PLEASE NOTE THE REVISED DATE FOR THIS MEETING

Transcription

1 Chairman s Office Trust Headquarters Blackpool Victoria Hospital Whinney Heys Road Blackpool Lancashire FY3 8NR Telephone: judith.oates@nhs.net PLEASE NOTE THE REVISED DATE FOR THIS MEETING 19th September 2018 Dear Board Members Blackpool Teaching Hospitals NHS Foundation Trust Board of Directors Meeting The next meeting of the Board of Directors of the Blackpool Teaching Hospitals NHS Foundation Trust will be held in public on Wednesday 26th September 2018 at 9.30 am in the Board Room, Victoria Hospital, Whinney Heys Road, Blackpool, FY3 8NR. Members of the public and media are welcome to attend the meeting but they are advised that this is a meeting held in public, not a public meeting. Any questions relating to the agenda or reports should be submitted in writing to the Chairman at the above address at least 24 hours in advance of the meeting being held. The Board may limit the public input on any item based on the number of people requesting to speak and the business of the Board. Enquiries should be made to the Foundation Trust Secretary on or judith.oates@nhs.net Yours sincerely J A Oates (Miss) Corporate Assurance Manager/ Foundation Trust Secretary Page 1 of 23

2 A G E N D A Agenda Item Number Agenda Item Duration Purpose/ Expected Outcome 1 Chairman s Welcome and Introductions Mr Butler to report. (Verbal Report). 2 Declaration of Interests Concerning Agenda Items Mr Butler to report. (Verbal Report) am (1 minute) 9.31 am (1 minute) For Information For Information 3 Apologies for Absence Mr Butler to report am (1 minute) For Information 4 Minutes of the Previous Board of Directors Meeting held in Public on 25th July 2018 Mr Butler to report. (Enclosed). 5 Matters Arising:- a) Action List from the Previous Board of Directors Meeting held in Public on 25th July 2018 Mr Butler to report. (Enclosed). b) Action Tracking Document Mr Butler to report. (Enclosed). 6 Overview of Challenges and Debates Outside Formal Board Meetings from Non-Executive Directors and Executive Directors - Board Members to report. (Verbal Report) am (2 minutes) 9.35 am (2 minutes) 9.37 am (3 minutes) 9.40 am (5 minutes) For Approval For Discussion For Discussion For Discussion 7 Patient Story DVD Professor O Donnell to report am (10 minutes) For Discussion 8 Executive Reports:- a) Audit Committee: feedback from the meeting held on 4th September 2018 Mr Bennett/Mr Hearty to give a presentation. b) Finance Committee: feedback from the meeting held on 19th September 2018 Mr Bennett/Mr Cullinan to give a presentation. c) Winter Plan Ms Groves to give a presentation. d) Medical Examiners Professor O Donnell to report. (Enclosed). e) Chief Executive s Report Mrs Swift to report. (Enclosed). 9 Chairman s Report:- a) Chairman s Update. (Verbal Report). b) Confirmation of Chairman s Action. (Enclosed). c) Affixing of the Common Seal. (Enclosed). d) Feedback from Clinical Commissioning Group Governing Body Meetings: am (10 minutes) am (10 minutes) am (20 minutes) 10.35am (5 minutes) am (5 minutes) am (5 minutes) am (3 minutes) am (2 minutes) am (10 minutes) For Discussion/ For Approval For Discussion/ For Approval For Information For Information For Information For Information For Approval For Approval For Information Page 2 of 23

3 i) Blackpool: 4th September 2018 Mr Finnigan to report. (Verbal Report). ii) Fylde & Wyre: 18th September 2018 Mr Cullinan to report. (Verbal Report). 10 Key Themes for Team Brief Mr Butler to report. (Verbal Report). 11 Trust Values / Examples of Value of the Month Mr Butler to report. (Verbal Report) am (5 minutes) am (5 minutes) For Discussion For Discussion 12 Attendance Monitoring Mr Butler to report. (Enclosed) am (1 minute) For Information 13 Any other Business Mr Butler to report. (Verbal Report). 14 Items Recommended for Decision or Discussion by Board Committees Mr Butler to report. (Verbal Report). 15 Questions from the Public Mr Butler to report. (Verbal Report). 16 Date of Next Meeting Mr Butler to report. (Verbal Report) am (1 minute) am (1 minute) am (10 minutes) am (1 minute) Total Duration 1 hours, 59 minutes For Discussion For Discussion For Discussion For Information RESEARCH MATTERS AND SAVES LIVES - TODAY S RESEARCH IS TOMORROW S CARE Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality up to date care. We are actively involved in undertaking research to improve treatment of our patients. A member of the healthcare team may discuss current clinical trials with you. Chairman: Pearse Butler Chief Executive: Wendy Swift Page 3 of 23

