust is expecting a challenging winter as the Gloucester health system is challenged. Dorset: The challenge for Dorset Out of Hours Services is the age profile of GPs and the ability to recruit new GPs. Finance JK gave a brief on finances and advised that the full report would be received in the Confidential section of the Meeting. JK reported that the Trust planned to have a breakeven position at the end of the year. As at the end of October 2016 this is being delivered. The Trust is working within the agency cap. The Cost Improvement Plan continues to deliver in accordance with projections within the plan. JK reported on the reds in the summary dashboard. There have been Practice Code issues with regard to regional drug invoices and the finance team is reviewing these. Debtors figures have been persistent most of the year and the reasons they are down is due to the non-payment of handover delays by the Commissioners. The main change comes with the introduction of a different risk system from NHS Improvement. Now migrated from Risk Assessment Framework to the Single Oversight Framework with new metrics. It was noted that the agency spend still includes GPs but it was noted that this has been raised with and is being considered by NHS Improvement.



Page 9 of 19

10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 10.9

JW presented the Corporate Risk Register and Board Assurance Framework. JW reported that following feedback from the Trust Board of Directors at the previous Trust Board of Director Meetings a rigorous review of risks and forecast risks has been undertaken at Directorate level. Changes made include; combining some of the risks, updating some of the narratives and challenging the actions to ensure the controls are correct. Board Assurance Framework (BAF) JW reported that there has been a reduction in risks that score 20. There had previously been nine and these have been reduced to five. Three risks were closed and one was downgraded. There are two Internal Audit risks that sit below the BAF but there are areas that the Trust Board of Directors requires deep dives into. The five risks scoring 20 are: -Performance Targets Purple and Red (ARP) -Commissioner Affordability -Call Stacking (A&E) -National Position on Paramedic Bandings -Service Line Financials (A&E) Deep Dive: Performance Targets Purple and Red (ARP) JW reported that there is work in place for managing the risks. HS commented that the forecast risk is still a 10 which is optimistic. ACTION: JW to review risk and link patient experience. The risk must be realistic. There has been a rise in the number of delay related incidents. ARP should see this risk reduce which was the reason it was reduced to 10. Deep Dive: Commissioner Affordability It was noted that the risk score was optimistic. JW advised that this may change following the Confidential section of the Meeting. Deep Dive: Call Stacking (A&E) The forecast was noted to be realistic. JW reported that there is an improving position and this should change for the next report. Deep Dive: National Position on Paramedic Banding JW reported that the forecast remains the same. EW updated the Trust Board of Directors on national negotiations with regard to funding. The Ambulance Sector Employers see the funding with the Government. The

JW


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10.10 10.11 10.12 10.13 10.14 10.15 10.16 10.17

financial cost could not be borne by Ambulance Services without restriction of services and consultation. Staff Side would move to national industrial action. The Trust is putting as much effort as possible to reach a solution nationally. JF reported that Jeremy Hunt, Health Secretary made a promise to look at the banding and that industrial action is not aimed at employers but at the government for not delivering. Deep Dive: Service Line Financials (A&E) In year the rating can remain but there may be a need to review the date of the forecast. Risks Sitting Below the BAF Deep Dive: Quality – Investigation Delays JW reported an increase in the number of complaints; Serious, Moderate and Adverse. The team is looking at redeploying and reassigning investigations. There is a review of where the risks lie and the need for increased capacity. NLC advised that a number of plans to address this are in place. Deep Dive: Delay in arrival of back up resources JW noted that delay in arrival of back up resources is the subject many of the patient complaints. The Score of 8 may need to be revised during the winter months. Rota Reviews have been undertaken across the region. The Trust will increase the Double Crewed Ambulance Fleet with extra resources by April 2017. However, there will be a reduction of 40 Rapid Response Vehicles. HS considered the forecast remaining at 8 throughout and requested that forecasts are realistic and not optimistic. PL reported that with the challenges expected the risk may rise rather than reduce. The risk would be reviewed not in isolation. JW advised that the forecast is about risk change and needs to be more contemporary. HS stated that with urgent care performance being good with the Trust being 2nd and 4th highest rated. It is good to see the new risk regarding escalation delays alongside other new risks. The management of controlled drugs was added following CQC feedback in the Out of Hours Service and there are additional controls now in place. TUPE litigation was noted by the Trust Board of Directors.


Page 11 of 19

10.18 The Trust Board of Directors noted and took assurance from the Risk Registers and the Board Assurance Framework. The Trust Board of Directors comments were noted by JW and these would be considered in the next Report.

11.0 Patient Safety and Experience Report

11.1 11.2 11.3 11.4 11.5 11.6

JW presented the Patient Safety and Experience Report covering the period 1 September 2016 to 31 October 2016. JW reported that the Trust is continuing to see a rise in the number of adverse incidents reported. This is a positive step as staff have a culture of being open and transparent in reporting. The consequence of this is that each of the incidents has to be investigated. There has been a rise in complaints, mainly due to delays in response times and delays in back up from resources. There is a backlog of incidents and it has been challenging to close down 75% of incidents in 25 working days. There are no outstanding incidents over 12 months old for A&E. The Urgent Care Incidents are now down to 79 over 12 months old and the aim is that these will be completed by the end of December 2016. In the last month there has been further traction in terms of closing of adverse incidents for both service lines. The Trust is now down to under 1,000 in the backlog for the Urgent Care Service. JW commended the staff for getting the incidents investigated and closed down on the Datix system and it is expected that Urgent Care will achieve compliance with the 75% closure target. At a meeting with the CCG on 23 November 2016 they confirmed they are keen to work with the Trust on serious and moderate incidents with a concise reporting system on incidents. This assists with capacity. Friends and Family Test (FFT) was discussed. JW noted that the response rates are low in Ambulance Trusts. The Association of Ambulance Chief Executives has been working with the Department of Health to get movement on whether they are the right choice of questions for the Ambulance Services. HS commended the structuring of the learning themes within the report. HS would like to understand more of the issues with access, waiting and with delays in crews not booking on in a timely manner. KW stated that there is a management issue of staff not booking on. They should book on at the start of their shift but they may be checking vehicle first. They should book on regardless. NLC reported that staff are being reminded of


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11.7 11.8 11.9

this, particularly for those who are booking on in the morning. NLC advised that there is now an extended time for checking the vehicle at the start of shift where the clinical hub will not dispatch them to an incident. It is recognised that there are more checks to complete with the Electronic Care System (ECS), drugs bags and medical equipment. This is work in progress. JF reported that the extra time for checking the vehicle has been received well by the staff and staff side has encouraged this. The Trust Board of Directors noted staff FFT had increased. Ombudsman cases were discussed and in response to a question from PT with regard to how long does the Ombudsman cases remain outstanding JW advised that the Trust has a low number of ombudsman referrals compared to other Trusts. There have been increasing delays from the Ombudsman in relation to their response. The two cases still under review and have been delayed due to the Ombudsman not the Trust. The next full report to the Trust Board of Directors is due in January 2017. ACTION: JW to liaise with PT over the Ombudsman delays outside of the meeting. This was confirmed with PT in the meeting. The Trust Board of Directors took assurance from the Patient Safety and Experience Report covering the period 1 September 2016 to 31 October 2016.

JW

12.0 Information Governance YTD Report 2016/17

12.1 12.2 12.3 12.4 12.5

FG presented the Information Governance Year To Date Report 2016/17. A scheduled interim IG Toolkit assessment was submitted on 28 October 2016 and showed a current score of 80%. The target score is 75%. Business Continuity training has increased due to the Electronic Care Patient Record and CAD. There has been work undertaken on information, security and asset health checks over the recent months. There have been pressures across the organisation to uplift in Freedom of Information (FOI) requests. It has been challenging to meet the 20 day turnaround. The target is 95% and the Trust is currently at 89.5%. The Director Group has been reviewing plans on how best to increase volume and this is under review. KW advised that he reviews the FOIs and noted that there are some very positive responses as a result of FOIs which demonstrates transparency. KW was concerned with the number of FOIs received from University


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12.6 12.7 12.8 12.9

Students requesting information for university dissertations. FG stated that the team has also seen an increase in commercial FOIs and those from suppliers. PT noted the large increase in FOIs. PT would like to see the evidence that this is due to students. Hard figures should be reported not just the percentages. A quarter of FOIs are from the media. There is a need to see how many there are and whether they hit a point after a particular incident that has attracted attention. If the trend of increase continues the Trust will have a resource and reputational issue. ACTION: FG to add an extra column to the table to contain the hard figures for future reports. FG noted that university students and suppliers require more time to provide information to them. CCTV requests have increased and also take time and often require 3-4 hours per request to serve. The Fleet Team assist the IG Team with these requests. FG noted that two thirds of the requests for CCTV review are internal serving in accident and insurance claims. Police are also requesting information from CCTV footage. KW noted that there have been discussions with the police about body worn cameras. The Ambulance Services are considering wearing them in some areas. The servicing and serving of the equipment could be challenging. There has been an improving position with incidents due to the roll out of the Electronic Care System moving from paper records to electronic. The rollout concludes in next 5-6 weeks. The Trust Board of Directors took assurance from the Information Governance Year To Date Report 2016/17.

