Minute No by benbenzhou


									Minutes of the Thirty-Seventh Board of Directors’ Meeting of the Sheffield Health
and Social Care NHS Foundation Trust Held on Wednesday 26th October 2011 in the
Rivelin Boardroom at the Fulwood House Conference and Training Centre, Old
Fulwood Road, Sheffield S10 3TG
                                                                                       Item 4
Present:                                                                                BoD
1. Prof. Alan Walker        Chair                                                    Meeting of
2. Kevan Taylor             Chief Executive
3. Mick Rodgers             Deputy Chief Executive/Executive Director of Finance
4. Clive Clarke             Executive Director of Operational Delivery and Social Care
5. Prof. Tim Kendall        Executive Medical Director
6. Susan Rogers, MBE        Non-Executive Director/Vice Chair
7. Cllr. Mick Rooney        Non-Executive Director/SID
8. Anthony Clayton          Non-Executive Director/FIC Chair
9. Martin Rosling           Non-Executive Director/A&AC Chair
10. Mervyn Thomas           Non-Executive Director/QAC Chair

In Attendance:
11. Chipo Kazoka            Foundation Trust Company Secretary
12. Dean Wilson             Associate Director of Human Resources
13. Pam Stirling            Associate Director of Strategic Development
14. Emma Brecknock          Member of the Public (Capsticks, Solicitors)
15. Susan Wood              Public Governor (in part attendance)
16. Mia Bajin               Staff Governor (in part attendance)

Liz Lightbown                Executive Director of Nursing & Integrated Governance
Rosie McHugh                 Associate Director of Organisational Development
Sue Gass                     Personal Assistant to the Chief Executive

SID: Senior Independent Director
FIC: Finance and Investment Committee
A&AC: Audit and Assurance Committee
QAC: Quality Assurance Committee

                                         Page 1 of 11
                                                 Item                                  Action
1/10/11   Welcome and Apologies
          The Chair called the meeting to order and welcomed all those

          A special welcome was extended to Councillor Mick Rooney and
          Mr. Martin Rosling who had been recently appointed by the Council
          of Governors to continue serving as Non-Executive Directors of the
          Trust. In response to the Chair’s invitation, Board members
          expressed their congratulations to the two recently appointed Non-
          Executive Directors.

          Apologies from Liz Lightbown, Rosie McHugh and Sue Gass were

          The Chair informed members that the Carer’s Story (scheduled as
          the second item on the agenda) would be presented at a later stage
          of the meeting.

2/10/11   Declarations of Interest
          There were no declarations of interest made or any changes to
          existing ones.

3/10/11   Minutes of the Open Session of the Board of Directors’
          Meeting held on 22nd September 2011

          Minutes of the open session of the Board of Directors’ meeting held
          on 22nd September 2011 were agreed as a correct record.

          (Professor Tim Kendall joined the meeting at this point)

4/10/11   Matters Arising from the Minutes of the Open Session of the
          Board of Directors’ Meeting held on 22nd September 2011
          The following matters arising from the minutes of the open session
          of the Board of Directors’ meeting held on 22nd September 2011
          were noted:

          Minute 05/9/11
              The Associate Director of Human Resources reported that
                he will update the Board at its November 2011 meeting on
                progress that will have been made in implementing the staff
                                                                                     Dean Wilson
                giving scheme for the Uganda Partnership Project
              The Trust received a good response from staff to the 12 for
                12 cycling month campaign. The level of response
                surpassed the expectations of the 12 for 12 Campaign Team