4 Minutes of the Blackpool Teaching Hospitals NHS Foundation Trust Board of Directors Meeting held in Public on Wednesday 25th July 2018 at am in the Board Room, Trust Headquarters, Blackpool Victoria Hospital Present: Mr Pearse Butler Chair Non-Executive Directors Mr Mark Cullinan Mr Steve Finnigan Mr Alan Roff Mrs Mary Whyham Mr Michael Hearty Mr Keith Case Executive Directors Mrs Wendy Swift Chief Executive (for items 56/18 65/18) Mr Tim Bennett Deputy Chief Executive/Director of Finance Professor Mark O Donnell Medical Director Mrs Marie Thompson Director of Nursing & Quality In Attendance: Mr Paul Renshaw Interim Director of Workforce Mrs Janet Barnsley Interim Director of Planned Care Mr Matthew Burrow Head of Corporate Assurance Governors (observers) 3 Members of Public (observers) 6 50/18 Chair s Welcome and Introductions The Chair welcomed attendees and observers to the Board Meeting in Public and drew attention to the house-keeping rules. The Chair stated that he was reviewing with the Governors the arrangements for managing the acoustics in the Board Room and he asked Board members to speak clearly. 51/18 Declarations of Interests The Chair asked Board members to declare any interests in relation to the items on the agenda other than the standard declarations and also asked Board members to alert him to any interests that needed to be declared as a result of the discussions during the meeting. Mrs Barnsley declared an interest as a substantive employee of Blackpool CCG, however, she stated that there were no conflicting items on the agenda. 1 Page 4 of 23

5 52/18 Apologies for Absence Apologies for absence were received from Mrs Berenice Groves (Interim Director of Urgent & Emergency Care) and Miss Judith Oates (Corporate Assurance Manager/Foundation Trust Secretary). It was noted that Mrs Wendy Swift (Chief Executive) had left the meeting and would join the meeting later. 53//18 Minutes of the Previous Board of Directors Meeting Held in Public RESOLVED: That the minutes of the previous Board of Directors Meeting held in public on 23rd May 2018 be approved and signed by the Chairman. 54/18 Matters Arising:- a) Action List from the Board of Directors Meeting held on 23rd May 2018 It was noted that five items on the Action List had been completed and five items were not yet due for completion. Mrs Whyham stated that herself and Mr Roff had aligned the arrangements of both the Strategic Workforce Committee and the Quality Committee. Mr Bennett provided an update on the on-going discussions with the Specialist Commissioners on the expansion of the cardiac catheter laboratory facility which was currently going through the business case process. Mrs Thompson updated the Board on the Blackpool Public Health proposal for a smoking cessation service which would provide the Trust with 95k to establish a small team to deliver the service which the Executive Directors had agreed to support in principle. b) Action Tracking Document With regard to the Action Tracking Document, it was noted that two items were outstanding which had been updated on under items 50/18 and 54/18(a) and two items were not yet due for completion. 55/18 Overview of Challenges and Debates Outside Formal Board Meetings from Non- Executive Directors and Executive Directors The Chair provided Board members with the opportunity to report on any challenges/debates that had taken place outside formal Board meetings. It was noted that none of the Board members had any challenges/debates to be discussed. 56/18 Better Care Now The Chair stated that Professor ODonnell would deliver a presentation on Better Care Now (BCN). Professor O Donnell stated that the BCN project was the Trust s number one priority, and that he and Mrs Thompson had led a programme of engagement meetings with senior leaders. Professor O Donnell stated that the BCN view was does the service we provide pass the me test? It was noted that Professor O Donnell reiterated this message to all junior doctors at induction. 2 Page 5 of 23

