Agenda - 28 July 2021 Trust Board of Directors Meeting held in Public Date: Wednesday 28 July 2021 Location: via MS Teams Start Time: 09:00 Finish Time: 12:00 Timings Item No Lead Paper/Verbal Opening Matters 09:00 P1-107-21 Welcome & Apologies: KD Verbal Declarations of Committee Members’ and other attendees’ P1-108-21 KD Verbal interests concerning agenda items: P1-109-21 Minutes of last meeting: 30 June 2021 KD Paper P1-110-21 Matters arising/Action Log KD Paper P1-111-21 Chair’s Report to the Board KD Verbal Risk and Assurance 09:15 P1-112-21 Quality Committee Chair’s Report TJ Paper 09:25 P1-113-21 Performance Committee Chair’s Report GB Paper 09:35 P1-114-21 Charitable Funds Committee Chair’s Report EA Paper 09:45 P1-115-21 Audit Committee Chair’s Report MT Paper 09:55 P1-116-21 Audit Committee Annual Report to the Board MT Paper 10:05 P1-117-21 Patient Story KS Verbal 10:25 P1-118-21 Patient Experience Visits JSp Paper 10:35 P1-119-21 New Consultant Appointments: None to note 10:40 P1-120-21 Integrated Performance Report: Month 03 JSp/JSh Paper 10:50 P1-121-21 Finance Report: Month 03 JT Paper 11:00 P1-122-21 a)Mortality Annual Report SK Paper Agenda: April 2021: Version 2: Author: Corporate Governance Trust Board Part 1 - 28 July 2021-28/07/21 1 of 298 Agenda - 28 July 2021 b) Mortality Dashboards 11:10 P1-123-21 Safeguarding Annual Report JSp Paper 11:20 P1-124-21 Freedom to Speak Up Annual Report AW Paper 11:25 P1-125-21 Infection, Prevention and Control Annual Report JSp Paper System Working 11:30 P1-126-21 Cheshire & Merseyside Cancer Alliance Performance Report LB Paper 11:35 P1-127-21 Inequalities of Access to Services LB Paper 11:45 P1-128-21 Cheshire & Merseyside Cancer Alliance Annual Report LB Paper Corporate Governance 11:55 P1-129-21 Board Development AW Paper 12:00 P1-130-21 Regulation 5 Declarations (Fit and Proper) AW Paper P1-131-21 Board Meeting Review ALL Verbal Next Meeting: Date: Wednesday 29 September 2021 Location: TBC Start Time: 09:00 Finish Time: 12:30 Agenda: April 2021: Version 2: Author: Corporate Governance 2 of 298 Trust Board Part 1 - 28 July 2021-28/07/21 P1-109-21 Minutes of last meeting: 26 May 2021 Minutes of the Trust Board of Directors held in Public Held on: Wednesday 30 June 2021 Location: The Spine & via MS Teams Start time: 09:00 hours Finish time: 11:20 Present Kathy Doran (KD) Chair Mark Tattersall (MT) Non-Executive Director Terry Jones (TJ) Non-Executive Director Geoff Broadhead (GB) Non-Executive Director Elkan Abrahamson (EA) Non-Executive Director Asutosh Yagnik (AY) Non-Executive Director Liz Bishop (LB) Chief Executive James Thomson (JT) Director of Finance Joan Spencer (JSp) Chief Operating Officer & Interim Chief Nurse Jayne Shaw (JSh) Director of Workforce and OD Sheena Khanduri (SK) Medical Director Sarah Barr (SB) Chief Information Officer Tom Pharaoh (TP) Director of Strategy In attendance Emily Kelso (EK) Corporate Governance Manager (minutes) Jane Wilkinson (JW) Lead Governor Maria Maguire (MM) Head of Research Governance & Sponsorship Emma Whitby (EW) Head of Research Deliver Alun Evans (AE) Staff Side Representative Observer Myfanwy Borland Public Governor Agenda item Item no. Action Chair Welcome and Note of Apologies P1/89/21 The Chair welcomed all to the meeting with apologies noted from Anna Rothery Non- Executive Director and Angela Wendzicha Associate Director of Corporate Governance. Declarations of Board Members and other attendees’ interests concerning P1/90/21 agenda items: Mark Tattersall – Nominated Non-Executive Director for PropCare Version: 1.0 Ref: FCGOMINS Review: May 2024 Trust Board Part 1 - 28 July 2021-28/07/21 3 of 298 P1-109-21 Minutes of last meeting: 26 May 2021 Terry Jones – Director of Liverpool Head and Neck Centre and Associate Medical Director for Research, Liverpool University Hospital NHS Foundation Trust Geoff Broadhead – Nominated Non-Executive Director for CPL James Thomson – Executive Lead for PropCare and CPL Minutes of Previous Board Meeting: 26 May 2021 P1/91/21 The Board approved the minutes of the Board meeting held on 26 May 2021. The Trust Board: Approved the minutes of the Board meeting held on 26 May 2021 Matters Arising/Action Log The Board noted that actions were either complete, on the Agenda or not yet due, in addition the following update was provided: P1/92/21 JSh confirmed that the Trust would be working with an external provider on Unconscious Bias Training instead of the Specialist Trust Alliance; dates for training were to be confirmed. The Trust Board: Noted the position in relation to the Action Log. Chair’s Report to the Board KD informed the board of two senior appointments made: Julie Gray Chief Nurse, who would start on the 1st October 