COUNCIL OF GOVERNORS’ A Meeting of the Council of Governors will be held at 10.00 am on Wednesday 22 nd November 2017, in Rooms 9 & 10, Education Centre, Queen Elizabeth Hospital
A G E N D A
1. Apologies for Absence:
2. To Sign the Attendance Register:
3. Chairman’s Business
4. Minutes of the Previous Meeting Enclosure To approve the minutes of the previous meeting of the Council of Governors held on Wednesday 27 th September 2017
5. Matters Arising from the Minutes
6. Chief Executive’s Briefing Enclosure To receive the Chief Executive’s routine briefing report
Items for Decision:-
7. Constitution Review Enclosure To approve amendments to the Trust’s Constitution presented by the Trust Secretary
8. Lead Governor Appointment Enclosure To approve the appointment of a lead governor, presented by the Trust Secretary
Items for Assurance:-
9. Finance and Activity Performance Presentation To receive a report on the Trust’s current performance, presented by the Director of Finance and Informatics
10. Performance Report Enclosure To receive the routine briefing report presented by the Director of Strategy and Transformation
11. Learning from Serious Incidents and Duty of Candour Report Enclosure To receive the report presented by the Head of Risk
12. Committee Assurance Report Enclosure To receive a report for assurance from the Quality Governance Committee, presented by the Chairman of the Committee
13. Integrated Learning Report Enclosure To receive a summary report from the Head of Risk on the Complaints, Litigation, Incident and PALS Report
Items for Discussion:-
14. Membership Development Working Group Enclosure To receive a progress report on the work of the Membership Group, presented by the Chairman of the Group
15. Membership Feedback Verbal For governors to feedback on events attended and activities undertaken, and to report any queries or comments received
Items for Information:-
16. Governor Activities Enclosure To receive a report on the activities of governors, presented by the Trust Secretary
17. Election 2017 Update Enclosure To receive an update on election process for 2017, presented by the Membership Co-ordinator
18. Calendar of Events for 2018 Enclosure To receive the calendar of meetings and events for governors for 2018, presented by the Membership Co-ordinator
19. NHS Providers Governor Advisory Committee Elections Enclosure To receive a briefing for information, presented by the Trust Secretary
20. Date and Time of Next Meeting The next meeting of the Council of Governors will be held on Wednesday 28 th February 2018 at 10.00 am in Rooms 9 & 10, Education Centre
21. Exclusion of the Press and Public To resolve to exclude the press and public from the remainder of the meeting, due to the confidential nature of the business to be discussed
COUNCIL OF GOVERNORS’ A Meeting of the Council of Governors will be held at 10.00 am on Wednesday 22 nd November 2017, in Rooms 9 & 10, Education Centre, Queen Elizabeth Hospital
A G E N D A
1. Apologies for Absence:
2. To Sign the Attendance Register:
3. Chairman’s Business
4. Minutes of the Previous Meeting Enclosure To approve the minutes of the previous meeting of the Council of Governors held on Wednesday 27 th September 2017
5. Matters Arising from the Minutes
6. Chief Executive’s Briefing Enclosure To receive the Chief Executive’s routine briefing report
Items for Decision:-
7. Constitution Review Enclosure To approve amendments to the Trust’s Constitution presented by the Trust Secretary
8. Lead Governor Appointment Enclosure To approve the appointment of a lead governor, presented by the Trust Secretary
Items for Assurance:-
9. Finance and Activity Performance Presentation To receive a report on the Trust’s current performance, presented by the Director of Finance and Informatics
10. Performance Report Enclosure To receive the routine briefing report presented by the Director of Strategy and Transformation
11. Learning from Serious Incidents and Duty of Candour Report Enclosure To receive the report presented by the Head of Risk
12. Committee Assurance Report Enclosure To receive a report for assurance from the Quality Governance Committee, presented by the Chairman of the Committee
13. Integrated Learning Report Enclosure To receive a summary report from the Head of Risk on the Complaints, Litigation, Incident and PALS Report
Items for Discussion:-
14. Membership Development Working Group Enclosure To receive a progress report on the work of the Membership Group, presented by the Chairman of the Group
15. Membership Feedback Verbal For governors to feedback on events attended and activities undertaken, and to report any queries or comments received
Items for Information:-
16. Governor Activities Enclosure To receive a report on the activities of governors, presented by the Trust Secretary
17. Election 2017 Update Enclosure To receive an update on election process for 2017, presented by the Membership Co-ordinator
18. Calendar of Events for 2018 Enclosure To receive the calendar of meetings and events for governors for 2018, presented by the Membership Co-ordinator
19. NHS Providers Governor Advisory Committee Elections Enclosure To receive a briefing for information, presented by the Trust Secretary
20. Date and Time of Next Meeting The next meeting of the Council of Governors will be held on Wednesday 28 th February 2018 at 10.00 am in Rooms 9 & 10, Education Centre
21. Exclusion of the Press and Public To resolve to exclude the press and public from the remainder of the meeting, due to the confidential nature of the business to be discussed
COUNCIL OF GOVERNORS’ A Meeting of the Council of Governors will be held at 10.00 am on Wednesday 22 nd November 2017, in Rooms 9 & 10, Education Centre, Queen Elizabeth Hospital
A G E N D A
1. Apologies for Absence:
2. To Sign the Attendance Register:
3. Chairman’s Business
4. Minutes of the Previous Meeting Enclosure To approve the minutes of the previous meeting of the Council of Governors held on Wednesday 27 th September 2017
5. Matters Arising from the Minutes
6. Chief Executive’s Briefing Enclosure To receive the Chief Executive’s routine briefing report
Items for Decision:-
7. Constitution Review Enclosure To approve amendments to the Trust’s Constitution presented by the Trust Secretary