FG


13.1 13.2 13.3

LB provided the Communications update. The Trust Board of Directors noted that for September 2016 there had been 448 media mentions of South Western Ambulance Service compared to 1258 in August 2016 and 620 in October 2016. LB advised that the increase in media mentions in August 2016 was due to the CQC Inspection. Volume of coverage for proactive media has now formed the majority of the coverage. There have been step changes over the last three reports provided. It is BBC Ambulance Day on 30 November 2016. This is a national BBC event to demonstrate unprecedented demand. West Midlands Ambulance


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13.4 13.5 13.6 13.7 13.8 13.9

Service has chosen not to take part. This Trust is embracing this event. The Trust covers three BBC regions. There will be interviews with the Chief Executive. Filming has taken place in Somerset in preparation. Key messages are provided to demonstrate the reasons why patients are not always conveyed. There have been Clinical Hub interviews, filming on the Simbulance (clinical simulation vehicle), information regarding ECS and the Staying Well Service is appearing on the One Show on 29 November 2016. There have been additional FOIs from the BBC on paramedic recruitment. This Trust has the best recruitment figures and vacancies in the country. TF arrived at the meeting. The day will commence with BBC breakfast news nationally ending up through to the News at 10pm. There will be links to social media. There will be local radio station interviews on the day and NLC and KW will be involved in those. There will also be live broadcasts on the day. The Comms Teams nationally have been liaising. The primary objectives of the day are to show the challenges faced and for the staff to be proud that they work for this service. The public will understand what goes on day to day within an Ambulance Trust. ACTION: LB to ensure the briefing is circulated to the Governors. LB to liaise with MM.

LB

14.0 Health and Safety Report and KPI’s

14.1 14.2 14.3 14.4

JW presented the Health and Safety Report and KPI’s. The Report was taken as read. JW gave thanks to Paul Quick, Performance Manager for working with Anne Payne, Health, Safety and Security Manager to design a framework for reporting KPIs where they have quantifiable data. Three areas had been highlighted as red. JW advised that these mainly relate to work place assessments and security checklists. Operational capacity has also been an issue. Actions are in process to improve the position. JW gave thanks to the Unions for encouraging and providing Work Place Representatives who attend the Health and Safety Committee. HS noted that the majority of the Trust Board of Directors have completed


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14.5 14.6 14.7 14.8 14.9

Health and Safety Training. A second date is scheduled to include those unable to attend the first session and also the Deputy Directors. HS noticed the security incidents and abuse to staff has increased. JW acknowledged that this has been and continues to be a concern. The team is working to support staff. PL questioned whether this is due to dementia and mental health, patient reacting to strange situation. JW advised it is a rise in verbal abuse. KW stated that would be understandable but it is a mix. ACTION: JW to put together a Sub Group to spend time to look at the zero tolerance issue of abuse to staff. This could be part of discussions at the Trust Board Seminar in December 2016 as well. PL noted that the three tables on page 11 show the same graph but the titles are different. JW explained that these have been completed at the same time. JF asked if there could be an article about staff abuse being reported to the police in the Chief’s Bulletin. EW advised that the problem would be that CPS requirements have increased so much so that the CPS might not take action. KW had taken action in Cornwall about raising an issue where CPS had not prosecuted. KW advised that the view from some Ambulance Services would be that NHS Protect could provide support to staff. Further discussions would be needed with regard to financial support for this. PT reported that there had been all party discussions regarding abuse of staff but unfortunately there was no one from the Ambulance Sector at the meetings. ACTION: NLC to discuss with Adrian Healey, Head of Tri-Service Development. The Trust Board of Directors took assurance from the Health, Safety and Security Report.

JW NLC

15.0 Security Management Strategy

15.1 15.2 15.3

JW presented the Security Management Strategy .This had been approved by the Health & Safety Committee. FG highlighted that if someone was able to get into premises they could access computers and exploit the Trust position. Therefore, this links to cyber security and the IT agenda that the Trust is faced with. JW reported that the Strategy has been developed by the National Group to ensure that it is consistent across the services.


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15.4

The Trust Board of Directors approved the Security Management Strategy.

16.0 CQC Action Plan and TOR for the Quality Development Group

16.1 16.2 16.3 16.4 16.5 16.6 16.7

NC presented the CQC Must do action plan and draft plan. The Trust received its final report following the CQC inspection of the Trust services at the Quality Summit on 30 September 2016. It was agreed at the Quality Summit that the Trust would produce an action plan in response to the Requirement Notice and Must Do items in the report and would engage on this work with stakeholders throughout the Trust area. The CQC confirmed the deadline date of 9 December 2016 for completion of the plan to allow the Trust to complete its engagement programme. The Trust has engaged in consultations with the CCG and Healthwatch to develop the Action Plans. The Trust has run one engagement event with Healthwatch and one further is planned. The function of the Quality Development Group will change to include deep dives at each meeting to test assurance of delivery. HS stated that the Action Plan reads well and sets out the objectives clearly. HS asked for the Terms of Reference to be amended. At present they state that the updates on the Action Plan will be provided to the Quality Committee every six months. This is not frequent enough and should be increased to every meeting. ACTION: JW to amend the Terms of Reference for the Quality Development Group to state that the CQC Action Plan will be reviewed by the Quality Committee at each meeting. The Annual Schedule has been developed for the Quality Development Group and the first two deep dives will cover Appraisals and Infection Control. ACTION: JW to ensure that the NEDs are invited to the Quality Development Group. The Trust Board of Directors approved the CQC Must Do Action Plan and Draft Action Plan. The Trust Board of Directors would provide any further feedback on the plans to JW by 7 December 2016 for inclusion in the final version to be submitted to the CQC on 9 December 2016.

JW JW

17.0 Procurement Policy


Page 17 of 19

17.1 17.2 17.3 17.4 17.5

JK presented the Procurement Policy for approval by the Trust Board of Directors. JK reported that the Policy had been received and recommended for approval by FIC when they met in October 2016. JK asked that the Trust Board of Directors approve the Procurement Policy subject to an amendment to paragraph 2.2. Since the Policy was submitted to FIC the system and process regarding management of licenses in Trust has been submitted to the Quality Committee and Audit & Assurance Committee. The amendment will reflect what has already been agreed. PL requested clarification about the process and what arrangements would be in place for post tender in Trust. If the Trust got to a preferred provider, at that stage would there still be post tender negotiation. JK advised that would be normal so long as it was not undoing what has happened. ACTION: JK to reflect in the Procurement Policy the recognition of the ability to get best value and have post tender negotiation. The Trust Board of Directors approved the Procurement Policy subject to amendments to 2.2 and the inclusion of recognition of the ability to get best value and have post tender negotiation. ACTION: JK to circulate the amendments to the Procurement Policy to the Trust Board of Directors.

JK JK

18.0 Quality Committee Assurance Reports

24 August 2016

17 October 2016

Quality Committee Minutes

24 August 2016

18.1 18.2 18.3

HS reported that she had met with the Chairman of the Welsh Ambulance Service to discuss Governance. The Chairman had asked if he could meet with the Chairs of the Trust’s various Committees in January 2017. ACTION: HS and MM to discuss with the Chairs of the Trust Committees. VJ reported that she will be doing a presentation on the work of the Quality Committee to the Council of Governors at their meeting on 1 December 2016. VJ presented the two Assurance Reports from the Quality Committee, dated 24 August 2016 and 17 October 2016.

HS/ MM


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18.4 18.5 18.6 18.7 18.8 18.9

VJ reported that all matters at the Extraordinary Quality Committee meeting in August 2016 have been taken over as they were to do with the change of providers in NHS 111 Devon Contract. Focus on NHS 111 call auditing is still a matter for concern and remains under review. At the Quality Committee in 17 October 2016 the Committee reflected on the time allocated to the Quality Committee. It was agreed that the meeting would increase in length from two hours to three hours in order to get through the business. At the request of the Trust Board of Directors the Quality Committee reviewed concerns about the implementation of the Restraint Policy. Staff had been concerned about the risk they are exposed to in restraining people. The Restraint Policy was approved and the Committee had requested assurance that a risk assessment would be completed and that restraint would be included within the Safeguarding Reports. The Quality Committee noted that the RCAP was evolving into the RCAP 3 but still required review. Therefore the Extraordinary Quality Committee would remain in place, alternating with Trust Board of Directors Meetings. This would maintain monthly review of the RCAP by one of the three committees. The next Extraordinary Quality Meeting was due to be on 8 December 2016. However, this now clashes with the Westminster Briefing on the Freedom to Speak Up and also with the next CQC Visit to the Trust. Therefore, the Committee date has changed to 14 December 2016. The Trust Board of Directors took assurance from the two Quality Committee Assurance Reports and noted the Minutes of 24 August 2016 for information.

19.0 Audit & Assurance Committee Assurance Report

13 October 2016 Audit & Assurance Committee

24 August 2016

19.1 19.2

PL presented the Audit and Assurance Committee Assurance Report of 13 October 2016 and provided the Minutes of the Audit and Assurance Committee on 24 August 2016 for information. PL noted the work undertaken with regard to understanding licence requirements in organisation. FG and team have been assisting with this.


Page 19 of 19

19.3 19.4 19.5 19.6

Major work completed on prioritising the risks associated and putting a regime in place. The Committee finalised the revision to the Internal Audit Plan for the current year. This had to be redesigned to accommodate the structure provided by Internal Audit and to fit into the original financial envelope. PL advised that as it is the final year the PwC would provide external auditing of contracts there is a meeting next week of a Sub Group of Governors to commence the re-tendering for the external auditing contract. PL advised that there has been a callout for interest in the region for Audit Committee Chairs to get together to share good practice. The Trust has put forward that it would be interested and is waiting to see if anything develops from that. The Trust Board of Directors took assurance from the Audit and Assurance Committee Assurance Report and noted the Minutes of 24 August 2016 for information.

20.0 Any Other Business

Identification of New Risks (Incl. Health & Safety)


20.1 20.2 20.3

No further business was discussed. No new risks were identified. No new legislation was identified.

