68th Meeting of the Board of Directors
Thursday 3rd May 2012
2.30pm Boardroom, Pinewood House
Board of Directors
Dave Mellish Chair
Archie Herron Vice Chair & Non-Executive Director
Anne Taylor Non-Executive Director
Sally Jacobson Non Executive Director
Paul Ward Non Executive Director
James Kellock Non Executive Director
Seyi Clement Non-Executive Director
Stephen Firn Chief Executive
Helen Smith Deputy Chief Executive & Director of Service Delivery
Ify Okocha Medical Director
Wilf Bardsley Director of Nursing & Governance
Ben Travis Director of Finance
Simon Hart Director of HR & Organisational Development
Rachel Evans (For Items 8 & 9) Director of Estates and Facilities
Ann Rozier Trust Secretary & Head of Governance
Keith Soper Head of Compliance
1. Apologies for Absence Noted
2. Minutes of the Board of Directors Meeting held on the 1st March 2012 Agreed
The Minutes were agreed as an accurate record.
Item 6 Transfer of Community Properties. SF advised that guidance has been issued
confirming that transfer to the new provider will occur where occupancy exceeds 50%.
Transfers must be completed before the end of March 2013. Any Primary Care Trust
buildings that have not transferred will be retained and managed by a Department of Health
Item 9 NE Action Plan. WB stated that the action plan would be brought to the July
meeting of the Board of Directors WB/AR
Item 12 Compliance Report. SF updated colleagues on the serious incident discussed at
the previous meeting. The main cause of death was recorded as a congenital heart
condition, however the toxicology results indicated drug use, although not to a fatal level. In
addition, investigations by the police found some evidence of drug activity at the inpatient
unit. As a result, the investigation has been escalated to a Level 5 (Board Level) inquiry.
WB added that immediate action has been taken in respect of additional room searches,
including the use of police dogs.
3. Minutes of the Board of Directors Meeting held on the 5th April 2012 Agreed
The Minutes were agreed as an accurate record.
4. Key Performance Indicator Report - March 2012 Noted
Monitor targets remain on track. There was a slight deterioration in waiting time at the
Urgent Care Centre to 191 minutes, but this remained within the threshold of 240 minutes.
This reflected the increased activity at local Accident and Emergency departments, which
impacts on the number of patients and presenting conditions seen at the UCC. The service
is aligning workforce to periods of anticipated high demand. Whilst not a specific target
reported to Monitor, related to the increased demand performance against the median
waiting time at the UCC has decreased to 59 minutes, 1 minute inside the 60 minute target.
IO - Patient Group Directions have been introduced following approval at the Medicines
Management Board to enable nursing staff to prescribe and administer certain drugs, rather
than relying on a doctor to prescribe, thereby causing delays.
AH - Can nurses not write prescriptions?
WB - Not routinely.
The trust has seen a deterioration in performance against the 18 week referral to treatment
target for admitted consultant led services, as detailed in the compliance item. Occupancy in
acute adult services rose substantially without a single identifiable reason. Colleagues in
South London and the Maudsley NHS Foundation Trust reported similar peaks. Occupancy
at the Bevan Unit reduced as a result of the additional work put in place following receipt of
the winter pressures monies.
DM - Is it correct that many were first time attendees to acute adult mental health services?
HS - More detailed analysis is being undertaken.
5. Director of Service Delivery Report Noted
Training provided to the director of finance, director of service delivery, service and clinical
directors on pitching for new business was warmly received and provided a number of tools
to support future bids. This was considered important, particularly with competition from
private providers. Commissioners have requested the trust work with South London
Healthcare NHS Trust to develop pathways of care for frail elderly and cardiology services.
AT - Will the pathway development also include working with Bromley Healthcare?
HS - In future, yes.
DM - The paper suggests a significant increase in district nursing demand. Is this accurate?
HS - There have been a large number of tests, e.g. hearing tests, performed by district
IO - This added workload impacts on their ability to add and update care plans to RiO, as
evidenced in QSIP and CQUIN attainment.
DM - The positive impact of and potential financial savings from the voluntary car service
should be formally recognised from the Board.
SF - A recognition award was given to the lead member of staff some time ago but further
thanks would be gratefully received. SF/DM
SC - Has any feedback been received following the unsuccessful bid for Eastern and Coastal
SF - Not formally, although I met with the successful bidder and it was clear they had a very
good understanding of what commissioners were looking for, which is a strategy the trust
will be utilising in future bids.