8. Lead Governor Appointment Enclosure To approve the appointment of a lead governor, presented by the Trust Secretary
Items for Assurance:-
9. Finance and Activity Performance Presentation To receive a report on the Trust’s current performance, presented by the Director of Finance and Informatics
10. Performance Report Enclosure To receive the routine briefing report presented by the Director of Strategy and Transformation
11. Learning from Serious Incidents and Duty of Candour Report Enclosure To receive the report presented by the Head of Risk
12. Committee Assurance Report Enclosure To receive a report for assurance from the Quality Governance Committee, presented by the Chairman of the Committee
13. Integrated Learning Report Enclosure To receive a summary report from the Head of Risk on the Complaints, Litigation, Incident and PALS Report
Items for Discussion:-
14. Membership Development Working Group Enclosure To receive a progress report on the work of the Membership Group, presented by the Chairman of the Group
15. Membership Feedback Verbal For governors to feedback on events attended and activities undertaken, and to report any queries or comments received
Items for Information:-
16. Governor Activities Enclosure To receive a report on the activities of governors, presented by the Trust Secretary
17. Election 2017 Update Enclosure To receive an update on election process for 2017, presented by the Membership Co-ordinator
18. Calendar of Events for 2018 Enclosure To receive the calendar of meetings and events for governors for 2018, presented by the Membership Co-ordinator
19. NHS Providers Governor Advisory Committee Elections Enclosure To receive a briefing for information, presented by the Trust Secretary
20. Date and Time of Next Meeting The next meeting of the Council of Governors will be held on Wednesday 28 th February 2018 at 10.00 am in Rooms 9 & 10, Education Centre
21. Exclusion of the Press and Public To resolve to exclude the press and public from the remainder of the meeting, due to the confidential nature of the business to be discussed
COUNCIL OF GOVERNORS’ ANNUAL GENERAL MEETING Minutes of the Council of Governors’ Annual General Meeting held at 10.00 am on Wednesday 27 th September 2017 , in the Lecture Theatre, Education Centre, Queen Elizabeth Hospital
Present: Mrs JEA Hickey Chairman
Mrs E Adams Public Governor – Central Mrs S Begg Public Governor – Central Mr S Connolly Public Governor – Central Mrs C Coulson Public Governor – Western Professor P Dawson Appointed Governor Mr A Dougall Public Governor – Eastern Mrs J Doyle Appointed Governor Mrs C Ellison Staff Governor Reverend J Gill Public Governor – Western Mr J Holmes Public Governor – Central Mrs M Jobson Public Governor – Eastern Mrs J Lockwood Public Governor – Western Mr M Loome Public Governor – Central Mr A Rabin Public Governor – Central Mr A Sandler Appointed Governor Mr R Stead Staff Governor Mrs M Summers Public Governor – Western Mrs J Todd Public Governor – Western
In Attendance: Mrs D Atkinson Trust Secretary Dr R Bonnington Non-Executive Director Mr S Bowron Non-Executive Director Mr A Colwell Head of Facilities (for item G/17/44) Mrs C Coyne Director of Diagnostic and Screening Services Mr D Gilbert Mental Health Modern Matron (for item G/17/46) Mr P Hopkinson Non-Executive Director Mrs N Kenny Associate Director Medicine Mr M Laing Associate Director Community Services Mrs K Larkin-Bramley Non-Executive Director Mrs H Lloyd Director of Nursing, Midwifery and Quality Mr J Maddison Group Director of Finance and Informatics Mr N McDonaugh Associate Director Surgery Mr ID Renwick Chief Executive Mr J Robinson Non-Executive Director Mrs S Watson Director of Strategy and Transformation Mrs J Williamson Membership Co-ordinator
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Apologies: Dr F Ahmad Staff Governor Mr A Beeby Medical Director Mrs J Coleman Staff Governor Cllr M Foy Appointed Governor Cllr M Gannon Non-Executive Director Mrs A Hayward Staff Governor Mrs G Henderson Public Governor – Western Mrs H Jones Public Governor – Central Mr D Shilton Non-Executive Director Dr L Ternent Appointed Governor
Agenda Action Discussion and Action Points Item By G/17/34 Chairman’s Business:
Mrs JEA Hickey, Chairman, opened the meeting by asking if anyone present had any revisions to their declared interests.
She welcomed Dr R Bonnington, Non-Executive Director, to her first Council of Governors’ meeting.
Mrs Hickey concluded her report by reminding governors that the next Workshop will be held on Wednesday 4 th October 2017 from 10.00 am to 12.00 pm. The session will focus on patient flow.
G/17/35 Minutes of the Previous Meeting:
The minutes of the Council of Governors’ Meeting held on Wednesday 24 th May were approved as a correct record.
G/17/36 Matters Arising from the Minutes:
The action plan was updated accordingly to reflect matters arising from the minutes.
G/17/37 Chief Executive’s Briefing:
Mr ID Renwick, Chief Executive, presented his routine briefing report.
He began by reporting that the Trust is continuing to report a relatively strong financial and regulatory performance. He added that A&E performance showed signs of some pressure in August but this appears to be back on track. Page 2 of 23
Agenda Action Discussion and Action Points Item By
Mr Renwick informed the group that the Trust is currently finalising plans for winter, and the final plan will be presented to the Board of Directors in October 2017 for approval.
He reported that the STP process continues slowly and the process has now started to discuss how to bring the three separate STPs across the North East together. A single lead has been identified and it is expected that Mr Alan Foster, currently Chief Executive at North Tees NHS Foundation Trust, will be appointed from 1st October 2017.
Mr Renwick informed the group that alongside the regional work, the Trust is part of a group looking at the practicalities of developing an Accountable Care Partnership for Gateshead. He added that clinical leaders from across the patch have met to discuss which services need to be concentrated on first. He stated that as these discussions progress, he will provide updates to the Council of Governors.