Signed: (Chair)

Dated:


Trust Public Board of Directors Meeting – 26 January 2017 Page 1 of 2


Date Thursday 26 January 2017 Time 10.00



Members:

Mrs H Strawbridge OBE (HS), Mr K Wenman (KW), Mr T Fox (TF), Mr H Hood (HH) Mrs V James (VJ), Mr P Love (PL), Dr I Reynolds (IR), Mr F Gillen (FG), Mrs J Kingston (JK), Dr A Smith (AGS), Mrs J Winslade (JW), Mrs E Wood (EW) Ms G Bragg (GB)

Non Members:

Mr M McAuley (MM), Lord P Tyler (PT), Ms L Bowden (LB), Mr N Le Chevalier (NLC) Mr A South (AS)


Administration Mrs J Smalley (JS)

Opening business







6 Questions from the Public Verbal HS

7 Minutes of Previous Meeting

24 November 2016 & 29 September 2016 Paper 1 HS


Trust Public Board of Directors Meeting – 26 January 2017 Page 2 of 2





12 Health and Safety Report Paper 6 JW


14 Data Quality Report Paper 8 FG

15 Violence and Aggression Deep Dive Paper 9 JW

Items for approval

16 Health and Safety Strategy Paper 10 JW


17

Extraordinary Quality Committee Assurance Report

Wednesday 14 December 2016

Extraordinary Quality Committee Minutes

Wednesday 24 August 2016

Paper 11 VJ

18

Audit Committee Assurance Report

Thursday 12 January 2017

Audit Committee Minutes

Thursday 13 October 2016

Paper 12 PL

Closing business

19

Any Other Business



Verbal HS

Trust Public Board of Directors Meeting 26 January 2017

Page 1 of 17

Minutes Trust Public Board of Directors Meeting Thursday 26 January 2017, 10.00 hours Boardroom, Trust Headquarters, Abbey Court, Eagle Way, Exeter EX2 7HY Chair Mrs H Strawbridge OBE - Chairman Administration Mrs J Smalley – EA & Business Manager to Chairman and Chief Executive

Members: Mrs H Strawbridge OBE HS Chairman Mr K Wenman KW Chief Executive Mr P Love PL Non-Executive Director Mr T Fox TF Non-Executive Director Mr H Hood HH Non-Executive Director Mrs V James VJ Non-Executive Director Dr I Reynolds IR Non-Executive Director Mrs G Bragg GB Non-Executive Director Mrs J Kingston JK Deputy Chief Executive/Executive Director of

Finance Mr F Gillen FG Executive Director of IM&T Dr A Smith AGS Executive Medical Director Mrs J Winslade JW Executive Director of Nursing and Governance Mrs E Wood EW Executive Director of HR & OD Non Members: Mrs L Bowden LB Acting Head of Marketing, PR and Communications Mr N Le Chevalier NLC Director of Operations Mr M McAuley MM Trust Secretary Lord P Tyler PT Adviser to the Trust Board Mr C Nelson CN Joint Branch-Secretary, Unison


Page 2 of 17



1.1 HS welcomed everyone to the meeting and thanked them for attending.

2.0 Declarations of Conflict of Interest

2.1 No declarations of interest were declared.

3.0 Patient Story

3.1 3.2 3.3 3.4 3.5 3.6

HS welcomed Mr Pike and his son Dr Pike to the meeting to talk about their experience of the service on 11 June 2016. Mrs Pike, who had Alzheimers since 2010 and had been in gradual health decline, was being taken for her bath by Mr Pike. Mrs Pike had cried out and then fallen backwards. Mr Pike initially thought she had fainted but quickly realized that it was something more serious. She was not fully conscious but was able to communicate with him. He dialed 999 at 22:10 hours. The 999 call was triaged and assigned an Amber response category, based on the patient being unconscious and breathing. Mr Pike dialed 999 again approximately 20 minutes later. He advised the Call Adviser that his wife was no longer breathing. Mr Pike reported that the Call Adviser was excellent and stayed on the line instructing Mr Pike in how to do CPR and he did as instructed. This call was triaged as a Red category and the Area Dispatcher identified and dispatched appropriate ambulance resources. A volunteer Community First Responder was mobilized at 22:34 hours, a double crewed ambulance (DCA) was allocated at 22:36 hours, a HEMs team, consisting of a Critical Care Paramedic and a Paramedic in the air ambulance were dispatched at 22:37 hours. The Dispatcher also issued a general broadcast to all crews in the area of the incident. Following the general broadcast a DCA closest to the scene was allocated to the incident. Mr Pike advised that they live approximately 10 miles from Bristol and the same distance from Bath. To receive an ambulance within 8 minutes is not realistic. The DCA arrived 20 minutes after the second 999 call. From the initial call the time taken to arrive was 40 minutes and 20 seconds. Life Support resuscitative measures were given for 44 minutes before these


Page 3 of 17

3.7 3.8 3.9 3.10 3.11

were halted and Mrs Pike was recognized as deceased. Mrs Pike’s son, Dr Shaun Pike had arrived during the night and both he and Mr Pike gave thanks to all who did respond and for their professionalism. Dr Pike advised that one of the crews was still with his father, providing aftercare, when he arrived and they were both grateful for this. Mr Pike asked that a different term be given for this item on the Agenda. It should be Patient Experience not Patient Story. ACTION: JW to change the item to Patient Experience for future Trust Board Meetings. Mr Pike noted that the first Call Handler was on probation. Mr Pike was impressed that this had already been picked up prior to him initiating contact with the Trust and an investigation was underway. Mr Pike commended the work undertaken by Caroline Tonks (CT), Investigating Officer. It had been recognized that the first Call Adviser should have stayed on the line. JW advised that during a probationary period there may be adverse audits and incidents are investigated. ACTION: JW to feedback thanks to CT. HS and KW thanked Mr Pike and Dr Pike for attending and providing their feedback. The Trust has taken the learning from this incident. The Trust Board of Directors reviewed the Trust Investigation Findings and took assurance from these.

JW JW


4.1 4.2

HS reported that the Trust is managing well with winter pressures. The National Audit Office Report was released today and this documents the pressures on the ambulance services. HS reported that the Trust is in the process of electing new members of the Council of Governors to replace those completing their three year term. In previous years Governors were elected at the same time. This year the Trust has introduced a system where Governors will be elected for one, two or three years so that in the future they will not all need to be elected at the same time. This should protect some continuity with the Council of Governors. The Trust has already reappointed eight because within their areas there were not enough put forward to necessitate re-election so they would be automatically re-elected. Adrian Rutter has put himself forward as Lead Governor and the Deputy


Page 4 of 17

4.3

Lead Governor will remain. There is an Open Day for new Governors during the first week in March 2017.


5.1 5.2 5.3 5.4

Band 6 Paramedic Update KW reported that the Band 6 is progressing well. EW and team are working with Unions. EW and KW have been involved nationally to ensure there is a consistent approach to how this would be applied. There has been no information on the funding from NHS England yet. KW has approached NHS Improvement with regard to Ambulance Trusts receiving the back pay by 7 February 2017 otherwise end of year positions would need to be reviewed. The month 10 ledger closes on 9 February 2017, if the funding is not received the Trust could have a deficit forecast. Pay is being backdated to 1 September 2017. There is work to be completed on the second stage of the job description regarding skills and knowledge for paramedics as there would be an expectation this would meet the Urgent and Emergency Care Review standards. Ambulance Response Programme (ARP) Update KW advised that the Trust was not advised that there would be media coverage on ARP. The Trust had received a letter from NHS England asking the Trust to continue under the pilot principles whilst they are waiting for an understanding of what the new performance standards would be. Winter Pressures KW thanked staff for their support of the Trust over the Christmas and New Year period. Staff have worked amazingly hard at every level in the organisation.


6.1 There were no questions from the public.

7.0 Minutes of the Previous Meeting

24 November 2016

29 September 2016

7.1 The Trust Public Board of Directors Minutes of 24 November 2016 were


Page 5 of 17

7.2

reviewed and they would be amended to include that Tony Fox joined meeting for first hour. The Minutes were approved as a correct record of proceedings subject to this change. The Trust Public Board of Directors Minutes of 29 September 2016 had been amended to include changes received from JW at the previous meeting. The Trust Board of Directors approved the Minutes of 29 September 2016 as a correct record of proceedings.


8.1 The Action Point Register was updated and would be circulated.

9.0 Integrated Corporate Performance Report

9.1 9.2 9.3 9.4 9.5

KW presented the Integrated Corporate Performance Report (ICPR). Performance and review of Christmas KW advised there had been much greater interest in ambulance services nationally with regard to long delays experienced. ARP causing long delays had not necessarily been the case. There have been a combination of factors including resource levels, demand and handover delays. The Christmas Period had been challenging. Whilst the level of activity had been above 2% on the previous year there had been days when activity had been high with over 3,300 incidents on one day. Activity was always at 2,900-3,000 incidents and this had impacted on performance. Across December 2016 Category 1 had been at 69.7%. The Trust is just over 70% on Category 1 year to date. Core Cover over Christmas had been at 116%. There had been 16% more resources over the Christmas period. Incentives were paid. The Trust does have restricted annual leave for frontline staff over the Christmas period to enable the level of capacity provided. The Trust is reviewing activity day by day to forecast for Christmas 2017 to ensure cover is appropriate. Over New Year the Hear and Treat rates had been at 19%. See and Treat at 36% for New Year. The 111 had impacted by 28% on the 999 Service on New Year’s Eve. The impact would normally be around 10-12%. It was noted that the 111 impact was Trust wide and not just the impact from the 111 services that the Trust provides for Dorset and Cornwall, this includes impact from private 111 providers. There had