                                          Page 2 of 11
                 Mervyn Thomas reported that he was not able to meet with
                  Mark Parker and Steph Grant from the Long-Term                       Mervyn
                  Neurological Conditions Service. He undertook to report to           Thomas
                  the Board the outcome of his meeting when it takes place
          Minute 06/9/11
               There has been no response from Governors to the invitation
                  that was extended to them to put themselves forward to be
                  nominated to carry the Olympic Torch when it passes
                  through Sheffield
          Minute 08/9/11
               The Associate Director of Strategic Development confirmed             Stirling/Liz
                  that she would be meeting with the Executive Director of            Lightbown
                  Nursing and Integrated Governance to discuss work on
                  safeguarding issues relating to the transitional age group
          Minute 10/9/11
               The Associate Director of Human Resources undertook to
                                                                                     Dean Wilson
                  circulate an update report on the Vacancy Control Panel to
                  Board members outside the meeting before bringing it for
                  discussion at the November 2011 Board Meeting
          Minute 11/9/11
               Councillor Mick Rooney reported that he will need a formal
                  request from the Trust to enable him to make the contacts
                                                                                     Pam Stirling
                  that he offered to pursue with Sheffield International Venues.
                  The Associate Director of Strategic Development confirmed
                  that Julie Leeson would make this formal request to
                  Councillor Rooney
          Minute 12/9/11
               The Deputy Chief Executive confirmed that the Trust had not
                  submitted a tender for an opportunity to provide substance
                  misuse services in Derby, the basis of which was outlined in
                  his e-mail to Non-Executive Directors dated 3rd October 2011
5/10/11   Quality Assurance Committee (‘QAC’)
          The Board received the minutes of the QAC meeting held on 6th
          September 2011. The QAC Chair assured the Board that the QAC
          holds detailed discussions on quality issues and that this was
          reflected in the minutes of the QAC meetings. The Board also noted
          that in future, there will be no verbal updates on QAC meetings as
          the Chair will only be presenting minutes of the Committee’s
          meetings and taking questions on these.
6/10/11   Medical Revalidation
          The Board received a paper on Medical Revalidation from the
          Executive Medical Director who informed the Board that work on
          this area is progressing well. The Trust is now waiting for a national
          decision on the matter to be taken. The Board also noted that:
                                          Page 3 of 11
                there is a possibility that some individuals may face
                 difficulties getting revalidated
               adequate steps have been taken (on a reciprocal basis with
                 other regional Trusts) to deal with the possibility of claims of
                 conflicts of interest being raised (against the Executive
                 Medical Director) in the course of carrying out the
                 revalidation process. In these instances, his counterparts
                 from other Trusts would lead in carrying out the process and
                 he would reciprocate the gesture when called upon
               actions to be taken in relation to those who fail to get through
                 the revalidation process range from re-training to following
                 alternative career paths
               the Trust’s normal appraisal processes should be able to
                 pick-up, in advance, the likelihood of any of its medical
                 doctors facing difficulties with their revalidation. The normal
                 working of the revalidation process is such that it should not
                 throw up any surprises of an adverse outcome for the
                 medical professionals concerned
               further reports on the matter will be taken to future QAC             Prof Tim
                 meetings                                                             Kendall
7/10/11   Sickness Absence
          The Board received the report on sickness absence from the
          Associate Director of Human Resources. The Board noted that
          stress has, for the first time, become the highest cause of long-term
          sickness absence in the NHS across the country. This is currently
          being attributed to the pressures outside of the work environment
          which the current economic climate is exerting on people’s lives.

          The Trust has, in partnership with Occupational Health Service,
          been carrying out detailed reviews of existing cases of long-term
          sickness absence and reductions in these have been made.

          The Associate Director of Human Resources undertook to publish
          sickness absence ‘league tables’ for each Directorate in the Trust
                                                                                     Dean Wilson
          along with data comparing the Trust’s performance to other regional
          Trust’s. The published material will also include information on the
          steps that management is taking to address the problem.

          The Board entered into a discussion on the matter noting, among
          other things that:
              the Workplace Wellbeing Service has confirmed to the
                 Associate Director of Human Resources that access to the
                 service has levelled out for staff on long term-sickness
              the Workplace Wellbeing Service should be asked to re-
                                                                                     Dean Wilson
                                          Page 4 of 11
                 advertise itself in order to raise its profile amongst staff. It
                 should also look at finding techniques that will address
                 needs of older women
               not all of the worst 1% long-term sickness absence cases
                 are the same. Those that form part of the recurrent cases
                 are, for various reasons, not necessarily subject to
                 escalation procedures
               the Trust needs to consider what it can do to address the               Dean
                 level of sickness absence in the Dementia Directorate                  Clarke
               the contract with the Occupational Health Service is still
                 under review
8/10/11   Service Performance
          The Board received:
          i) The Quarter 2 Performance Report and Monitor Declaration:
          The Deputy Chief Executive pointed out that he has informed
          Monitor (the Independent Regulator of NHS Foundation Trusts) that
          the Trust will be declaring its Governance Risk Rating as ‘Amber-
          Green’ because the Trust does not have any outstanding
          compliance actions with the Care Quality Commission (CQC). At
          his request, the Board agreed to declare the Trust’s Governance
          Risk Rating as ‘Amber-Green’ subject to confirmation (delegated to
                                                                                     Mick Rodgers
          the Finance Director) of the outstanding information on Data
          Completeness Identifiers.