JK - Do we know how much is being saved through the use of video conferencing?
HS - It is already well used across the trust and is being piloted on Shrewsbury Ward.
WB - One example of a recent meeting held via teleconferencing saved at least £1k.
6. Reconfiguration of Community Services Noted
The consultation closed at the end of April. 65 responses were received, including from local
authorities, which were supportive of the proposed structural changes. Some concerns have
been raised and these will be considered as part of the outcomes paper to be produced. In
addition, a formal six monthly review will take place, which will consider management
capacity. Interviews for service director posts are scheduled for 17th May 2012.
HS - No changes to service delivery are proposed and therefore no public consultation was
required. A further update paper will be presented to the next meeting of the Board of
The Board of Directors noted the progress and supported proceeding with the service
7. Olympic Planning Assurance Noted
The trust has submitted a statement of Games readiness to NHS London, based on the
results of completed local impact assessments and review of plans for services, particularly in
areas where logistical difficulties are predicted. The main impact is anticipated in Greenwich,
where travel and parking are expected to be problematic.
SF - GCHS undertakes around 500 home visits a day. Services have plans to ensure those
patients requiring visits and support will receive it.
DM - The police has confirmed that all leave is cancelled over the Olympic period therefore
the knock on affect is likely to result in leave being taken in September and October,
resulting in reduced resources to deal with section 135/136. Assurance has been given that
the significant number of officers on reserve during Games’ time will be allocated to section
135/136 if necessary.
JK - Will trust leave follow a similar pattern?
SH - No, services were required to complete rotas some weeks ago and minimum staffing
levels will be maintained at all times on a service by service basis.
The Board of Directors noted the progress made.
8. Annual Report on Sustainability Approved
In 2010 the Board of Directors approved a sustainability development plan with targets set
for carbon reduction from a baseline year of 2007. The plan was to achieve a 10%
reduction in carbon emissions by 2012. Good progress has been made against reducing
carbon usage in buildings as a result of a number of schemes, although further investment
might be required. Reductions are more difficult to calculate for travel and procurement but
there are plans in place to reduce travel emissions through the cycle to work and lease car
schemes, which will also deliver financial savings. Of the required overall reduction 40% has
already been achieved. Firm plans are in place to achieve a further 40%.
JK - Welcome report. LED lighting project appears critical. It would be useful to get further
updates and to consider the overall benefits of all new projects, such as video conferencing.
BT - What are the consequences of not achieving the target?
RE - Unknown at individual organisation level as NHS wide target.
The Board of Directors welcomed the progress and approved the report.
9. Estates Capital Programme Approved
The capital programme includes significant work in older people’s services and a focus on
addressing ligature risks. The programme also details the potential purchase of the Market
Street building, which would then require further investment prior to use as a multi-
functional clinical space.
DM - If other opportunities arise is there room to flex the programme?
RE - Yes, the programme only includes committed to expenditure.
AH - Will the transfer of community properties impact on the programme?
RE - No.
The Board of Directors approved the programme.
10. Quality Report - March 2012 Noted
An update was provided detailing key exceptions at the 2011/12 year end position (red and
Carer details recorded on RiO (mental health)
Section 132 compliance (mental health)
CPA review within last 6 months (mental health)
Follow up within 7 days of discharge (mental health)
Care plans on RiO (community)
Chlamydia screening (community)
Pressure Ulcers (community)
Care plans on RiO (community)
Pressure ulcers (community)
Receipt of referral within four hours (community)
Discharge summaries to GPs within two working days (community)
Smoking cessation (community)
The Board of Directors were advised that the trust achieved 100% of the CQUIN goals for
mental health. The adverse variance as a result of the non-achievement of community
health service CQUINs for 2011/12 is estimated at £268k, which will be agreed with
commissioners as part of a review of performance. CQUINs for 2012/13 have been agreed.
DM - How does performance compare to other NHS trusts?
IO - The information is not easily available.
AH - Good progress has been made by GCHS in respect of discharge summaries, however
CQUINs in community health services have generally been difficult to achieve. Are the
CQUINs for 2012/13 as challenging?
BT - Discussions with commissioners regarding targets for 2012/13 are on the basis that the
CQUINs must be achievable.