6 Professor O Donnell explained the journey of a patient which was suboptimal and stated that there was a direct correlation between an increased waiting time in A&E and a longer length of stay (approximately an 85% increase). It was reported that the BCN project was up and running, focusing on the Combined Assessment and Treatment Unit, on-going care in hospital and discharge; it being noted that the project had been successful in starting to reduce Delayed Transfers of Care (DTOC) and stranded patients (defined as 7 days or longer). Professor O Donnell advised that recent bed modelling indicated that the Trust would need a further 40 beds to manage winter pressures and that an investment had been made in nurse staffing and junior medical staff. Professor O Donnell stated that all staff should be able to answer the following four patient questions:- What is the matter with me? What is going to happen today? When I am going home? What is needed to get me home? Professor O Donnell reported that the Trust had a good compliance with daily Board rounds at approximately 85%, however, morning discharges had decreased over the last 2 years which was a trend that needed to be reversed. Professor O Donnell stated that the BCN project had developed four must do s for staff as follows:- Recognise Length of Stay as a HARM Change OUR mind-set from hospital to home Adhere to our PROFESSIONAL STANDARDS Use Red to Green Days/SAFER/Discharge to Assess The Chair thanked Professor O Donnell for the presentation and asked Board members for views. Mr Case asked about the arrangements in place with the wider health system to support the BCN project. Professor O Donnell stated that daily telephone conferences had taken place around DTOC and stranded patients. In addition, discussions were taking place regarding offering hot clinics with GPs to facilitate reviewing patients quickly. At this juncture, Mrs Swift joined the meeting. Mr Finnigan queried how the BCN project would be monitored. Professor O Donnell stated that the governance structure was through the BCN meeting which monitored the BCN action plan and that supplementary workstream meetings monitored approximately 30 KPIs. Mrs Thompson stated that at the engagement meetings staff still did not understand that the Trust had integrated acute and community care. Mr Hearty stated that the CCGs reviewed the Trust s performance, such as RTT and A&E, and that a BCN project presentation to a CCG Board meeting would be useful to assist them in understanding the impact on the Trust of outside activities. RESOLVED: That the Chair would contact the local CCGs to offer a presentation on the BCN project at their Board meetings. 3 Page 6 of 23

7 Action To Be Taken Following The Meeting The Chairman has discussed this item with the CCG Chairs. 57/18 Executive Reports:- a) Strategy and Assurance Performance Reporting Mrs Swift reported that the presentation included feedback from the Board Committees. Quality Mr Roff reported on the discussions at the Quality Committee meeting held on 18th July 2018 stating the Committee still had concerns regarding:- The performance of the care at the right time indicator due to the Trust s ability to meet the national A&E performance target. The long term challenges facing the Trust due to the shortage of nurses in the UK required to deliver NHS nursing services. The need to develop a CQC dashboard to easily monitor the CQC action plan. The Patient Experience Survey and that the dissemination of the results and ownership of subsequent action plans within the divisions which needed to improve. With particular reference to 14 questions, the Trust was performing below national norms and this needed to be proactively addressed with staff in all divisions. In addition, Mr Roff advised that the Committee was still focussing on the 1 hour delivery target for sepsis antibiotics. Mr Thompson reported on the Friends and Family Test results and stated that the Trust continued to perform well with a rating of 96% in Quarter 1, however, there were improvements to be made as the A&E response rate was only 10%. Professor O Donnell stated that SHMI remained challenging and that the Trust rating was currently 115, however, it was anticipated that in the next iteration of SHMI the rating would improve to under 115. Professor O Donnell stated that the internal HED modelling supported that statement with a rating of 112. Mrs Swift thanked Mr Roff, Mrs Thompson and Professor O Donnell for the Quality Committee reporting and asked Mrs Whyham and Mr Renshaw for the Strategic Workforce Committee reporting. Workforce Mr Renshaw reported on the Strategic Ambitions allocated to the Strategic Workforce Committee, stating that there were currently 60 medical vacancies across the Trust, However, the Trust had 50 offers out with candidates and was developing a clinical vacancy microsite to support attracting good candidates. Mr Renshaw stated that a medical workforce strategy was in development and that it would include options to transform services. 4 Page 7 of 23