          ii) The Monthly Performance Dashboard Report (for the 6
          months’ period ending September 2011):
          Board members entered into a discussion on the monthly
          performance dashboard report covering the following issues,
          among others:
                 the extreme variation in the monthly performance shown in
                   the „Effectiveness of Treatment‟ graph for the Substance
                   Misuse Service does not portray clear and meaningful
                   information for the Board to use. The Deputy Chief                Mick Rodgers
                   Executive undertook provide clarification for the Board on
                   the nature of the information that the graph sought to
                 the Board agreed that a paper on the Substance Misuse              Clive Clarke
                   Service should be brought to one of its future meetings
                 the Board needs to be given some clarification on why the
                   organisation’s annual performance against the
                   „Employment Rates-Mental Health Clients on Care
                                                                                     Mick Rodgers
                   Programme Approach‟ indicator is shown as ‘red’ since this
                   does not appear to be an fair representation of the
                   organisation’s performance at this point in time
                                          Page 5 of 11
                     the Trust should expect financial penalties to be imposed
                      on it (by NHS Sheffield) for its excessive levels of ‘out of
                      area acute admissions’. The Board noted that August 2011
                      was a particularly bad month (in the Trust and nationally)
                      for this area of performance
                     there is a nationwide growth in bed occupancy which, if left
                      unchecked, could become very unmanageable. These                      Chipo
                      issues and others connected to it should be discussed at           Kazoka/Rosie
                      an Acute Care Reconfiguration board development session

          iii) The Finance Report(s) for:

             i)        the period ending 31st August 2011: The Board noted
                       the contents of this report

             ii)       the period ending 30th September 2011: The Executive
                       Director of Finance informed the Board that because the
                       Trust was not achieving its Cost Improvement Plan (CIP)
                       targets, it was just holding on to a ‘Level 3’ Financial Risk
                       Rating with Monitor. Details on this were reserved for
                       further discussion in the confidential session of the
                       meeting. In the meanwhile, the Board noted the contents
                       of the report. The Board agreed that it should submit to
                       Monitor, a declaration that the Trust’s Financial Risk
                       Rating should be at ‘Level 3’.

          iv) The Board’s Self-Assessment Against Monitor’s Quality
          Governance Framework
          The Board approved the contents of this paper.

9/10/11   Finance and Investment Committee (‘FIC’)
          The Board received:
          i) the minutes of the FIC meeting held on 25th July 2011 and noted
          their contents
          ii) the FIC Chair’s report on the FIC meeting held on 26th
          September 2011 and noted its contents. The FIC Chair pointed out
                  progress on the development of the Assessment and
                    Treatment Unit (ATU) is being closely monitored by the
                    FIC. He reported that the completion of the project is
                    expected to fall behind schedule and the FIC has been
                    made fully aware of the reasons for this. The FIC has,
                    however, maintained the position that the project should be
                    delivered on time and within budget
                                              Page 6 of 11
10/10/11 Audit and Assurance Committee (‘A&AC’)
         The A&AC Chair reported that this item should not have been on
         the agenda as he did not have anything to report to the Board.
11/10/11 Board Risk Profile
         The Company Secretary presented the Board Risk Profile on behalf
         of the Executive Director of Nursing and Integrated Governance. He
         pointed out that:
                the Profile contained an extract of the risks from the Trust’s
                  Corporate Risk Register which remain rated as ‘red’ after
                  application of the controls shown in the Profile
                the Profile will, from now onwards, be presented to the
                  Board on a monthly basis. This will give the Board the
                  opportunity to: maintain its vigilance in monitoring the
                  corporate risks that the Trust is exposed to; challenge the
                  justification of the risks remaining in the Corporate Risk
                  Register; challenge the controls that are being applied to
                  treat the risks and; gauge the level of the Trust’s risk
                  appetite in relation to those risks that cannot be mitigated
                  with the application of a reasonable level of controls
         Board members entered into a discussion based on the
         presentation, which covered the following issues:
                 the Board maintains the position that exception reports of
                    the ‘red’ risks on the Corporate Risk Register should be
                    provided to it on a monthly basis by the presentation of
                    the Board Risk Profile
                 the controls against the risk of „Loss of income due to
                    self-directed support‟ ,as recorded in the Profile, appear
                    inadequate. There is, however, a lot of work that is being
                    done to control this risk and this is not captured in the
                    Profile. A way of capturing these efforts in the Corporate
                    Risk Register (and the Profile) needs to be found so that   Liz Lightbown
                    they can be properly shown as the controls aimed at
                    mitigating this risk.