Page 6 of 17

9.6 9.7 9.8 9.9 9.10 9.11

been 150 hours lost on handover delays on New Year’s Eve. January 2017 Performance showed the Trust at 70% year to date which is on target for the year. Hear and Treat rates have remained the same at 14%. See and Treat is at 35% and See and Convey is at 45%. Activity has increased for the 111 services. Green Pilot The Trust has been approached by Dorset CCG asking whether the most expensive resource is deployed and whether a cheaper resource could be sent. The difficulty has always been that the Trust bases deployment on the information received from the caller whether they are a member of the public or a Health Care Professional. ARP is about sending the right resource at the right time. Dorset CCG is looking to withdraw funding on a cost per call basis to give to another provider or give back to the Trust for the right level of resource. This would be a more sophisticated model. Since April 2016 when the Green Pilot commenced there were 13,500 calls. Of those calls approximately 10 were identified as not requiring paramedic response when the call came in. Of the 13,500 calls 6,000 actually received a non-paramedic response. This could be improved upon but it is difficult with the triage calls. The cost variants between what the Trust would provide and what a private provider would provide is quite marginal. NLC advised there would be a full evaluation report of the Green Pilot at the end of March 2017. The jobs had been identified accurately. There is a small need to increase green vehicles in the East and West Divisions as there are some Patient Support Vehicles (PSVs) in Devon, Cornwall and Dorset but there are none in the North. St John crews have been brought in to augment the service and all 7 are fully utilised. Whether this should be extended has been reviewed and there is not a great need identified. If the Trust converted A&E vehicles to PSVs, the flexibility would be lost within the service. The Trust would need additional money to expand the PSV service; therefore this is not a cost saving method. The Trust is not looking to continue the trial beyond end of March 2017. Hospital handovers were discussed. KW reported that if you benchmark handover delays with difficulties experienced by other Ambulance Trusts this area is doing well. The issues for the Trust revolve around 4-5


Page 7 of 17

9.12 9.13 9.14 9.15 9.16 9.17

hospitals. The Trust has a good relationship with those Trusts. NLC advised that the Trust submits a national return to NHS England. In context this Trust loses 4,000 hours a month to handover delays and other Trusts experience up to 14,000 hours lost. HS had raised ambulance handover delays at the recent NHS Improvement Chairs Conference. HS would be attending the NHS Improvement Chairs Advisory Partnership Meeting on 30 January 2017 and would raise this again. ACTION: NLC to provide HS with further information on handover delays. Rota Review EW advised that the Rota Review showed more Emergency Care Assistants (ECAs) going forward in the North Division. There had been a spike in attrition plus an increase in the workforce. There had been a 12 month issue because of the volume. There will be 120 ECA vacancies next year and the plan is that it will take time to even out. It was noted that the trajectory continues to be reported to the Trust Board of Directors. UCS As noted above the 111 service had a busy Christmas Period. The 111 services that the Trust provides in Dorset and Cornwall performed well and managed to remain broadly in line with trajectories. There was nothing adverse to report on 111 progress. The recruitment programme is ongoing. The team is focusing on the level of competence for call answering in 111 and there have been improvements to this and action plans are in place. HS reminded the Non-Executive Directors that they should be visiting the 111 Hub. GB confirmed that she has a visit booked in mid-February 2017. JW advised that the Out of Hours Service for Dorset was good over the Christmas Period. Gloucester Out of Hours had been challenged over Christmas Eve and Christmas Day. The service had been supported by the Dorset team with managing the integrated queue. JW gave thanks to the UCS staff. PTS Performance in PTS is largely on plan. The new provider has been announced as EZec. EZec currently provide services in Dorset. EZec met with Trust PTS staff in Bristol on 23 January 2017. No formal meetings have taken place and Union recognition has not been

NLC


Page 8 of 17

9.18 9.19 9.20

discussed yet. The Trust is trying to retain as many staff as possible for vacancies in the Bristol area. CN reported that the unions are working with EZec and trying to make the transition as smooth as possible. Financials JK reported that the Trust is close to the Agency CAP year to date. There is only £1,000 difference. The Trust has not received feedback with regard to sessional GPs from NHS Improvement. ACTION: HS to raise again at the next Chairs Advisory Partnership at the end of January 2017.

HS


10.1 10.2 10.2.1 10.2.2 10.2.3 10.2.4 10.2.5

The Corporate Risk Registers were taken as read. JW highlighted the two new risks added. Deep Dives 5. Performance Targets for Purple and Red (ARP) JW advised performance targets would require review again in light of next steps for ARP and risks moving forward once national performance targets are confirmed. Controls are in place for the purple and red targets. NLC reported that there will be a deep dive into Category 1 delays of 16 minutes or more. 6. Deep Dive Commissioner Affordability JK reported that the review post contract but would remain high. The risk will reflect that when the March 2017 Budget is brought to the Trust Board of Directors. The risk score of 15 will be reviewed in March 2017. 7. Deep Dive Call Stacking JW reported that the Call Stacking Risk had remained the same since the last Trust Board Meeting. Issues remain within the Hubs. There are a number of actions to be achieved by April 2017 to mitigate the issues. 8. Deep Dive National Position on Paramedic Banding The risk score of 20 remains as funding is still awaited. 9. Deep Dive Service Line Financials (A&E) JK stated that from an in-year perspective there are no issues with the A&E budget. JK and HH would share the detail with the Finance and Committee (FIC) for continuity.


Page 9 of 17

10.2.6 10.2.7 10.2.8 10.2.9 10.2.10

10. Deep Dive Quality – Asbestos Management JW advised that Asbestos Management has been included in the Deep Dives as the management of Asbestos is a legal requirement. Controls are moderate and these will be reviewed by the Risk Assurance Group again to ensure the Trust delivers against the legislation. There is focus on contractor compliance and having policies and procedures in place to protect contractors entering Trust premises. It was noted that the Estates Strategy would be presented at the Confidential Trust Board of Directors Meeting today. JW confirmed that the Health and Safety Non-Executive Director Lead is VJ. VJ reported that the Quality Committee has reviewed estates and RCAP escalated and the level of governance was impressive. Two new compliance officers have just been employed. 11. Deep Dive Quality – Audit Compliance The Deep Dive provides a joint position on call audit compliance for 999 and 111 services. As noted previously this is not resourced. The Trust is now meeting and exceeding the internal target each month. Audits have increased since July 2016. Assurance is stronger and there are detailed plans for A&E and Urgent Care. There is a governance link to the NHS Quality Group. Joint levelling has been established with peer review across both service lines. Theming of reports in Urgent Care. The 999 service will start theming reports shortly. JW expects 111 call audits to hold and for 999 service call audits to improve over the next few months. JW confirmed that the CQC will visit regularly, informally and JW has updated them on the improvements and actions in place. PL asked if the Trust should be monitoring the licence target rather than the internal target. JW stated that the Trust has to be realistic and it is important to continue to make sure 111 meets the internal target for governance with a reasonable threshold for the services the Trust has. CQC will look at the Pathways licence and the progress made. One of the CQC Must Do Actions was to demonstrate an improvement since July 2016. A significant improvement has been made with the introduction of the internal target. JK reported that an internal business case has been shared with Dorset CCG and this will be shared with Kernow CCG. The business case seeks further investment for call auditing performance. JK will be discussing this with Paul Vater, Kernow CCG on 27 January 2017 and will continue to raise this with Commissioners. NLC stated that with the new rotas call answering should improve. A report on Call Audit


Page 10 of 17

10.3 10.4 10.5 10.6

Compliance in Urgent Care and the 999 Service would be submitted to the Quality Committee. ACTION: Quality Committee to review Call Audits. JW to action. Definition of Split Brain IT System was discussed. FG advised that Split Brain is where the Trust can split the Computer Aided Dispatch System if it went down in one area. Safeguarding referrals from the Electronic Patient Record were discussed. JW this is where there is a delay between the Electronic Care System (ECS) and the referrals arriving with the Safeguarding Team. There is a change that needs to happen to provide the assurance but this is currently unresolved. CN advised that his understanding from the assurance at the A&E Service Line Meeting is that they are being recovered every day and sent to Safeguarding, they are not being missed they are not receiving them quickly. There is a manual process undertaken every day to ensure they are all received. Work is ongoing with Clinical Audit in respect for providing information via the web portal. ECS was discussed and FG reported that there has been a situation at Weston Hospital where there have been difficulties when diverting patients to Taunton and Somerset Hospital or to Bristol. The team is working with Weston Hospital. The Trust Board of Directors took assurance from the Board Assurance Framework and Risk Register.

JW

11.0 Patient Safety and Experience Report

11.1 11.2 11.3

JW presented the Patient Safety and Experience Report, 1 November 2016 to 31 December 2016. JW reported that with regard to 111 incidents the Trust achieved the trajectory to have a rolling number reported each month. This has now reduced the backlog to a much improved position. JW reported that there is a theme throughout the report about delays and access in waiting. There has been an increase in the numbers of adverse incidents, serious incidents and complaints related to delays. The spectrum from patient experience is that where there is no harm but the delay impacted the patient personally through to harm. The report demonstrates this rise.


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11.4 11.5 11.6 11.7 11.8 11.9 11.10

The Quality Development Forum and Learning From Experience Group have now merged to become one forum chaired by Sally Arnold-Jones (SAJ), Clinical Development Manager. The new forum has good representation across the Trust. JW and SAJ have revised the learning process. GB noted that ARP allows the Trust to target serious cases and asked if there was any analysis undertaken with regard to these complaints to see if they relate to delays by seriousness of incident and where there has been a drop in the top level of incident. JW reported that all complaints are graded from 1-3. Some delay serious incidents would related to patients at the top spectrum of serious illness. If the delay is caused following triage which did not result in the right response or there was a delay in resource to get to the patient, there are a multitude of reasons for delays, the team review staffing, resourcing and other areas and these are all included in the incident reports on an analytical level. NLC advised that the team does not correlate categories to the complaints. ACTION: JW agreed to correlate the data for the Quality Committee. This will then provide assurance that C1 and C2 categories are not increasing. The Trust Board of Directors noted that HCP feedbacks had increased. JW reported that a number of these are from GPs. This is about jointly understanding the pressures on our systems. KW reported for assurance that there has been significant work with Working Time Solutions to work to build a rota to help with peaks and demand. HS stated it was encouraging that for the A&E Service Line there was only one investigation outstanding that was over 12 months ago. ACTION: JW to add the reason why it has taken so long for outstanding investigations to be closed to future reports. It was noted that for Urgent Care there were 77 issues being investigated after 12 months. JW stated that they would be low and negligible or would have gone through a different process. These should all be closed by the next report. The Trust Board of Directors took assurance from the Patient Safety and Experience Report November 2016 to December 2016 and noted that the Quality Committee would receive a report showing the correlation of categories of complaints and that reasons would be provided in future reports as to why investigations are outstanding over 12 months.