8 Mr Renshaw stated that the Trust had performed well in the Staff Satisfaction and Engagement Survey (SSES) compared to other Trusts, however, improvements were needed to the way in which the Trust communicated with staff. It was noted that the Strategic Workforce Committee would undertake deep dives with the divisions into improvement areas identified in the SSES. Mr Renshaw reported from the Strategic Workforce Committee meeting on 17th July 2018 stating that the Committee had concerns regarding:- The Health Education England North West Quality Monitoring Visit and the Educational Enhanced Monitoring by the GMC regarding the management of emergency care trainees. The development of a Medical Workforce Strategy which may require significant Trust investment and would involve the nursing workforce supporting the strategy through initiatives such as Advanced Practice. Mrs Whyham added that the Strategic Workforce Committee had reviewed the Revalidation and Appraisal Annual Report. She advised that Dr Chris Dunkley would be relinquishing the role of Safe Working Guardian and would be replaced by Dr Andy Ng. Mrs Whyham thanked Dr Dunkley for his contribution. Mrs Swift thanked Mr Renshaw and Mrs Whyham for the Strategic Workforce Committee reporting and asked Mr Cullinan and Mr Bennett for the Finance Committee reporting. Finance Mr Bennett reported from the Finance Committee meeting held on 18th July 2018 stating that the Committee had concerns regarding:- Year to date underlying performance the Trust had a deficit for the Trust of 7.1m which was 0.9m worse than budget (pre-impairment and PSF) and 0.6m worse than plan (pre-psf). This included one-off mitigations totalling 0.6m which had been applied in Quarter 1. Payment for A&E performance the Trust had missed the target for Quarter 1 which had resulted in a loss of 0.3m. Mr Bennett reported that significant improvements were required in Quarters 3 and 4 and that the Trust had put in place controls and corrective actions to mitigate the position through a turnaround process, management of pay cost run rates and cash mitigations. Mrs Barnsley reported that there had been no cases of MRSA, however, the Trust was slightly above the trajectory on CDiff. In relation to A&E performance the Trust was below the national 95%, however, the Trust had a plan to achieve 90% by September 2018 and 95% by March Mrs Barnsley stated that the quarterly position for the cancer targets had yet to close and, at present, the Trust data indicated that the organisation would not meet the urgent GP referral targets and the 62-day targets. Mrs Barnsley stated as a mitigation 300 patients would be transferred to the Spire Hospital to assist with Trust activity. Professor O Donnell reported on the length of stay data presented at the Finance Committee meeting which was based on a basket of 50 conditions which remained unchanged, however, the overall length of stay Strategic Ambition had improved. Professor O Donnell stated that readmission data was on the improvement trajectory. 5 Page 8 of 23

9 Mrs Whyham asked Mrs Barnsley about the financial implications of 300 patients being transferred to the Spire Hospital. Mrs Barnsley stated that no cost would be incurred by the Trust as the activity would be funded through the CCGs. Mrs Whyham questioned whether the Trust was underperforming on the cancer targets and Mrs Barnsley stated that patient choice was significantly affecting the Trust s performance. In conclusion Mr Cullinan stated that the Trust was under significant financial and performance pressures which, in part, was due to the difficulties in managing winter pressures in 2017/18, however, the Trust was making good progress in recovering the position. Mr Cullinan stated that the Trust needed to be mindful that winter was approaching and that plans needed to be ready. Mrs Swift thanked Mr Cullinan, Mr Bennett, Mrs Barnsley and Professor O Donnell for the Finance Committee reporting and asked Mr Hearty for the Audit Committee reporting. Audit Mr Hearty stated that a meeting of the Audit Committee had taken place on 3rd July 2018 and the Audit Committee had provided assurances as follows:- The Board Assurance Framework which had been reviewed by the Board Committees. A positive Assurance Framework discussion with Mr Cullinan regarding the performance of the Finance Committee. A productive Corporate Risk Deep Dive with the Scheduled Care Division and Unscheduled Care Division regarding demand and capacity. An assurance discussion regarding the Complaints Review Process which had been requested by the Council of Governors and good assurances were provided. Mr Hearty stated the Committee had concerns regarding risk management and the Corporate Risk Register which had not been reviewed and therefore the Committee agreed to establish a Risk Committee to aid in the management of risk. b) NHSI Use of Resources Assessment Mr Bennett stated that the Use of Resources assessment had taken place in November 2017 and that the report had been received in May It was noted that the report highlighted that the Trust was Good for the use of resources. Mr Bennett reported that the assessment stated the Trust was:- In the lowest 25% for non-pay spending. In line with the average for overall pay spending. In the lowest quartile for pathology testing costs. In the lowest quartile for corporate services costs. To be commended for establishing BFW Management Ltd (Atlas). Mr Bennett reported that the assessment highlighted a few areas for improvement which were readmission, length of stay and staff sickness. 6 Page 9 of 23