He reminded the group that usually at this time of year there is a planning process in place for governors to be involved in the development of the Trust’s Annual Plan. He added that a two year plan was developed last year and to date there are no timescales set for the following year. He stated that governors will be kept up to date as the planning requirements become clearer, and appropriate meetings will be arranged once the timings are known.
Mrs JEA Hickey, Chairman, stated that she had discussed dates for planning meetings with Mrs D Atkinson, Trust Secretary, and dates have been held provisionally for November, December and January.
Mr ID Renwick, Chief Executive, concluded his presentation by reporting that the Trust’s Star Awards had taken place the previous week. The event was bigger and better than all previous events and he expressed his thanks to staff involved in the organisation of the night. He added that the event was fantastic and gave his congratulations to all those nominated staff and teams, and the overall winners.
After further consideration, it was:
RESOLVED: to receive the report for information
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Agenda Action Discussion and Action Points Item By G/17/38 Declarations of Interest – New Governors:
Mrs D Atkinson, Trust Secretary, presented a paper detailing the declared interests of newly elected staff governors, Mrs C Ellison and Mr R Stead.
Name Position Interest Interest of Spouse Mrs C Ellison Staff Governor None None
Mr R Stead Staff Governor None None
After further discussion, it was:
RESOLVED: to approve and record in the minutes, the declared interests of staff governors, Mrs C Ellison and Mr R Stead
G/17/39 Annual Report and Accounts 2016/17:
Mr ID Renwick, Chief Executive, presented the Annual Report and Accounts 2016/17.
He stated that the Trust is required to produce an Annual Report, which is a retrospective look back at the organisation’s performance.
Mr Renwick commented that the Annual Report gives the Trust the opportunity to reflect on the 12 month period, looking at the financial and quality performance and highlight key achievements and developments.
He stated that the Trust reported a strong year-end financial performance that enabled access to additional payments from NHS Improvement.
Mr Renwick reported that the last financial year was the first full year of the Emergency Care Centre, and alongside the excellent staff, the building itself is part of allowing the Trust to deliver a good strong performance, particularly on the A&E four- hour target.
He added that one of the main achievements of the year was welcoming community services to the Trust. The addition of the service is already making such a difference to patients, with great potential to do better things for patients closer to their
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Agenda Action Discussion and Action Points Item By homes.
Mr Renwick stated that the next 12 months is another exciting but very busy time for the Trust. The winter period will be difficult but with good management he is hopeful for success.
He concluded his report by thanking Mrs D Atkinson, Trust Secretary, for the co-ordination of the production of the Annual Report. He stated that the document provides an opportunity to review the highlights of the year, but he will continue to share information with the Council of Governors throughout the year.
Mrs JEA Hickey, Chairman, stated that the report contains a lot of prescribed information but also some key messages. She congratulated all staff on a good year.
After further discussion, it was:
RESOLVED: to receive the Annual Report and Accounts 2016/17
G/17/40 Annual Management Letter 2016/17:
Mr J Maddison, Group Director of Finance and Informatics, presented the annual management letter 2016/17.
He reminded the group that the purpose of the annual audit letter is to review and ensure that the annual accounts and report and quality account are fit for purpose and discharge the statutory duties required of the Trust.
Mr Maddison reported that the auditors, KPMG, review the documents and the annual audit letter provides assurance to the Board of Directors and the Council of Governors.
He drew attention to the paper, agenda item 9, informing the group that there are three opinions which are reported on: the financial statements; use of resources; and the annual governance statement. The Auditors were able to provide positive opinions in all three areas.
He stated that the key headlines are that the Trust reported an unqualified set of accounts, the Trust has delivered and has proper processes, and the annual governance statement reported no significant issues.
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Agenda Action Discussion and Action Points Item By Mr Maddison reported that two recommendations were made; one which was low risk on the annual accounts and one medium risk on quality accounts relating to data quality. He stated that both recommendations are being addressed.
He concluded his report by stating that in summary, the audit letter is a very good report.
Mrs JEA Hickey, Chairman, stated that the report is a significant assurance report for both the Board of Directors and the Council of Governors. She noted that, in her experience, it was unusual to have no adjusted or unadjusted audit differences that affected the bottom line surplus. This was indicative of the high quality of financial information produced and this is a great credit to Mr J Maddison, Group Director of Finance and Informatics, Mrs J Bilcliff, Operational Director of Finance and their team, and great source of assurance for governors.
After further discussion, it was:
RESOLVED: to receive the report for assurance
G/17/41 Finance and Activity Performance:
Mr J Maddison, Group Director of Finance and Informatics, presented the financial headlines at Month 5.
He reported that at the end of August the Trust’s actual deficit was £911k, which is a positive variance against plan of £72k.
Mr Maddison stated that in order for the Trust to hit the financial control total, a level of income from the CCG was planned along with a level of expenditure required to deliver the treatment and care of patients. As part of that we are required to improve efficiency and cost effectiveness each year, and this year savings of £12.5m are required.
He added that at Month 5, the Trust has actioned CRP savings of £3.7m, which is £958k behind plan. However, as the Trust has recovered more income and spent less, overall the performance is slightly ahead of plan.
Mr Maddison reported that at the end of August, the Trust’s cash balance was £6.6m. This is monitored on a daily basis as significant fluctuations can be experienced. He added that this will reduce in October when the Trust repays interest and dividend payments and spends more on capital infrastructure.
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Agenda Action Discussion and Action Points Item By
He stated that the Trust’s rating for use of resources is currently 2, where 1 is the best rating.
Mr Maddison concluded his report by informing the group that for the wider NHS, the Q1 national deficit for NHS providers was £736m, £30m worse than planned and £213m worse than the year-end target.
Mrs JEA Hickey, Chairman, asked the governors for feedback on how they would like to see the financial report presented in future.
Mrs D Atkinson, Trust Secretary, stated that the Governors had recently attended a workshop with Mrs J Bilcliff, Operational Director of Finance, to discuss the format of the reports and feedback from this is being considered in developing reporting going forward.