                    The Board also needs to have a substantive strategic
                    discussion on how it will respond to the risk that Self-          Clive Clarke
                    Directed Support poses to the Trust within the short to
                    medium term

                   with regard to the risk of „Loss of income due to potential
                    loss of contracts with Sheffield Teaching Hospitals NHS
                    Foundation Trust‟ the Board was informed that this Trust          Liz Lightbown
                    has agreed a facilities management review with Sheffield
                    Teaching Hospitals and this needs to be added to the
                                           Page 7 of 11
                   controls applicable to this risk
               the Trust no longer faces the risk of „insufficient resources
                   to ensure all staff are compliant with statutory and
                                                                                       Liz Lightbown
                   mandatory training requirements…‟ This risk should
                   therefore be removed from the Corporate Risk Register
               the Head of Integrated Governance will be meeting the
                   Executive Directors and the Non-Executive Directors to
                   ask them to identify the three significant risks which they
                   consider the organisation is exposed to. These will be
                   included in the Corporate Risk Register
               the Board agreed that whilst the format of the Profile is
                   acceptable, its content will be subject to continuing review
                   by the Board on a monthly basis
               the Board was asked to note that most of the risks on the
                   Profile were finance-related
               the risk of „Inability to deliver financial QIPPs in 2011/12
                   resulting in financial deficit‟ is a current and valid risk and
                   should remain on the Corporate Risk Register. Further
                   actions to mitigate this risk will be identified as the Trust
                   develops its Financial Plan. There is a possibility that the
                   magnitude of the risk may be reduced by December 2011
         Subject to the abovementioned remarks, the Board accepted the
         Board Risk Profile.
12/10/11 Governors’ and Membership Matters
         The Chair reported that:
             this year’s Annual Members’ Meeting was significantly better
               than last year’s. Board members responded warmly to the
               Chair’s invitation to pay special thanks to members of staff
               (namely, Sam Stoddart, Karen Cunningham, Sue Gass,
               Susan Kay and Carolyn Drabble) whose efforts helped to
               bring about such a successful event
             the Trust’s Governors will be calling representatives from
               NHS Sheffield to explain why it is not commissioning the
               provision of an Aspergers service for the people of Sheffield
             the high level of ‘out of town’ acute admissions was raised at
               the last Council of Governors’ meeting
             the Council of Governors received an excellent presentation
               on the Community Mental Health Teams (CMHT)
               reconfiguration proposals from Gaby Dale, Guy
               Hollingsworth and Clive Clarke
             while recognising that the Trust is going through financial
               difficulties and that measures have been taken by the
               Executive Director of Finance to control non-urgent non-pay
               expenditure, the Chair suggested that the current
                                            Page 8 of 11
               expenditure on hospitality at Council of Governors’ meetings
               should still be maintained until a viable alternative way of
               facilitating this can be found
13/10/11 Trust Governance Structure
         The Board received, for approval, the paper on the Trust’s
         Governance Structure. Board members entered into a discussion
         based on the contents of the paper and raised the following points:
             there should be an explanation of what the ‘Service
                Directorates Governance Groups’ are and what they do.
                This is not given in the paper even if these groups are
                represented on the in diagram in the paper
             the diagram conveys the impression that the ‘Service
                Directorates Governance Groups’ report to the ‘Strategic
                Leadership Group’. This is not the case and the diagram
                should be amended to ensure that it does not convey this
                wrong impression
             the position of the Council of Governors in the diagram
                should be raised so that it sits alongside the Board of
             the name of the Council of Governors’ ‘Appointments and
                Remuneration Committee’ should be changed to the
                ‘Nominations and Remuneration Committee’
             the Quality Assurance Committee (‘QAC’) has a noticeably
                large number of groups reporting to it. This is a potential
                cause of concern and the Executive Director’s Group should
                look into it. The QAC’s meetings tend to be heavily loaded
                and long. The QAC needs to review the way in which it
                carries on its work in order to ensure that its tasks do not
                become unduly onerous. Board members recognised, at the
                same time, that the QAC was still in the early days of its
             the Infection Prevention and Control Group is not listed
                amongst the groups that report to the QAC when it actually
                does. This omission must be corrected