10 Mr Bennett stated that for governance purposes the assessment would be overseen by the Transformation Executive Board and assurance provided to the Finance Committee. Mr Case stated the assessment had a flaw as it did not link the effectiveness to the outputs of the organisation. Mr Case asked whether Board members were clear about what it would take to move from Good to Outstanding. Mr Bennett stated the Trust was clearly aware of the criteria for each domain. The Chair asked the Board to acknowledge, reflect and appreciate the staff for achieving a Good rating, however, the balance of recurring and non-recurring savings was a significant concern. c) Beckman Coulter Contract The Chair stated that the contract had been enclosed with the agenda for consideration and approval. Mr Bennett stated that the 3 year contract had been reviewed by the Finance Committee and it had been recommended that the Board of Directors approve the contract. RESOLVED: That approval be given for the Chair to sign the Beckman Coulter Contract. Mr Roff asked for an update on the Pathology Collaboration. Mr Bennett stated that the collaboration was developing an outline business plan, which would now include East Lancashire Hospitals Trust. It was noted that the redrafted document would be submitted to the Board in due course. RESOLVED: That the revised outline business plan for the Pathology Collaboration be submitted to a future Board meeting. Action To Be Taken Following The Meeting This action is subject to a delay of 2-3 months whilst the numbers for East Lancashire Hospital Trust are included in the business case. d) Chief Executive s Report The Chief Executive s report was provided for information. Mrs Swift welcomed Mr Butler into the post of Trust Chair. Mrs Swift reported on several Executive Director changes; it being noted that Mrs Oliver would be leaving the Trust at the end of the month and that Mrs Barnsley and Mrs Groves had been appointed as interim Executive Directors. Mrs Swift also reported that Mr Jim Gardener had been appointed as a Clinical Non-Executive Director. Mrs Swift advised that the BAF has been updated by the Board Committees. RESOLVED: That the Board Assurance Framework be approved by the Board of Directors. 7 Page 10 of 23

11 58/18 Chairman s Report a) Chairman s Update The Chair stated that he was visiting many areas of the Trust and that he was impressed by the commitment of staff. b) Proposed Review of the Chair/NED Recruitment Process and Proposed Amendments to the Trust Constitution. The Chair stated that queries had been raised by Governors and an MP regarding the recruitment of the Trust Chair and a Clinical Non-Executive Director. The Chair reported that he had established a Governors sub-group to review the process and to suggest amendments; it being noted that revised documents had been drafted for the Governors, however, they had requested more time to review the documents. The Chair stated that the vacancy being created by Mr Roff in August 2018 would therefore need to be filled under the existing Constitution and that NHSI would be informed. RESOLVED: That the Chair would inform NHSI about the intention to recruit a Non- Executive Director under the existing Constitution. Action To Be Taken Following The Meeting This item has been actioned. c) Annual Members Meeting 2017/18 The Chair stated that the recent joint Annual General Meeting/Annual Members Meeting with the local CCGs had been fantastic and demonstrated real joint working. RESOLVED: That the minutes of the joint Annual General Meeting/Annual Members Meeting held on 5th July 2018 be approved and recommended to the next Annual General Meeting/Annual Members Meeting for approval. d) Feedback from Clinical Commissioning Group Governing Body Meeting Blackpool CCG Meeting 3rd July 2018 Mr Hearty provided feedback from the Blackpool CCG Governing Body Meeting held on 3rd July 2018 as follows:- General It was the first meeting since the end of the 2017/18 reporting year. There was much on the agenda taken up with relatively old data on finance and performance, most of which was captured in the CCG Annual Report and Accounts for 2017/18. There had been discussion about the early numbers on both finance and performance for 2018/19. Finance The finances were on target at Month 2. The net risk of 1.1m remained in relation to QIPP delivery, mental health pressures, contract over-performance and CHC. Performance The Month 1 data was available which indicated a mix of results. 8 Page 11 of 23

12 There were plenty of reds around waiting times generally and in respect of cancer specifically. There were plenty of greens around operational performance and mental health. Presentation There was an interesting presentation around alternative models of primary care. Fylde & Wyre CCG Meeting 17th July 2018 It was noted that a Non-Executive Director had not observed the Fylde & Wyre CCG Governing Body meeting held on 17th July 2018 because it coincided with the Trust s Remuneration Committee meeting. 59/18 Key Themes from Team Brief It was noted that the key themes from the meeting would need to be cascaded to staff via the Team Brief. RESOLVED: That the Chief Executive would determine the items to be included in the Team Brief. Action To Be Taken Following The Meeting This item has been actioned. 60/18 Trust Values / Examples of Value of the Month It was noted that the values had been reflected during the meeting. It was further noted that the Value of the Month for August would be identified for Team Brief on 7th August /18 Attendance Monitoring It was noted that attendance at Board meetings continued to be good. 62/18 Any other Business a) Thank You It was noted that Mr Roff would be leaving the Trust at the end of August 2018 and the Chair thanked him for his dedication and contribution to the Trust during his seven years as a Non-Executive Director. 63/18 Items Recommended for Decision or Discussion by Board Sub-Committees RESOLVED: That items to be recommended for decision or discussion by Board Committees would be noted from the minutes of the meeting. 64/18 Questions from the Public The Chair reported that he had not received any questions in advance of the meeting from members of the public. 65/18 Date of Next Meeting The next meeting will take place on Wednesday 31st October Page 12 of 23