After consideration, it was:
RESOLVED: to receive the report for assurance and information
G/17/42 Performance Report:
Mrs S Watson, Director of Strategy and Transformation, provided the Council of Governors with an update on performance against national and local targets.
She reported that the report, agenda item 11, provides an update of the Trust’s performance to the end of August 2017.
Mrs Watson reported that the report shows a strong performance, but with some challenges.
She gave a summary of the key issues, reporting that, as expected, the Trust is not meeting the Single Oversight Framework (SOF) requirement in relation to the Mental Health priority indicators. Actions to improve reporting levels continue.
Mrs Watson stated that the greatest concern is that the Trust did not achieve the A&E four-hour standard in August. The medical business unit is taking action to address the issues and the forecast for September and Q2 overall is that the standard will be met, though risk remains. Failure would trigger a further potential support need by NHSI and have STF implications. She
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Agenda Action Discussion and Action Points Item By noted that A&E performance nationally is receiving a significant amount of attention. The Trust continues to be a strong performer in comparison with others.
The Trust has not met the SOF standard diagnostics waiting for the third consecutive month in August, and there is currently a six week wait fail. She stated that this is related to echo- cardiogram tests and a plan has been provided to NHSI showing that this is expected to be back on track by the end of October.
She highlighted the workforce metrics performance, stating that the sickness absence is still red but is showing a reduction month on month. She stated that the sickness absence target was reset after work was undertaken to look at where the target should be, and this was agreed as 4%.
Mrs Watson concluded her report by stating that Mandatory Training and appraisal targets were not achieved. These areas are being reviewed regularly through the HR Committee and the Business Units and plans are in place to improve. This will continue to be reviewed to ensure that an improvement is achieved.
Mr M Loome, public governor, asked what the reasons were for not achieving the Mandatory Training and appraisal targets.
Mrs Watson stated that a level of understanding is needed on these targets and the Trust is moving towards this. She stated that there have been a few issues with Community Services and summer holiday scheduling.
Mrs N Kenny, Associate Director Medicine, stated that the doctors and medical cover documentation is currently in a backlog in the system. She stated that unfortunately some staff go over the 12 months’ timeframe, however the plan is to complete as many appraisals and Mandatory Training as possible before the winter period.
Mr J Holmes, public governor, stated that it was disappointing to see that the workforce metrics continue to be all red, however on closer examination there is an improvement on all areas.
Mrs J Doyle, appointed governor, stated that any workforce changes will take time to embed and this is understandable . She added that ensuring appraisals are meaningful is more important than a quick turnaround in completions.
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Agenda Action Discussion and Action Points Item By Mr S Connolly, public governor, asked if there are any particular areas where sickness absence is a concern.
Mrs S Watson, Director of Strategy and Transformation, stated that there are no particular areas of concern.
Mrs JEA Hickey, Chairman, stated that the C.diff figures in the report show the total cases. However, if the Trust feels that any case was unavoidable, they are taken through appeals panel . She added that three of the cases in July 2017 have been confirmed as unavoidable and two other appeals are still outstanding, so the total may reduce further.
After consideration, it was:
RESOLVED: to receive the report as assurance against the management governance indicators and local supporting measures of improvement management
G/17/43 Committee Assurance Report:
Mr J Robinson, Non-Executive Director and Chairman of the HR Committee, presented an assurance report from the meeting held on 13 th June 2017.
He reported that the Committee have undertaken a lot of work throughout the year, and after each meeting an assurance report on the issues is discussed.
Mr Robinson reported that the Board of Directors approved the Trust’s People Strategy in September 2016, which included workforce challenges along with a series of actions being rolled out. This strategy and the actions are reviewed regularly at the Committee and this is progressing well so far.
He stated that it is encouraging to see new developments coming through, for example the contribution of Allied Health Professionals (AHPs) and the integration with medical and nursing staff across the Trust.
Mr Robinson stated that the workforce metrics are improving, but are still not good enough. This is subject to a lot of discussion and will continue to be closely monitored. The Committee have debated absence management and appraisals in great detail and work continues.
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Agenda Action Discussion and Action Points Item By He concluded his update by stating that the Committee has reviewed a whole range of HR policies to ensure they are relevant in times of considerable change. They have also received presentations on initiatives including the contribution of volunteers to the work of the hospital and the Trust will also be looking to see how volunteering in community services could work.
After further discussion, it was:
RESOLVED: to receive the report for assurance
G/17/44 PLACE Report:
Mr A Colwell, Head of Facilities, QE Facilities, presented to the group the outcome of the annual Patient Led Assessment of the Care Environment (PLACE) undertaken in 2017.
He thanked the governors and patient representatives for their contribution to the process. He stated that the report shows incremental progress over the year and is a positive message for patients.
The team undertook assessments in acute and community ward areas, the emergency department, outpatients and external areas such as car parks and entrances. They also assessed internal areas such as refreshment areas, toilets and food.
He reported that the assessment included food and hydration, privacy, dementia, dignity and wellbeing and condition, appearance and maintenance of healthcare premises. He added that the disability standard is a newly introduced standard.
Mr Colwell reported that during the process a number of general themes for improvement were considered. These included sections of external roadways in need of repair which are part of a regular maintenance programme. He also stated that cigarette ends are being discarded at the main entrance and smoking on site remains an issue. Some site maps and internal signage also needs to be updated.
He reported that as part of the dementia friendly environment assessment, a number of areas were identified and he outlined the improvements made in the last 12 months, including displaying large face clocks, new toilet signage and variable seating in outpatients. Mr Colwell stated that there is still a level of significant investment required under this standard to
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Agenda Action Discussion and Action Points Item By ensure compliance.
Mr Colwell continued highlighting the food scores, which were very good and of a high standard overall. There are however a few areas for improvement and the assessment received a mixed response in how food is presented, which will be taken forward.