SC - How is the gap between reported levels of Chlamydia screening and the audit results
IO - A recent audit looked for specific written evidence of an offer of a test. Suspect in
reality the offer was being made but not always recorded. Post audit performance has
SC - Is there further support that could be provided to district nurses?
WB - The new version of RiO is released in June. In addition, a trial of the use of digi-pens
is underway. It is recognised there is a cultural shift required in some community services in
respect of record keeping.
SF - Recent complaints investigations in community services have identified some gaps in
record keeping standards. The trust has also had to declare a breach of a Monitor target for
the first time, again relating to community health services. Appointments to service and
clinical director roles in the new structure are important to ensure appropriate oversight and
SJ - It is important the organisation knows where problems are and that these are being
11. Compliance Report - March 2012 Noted
The latest Care Quality Commission Quality and Risk Profile shows reduced risk ratings for
Outcomes 11 (Safety, availability and suitability of equipment) and 16 (Assessing and
monitoring the quality of service provision). Good progress has been made in respect of
health and safety assessments, compliance with mandatory training requirements and PDRs.
There has also been an improvement in the trust’s response to issued safety alerts. The
overall increase in complaints was noted. It was agreed that fuller analysis be presented to
the next meeting of the Board of Directors.
SC - Are complaints still concerning communications and attitude?
SF - Yes. Numbers are highest in the acute adult directorate and a number relate to Betts
Ward. There is an initiative to promote care and compassion in the directorate, including the
recording of patient experiences to share with staff and patients. The Executive Team has
also agreed that every upheld complaint about staff attitude should result in a formal
meeting with the member of staff.
A Coroner’s Rule 43 report was issued to the trust in respect of the death of TE. The issue
raised was the safety and suitability of the transfer of TE and the trust, along with another
NHS provider and private provider, were cited in the report. An open verdict was reached at
the Inquest. The Rule 43 report did not concern the care and treatment provided to TE.
The Director of Nursing and Governance and Director of Adult Acute Mental Health Services
are conducting a supplementary investigation to review the circumstances surrounding the
transfer of care to inform the trust’s response to the report. Initial findings suggest there
was good dialogue and an appropriate exchange of clinical information prior to transfer. The
Secretary of State for Health, to whom the report was submitted, is required to respond
within 56 days. The trust will respond to HM Coroner within 28 days following liaison with
the NHS and private provider.
JK - The letter from HM Coroner could be read as implying that there was a financial
motivation to the transfer.
WB - This was not the case.
AH - The report suggests the level of observations reduced following TE’s transfer.
WB - The observation level was previously higher but at the time of transfer observations
had already been reduced and this level was maintained after transfer.
The outcomes of two Independent Homicide Investigations (LJ and AA) have been received.
Two recommendations for the trust were contained in the reports, namely i) the introduction
of sub MAPPA or risk panel meetings and ii) auditing of the use of clinical assessments as
part of monthly supervision sessions benchmarked against practices in other trusts.
Publication of the report into AA has been delayed because the other NHS Trust involved in
the care of AA disputed the findings.
The report following the interim review of the Short Breaks Service in Wensley Close from
Ofsted has been received and ‘good progress’ was deemed to be being made. This is the
best possible rating for an interim inspection.
A briefing paper was circulated to members describing the impact of the inability of specialist
foot surgery to meet the Monitor target of referral to treatment time within 23 weeks in
Quarter 4. 16 patients waited longer than 23 weeks for podiatric surgery in February and
March 2012 due to a lack of available theatre time. As a result, the trust’s governance rating
has moved to Amber/Green. For 2012/13 the target has reduced to 18 weeks. The service
has not met this target in April 2012 and therefore this will result in a further breach for
Quarter 1. A robust plan is in place to bring the service in line with the new 18 week target
by the beginning of Quarter 2.
Monitor has introduced an additional new referral to treatment target covering all consultant
led services, requiring 92% of all patients on an 18 week pathway to have completed the
pathway within 18 weeks. The services covered by this target include community
paediatrics, specialist foot surgery, dental and contraception and sexual health. A review of
data from community paediatrics indicates that, whilst the backlog is not as significant as
first suspected, the target will not be met in Quarter 1. Additional management resources
have been allocated to the service to review the data and ensure additional capacity is
available for those children who need to be seen. The impact of non-compliance with two
targets will result in the trust’s governance rating moving to Amber/Red.