13 Board of Directors Meeting 25th July 2018 Action List Minute Ref/No Date Of Meeting Agenda Item Heading Action To Be Taken Person Responsible Date To Be Completed Change Of Date Progress 56/ Better Care Now Contact the local CCGs to offer a Chairman The Chairman has discussed this item with the presentation on the BCN project at their CCG Chairs. Board meetings. 57/18(c) Beckman Coulter Contract Arrange for the Chairman to sign the contract documentation. Judith Oates The contract documentation was signed on RAG Status Green Green 57/18(c) Beckman Coulter Contract - Pathology Collaboration Submit the revised outline business plan for the Pathology Collaboration to a future Board meeting. Tim Bennett This action is subject to a delay of 2-3 months whilst the numbers for East Lancashire Hospital Trust are included in the Business Case. White 58/ Proposed Review of the Chair/NED Recruitment Process and Proposed Amendments to the Trust Constitution Inform NHSI about the intention to recruit a NED under the existing Constitution. Chairman This item has been actioned. Green 59/ Key Themes for Team Brief Determine the items to be included in the Team Brief. Wendy Swift This item has been actioned. Green RAG Rating Green Amber Red White Completed Within Date For Delivery Incomplete But Within Date For Delivery Not Complete Within Date For Delivery Not Yet Due Page 1 Page 13 of 23

14 Board of Directors Meeting Action Tracking Document Minute Ref/No Date Of Meeting Agenda Item Heading Action To Be Taken Person Responsible Date To Be Completed Change Of Date 33/ Questions from the Public Address the issue of poor acoustics. Judith Oates Progress Enquires have been made about the possibility of Red installing an audio/microphone system in the Board Room. A desk mounted wireless solution has been recommended and a site visit has been arranged for The site visit was cancelled at short notice and is being re-arranged. Costings have been received and are being considered by the IT Developments Team. The Chairman is reviewing with the Governors the arrangements for managing the acoustics. The costs associated with an audio/microphone system are expensive and therefore alternative arrangements are being considered, i.e. a portable PA system. RAG Status Item 15/ Questions from the Public Raise with the Specialist Commissioners the issue of adopting innovative practice within the Trust. Wendy Swift/ Tim Bennett Janet Barnsley Discussions have commenced with the Specialist Commissioners around plans to develop Cardiac Services. These discussions are on-going. An update was provided to Board members at the meeting on confirming that the expansion of the cardiac catheter laboratory facility was currently going through the business case process. Red 24/ Strategy and Assurance Performance Reporting - Workforce Undertake work around forecasting in order to pre-empt the staffing issue. Paul Renshaw September/ October The medical workforce strategy work is underway and will be reported to the Board as planned in July. The capacity and demand work that has just started will enable better forecasting of our staffing requirements and this will be completed in September/October White 40/18 (a) L&SC Provider, Acute & Specialist Services Programme Update Liaise with Gemma Stanion about a further update to the Board. Mark O'Donnell Mark O'Donnell and Gemma Stanion attended the Fylde Coast Executive Strategy Group on to discuss the programme. Mark O'Donnell is arranging to discuss with Gemma Stanion the timescale for providing a further update to the Board. Red 40/18 (c) Quality Strategy Metrics and Targets Year 3 Green Amber Red White Complete Within Date For Delivery Incomplete But Within Date For Delivery Not Complete Within Date For Delivery Not Yet Due Use the format of the document as the theme for future strategies. Executive Directors on-going This item will be considered for future strategies. White 21/09/2018 Page 1 Page 14 of 23

15 Board of Directors Meeting Action Tracking Document 21/09/2018 Page 2 Page 15 of 23

16 Board of Directors Meeting 26th September 2018 Medical Examiners Report Prepared By: Professor Mark O Donnell, Medical Director Contact Details: Ext Date of Report: 30 th August 2018 Purpose of Report: To update the Board on national progress regarding implementation of Medical Examiners For information Recommendations: To note the report. For Discussion For Approval Sensitivity Level: 1 Not sensitive: For immediate publication 2 Sensitive in part: Consider redaction prior to release 3 Wholly sensitive: Consider applicable exemption Page 16 of 23