He drew attention to the paper, agenda item 13, highlighting the Trust scores in comparison with other local Trusts. He stated that the Trust is above the national average in all of the key areas.
He concluded his report by stating that a number of issues continue in regard to the dementia standard and the privacy and dignity standard, with the possibility of new standards being implemented for next year.
Mr J Holmes, public governor, reported that the group involved in the assessments work to a strict set of guidelines. The Trust is doing a fantastic job to provide everything that is needed when the financial position continues to be challenging.
Mrs JEA Hickey, Chairman, thanked Mr Holmes for his useful comment. She stated that the Trust is not in a financial position to change everything instantly, and any investment needs to be included in the year’s plans.
Mr A Sandler, appointed governor, asked Mr Colwell who the assessors in the process are.
Mr Colwell stated that the assessors are independent and external, and he is happy to take any additional inspectors.
Mr M Loome, public governor, asked if the Trust has considered a smoking ban on the hospital premises to try to deal with the amount of cigarette ends discarded.
Mr ID Renwick, Chief Executive, stated that the Trust introduced a smoke free site a number of years ago; however this is a difficult issue to police. There is also a public footpath through the site that is used by smokers which makes it more difficult.
Mrs JEA Hickey, Chairman, commented that this is a sensitive issue and patients have been challenged or not challenged due to any level of distress. The Trust is committed to a smoke free site but there is an element of sensitivity.
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Agenda Action Discussion and Action Points Item By Mrs JEA Hickey, Chairman, gave thanks to those involved in the PLACE inspections, and thanked Mr A Colwell, Head of Facilities, QE Facilities, for his presentation.
After further discussion, it was:
RESOLVED: to receive the report for assurance
G/17/45 Audit Committee Annual Report:
Mrs K Larkin-Bramley, Non-Executive Director and Chair of the Audit Committee, presented to the group the Annual Report of the Audit Committee for 2016/17.
She drew attention to the paper, agenda item 14, and outlined the key points.
Mrs Larkin-Bramley stated that the purpose of the report is to inform the Council of Governors how the committee has met its terms of reference throughout the year.
She reminded the group that the Committee’s primary role is to conclude upon the adequacy and effective operation of the organisation’s overall internal control system. The committee independently monitors, reviews and reports to the Board on those processes and takes assurance from various Trust committees and from internal and external audit.
She stated that one of the main areas of work for the committee is to review the annual report and accounts. This year the Trust received strong assurance from the External Auditors and a very positive opinion.
Mrs Larkin-Bramley reported that a key area of work during the year was to appoint new External Auditors. She thanked the governors involved in the process, Mr M Loome and Mr S Connolly, public governors, and Mrs J Coleman, staff governor.
After further discussion, it was:
RESOLVED: to receive the report for information
G/17/46 CQC Mental Health Inspection:
Mrs N Kenny, Associate Director Medicine, and Mr D Gilbert, Mental Health Modern Matron gave an update presentation on
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Agenda Action Discussion and Action Points Item By the Mental Health Improvement Programme, following the CQC inspection.
She informed the group that the improvement journey has been ongoing since the Mental Health review in 2015/16, which gave the Trust a range of actions to complete.
Mrs Kenny recapped the services covered by the Trust’s Mental Health provision, giving an overview of the locations and patients’ services.
She reminded the group of the unannounced visit by the CQC in December 2016. This visit covered community teams (from East and Central localities) and the Sunniside and Cragside units.
Mrs Kenny reported that from that visit, eight requirement notices in relation to regulatory breaches were given; three for community and five for Sunniside and Cragside.
She reviewed the progress made to date in the three areas: improving the safety of the ward environment; increasing the effectiveness of the care and treatment provided; and improved care approach.
The work has included installing new observational mirrors, new signage, and reviewing and removing any blanket restrictions, which are now all subject to an individual risk assessment.
Mrs Kenny reported that an in-depth programme of work has been undertaken including a Care Programme Approach being embedded, the appointment of an Activities Co-ordinator and an adopted use of a structured evidence-based template for all Wellness Intervention Plans.
She highlighted the work undertaken to improve the care approach which includes ensuring all staff are up to date with Mandatory Training, conducting regular supervision and the availability of snacks and drinks for patients throughout the day. Additional staff have been redeployed including a ward clerk.
Mrs Kenny explained that the Trust is addressing the ‘must do’ actions, and phase 2 will begin shortly. Ten actions have been completed in ward based services, with four in community. The plan for the next month is to complete the audit and review and turn the gaps in assurance to a green rating.
She commented that all relevant policies have been reviewed, along with the minutes of various meetings. A Quality
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Agenda Action Discussion and Action Points Item By Improvement Lead is now in post from NTW and a new Nurse Consultant post.
Mrs Kenny reported that a peer review was undertaken and this was a positive experience, which identified a small number of further areas of development. These include a programme of the top three key areas of risk. She added that a lot of good progress has been made to date but this will require further investment for any structural changes that are needed. The IT replacement programme is also key, as the system is not fit for purpose.
She gave the group an update on the environmental plans for Cragside and Sunnside. She explained that Cragside is designed in a square and patients can only walk half way round. This is causing some frustration that patients cannot continue to walk and have to turn around and come back.
Mr D Gilbert, Mental Health Modern Matron, added that this causes patients a level of emotional distress as when they are faced with a locked door, they will try to open the door, thus causing them to become highly distressed. He stated that this area needs to be future proofed, along with a number of other areas including good lighting, good use of colour and single bed areas. He commented that the potential work allows for the surroundings to be made more familiar and homely.
Mrs Kenny gave an overview of the Mental Health Model for Delivery, which will consolidate all of the improvement work that the Trust has been doing. There are five work streams which are reported up to the Mental Health Steering Group.