SJ - Has private theatre provision been considered?
HS - Yes, although private theatre capacity is difficult to acquire. A locum community
paediatrician has been recruited, although these are rare.
AH - Do the problems in community paediatrics suggest disciplinary procedures are required?
HS - Investigations are already underway to understand the reasons for the apparent lack of
oversight of the waiting list data.
12. Governance Board update Approved
Updated terms of reference for the Governance Board were presented. The Same Sex
Declaration was approved at the Governance Board and has been published on the trust’s
website. In addition, amendments to the Mental Health Act Scheme of Delegation were
agreed. One new risk in respect of the possible misappropriation of patient monies has been
added to the corporate risk register. This is rated as moderate.
JK - The corporate risk register only contains one high risk. Does this feel valid?
SF - That is a healthy challenge. Up until the recent Monitor declaration the trust had been
rated as green for governance. In addition, the trust’s financial risk rating of 5, a low-risk
Quality and Risk Profile and no major transactions on the horizon all provide further
assurance, however further review of new and existing risks will take place at the next
The Board of Directors approved the changes to the terms of reference.
13. Business Committee update Approved
The first meeting of the new Business Committee was held in April and the minutes shared
with colleagues for information. Key points discussed were noted, which included the terms
of reference, presented to the Board for approval. Board members were advised the
membership of the Business Committee now includes three non-executive directors, plus the
Chair. There are three executive members.
DM - Suggest an update on SARD (revalidation software) be brought to the next meeting of
the Board of Directors. BT/DM
The Board approved the terms of reference.
14. Council of Governors update Noted
An away day for the Council of Governors (CoG) is scheduled for 10th May 2012 to include a
session on the implications of the new Health and Social Care Bill. In addition, a discussion
is planned on the role of the CoG and its relationship with the Board of Directors. The next
formal meeting of the CoG is scheduled for 21st June 2012.
15. Sealing of Trust Documents Approved
The Board approved the use of the Trust Seal in respect of:
Lease between Oxleas NHS FT and Alzheimer’s Society of White Gables, 18 Bromley
Lease between Oxleas NHS FT and The Royal Borough of Greenwich of gardens at
Goldie Leigh Hospital.
16. Finance Report Noted
The reported year end surplus stands at £5.1m, which includes a technical adjustment from
the external auditors as a result of a recalculation of PFI costs and the impairment following
the revaluation of the site. The trust’s Monitor financial rating stands at 5. The CRE gap
was slightly higher than expected at £1.4m as a result of some schemes not commencing as
expected, however this was covered by central reserves. As a result, the CRE target for
2012/13 has increased.
AT - The level of accruals has increased year on year.
BT - These are being reviewed with external auditors. The plan is to reduce the level of
provisions over time and use them to fund items via the Discretionary Fund.
17. Gifts and Hospitality Policy Approved
BT presented the updated policy following review within the Executive Team. The policy
clarifies the requirement to declare and the process for doing so and sets out sign off
arrangements alongside guidance for staff and managers to enable appropriate decisions to
be made. The policy has been reviewed by Counter Fraud. Staff will be advised of the new
policy via a payslip attachment and through regular trust communication channels.
SJ - Suggest the examples given state ‘not exhaustive’.
AH - Assuming this applies to Non-Executive Directors, sign off by the Chair for such items
should be clarified.
JK - Welcomed but need to consider how shared with contractors, volunteers and governors.
SF - For clarity the zero tolerance reference is in respect of not reporting gifts and
hospitality. There will always be an element of judgement as to what is acceptable.
Noting the suggestions, the Board of Directors approved the policy. BT
18. Workforce Report - March 2012 Noted
Sickness Absence - 4.13%. Rolling 12-month average is 4.12% down from 4.76%. A
target of under 4% has been set for 2012/13.
Vacancy & Turnover - Vacancy rates have reduced to 8.58%. ALD and GCHS have the
highest rates of 13.4% and 11.6% respectively. Vacancies are being controlled and
monitored closely. Turnover remains at an overall low level.
PDR Uptake - Overall Trust compliance is at 86%. All directorates have met the 80%
National Staff Survey - Relative to other mental health and learning disability
organisations the trust received the best overall scores and was rated the second best NHS
provider nationally. The full report is available for interested colleagues.