2021 Margaret Saunders – Associate Director of Corporate Governance, who would start at the Trust on the 1st September 2021 KD informed the Board that she had recently attended the North West Regional Chair meeting, which was the last meeting for Bill McCarthy, as he would be retiring in July, P1/93/21 it was noted that his replacement would be Amanda Doyle originally a GP from Blackpool, who had spent considerable time in senior management within the NHS. The vaccine programme was discussed and vaccination rates within the region were noted. Vaccine education and engagement programmes targeting underrepresented communities were now a key focus. Long Covid services were being set up with £11m funding being allocated to the region. Integrated Care System implementation was still anticipated for April 2022. Quality Committee Chair Report TJ provided an overview of the report, alerting the Board to the following: The committee had received an update on progress in relation to the Aseptic Unit and monthly reports will continue until sufficient assurance was P1/94/21 received. The committee had requested a deep dive on the risks surrounding the ECMC, which was to be presented in July. TJ Alerted the Board to the two separate papers requested by the committee; A deep dive on those risks/issues recorded under the Communications category and a paper on trends within the Communications category relating to virtual consultations. Version: 1.0 Ref: FCGOMINS Review: May 2024 4 of 298 Trust Board Part 1 - 28 July 2021-28/07/21 P1-109-21 Minutes of last meeting: 26 May 2021 TJ further advised of the JACIE Accreditation Preparedness report presented by Dr Muhammad Saif. The report detailed the complex nature of stem cell transplants and the highly robust accreditation quality standards set out by JACIE. Assurance was provided on the progress to date. KD enquired into the expected timescale for JACIE Accreditation. LB responded that an exact time scale had not been confirmed. It was expected that the inspection would take place before the end of the 21/22 financial year. MT sought clarity on the level of assurance the committee had received on the two Alert items on the Chairs report, which also featured on the BAF. TJ confirmed that progress on the Aseptic Unit was within the planned timescales, the impact on Research and clinical trials was to be investigated further and would be addressed in the ECMC deep dive. GB added that the Aseptic Unit issues and the impact on Research were also a focus for the Performance Committee ; Research Business Plan report had been received and was now a quarterly standing agenda item, in order for the committee to quantify the impacts on income. SK gave assurance that those studies not requiring aseptic unit input were progressing well and that the Trust had recently been the first to gain approval for a radiotherapy brain tumor study along with transgene studies as reported in the media. JW queried the percentages of trials affected because of the Aseptic Unit issues. TJ confirmed this figure could be provided in July and had been requested by the committee as an exception report from the IPR. Medicine Management Seminar - TJ provided feedback from the seminar which had been requested by the Quality Committee in response to medicines management risks and issues. An overview of the principles around medicines management and assurances on the processes in place had been provided by subject matter experts. The format and facilitation of the session was valued and further sessions on topics of interest would be well received. KD confirmed that that the Board work plan was to be further developed to include developmental & information sessions. The Trust Board: Discussed and noted the content of the report. Audit Committee Chair’s Report MT provided an overview of the report, alerting the Board that despite the assurances given at the 26 May 2021 meeting, the auditors had missed the deadline and as a result, the planned extra ordinary Trust Board meeting had been rescheduled to 28th June prior to the Board meeting. It was noted that the CCC team had delivered to timescales and the delay was not attributable to any internal failures. P1/95/21 The Board discussed the upcoming appointment process for the Trust’s External Auditors and the considerable market gap. MS confirmed there were a number of new suppliers and that exploratory conversations would take place to determine suitability. It was noted that as per the constitution, the Council of Governors would meet and make the final decision on the appointment of the external auditor; this meeting was scheduled for September and that the Trust would follow a stringent procurement process to shortlist.