She concluded her presentation by informing the group that there is an opportunity to develop a strategy for mental health in Newcastle and Gateshead; a programme called ‘Deciding Together, Delivering Together’. This is an enormous programme of work which will review all mental health services, excluding the older persons’ inpatient services provided by the Trust, and a redesign of services in a community setting. She stated she will bring further updates when appropriate.
Mr S Connolly, public governor, asked if the current care plans are not person centred or holistic.
Mr Gilbert stated that it is regarding the way that the plans are worded. By changing this to wellness intervention plans it ensures that staff think more individually about patients and ensure documented plans reflect any individualised care.
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Agenda Action Discussion and Action Points Item By
Mrs C Coulson, public governor, commented on the need for additional staff resources.
Mr Gilbert stated that this related to the recruitment to leadership posts and other roles including registered nurses and healthcare assistants. The Trust is trying to use other mechanisms, for example social media to assist in recruitment . This has been found to be a positive experience, but in future the Trust will look at succession planning and the way forward.
Mr M Loome, public governor, asked how the inspection comments have affected staff morale.
Mr Gilbert stated that the staff feel very strongly about their work and the care they provide. Staff were deeply affected and when the findings were presented to staff there was some distress. He added that the caring element of the inspection was seen as good. Mr Gilbert commented that events have been held to help work through the comments, and staff are being taken on a journey of what comes next rather than dwelling on this outcome and they have responded positively.
Mrs S Begg, public governor, asked what the Trust’s arrangements are for children accessing A&E for psychiatric problems.
Mrs Kenny stated that there has been a small number of incidents, and this has involved patients being admitted to an adult ward even though they were not quite classed as adults. Further analysis of these is being undertaken to identify areas for improvement.
After further discussion, it was:
RESOLVED: to receive the update for assurance
G/17/51 Quality Account Priorities Update:
Mrs H Lloyd, Director of Nursing, Midwifery Quality, provided the governors with an update on the progress made against the Quality Priorities. She highlighted each priority and the work ongoing.
She reported that Priority 1 is a very specific priority on the impact of hip or knee replacement in relation to the national Patient Reported Outcome Measures (PROMs) tool. She
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Agenda Action Discussion and Action Points Item By advised the group that this was chosen as a priority as the Trust was not performing as well as other organisations.
Mrs Lloyd stated that a lot of work has been carried out in mapping and re-designing the patient pathway, improving rehabilitation services and undergoing further work with the North East Quality Observatory Service (NEQOS). The Trust also looked at patient selection along with consultant level data. She added that the improvements in this priority will not be seen immediately as follow-up with patients happens a number of months after their operation and then takes time to collate.
She reported that Priority 2 relates to mortality reviews and this is a key priority for the Trust. An RPIW event was held recently to ensure that the guidance is undertaken correctly.
Mrs Lloyd reported that this priority is progressing well, and a single database is now being used. Training sessions have been carried out and a new policy introduced, which focusses on learning from mortality reviews and all patient deaths. She added that work is also ongoing to ensure that deaths in A&E are included in the database, and build and test the level 2 mortality council review element.
She stated Priority 3 focusses on improving the patient safety culture, including capturing and driving excellence in patient safety and incidents and what the Trust can learn from them.
She added that Root Cause Analysis (RCA) training has been carried out in depth, along with the introduction of human factors training.
Mrs Lloyd reported that Priority 4 relates to Local Safety Standards for Invasive Procedures (LocSSIPs) and National Safety Standards for Invasive Procedures (NatSSIPs).
The Trust has developed a programme to ensure a LocSSIP is produced for all invasive procedures, which will add to the improvement of patient safety to ensure that mistakes do not happen.
She stated that Priority 5 focusses on complaints investigations and actions and how the Trust can improve the process. This includes ensuring that the investigator is thorough and that a high standard is followed.
This priority includes Duty of Candour and ensuring that earlier meetings take place to deal with problems as early as possible .
Page 16 of 23
Agenda Action Discussion and Action Points Item By This is supported by NEQOS and the Trust is working regionally to share good practice.
After further discussion, it was:
RESOLVED: to receive the update for information
G/17/47 Membership Development Working Group:
Mr M Loome, public governor and Chairman of the group, provided an update report on the work of the Membership Development Working Group.
He drew attention to the paper, agenda item 16, which gave a breakdown of membership totals and membership numbers by constituency.
Mr Loome reported that the next main event for membership is Membership Week which runs throughout the week commencing 30 th October 2017. This will involve a number of information stands in various locations around the hospital.
He added that the main event in Membership Week is the Open Afternoon on 1 st November. He stated that over 20 information stands have been arranged with refreshments and scones available for all attendees.
Mrs D Atkinson, Trust Secretary, added that information leaflets have been printed and governors will be distributing them around their constituencies. The leaflets will also be sent to local groups and patient areas.
After further discussion, it was:
RESOLVED: to receive the update for information
G/17/48 Membership Feedback:
Mrs S Begg, public governor, reported that she has been undergoing treatment at the hospital since November 2016. She stated that the staff are wonderful and her experience has been incredible. She gave thanks to the staff for the kindness and professionalism shown throughout her treatment.
Mr A Dougall, public governor, reported that the zebra crossing that he had been petitioning for has now been installed.
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Agenda Action Discussion and Action Points Item By
Mrs E Adams, public governor, reported that she receives a lot of positive feedback from patients during recruitment in OPD.
Mrs C Coulson, public governor, reported that she had been talking with a member of the public regarding his care, and in particular once he had been taken to the discharge lounge. Concerns had been expressed regarding the facility, in particular communication to patients regarding the length of time they could expect to be in the lounge.
Mrs JEA Hickey, Chairman, reported that she has personally visited the discharge lounge before and it is an important part of patient flow experience. She asked Mrs N Kenny, Associate Director Medicine, to speak with Mrs Coulson after the meeting.
Mrs Coulson also reported that she had attended Blaydon Library with the membership information stand. She stated that she enjoyed the session and will look into attending on a monthly basis.