          The Executive Directors’ Group needs to review the Governance
          Structure in order to ensure that it is fit for purpose. A revised
          structure that takes into account the above mentioned comments
          should be brought to the November 2011 Board meeting for
                                                                                     Liz Lightbown

14/10/11 Chief Executive’s Update
         The Chief Executive informed the Board that there is a discussion
         in the city about GP Associations. There has been no decision
         made on them as yet. The thinking on this matter has shifted from
                                          Page 9 of 11
          what it was in its initial stages. The new thinking takes into account
          the fact that most GPs are independent private service providers.
          The intention now is for GP practices to come together to form GP
          Associations that will lead in shaping the integration of health and
          social care provision in the community. This is captured in a
          concept paper that has been released to the primary care sector by
          the Local Medical Committee (‘LMC’). The strategic implications of
          these plans, for the Trust, have been taken into account.

          The Chief Executive undertook to bring the concept paper to the
          Board for discussion. The Associate Director of Strategic
          Development also undertook to bring updates to the Board at its               Kevan
          November 2011 meeting on the developments that will have taken              Taylor/Pam
          place around this issue.

         The Chief Executive also thanked all those Board members who
         took part in the Mental Health Week events and those who
         attended the ‘Touching the Soul’ art exhibition held at the Jessop
         Wing of the Royal Hallamshire Hospital.
15/10/11 Any Other Urgent Business
         The date for the November 2011 Board meeting clashes with that of
         a planned national strike. The Board meeting will therefore be

          Board members were informed by the Chief Executive that plans
          were being made to mitigate the impact of the strike on the                 Kevan Taylor
          organisation. The Chief Executive undertook to provide Non-
          Executive Directors with further details on the development of these

         The Board meeting was adjourned for a brief comfort break.
16/10/11 ‘The Day the Singing Stopped: A Carer’s Story’
         On resumption of the meeting, the Chair welcomed Susan Wood
         who had come to the meeting to present her story of life with her
         husband prior to and after the onset of his dementia illness, and
         how his illness had impacted both of their lives. Sue’s husband had
         been a user of the Trust’s services from the onset of his illness up
         to the time that he passed away. She was accompanied by Mia
         Bajin, the Trust’s Public and Patient Involvement Manager (and
         member of the Council of Governors).

          After a few introductory remarks made by the Chair and Mia Bajin,
          Board members watched a video in which Sue narrated her story.
          The video provided the Board members with insights into the
                                          Page 10 of 11
          devastating impact of dementia on Sue’s husband and on her as a
          spouse and carer. At the end of the video, Board members took the
          opportunity to ask Sue several follow-up questions at the close of
          which, Board members joined the Chair in thanking her for
          attending the meeting and for sharing her very moving story. Board
          members also thanked Mia Bajin for accompanying Sue.

          Before leaving the room with Sue, Mia Bajin distributed DVDs to
          Board members containing Sue’s and other carers’ stories. She
          also informed them that efforts were underway to ensure that the
          stories were used to best effect.

         Mia Bajin, Susan Wood and Emma Brecknock then left the meeting
         room at this point.
17/10/11 Chief Executive’s Announcement of Confidential Business
         The Chief Executive provided an explanation of the matters to be
         discussed in the confidential session of the meeting (which was
         soon to follow) and the reasons why these matters were to be
         discussed in that part of the meeting.
18/10/11 Chair’s Motion to Exclude Members of the Public and the
         Press from the Remainder of the Meeting
         There being no further business to transact in the presence of
         members of the public and the press, the Chair proposed the
         following motion:
         “That in accordance with Standing Order 3.1 of the Board of
         Directors‟ Standing Orders, members of the public and the press be
         excluded from the remainder of the meeting for reasons of
         confidentiality and business sensitivity of matters to be discussed”

          The motion was adopted as a resolution of the Board.
          Date and time of next Board of Directors Meeting
          Wednesday, 23rd November 2011 at 9.00 a.m. in the Rivelin Board
          Room, Fulwood House Conference Centre, Sheffield S10 3TG.

Signed:                              23rd November 2011

                                         Page 11 of 11

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