JW JW


Page 12 of 17

12.0 Health Safety and Security Report

12.1 12.2 12.3 12.4 12.5 12.6

JW presented the Health, safety and security report for the Trust Board of Directors to take assurance that the Trust is compliant. JW reported that the work place assessments and risk assessments process has changed and the Trust was a year behind. JW advised that the expectation is for completion of all of the previous year assessments by Quarter One of 2017/18. The team is making good progress. There has been improved communication and processes between the Health and Safety Representatives, Infection Control and Union Representatives. Good feedback has been received from the Unions and Operations Managers. CN confirmed that there has been improved focus on Health, Safety and Security, with roadshows for awareness in Health and Safety all planned. New representatives are being trained. CN noted that feedback from station is being dealt with more visually. RIDDOR was discussed and TF noted first amber of 25% of incidents not reported on time. TF asked if this was a serious risk with the Health and Safety Executive. JW advised that the Health, Safety and Security Manager is working on this with operations to make improvements. The reporting is evolving. JW highlighted Objective 5, Develop a proportionate health and safety system to allow for the simplification of the management of risks encouraging a greater ownership of health and safety, enabling the formation of a positive health and safety culture across the organization. JW reported that there will be increased focus on accidents to staff. There has been focus on violence and aggression but there is a need for improvements to be made to prevent accidents whilst moving and handling patients in their homes. JW will be taking this back to the next Health and Safety Committee to get more assurance as there is more that can be achieved. ACTION: JW to raise accidents to staff whilst moving and handling patients in their homes to the Health and Safety Committee and seek assurance that improvements can be made. Site specific senior responsible officers was discussed. JW advised that there would be designated staff on stations responsible for Health and Safety and Estates issues. This had been agreed by the A&E Service Line and conference call with Operations Managers.

JW


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12.7 12.8 12.9 12.10 12.11

JW reported that the Violence and Aggression Deep Dive undertaken related to urban areas, mental health needs, alcohol abuse, patients with dementia. JW noted that results had shown that the Hub staff do not report verbal abuse much and are under reporting. Most of the verbal abuse incidents are reported by frontline staff. Hub staff received verbal abuse and this is normalized. Hub staff are being encouraged to report when verbal abuse takes place. It was agreed that more could be done to help staff. JW advised that the team is liaising with the Design Team about producing Zero Tolerance Posters. HS asked if anything could be linked to the Staying Well Service. KW advised that it would help those referred or those who have been a victim of violence and aggression. This is a national problem which should have national focus. JW advised there is a national group for Health and Safety Managers. It might be useful to look at the picture there. ACTION: JW to ask Anne Payne, Health, Safety and Security Manager to take to Violence and Aggression to the national group for future discussion and review. VJ asked if there is in the context of physical violence, any consideration of gender, mixed gender or single sex crews. This could link with the BME agenda. ACTION: JW to provide information of whether physical violence is gender specific. The Trust Board of Directors took assurance from the Health, Safety and Security Report.

JW JW


13.1 13.2 13.3

LB provided the Communications update to provide the Board with assurance on communication activities since the last Trust Board of Directors Meeting. LB drew attention the BBC Ambulance Day, 30 November 2016, which provided the public with key messages about resourcing and the challenges the ambulance service is faced with. LB reported that with recent coverage since the ambulance day there was a sense of better public understanding. Journalists had been replaying messages that the ambulance service does not have a finite amount of resources.


Page 14 of 17

13.4 The Trust Board of Directors took assurance from the Communications Update.

14.0 Data Quality Report

14.1 14.2 14.3 14.4 14.5 14.6 14.7

FG presented the Data Quality Report which provides the Trust Board of Directors with assurance from the on-going Trust activities in respect to Data Quality and the Information Assurance Steering Group. FG reported there has been work around ARP Phase 2 and call handling in the Hub. The Trust is expecting to receive new Ambulance Clinical Quality Indicator guidance in early 2017. CN left the meeting. FG advised that the team is working through Red 19 Transport figures from June to September 2016. The report should be available in February 2017. ECS rollout is now complete. The Clinical Audit Team has provided detail on activities they have conducted on the ECS data quality. Review of 30 records has taken place. Levels of correlation are in the 95th percentile. The Trust Board of Directors took assurance from the Data Quality Report.

15.0 Health and Safety Strategy

15.1 15.2 15.3

JW presented the Health and Safety Strategy. JW confirmed that this had been approved by the Health and Safety Committee. Amendments had been agreed on structural issues. JW would be working with EW to complete a Training Needs Analysis (TNA) for Health and Safety. JW confirmed that two members of the Trust Board of Directors have not done the IOSH Health and Safety Training. ACTION: MM to action. PL noted that within the KPI section it states Manual Handing e-Learning Annual, all staff to complete training. PL questioned whether this should be all staff. JW confirmed that it is a statutory requirement that all staff have this. PL noted that the aim is for 90% but with every member of staff being updated every two years. HS stated this is a review of the

MM


Page 15 of 17

15.4

Strategy rather than the Action Plan. All staff should have access to training and then this should be set as a KPI for the objective for the year. ACTION: JW to discuss manual handling with Adrian South, Deputy Clinical Director. The Trust Board of Directors approved the Health and Safety Strategy.

JW

16.0 Extraordinary Quality Committee Assurance Report

14 December 2016 Extraordinary Quality Committee Minutes

24 August 2916

16.1 16.2 16.2.1 16.2.2 16.2.3 16.2.4 16.2.5 16.2.6 16.2.7 16.2.8 16.2.9

VJ presented the Extraordinary Quality Committee Assurance Report covering the meeting on 14 December 2016. Highlights included the following: CQC visit and receiving early feedback from the Executive Team and officers involved. Freedom to Speak Up Event attended by VJ. ACTION: VJ to provide the Trust Board of Directors with a brief on the Freedom to Speak Up Event at the February 2017 Trust Board Seminar. MM to add to the Agenda for February 2017. 111 call audits. Focus on warm transfers and call answering. Weekend pressures building up on staff issues. Module 2 training. Seeking further assurance with RCAP on those issues and achieving full establishment of call advisers and the delayed implementation of version 12 of Pathways. JW confirmed that this was completed in January 2017. The Split Brain System had been discussed. FG confirmed that the CAD had been very stable since this was implemented in the North and the only test would be in ‘live’. Next meeting 9 February 2017, duration of meeting has been increased to three hours.

VJ


Page 16 of 17

16.3

Extraordinary Quality Committee Minutes

24 August 2016

Quality Committee Minutes of 24 August 2016 were noted for information.

17.0 Audit and Assurance Committee Assurance Report

12 January 2017 Audit and Assurance Committee

13 October 2016

17.1 17.2 17.3

PL presented the Audit & Assurance Committee Assurance Report. The internal audit programme, had been received 10 months into the year. This had been delayed and Internal Audit did raise that they had to renegotiate the plan and that had contributed to the delay. The Committee will be monitoring this for the March 2017 meeting. PL reported that he would be presenting a document on what sort of internal audit service the Trust would be looking for in the future. This would take into account the effectiveness and value for money. ACTION: JK, MM and PL to meet in February 2017 with a view to presenting at the Trust Board Seminar on 23 February 2017 on the internal audit service to lead through to discussion at the next Committee. Audit and Assurance Committee Minutes

13 October 2016

The Audit and Assurance Committee Minutes of 13 October 2016 were noted for information.

PL

18.0 Any Other Business

Identification of New Risks (Incl. Health & Safety)


18.1 18.2 18.3

No further business was discussed. There were no new risks identified. There was no new legislation identified.

Signed: (Chair)


Page 17 of 17

Dated:


Trust Public Board of Directors Meeting – 30 March 2017 Page 1 of 2

Trust Public Board of Directors Meeting Agenda

Date Thursday 30 March 2017 Time 10.00 - 1400

Venue Meeting Room A/B, Ground Floor, St James A, Bristol, BS32 4QJ

Chair Mr T Fox (TF), Chairman

Members:

Mr T Fox (TF), Mr K Wenman (KW), Mrs V James (VJ), Mr H Hood (HH), Mr P Love (PL), Dr I Reynolds (IR), Mr F Gillen (FG), Mrs J Kingston (JK), Dr A Smith (AGS), Mrs J Winslade (JW), Mrs E Wood (EW) Ms G Bragg (GB)

Non Members:

Mr M McAuley (MM), Lord P Tyler (PT), Ms L Bowden (LB), Mr N Le Chevalier (NLC) Mr A South (AS), Ms J Hodgman (JH)


Minutes Mrs J Smalley (JS)