17 Board of Directors Meeting 26th September 2018 Medical Examiners Purpose To update the Board on progress regarding the implementation of a scheme for Medical Examiners in England and Wales. Background The Government has proposed for several years that there should be a role of Medical Examiner. This is a senior clinician who would have oversight of death certification in hospital and liaise with HM Coroner regarding the need or otherwise for a Coroner s inquest. Pilot schemes in several areas of the country have shown benefits in terms of family satisfaction with the death certification process, a reduction in complaints to the Trust and a reduction in the number of Coronial inquests. The scheme was originally intended to be introduced nationally several years ago but had stalled. In June of this year the Department of Health and Social Care published the Government s response to a consultation on the scheme. The Trust had contributed to the consultation. In August the Medical Director and Trust Solicitor met with the Senior Coroner for Blackpool to discuss progress. The current stance is that the establishment of a Medical Examiner post is still not statutory but the Government is encouraging the introduction of these posts on a voluntary basis pending legislation. HM Coroner has asked if the Trust is minded to make such an appointment. Below is an extract from the Department s response to the consultation: The response to the consultation demonstrates that there is widespread support for the aims of the reforms and for the introduction of medical examiners but there were concerns about some aspects of the proposals. In particular, concerns were raised about how the proposed model, to be based in local authorities, would work in practice and about the proposed timeframes for implementing the system. Feedback on a proposed funding model was also received. Since the Government consulted on the package of Death Certification reforms events have moved on. New information on how medical examiners could be introduced across England within the NHS has been generated by our pilot sites and NHS Trusts that have adopted a medical examiner model to support their work on the Learning from Deaths process, which has been in place since March Going forward section 21 and 18 of the Coroners and Justice Act 2009 will be commenced, this will provide for the appointment of a National Medical Examiner and a power to introduce regulations that would require medical practitioners to report deaths to the coroner for which the coroner has a duty to investigate. We will progress with the introduction of the medical examiners by April 2019 and, in parallel, explore the option to amend the 2009 Act to make the requirement for medical examiners statutory. The revised plans are designed to respond to the issues raised in consultation, to reflect developments within the NHS and to build on elements of the process that have been shown to deliver real improvements, in particular, for the bereaved. Issues to consider 1) Does the Trust wish to proceed at this time? 2) How the post should be funded 3) Whether a suitable clinician can be recruited. 4) The request from HM Coroner that he be involved in the appointment process. Professor Mark O Donnell Medical Director Page 17 of 23

18 Board of Directors Meeting 26th September 2018 Chief Executive s Report Report Prepared By: Wendy Swift, Chief Executive Contact Details: Ext Date of Report: 20th September 2018 Purpose of Report: To provide the Board of Directors with an update on current issues, particularly the Board Assurance Framework, Code of Governance and Trust meetings/activities. 1 X 2 3 For information Recommendations: For Discussion For Approval The Board is asked to note the contents of the report and to note and approve the amendments made within the Board Assurance Framework. Sensitivity Level: 1 X Not sensitive: For immediate publication 2 Sensitive in part: Consider redaction prior to release 3 Wholly sensitive: Consider applicable exemption 1 Page 18 of 23

19 Board of Directors Meeting Chief Executive s Report 26th September 2018 Board Assurance Framework Update (BAF) The Audit Committee discussed the BAF, noting the amendments that had been made to BAF 4 and BAF 5 of the Framework by the Strategic Workforce Committee. The Quality Committee discussed the BAF at their meeting on 18th July and no amendments were made. The BAF was reviewed at the Finance Committee meeting in September and no amendments were made. The Strategy and Assurance Committee has not met since the last review. It is recommended that the Board of Directors approves the Board Assurance Framework. Corporate Risk Register Update (CRR) The Audit Committee has reviewed the Corporate Risk Register. The Trust has now set up a Risk Committee to discuss the risks escalated from the Divisional Risk Registers. The Risk Committee will review the Corporate Risk Register and report to the Audit Committee. It is recommended that the Board of Directors approves the Corporate Risk Register. Code of Governance - Chairman and Chief Executive Roles and Responsibilities In order to ensure compliance with the Code of Governance, the Trust is required to establish in writing the division of responsibilities between the Chairman and Chief Executive for review and approval by the Board of Directors. The document, which is included in the Reference Folder, reflects the respective roles of the Chairman and Chief Executive and no amendments have been made since the document was approved by the Board in July 2016 and reviewed by the Board in July The Board of Directors is requested to review and approve the Chairman and Chief Executive Roles and Responsibilities. Celebrating Success Judging Panel- 17th August 2018 This year s judging panel was faced with a very difficult task. Once again we saw an excellent response with more than 450 nominations in total. We were impressed with the outstanding quality of entries which made selecting a shortlist in each category exceedingly difficult and because of the high standard in all categories the decisions were incredibly tight with a number of nominations deserving recognition. The winners will be announced at the Celebrating Success Awards and Celebration Ball on Friday 9th November at the Winter Gardens. Clifton Hospital Tea Party and 30th Birthday Party It was a pleasure to attend the Clifton garden opening on 17th August which was officially opened by the Chairman, Mr Butler, and comedy legend, Bobby Ball. The garden will be of great benefit to all our patients, staff and relatives for years to come. Clifton Hospital celebrated its 30th Birthday on 7th September with a celebration birthday party for staff and patients. 2 Page 19 of 23