She also stated that she had recently visited A&E for a very informative tour.
Mr S Connolly, public governor, reported that he had been part of the recent Theatres open evening. He stated that this event was very interesting and he was really impressed with the safety checks. He thanked the staff involved.
He also stated that he had been part of the PLACE annual audit, adding that it was good to see the figures we have achieved in comparison with other Trusts.
Mr A Rabin, public governor, reported that he had spoken with a patient who had been waiting a long time for a response from an issue raised with PALS. He stated that it has now been eight weeks and asked if there is there a standard response time for queries.
Mr ID Renwick, Chief Executive, stated that there is a standard response time and this provides a quicker turnaround than a formal complaint. He suggested that Mr Rabin speak with Mrs D Atkinson, Trust Secretary, after the meeting.
Professor P Dawson, appointed governor, stated that with regard to workforce strategy and future workforce, the universities are working collaboratively with hospitals in the region. She added that the hospital always receives excellent
Page 18 of 23
Agenda Action Discussion and Action Points Item By feedback from students and a lot of students choose Gateshead as their first choice of placement.
She added that although a reduction in applications was expected due to the removal of the bursary, this has not affected enrolment. The university has continued to recruit across all fields and at the right quality.
Mrs M Summers, public governor, reported that she attended the recent Star Awards evening. She stated that listening to patient comments and the support that staff have for each other is wonderful.
Reverend J Gill, public governor, reported that she recently attended the Flu Day in Rowlands Gill. She stated that it was a good experience to talk to the public and hear the positive comments about the hospital.
Mr A Sandler, appointed governor, reported that he had visited the maternity unit for a tour. He stated that a member of staff mentioned that the reduction in the number of beds has provided a big challenge. He asked for feedback on this as he is currently trying to encourage the Jewish community to stay in Gateshead to have their babies.
Mr ID Renwick, Chief Executive, stated that bed numbers are reviewed in relation to the birth rate in the catchment area. More widely, the Trust is engaged in a broader review within the STP process and the work ongoing around the local maternity system (LMS) workstream. This work will be looking at maternity provision across the local area.
Mr N McDonaugh, Associate Director Surgery, stated that he is not certain that beds have been reduced. The unit’s current bed numbers has the capacity to take another couple of hundred births if needed, and there is no need currently to expand, although clearly numbers of patients can vary from day-to-day.
G/17/49 Lead Governor Appointment Process 2017:
Mrs D Atkinson, Trust Secretary, presented a paper detailing the Lead Governor appointment process, giving the appropriate documents to allow all governors to take part in the process.
She reminded the group that in November 2016, the Council of Governors appointed Mr J Holmes as Lead Governor for a second one year period. Mr Holmes will not be standing for re-
Page 19 of 23
Agenda Action Discussion and Action Points Item By election to the Council of Governors, so a new Lead Governor will need to be appointed.
Mrs Atkinson informed the group that the process will follow the same nomination procedures as in previous years. She asked for any interested governors to contact her direct. If more than one person is interested, a vote will take place. However, if only one governor is interested, they will be appointed following approval from the Council of Governors.
She added that the appointment of the Lead Governor will be brought to the November 2017 Council of Governors’ meeting. DA
Mrs Atkinson concluded her report by thanking Mr J Holmes for undertaking the role for the previous two years.
Mrs JEA Hickey, Chairman, noted that the required experience for those interested in being Lead Governor is being reduced to one year. She added that this will be added to the constitution in the next review.
After further discussion, it was:
RESOLVED: i) to note the briefing on Monitor’s recommendations for the Lead Governor ii) to note the principal responsibilities and person specification for Lead Governor iii) to note the appointment process for the Lead Governor iv) to agree to appoint a Lead Governor at the November 2017 meeting of the Council of Governors
G/17/50 Governors’ Annual Report 2017:
Mr M Loome, public governor, presented to the group the Council of Governors’ Annual Report 2016/17.
He drew attention to the report, agenda item 19, and stated that, once agreed, the report will be published on the Trust’s website and will be publicised in the membership newsletter.
He commented that the report gives details of who the Council of Governors are, their duties and responsibilities within the Trust, any achievements, committees in which governors are involved and any training undertaken.
Page 20 of 23
Agenda Action Discussion and Action Points Item By Mr Loome highlighted a couple of areas in which governors had been involved over the year. These included the recruitment of two new Non-Executive Directors, judging the Star Awards, taking part in the PLACE inspections and being part of the panel for the appointment of the external auditors.
He stated that the Council of Governors are working well as a group and are keen to be involved. They also meet regularly separately from the formal meetings to discuss any issues.
Mr Loome concluded his report by stating that the document is very clear, concise and complete and will enable any member to understand the governors’ role and involvement.
Mrs JEA Hickey, Chairman, gave her thanks to all governors who perform their role with great enthusiasm. She added that the Board of Directors welcomes the support and encouragement of the governors and the challenges that they are raising.
After further discussion, it was:
RESOLVED: to approve the report
G/17/52 Governor Activities:
Mrs D Atkinson, Trust Secretary, presented to the group a report compiled from governors ’ attendance at meetings and events from 15 th February 2017 to 15 th September 2017 inclusive.
Mrs Atkinson drew attention to the paper, agenda item 21, and the attached appendix which highlighted what governors have been involved in and how they are carrying out their role.
Mrs JEA Hickey, Chairman, noted that one of the graphs in the paper shows that the ‘disagree’ option had been chosen as a response. She invited the responder to come forward so that the comments could be explored further.
After consideration, it was:
RESOLVED: to receive the report for information
Page 21 of 23
Agenda Action Discussion and Action Points Item By G/17/53 Election Timetable:
Mrs J Williamson, Membership Co-ordinator, presented to the group a paper on the process to be undertaken for the next elections to the Council of Governors.