Disciplinary Hearings and Legal Spend - A total of 88 disciplinary investigations into
allegations of misconduct took place in 2011/12. 28 investigations were carried out in the
previous year (noting that GCHS was not part of the trust at this point). 14 resulted in
dismissal. The data will be further analysed to understand the reasons for the increase. The
legal spend on employment issues reduced in 2011/12 with 5 employment tribunal
applications in 2011/12. Of these 1 was withdrawn, 2 were dismissed at pre hearing stage
due to being out of time and 2 cases remain outstanding. There were no extra contractual
settlements made during the year.
JK - Should record praise for the excellent staff survey results.
DM - In addition, very good progress on PDRs.
SH - A rate of 87% for PDRs would put us in the top 20% based on staff survey results.
SJ - Could the disciplinary data be broken down by ethnicity and gender?
SH - Yes, it is being provided to the next Equality, Diversity and Human Rights Group.
19. Social Enterprise - Employment Approved
It is proposed that the trust forms a Community Interest Company (CIC) to help address the
inequitable position of service users wishing to come off benefits and re-enter paid
employment. Through forming a CIC, the trust will be able to establish a new and entirely
independent social enterprise company who can specialise in the recruitment market.
Following advertisement for an appropriate third sector specialist organisation, Twinings has
been selected as the preferred partner.
AH - Recommend month by month cash flow rather than lump sum payment.
BT - Formal six-monthly reviews of the financial position will take place.
SJ - Recommend the Board contains two non-executive directors.
DM - Fits with long term priority in respect of social inclusion.
The Board of Directors agreed the following:
To form a Community Interest Company (CIC) with its own Board.
To underwrite the CIC start-up funding ‘loan’ of £150k for the 1st years trading.
To establish a Social Enterprise Employment Company (SEEC) by contracting to
Twinings Enterprise, a Charity and Company Limited by Guarantee.
It was agreed a presentation was required at the next Council of Governors meeting. DM/BT
20. Chief Executive Strategic update Noted
The Board of Directors received an update on discussions regarding the future use of the
Queen Mary’s Hospital site. The possible strategic advantages and the links with relevant
pathways of care were noted, however the Board of Directors reflected on the need to be
fully sighted on risks and financial implications, including any further required investment.
Whilst actively committed to considering the potential use of the site, any decision would be
informed by a clear due diligence process.
DM - Suggest major item at next meeting of Board of Directors in June. DM
21. Delegation of authority for final approval of the Annual Report and Annual Plan Approved
The annual report and annual plan requires sign off by the Board of Directors prior to
completion by the due date to Monitor of 1st June 2012. An updated draft annual report was
shared and comments invited. SF advised that there were sections within the annual report
that required Board oversight and agreement, namely:
Compliance with Code of Governors
Annual Governance Statement
Quality Report and Accounts
SF proposed authority to sign off the above on behalf of the Board of Directors is delegated
to the Governance Board at their meeting on 15th May 2012. Because of the work required
by external auditors SF proposed the final financial accounts and statement be signed off at
the Audit Committee meeting on 22nd May 2012 on behalf of the Board of Directors.
In respect of the annual plan, the Board is required to report compliance with 16 statements.
14 out of 16 will be reported as compliant, with the exception of statement 11 relating to
performance against referral to treatment waiting times and statement 12 in respect of the
information governance toolkit.
DM - Colleagues are encouraged to submit any comments on the content to the Trust ALL
The Board of Directors agreed the statements and approved the delegation of authority and
sign off process. SF/AR
22. Health and Social Care Act 2012 Provisions relating to the Board of Directors - Approved
changes to the Trust
AR outlined the key changes and implications for the Board. The role and responsibilities of
the Council of Governors will increase, including the need for significant transactions and any
increase in non-NHS funded services to receive the approval of the Council of Governors.
DM - Propose a Joint Constitution Panel including representation from the Board of Directors
and Council of Governors be established to work through the detail of the changes required
to the constitution, based on the model constitution to be issued by Monitor.
The Board of Directors approved the proposed process. DM
23. Any Other Business Noted
DM advised that the planned joint meeting with colleagues from Sussex Partnership NHS
Foundation Trust has been cancelled, with a new date planned for July 2012.
Next meeting of the Board of Directors (Part 2)
7th June 2012, Bracton Conference Room
I confirm that the minutes of Board of Directors meeting of 3rd May 2012 are a true record
Dave Mellish, Chair