20 Reducing Sale of Sugar Sweetened Beverages on NHS Premises NHS England has been running a campaign as part of the Healthy Workforce Programme to reduce the sale of sugar-sweetened beverages (SSBs) on NHS premises. Following a consultation NHS England published their preferred approach to implementing a voluntary reduction scheme, rather than a ban, in April last year. As part of this, they asked all hospitals to sign up to the scheme and reduce the sale of SSBs to 10% or lower by the end of 2017/18 or a ban would come into play in July this year. So far NHS England have received a positive response from many of the hospitals across the country and the scheme has already shown a reduction in SSB sales from 15.6% in July 2017 to 8.7% in March 2018, helping our staff, visitors and patients to make healthier choices. Progress has been sufficiently strong that the ban was not deployed. So far there are only 2 NHS Trusts in the North who are yet to sign up to this initiative; Blackpool Teaching Hospitals is one of them. By signing up to the scheme the Trust agrees to: Reduce the total volume of monthly sugar-sweetened beverage sales per NHS outlet, aiming for a target of 10% or less of total volume of drinks sales; In agreeing to this goal provide NHS England with quarterly self-reported data; This data should comprise total monthly beverage sales by volume (litres), including the total number of sugar-sweetened beverage sales, on a site-by-site or outlet-by-outlet basis; Discussions have taken place with the Facilities Team at Blackpool Teaching Hospitals who have had agreement from; the food outlets based at Blackpool Victoria Hospital (Costa, Marks and Spencer, WH Smiths), the Restaurant and the Charitable Funds Shop (based in the Out-Patients Department) that they are all able to provide the data required to sign up to the sugar sweetened beverages commitment. Signing up to this initiative has been recommended by the Healthier Workforce Taskforce Group and is being presented to the Board for ratification. The Board of Directors is asked to ratify the recommendation of the Healthier Workforce Taskforce Group to sign-up to this initiative. Wendy Swift Chief Executive 3 Page 20 of 23

21 Board of Directors Meeting 26th September 2018 Confirmation of Chairman s Action The Directors are requested to confirm the action taken by the Chairman on behalf of the Board of Directors as follows:- Number Date Project Details PACS/RIS Contracts Provision of Linen and Laundry Services EY Consulting Judith Oates Corporate Assurance Manager/ Foundation Trust Secretary Page 21 of 23

22 Board of Directors Meeting 26th September 2018 Affixing of the Common Seal The Board of Directors is requested to confirm the affixing of the Common Seal as follows:- Number Date Contract Details Lease for Land and Buildings at Blackpool Victoria Hospital (Atlas/DWF) Judith Oates Corporate Assurance Manager/ Foundation Trust Secretary Page 22 of 23

23 Board of Directors Attendance Monitoring 1st April st March 2019 Attendees (quorate) Pearse Butler (Chairman) N/A N/A G Karen Crowshaw (Interim Chairman) G G N/A N/A N/A N/A Alan Roff G G G N/A N/A N/A Michael Hearty G Y G Mark Cullinan G G G Mary Whyham G G G Keith Case G Y G Steve Finnigan G G G Wendy Swift G G G Tim Bennett G G G Professor Mark O Donnell G G G Marie Thompson G G G Pat Oliver G G N/A N/A/ N/A N/A Attendees (non-quorate) Paul Renshaw G G G Janet Barnsley N/A G G Berenice Groves N/A G Y Attendance Apologies Deputy No Apologies / Deputy G A B R * attended as an observer Page 23 of 23