Opening business

No Topic Purpose Format Lead Timing

1 Welcome, Introduction & Apologies Information Verbal TF 10.00

2 Declarations of Interest Approval Verbal MM 10.05

3 A Patient’s Experience Information Verbal VJ 10.05

4 Report from the Chairman Information Verbal TF 10.25

5 Report from the Chief Executive Information Verbal KW 10.30

6 Questions from the Public Information Verbal TF 10.35

7 Minutes of Previous Meeting – 26 January 2017 Approval Paper 1 MM 10.40

8 Action Point Register Approval Paper 2 MM 10.45

9 Communications Update Information Paper 3 LB 10.50

Trust Public Board of Directors Meeting – 30 March 2017 Page 2 of 2

Quality and Patient Safety

10 Patient Safety and Experience Assurance Paper 4 JW 1100

11 Quality Strategy Approval Paper 5 JW 1110

12 Report from the Quality Committee Assurance Paper 6 VJ 1120

People and Workforce

13 Health, Safety and Security Report Assurance Paper 7 JW 1130

14 Ambulance Sector - Strengthening Racial Equality Assurance Paper 8 EW 1140

Performance and Finance

15 Integrated Corporate Performance Report Assurance Paper 9 KW 1150

16 Trust Financial Position Assurance Verbal JK 1200

Lunch 1210 – 1240 Regulation

17 NHSI Activity report Assurance Paper 10 JK 1240

Internal Control and Governance

18 Risk Register and Board Assurance Framework Assurance Paper 11 JW 1250

19 Terms of Reference: Executive Directors and Board Committee

Approval Paper 12 MM 1300

20 Report from the Audit & Assurance Committee

Assurance Paper 13 PL 1310

21 Corporate Governance Statement Approval Paper 14 MM 1320

22 Third Party Body Schedule Assurance Paper 15 JW 1330

23 Annual Declarations Assurance Paper 16 MM 1340

Policies and Strategies

24 Procurement Policy Approval Paper 17 JK 1350

Closing business

25

Any Other Business

Identification of New Risks (incl. Health & Safety) and New Legislation

Information - TF 1400



Date: 17 May 2017

Paper Title: Trust Membership & Engagement

Prepared by: Helen Braid, Committees & Membership Manager

Presented by: Robert Day, Public Governor for Dorset

Action: Decision

Recommendation:

The Council of Governors is recommended to establish a Task & Finish Group to develop an inclusive Governor engagement programme and report its proposals back to the Council.

Executive Summary:

This report provides an overview of the Trust’s public membership and seeks the establishment of a Task & Finish Group. The key points include:

The Trust’s public membership is broadly representative of the

Trust’s operating area, meeting NHS Improvements requirements.

Areas of geographical under-representation remain in

constituencies in the north of the region.

The Trust’s membership data contains a range of socio-economic

categorisations which can assist Governors in applying the most

appropriate methods of engagement to particular social groupings.

The Task & Finish Group will have the remit of reviewing

membership data and engagements methods used by other Trusts

to develop an engagement programme which can reach a wide

range of groupings within the Trust’s membership and wider public.


Trust Membership & Engagement

1. Background 1.1 The Council of Governors has the role of:

Developing and recruiting a membership which is representative of those eligible to become a member.

Representing the interests of the Members and the wider public. 1.2 This report provides the Council with an overview of the Trust’s membership and how it is

meeting the requirements of an NHS Foundation Trust Membership. 1.3 The report also considers how Governors might engage with the membership and the

wider public, highlighting in particular, the way in which the Trust’s membership data can assist in deciding the most appropriate methods of engagement.

2. A Representative Membership 2.1 The Trust measures how representative its membership is through the social

demographics prescribed by NHS Improvement and also by geographical constituency. Annex A sets out the socio-economic breakdown of the Trust’s Membership whilst the table below sets out the geographical spread.

2.2 Key points to highlight are:

The Trust’s membership is broadly representative of the region.

The main areas of under-representation include those under the age of 22 and males.

Geographically, membership is under-representative of the region in the areas of Wiltshire, Gloucestershire, Bristol and B&NES.

Constituency % of Population % of Trust Membership

Bristol and B&NES 11.56 8.73

Cornwall 10.09 21.73

Devon 21.30 22.35

Dorset 13.98 11.05

Gloucestershire 16.29 10.43

Isles of Scilly 0.04 0.53

Somerset 13.83 17.86

Wiltshire & Swindon 12.91 7.32


3. Representing the Interests of Members and Wider Public

3.1 In an area as large and diverse as the South West, there have always been challenges for Governors in engaging with Members and the public. Methods such as attendance at community events, county shows and on-line surveys have all been undertaken. In respect of face to face engagement there has been concern, that the majority of this activity takes place at County shows, which not capture the views of a wide cross-section of the public.

3.2 When considering engagement methods it is suggested that a starting point would to

establish which methods are likely to be successful with different section of the membership, as one size does not fit all. The way in which the Trust stores its membership data utilizes the “Acorn” marketing methodology which categorises individuals into groupings eg:

24% of the Trust’s membership (26% of the region) is classified as “Affluent Achievers”.

23% of the Trust’s membership (22% of the region) is classified “Financially Stretched”.

3.3 The Acorn methodology provides an overview of these groups identifying issues such as

their likely health issues; where and how they spend their leisure time; where they do their grocery shopping and how likely they are to respond to social or electronic media. All of this information can be used by Governors when deciding which engagement methods to utilize in a particular area or on a particular subject.

3.4 In addition, research undertaken by Membership Engagement Services and Monitor has

highlighted the ways in which other Trusts engage with their membership and the public. These include:

Visiting town centre shopping areas;

Speaking to visitors to supermarkets;

Using other NHS sites such as GP surgeries or hospitals;

Linking with events provided by other Foundation Trusts or Healthwatch;

Utilising social media, especially for younger groups. 3.5 It is proposed that a review of the membership data is undertaken and proposals made for

an engagement programme which has a broader approach than attendance at county shows to ensure that a cross-section of views are obtained from the Trust’s membership and the wider public.

4. Recommendation 4.1 The Council of Governors is recommended to establish a Task & Finish Group to develop

an inclusive Governor engagement programme and report its proposals back to the Council.


Annex A Trust Public Membership as at 30 April 2017

Public % of

Membership Base % of Area

Age 14,036 100.00 5,496,908 100.00

0-16 1 0.01 1,026,795 18.68

17-21 210 1.50 328,013 5.97

22+ 12,936 92.16 4,142,100 75.35

Not stated 889 6.33 0 0.00

Age 22+ 12,936 92.16 4,142,100 75.35

22-29 1,864 13.28 533,143 9.70

30-39 1,610 11.47 624,329 11.36

40-49 1,953 13.91 709,309 12.90

50-59 2,197 15.65 753,774 13.71

60-74 3,353 23.89 972,490 17.69

75+ 1,959 13.96 549,055 9.99

Gender 14,036 100.00 5,496,906 100.00

Unspecified 26 0.19 0 0.00

Male 6,062 43.19 2,703,076 49.17

Female 7,948 56.63 2,793,830 50.83

Ethnicity 14,036 100.00 5,288,935 100.00

Asian 116 0.83 105,537 2.00

Black 92 0.66 49,476 0.94

Mixed 92 0.66 71,884 1.36

Other 1,255 8.94 15,609 0.30

White 12,481 88.92 5,046,429 95.41

Acorn Socio-Economic Category 14,036 100.00 5,496,906 100.00

Affluent Achievers [1] 3,432 24.45 1,462,219 26.60

Rising Prosperity [2] 584 4.16 319,093 5.80

Comfortable Communities [3] 5,005 35.66 1,813,414 32.99

Financially Stretched [4] 3,275 23.33 1,203,669 21.90

Urban Adversity [5] 1,623 11.56 627,238 11.41

Not Private Households [6] 112 0.80 71,273 1.30

Not available [NA] 5 0.04 0 0.00

ONS/Monitor Classifications 14,001 99.75 1,588,702 100.00

AB 3,718 26.49 363,132 22.86

C1 4,052 28.87 489,567 30.82

C2 3,055 21.77 367,301 23.12

DE 3,176 22.63 368,702 23.21

Total membership 14,036 100.00 5,496,908 100.00


Page 1 of 1


Date: 17 May 2017

Paper Title: Council of Governors – Terms of Reference


Presented by: Marty McAuley, Trust Secretary

Action: Approval

Recommendation: The Council of Governors is asked to approve the Terms of Reference for the Council of Governors.

Executive Summary:

All decision making bodies should have a Terms of Reference document that describes its purpose, scope and authority as well as how it organised, its membership and when it meets. For the Council of Governors all of the above information is contained within the NHS 2006 Act, the Health & Social Care Act 2012 and the Trust Constitution. There is not, however, a single document which incorporates all of the information. Accordingly, Terms of Reference for the Council have been drafted. The attached draft contains all duties and responsibilities contained within the documents referred to above. Accordingly, all duties and responsibilities are either a statutory requirement or have been previously agreed by the Trust. Should any amendments be made to the statutory duties or those set out within the Constitution, then the Terms of Reference will be reviewed. In any event, the Terms of Reference will be reviewed on an annual basis as part of the Council of Governors self-assessment process.

Council of Governors

Terms of Reference

Version 1

Author Trust Secretary

Approved By Council of Governors

Approved Date

Date Issued

Review Date

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1. Constitution and Authority

1.1 Established in accordance with the NHS Act 2006 and the Constitution of the NHS

Foundation Trust.

1.2 The Council of Governors is authorised by the Board to investigate any activity within its terms of reference and is empowered to request any Non-Executive or Executive Director employed by the Trust to attend meetings for the purpose of providing advice, clarification, recommendation or explanation in respect of any matter that falls within its responsibilities.

1.3 As necessary, the Chairman may also require the production of any document if it

relates to the business of the Council of Governors. 1.4 The Council is required to operate within the Constitution of the NHS Foundation

Trust.

2. Roles and Responsibilities 2.1 To appoint or remove the Chairman and the other Non-Executive Directors. (The

removal of a Non-Executive Director requires the approval of three-quarters of the members of the Council of Governors).

2.2 To decide the remuneration and allowances, and the other terms and conditions of

office, of the Non-Executive Directors. 2.3 To appoint or remove the Auditor. 2.4 To be presented with the approved Annual Accounts, any report of the Auditor on

them and the Annual Report. 2.5 To consider disputes as to membership referred to it. 2.6 To consider resolutions to remove a Governor. 2.7 Approve (by a majority of the members of the Council of Governors present and

voting) an appointment (by the Non-Executive Directors) of the Chief Executive (and Accounting Officer) other than the initial Chief Executive.

2.8 Give the views of the Council of Governors to the Directors for the purposes of the

preparation (by the Directors) of the Forward Plan in respect of each Financial Year to be given to Monitor.

2.9 Consider the approved Annual Accounts, any report of the Auditor on them and the

Annual Report. 2.10 Respond as appropriate when consulted by the Directors.

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3. Specific Functions and Duties 3.1 Providing views to the Board of Directors on the strategic direction of the Trust and

targets for the Trust's performance and in monitoring the Trust's performance in terms of achieving those strategic aims and targets which have been set.

3.2 Developing and recruiting a representative membership. 3.3 Representing the interests of the Members of the Trust as a whole and the interests

of the public. 3.4 Holding the Non-Executive Directors, individually and collectively, to account for the

performance of the Board of Directors. 3.5 Approving significant transactions. 3.6 Approving any application by the Trust to enter into a merger, acquisition,

separation or dissolution. 3.7 Deciding whether the Trust’s non-NHS work would significantly interfere with its

principal purpose, which is to provide goods and services for the health service in England, or performing its other functions (see Chapter 11);

3.8 Approving amendments to the Trust’s Constitution. 3.9 Preparing and from time to time reviewing the membership strategy of the Trust and

its policy for the composition of the Council of Governors and the Non-Executive Directors.

3.10 Responding to any matter as appropriate when consulted by the Board of Directors;

and 3.11 Notwithstanding the provisions above, the Governors may exercise other functions

at the request of the Board of Directors.

4. Membership 4.1 The membership of the Council of Governors consists of:

o 19 Governors elected from the Public Constituencies o 6 Governors elected from the Staff Constituency o 1 Local Authority Governor; and o 7 Partnership Governors

4.2 The Chairman and Deputy Chairman of the Council shall be the Chairman and

Deputy Chairman of the NHS Foundation Trust. 4.3 If the Chairman or Deputy Chairman of the NHS Foundation Trust are not available,

another Non-Executive Director must chair the Council of Governors.

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5 Attendance

5.1 The Council of Governors has a number of regular attendees:

Chief Executive

Non-Executive Directors

Trust Secretary

Committee and Membership Manager

Committee and Membership Officer

5.2 The Council of Governors is empowered to request any Non-Executive or Executive Director employed by the Trust to attend meetings for the purpose of providing advice, clarification, recommendation or explanation in respect of any matter that falls within the responsibilities of the Council.

6. Governor Attendance Requirements 6.1 If a Governor fails to attend two or more consecutive meetings of the Council, his

tenure of office shall terminate at the following Council of Governors unless:

6.1.1 The Chair and Trust Secretary, in consultation with the Lead Governor and taking into consideration other Governor related activities he may have undertaken, are satisfied that the absence was due to a reasonable cause and he will be able to attend meetings of the Council of Governors again within such a period as is considered reasonable or,

6.1.2 at least 75% of the Council of Governors present vote in favour of the tenure

not being terminated at that meeting. 6.2 Notwithstanding the provisions of paragraph 5.2 above, if a Governor fails to attend

two out of three consecutive meetings of the Council of Governors and he has previously been the subject of a decision in his favour under paragraph 5.2 above, that Governor's tenure of office will be terminated immediately.

7. Frequency of Meetings 7.1 At least four meetings a year, including the Annual Members’ Meeting.

8. Quorum

8.1 One-third of the total number of Governors.

9. Administration

9.1 Meetings of the Council of Governors will be minuted by the Membership and

Committees Officer. 9.2 Annual cycle of business, record of actions, attendance and paper production to be

managed by the Trust Secretary.

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10. Reporting and Accountability 10.1 The Council of Governors is accountable to Trust Membership. 10.2 Following each meeting of the Council, an assurance report will be prepared by the

Chairman and Lead Governor for presentation at the next `Board meeting. 10.3 An Annual Report monitoring the effectiveness of the Council of Governors will be

prepared by the Chairman and Lead Governor for discussion. The agreed report will then be submitted to the Board for assurance.

11. Review 11.1 Terms of Reference to be reviewed annually as part of the self-assessment

process.


Page 1 of 4


Date: 17 May 2017

Paper Title: Remuneration & Recommendations Panel


Presented by: Marty McAuley, Trust Secretary

Action: Approval

Recommendation:


Agree the Terms of Reference for the Remuneration & Recommendations Panel

Agree the membership of the Remuneration & Recommendations Panel.

Note the work programme of the Remuneration & Recommendations Panel.

Executive Summary:

Following the changes in membership of the Council of Governors, three members of the Remuneration & Recommendations Panel have been lost, these being Paul Young, John Christensen and Alan Peak.

It is one of the duties of the Council of Governors to appoint members to the Panel. The report contains a proposed membership for the Panel which introduces new members, but also retains experience.

With the change in membership, the opportunity has been taken to encompass all of the duties of the Remuneration & Recommendations Panel into one Terms of Reference and this is presented for approval.

During 2017-18 the Panel will be required to consider re-appointments in respect of three Non-Executive Director positions, one of these being an annual re-appointment. Details of the work programme for the Panel is also provided for information.


Page 2 of 4

Remuneration & Recommendations Panel

1. Introduction 1.1 The Council of Governors has established a Remuneration & Recommendations Panel to

consider and make recommendations to the full Council in respect of the appointment and remuneration of the Chairman and Non-Executive Directors of the Trust.

1.2 The recent changes in membership of the Council of Governors has resulted in the

Remuneration & Recommendations Panel losing some of its existing membership. 1.3 The opportunity has also been taken to refresh the Terms of Reference of the Committee

and these are presented for approval.

2. Terms of Reference 2.1 The attached terms of reference are based upon the statutory duties of Governors in

respect of the appointment and remuneration of the Chairman and Non-Executive Directors, together with the requirements of the Trust Constitution.

2.2 The terms of reference set out the purpose, duties, membership and reporting

requirements for the Panel. 2.3 Should any amendments be made to the statutory duties or the Trust Constitution, then

the Terms of Reference will be reviewed. In any event, the Terms of Reference will be reviewed on an annual basis as part of the Remuneration & Recommendations Panel self-assessment process.

3. Appointments to the Remuneration & Recommendations Panel 3.1 The Council of Governors agrees appointments to the Panel. The required membership of

the Panel is as follows: Consideration of Chairman's Remuneration and/or Appointment of the Trust

Chairman A minimum of four Governors including at least one appointed, two public and one staff

Governor (selected by their peer Governors). Consideration of Non-Executive Director Remuneration and/or Appointment

The Trust Chairman plus a minimum of three Governors including at least one public, one staff and one appointed Governor (selected by their peer Governors).

3.2 In recent years the Panel’s membership has comprised more than the minimum required

to conduct its business. This has been helpful, given the challenges in convening meetings at a time convenient for all. It is proposed that this practice is continued.


Page 3 of 4

3.3 During 2016/17 the Panel membership was:

Trust Chairman

Adrian Rutter – Lead Governor and Public Governor, Devon

Dee Nix – Public Governor, Wiltshire & Swindon

Rae Care – Public Governor, Bristol & B&NES

Alan Peak – Staff Governor, A&E North

David Shephard – Staff Governor, A&E East

John Christensen – Appointed Governor, Air Ambulance Charities

Doug Hellier-Laing – Appointment Governor, Local Authorities

3.4 Neither Alan Peak, John Christensen or Paul Young have taken up a further term of office as a Trust Governor. This provides an opportunity to refresh the membership of the Panel whilst also retaining experience.

3.5 Proposed Panel membership going forward is the Trust Chairman and the following:

Existing Member plus New Member

Public Governors

Adrian Rutter – Lead Governor and Devon

Dee Nix – Wiltshire & Swindon

Rae Care – Bristol & B&NES

Simon Michell – Somerset

Staff Governors

David Shephard – A&E Dorset & Somerset

Neil Hunt – Admin & Support Services

Appointed Governors

Doug Hellier-Laing – Appointment Governor, Local Authorities

Bill Sivewright – Air Ambulance Charities

4. Work Programme of the Remuneration & Recommendations Panel 4.1 During 2017/18 Panel will be required to:

Consider future succession planning arrangements.

Consider the annual re-appointment of Gail Bragg.

Consider the re-appointment of Paul Love and Dr Ian Reynolds whose terms of office end in July 2018, as if re-appointments are not to be made then an appointment process will be required.

Undertake market testing of the current remuneration levels for Chairmen and Non-Executive Directors in the NHS.

Undertake an effectiveness self-assessment.


Page 4 of 4

5. Recommendation 5.1 The Council of Governors is asked to:

Agree the Terms of Reference for the Remuneration & Recommendations Panel.

Agree the membership of the Remuneration & Recommendations Panel.

Note the work programme of the Remuneration & Recommendations Panel. Helen Braid Committees and Membership Manager

Remuneration &

Recommendations Panel

Terms of Reference

Version 1

Author Trust Secretary

Approved By Council of Governors

Approved Date

Date Issued

Review Date

of 4

1. Constitution and Authority

1.1 Established and approved by the Council of Governors in liaison with the Board of

Directors to consider and make recommendations to the full Council of Governors in respect of the appointment and remuneration of the Chairman and Non-Executive Directors.

1.2 The Panel derives its powers from the Council of Governors and has no executive

powers, other than those specifically delegated in these Terms of Reference. The Panel is authorised to:

Seek any information it requires from any employee of the NHS Foundation Trust in order to perform its duties.

Obtain, at the Trust’s expense, outside legal or other professional advice on any matter within its terms of reference.

Call any employee to be questioned at a meeting of the Panel as and when required.

2. Purpose 2.1 Consider and make recommendations for the remuneration, appointments,

allowances and terms and conditions for the Chairman and Non-Executive Directors of the NHS Foundation Trust.

3. Duties 3.1 To consider the remuneration, appointments, allowances and terms and conditions

of the Chairman and Non-Executive Directors of the NHS Foundation Trust at a Remuneration and Recommendations Panel.

3.2 To undertake the shortlisting and interview of any future Chairman or Non-

Executive Directors of the NHS Foundation Trust in liaison with the Trust Secretary and to make recommendations to the full Council of Governors as appropriate

3.3 To assist the Council of Governors in these responsibilities the Panel shall:

(i) Determine and agree with the Council of Governors, in liaison with the Board of Directors, the framework, (ie these terms of reference), for the remuneration, appointments, allowances and terms and conditions of the NHS Foundation Trust’s Non-Executive Directors.

(ii) In determining such a framework, take into account all factors which it deems necessary. The objective of such a framework shall be to ensure that the Chairman and Non-Executive Directors of the NHS Foundation Trust are provided with appropriate incentives to retain and recruit high quality individuals, encourage enhanced performance and that they are, in a fair and responsible manner, rewarded for their individual contributions to the success of the Trust.

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(iii) Review the on-going appropriateness and relevance of the Remuneration and Recommendations Panel Terms of Reference.

(iv) Recommend the design of, determine targets for, and set upper limits of any performance related pay schemes where operated by the NHS Foundation Trust and recommend the total annual payments made under such schemes. Any performance related pay scheme should be aligned with the interests of the NHS Foundation Trust, patients and taxpayers and ensures that targets are challenging and contribute to the overall benefit of the organisation. Full disclosure will be made for any performance related pay and bonuses agreed by the Council of Governors.

(v) Ensure that contractual terms on termination, and any payments made, are fair to the individual, and the NHS Foundation Trust, aligned with the interests of the patients, that failure is not rewarded and that the duty to mitigate loss is fully recognised.

(vi) Within the terms of the agreed framework and in consultation with the Chairman and/or Chief Executive as appropriate, determine the total individual remuneration package of the Chairman and each Non-Executive Director including bonuses, incentive payments and other awards.

(vii) Recommend to the Council of Governors the policy for authorising claims for expenses from the Non-Executive Directors.

(viii) Be exclusively responsible for establishing the selection criteria, short listing, appointing and setting the terms of reference for any remuneration consultants who advise the Panel, which should be at least every three years or when considering making large changes: and to obtain reliable, up-to-date information about remuneration in other NHS Foundation Trusts.

(ix) Oversee any investigation of activities which are within its terms of reference.

4. Membership 4.1 Members of the Panel shall be appointed by the Council of Governors in

consultation with the Chairman of the Board of Directors and shall be made up of at least four members, including the Chairman of the NHS Foundation Trust and the majority of whom shall be Governors, and free from any conflict of interest.

4.2 Only members of the Panel have the right to attend Panel meetings. Other

individuals may be invited to attend for all or part of any meeting, as and when appropriate.

4.3 The Chairman of the Board of Directors shall not be permitted to attend Panel

meetings pertaining to his/her remuneration, and shall not receive minutes of such meetings.

4.4 Consideration of Chairman's Remuneration and/or Appointment of the Trust

Chairman - a Public Governor (casting vote) A minimum of four Governors including at least one appointed, two public, one staff and one appointed Governor (selected by their peer Governors).

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4.5 Consideration of Non-Executive Directors Remuneration and/or Appointment Chairman of the NHS Foundation Trust (casting vote) The Trust Chairman plus a minimum of three Governors including at least one public, one staff and one appointed Governor (selected by their peer Governors).

5 Attendance

5.1 The Panel is empowered to request attendance by any other individual acting in an advisory capacity to support the discussions of the Panel. Executive involvement may also be invited eg Chief Executive or Executive Director of Human Resources & Organisational Development.

6. Frequency of meetings 6.1 At least twice a year in order to discharge responsibilities or at such other times as

the Trust Secretary or Chairman of the Panel shall require.

7. Quorum

7.1 The quorum necessary for the transaction of business shall be three, including at

least one Public Governor and one Staff Governor.

8. Administration

8.1 The Remuneration & Recommendations Panel is minuted by the Membership &

Committees Officer. 8.2 Annual cycle of business, record of actions, attendance and paper production to be

managed by the Trust Secretary.

9. Reporting and Accountability 9.1 The Remuneration & Recommendations Panel is accountable to the Council of

Governors. 9.2 An Annual Report monitoring the effectiveness of the Remuneration &

Recommendations Panel will be prepared by the Chairman and Lead Governor for discussion. The agreed report will then be submitted to the Council of Governors for assurance.

10. Review 10.1 Terms of Reference to be reviewed annually as part of the Panel’s self-assessment

process.


Page 1 of 5


Date: 17 May 2017

Paper Title: Policy of Engagement: Board of Directors and the Council of Governors


Presented by: Helen Braid, Committees & Membership Manager

Action: Approval

Recommendation:


Approve the revised wording of the Policy of Engagement, Trust Constitution and Lead Governor Role & Responsibilities set out at Annex A and recommend approval to the Board of Directors; and

Take assurance from the governance arrangements outlined above to approve the required changes.

Executive Summary:

In July 2016 the Council of Governors and Board of Directors approved a Policy of Engagement which can be applied when the Council has concerns about the performance of the Board of Directors, compliance with the provider licence or other matters related to the overall wellbeing of the Trust. The Policy refers to concerns being escalated to a National Governors Panel. However, that Panel has now been disbanded. The report proposes amendments to the Policy, together with the Trust Constitution and Lead Governor Role & Responsibilities, which removes reference to the Panel and replaces it with NHS Improvement. No other changes to the Policy are proposed.


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Policy of Engagement: Board of Directors and the Council of Governors

1. Introduction 1.1 The NHS Foundation Trust Code of Governance requires the Council of Governors to

establish a Policy of Engagement with the Board of Directors which can be applied when the Council has concerns about the performance of the Board of Directors, compliance with the provider licence or other matters related to the overall wellbeing of the Trust.

1.2 In July 2016 the Council of Governors and Board of Directors approved the Policy of

Engagement. Since that time there has been a change in the arrangements provided by NHS Improvement to support Governors. The change has seen the disbanding of the National Panel to which issues could be escalated by the Council of Governors.

1.3 Reference to the Panel should therefore be removed from the following Trust documents:

Policy of Engagement: Board of Directors and the Council of Governors

Trust Constitution

Lead Governor Role & Responsibilities.

2. Approval of Amendments 2.1 The proposed amended wording of Policy, Constitution and Lead Governor role are at

Annex A for convenience rather than attaching each document in its entirety. 2.2 To amend the Constitution the Trust must gain approval for half of the members of the

Council of Governors who are present and voting at a Council meeting and half of the members of the Board of Directors present and voting at a Board meeting.

2.3 There would be no requirement to present the amendment to the next Annual Members’

Meeting as the proposed amendments do not amend the powers or duties of the Council of Governors, merely the body to which their concerns should be directed.

2.4 The Trust must, however, notify NHS Improvement of changes to the Constitution.


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3. Recommendation 3.1 The Council of Governors is asked to:

Approve the revised wording of the Policy of Engagement, Trust Constitution and Lead Governor Role & Responsibilities set out at Annex A and recommend approval to the Board of Directors; and

Take assurance from the governance arrangements outline above to approve the required changes.

Helen Braid Committees & Membership Manager


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Annex A Amendments

1. Policy of Engagement: Board of Directors and the Council of Governors

2. Scope 2.1 This policy:

sets out the roles and responsibilities of the Board of Directors and the Council of Governors and how the two bodies will interact with each other for the benefit of the Trust;

describes the formal and informal mechanisms by which Governors and Directors will interact and communicate with each other;

describes the methods by which Governors may engage when they have serious concerns about the performance of the Board of Directors, compliance with the Trust’s Provider Licence, or the welfare of the NHS Foundation Trust; including escalation to NHS Improvement (formerly known as Monitor) to which Governors may refer a question as to whether the Trust has failed or is failing to act in accordance with its Constitution.

3. Responsibilities - Lead Governor 3.30 Act as the point of contact between the Council of Governors and NHS

Improvement should the Council have serious concerns about the performance of the Board of Directors, compliance with the Trust’s Provider Licence, or the welfare of the NHS Foundation Trust and all other methods to resolve these concerns have failed.

4. Raising Serious Concerns Tier 5 4.7 If the matter is not resolved to the satisfaction of the Governor(s), the Trust

Secretary shall call an extraordinary meeting of the Council of Governors as soon as is reasonably practicable in accordance with the Council of Governors Standing Orders to consider the matter further. That meeting may resolve to take no further action or to consider referring the matter to NHS Improvement in accordance with Paragraph 16 of the Constitution. The extraordinary meeting of the Council of Governors will be minuted in order to record the outcome of the decision.

5. NHSI Improvement 5.1 As regulator of the Trust, NHS Improvement has authority to act where is concern

that the Trust may have failed, or is failing to act in accordance with the constitution or with Chapter 5 of the 2006 Act. .

5.2 In exceptional circumstances, the Council of Governors may refer a question to

NHS lmprovement if:


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the escalation process set out at Tier 1 – 4 has not resolved the issue; and

more than half of the members of the Council of Governors present and voting at a meeting, approve the referral.

5.3 NHS Improvement is not able to answer operational questions or act as an

independent arbitrator between the Council of Governors and the Board of Directors.

2. Trust Constitution 16A Council of Governors – referral to NHS Improvement

16A.1 In this paragraph 16A, NHS Improvement is the regulator to which a Governor of the Trust may refer a question as to whether the Trust has failed or is failing:

16A.1.1 to act in accordance with its Constitution, or

16A.1.2 to act in accordance with provision made by or under Chapter 5 of the 2006

Act.

16A.2 A Governor may refer a question to NHS Improvement only if more than half of the members of the Council of Governors present and voting at a meeting of the Council of Governors approve the referral.

meeting of the council of governors- 1 december 2016 paper 1 tony fox 5 action point register paper...

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