She drew attention to the paper, agenda item 22, which contained a schedule of dates and information for current governors whose tenure ends on 4 th January 2018.
After consideration it was:
RESOLVED: i) to note the key dates in the election process ii) to receive the report for information
G/17/54 Open to Questions:
Mr A Sandler, appointed governor, asked if the Trust had suffered any further effects from the recent cyber-attack.
Mrs C Coyne, Director of Diagnostic and Screening Services, stated that the Trust had managed the incident as it was evolving, and has felt no further effects from the attack. She added that although the Trust was not directly affected by the virus, further resilience plans have been put in place including extra security on every PC and system, and regular updates.
Mr Sandler queried if the transfer over to the NHS.net email addresses had been completed.
Mrs Coyne stated that although there have been some minor issues with the transfer of the email systems, this is now largely complete and gives the Trust an extra addition to the system’s security.
G/17/55 Chairman’s Closing Remarks:
The Chairman thanked everyone for their attendance and thanked staff for their presentations.
She also expressed thanks to Mr ID Renwick, Chief Executive, the Board of Directors, the Council of Governors and all colleagues for delivering an excellent service.
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Agenda Action Discussion and Action Points Item By G/17/56 Date and time of next meeting:
RESOLVED: that the next meeting of the Council of Governors will be held at 10.00 am on Wednesday 22 nd November 2017 in the Education Centre, Queen Elizabeth Hospital
Page 23 of 23
Actions from Council of Governors Meetings
Date of Minute Action Lead Current Position Meeting Reference 27/09/2017 G/17/49 To present, for approval, the appointment of the Lead Governor at DA Item on November’s agenda the November 2017 Council of Governors’ meeting
Council of Governors
Report Cover Sheet Agenda Item: 6
Date of Meeting: Wednesday 22 nd November 2017
Report Title: Chief Executive’s Briefing
Purpose of Report: To provide the Council of Governors with a brief update on key issues and events since the last meeting
Decision: Discussion: Assurance: Information: ☐☐☐ ☐☐☐ ☐☐☐ ☒☒☒
Brief summary to highlight key issues:
This paper provides a brief update on some of the key issues and events for the Trust since the last Council of Governors meeting.
Author: Ian Renwick, Chief Executive
Presented by : Ian Renwick, Chief Executive
Paper for Council of Governors Meeting Agenda Item: 6 22 nd November 2017
G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T
CHIEF EXECUTIVE’S REPORT
This paper provides a brief update on some of the key issues and events for the Trust since the last Council of Governors meeting.
Regulatory Performance
Our relatively strong financial and regulatory performance of Q1 has largely continued through the second quarter of 2017/18. A&E performance showed further signs pressure through October, but a strong recovery in November (to date) means that the quarterly performance is back on track. Further detail is included in the updates elsewhere on the agenda.
This has once again been reflected in a very positive Quarterly Review Meeting with NHSE/I (for Q2) which took place last week. However, it is inevitable that sustaining our current financial and service performance will become increasingly difficult over the coming months as winter hits and no likelihood of any additional resource being made available centrally.
Sustainability and Transformation Plans
Further to my previous updates, I can confirm that Alan Foster, Chief Executive of North Tees and Hartlepool FT, has been appointed to the role single lead for the combined STP across Cumbria and the North East.
Reflecting the importance of clinical leadership of the clinical and service transformation required to deliver against the key national STP drivers (clinical safety, workforce pressures and finance) workstreams based on clinical pathways continue to develop for the patch, with the full involvement of clinical staff. These will increasingly analyse the current and possible future state pattern of service delivery.
In addition, discussions around an Accountable Care Partnership for Gateshead continue, involving Gateshead Council, Newcastle Gateshead CCG, NTW NHS FT, and Gateshead Care Partnership. Now we are clearer on the way forward for the wider STP, we will be able to provide a clearer context and scope for this more locality focussed piece of work.
Secretary of State Visit
On Friday 29 th September 2017, the Trust received a visit from Jeremy Hunt, Secretary of State for Health, as part of a two-day visit to the north east of England. The visit was relatively low key and informal, but included an engagement session with around 40 of our staff to discuss quality and safety of care.
There was even time to fit in a flu jab, and feedback tells us that he was very impressed with what he heard and saw, and with the staff he met, during his visit.
Flu
With winter approaching, we have already begun to see confirmed cases of ‘flu presenting, and admitted to, the hospital. This therefore serves as a timely opportunity to remind members of the Council of Governors of the importance of having a ‘flu jab, particularly for those in high risk groups and for those active within the hospital who have contact with patients.
New Chairman at Newcastle Teaching Hospitals FT
We understand that NUTH FT completed the process to appoint a successor to Kingsley Smith around two weeks ago (with the appointment subject to formal Governor ratification at the time of writing). An update will be provided, if appropriate, at our meeting.
Ian Renwick Chief Executive November 2017
Council of Governors
Report Cover Sheet Agenda Item: 7
Date of Meeting: Wednesday 22 nd November 2017
Report Title: Constitution Review
Purpose of Report: To approve the Trust’s constitution
Decision: Discussion: Assurance: Information: ☒☒☒ ☐☐☐ ☐☐☐ ☐☐☐
Brief summary to highlight key issues:
The Council of Governors is asked to approve the amendment to the Trust’s Constitution.
Author: Mrs D Atkinson, Trust Secretary
Presented by : Mrs D Atkinson, Trust Secretary
Paper for Council of Governors Meeting Agenda Item: 7 22 nd November 2017
G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T
Constitution Review October 2017
Introduction:
Following the amendments made to the Lead Governor Appointment Process in 2016 the Governors have agreed that an additional change is required to broaden the range of Governors who are able to apply for the role.
The Council of Governors is asked to approve the following amendment to the Trust’s Constitution.
Lead Governor Appointment Process -Page 11 – 6.12.3
“He/she will be appointed from those in the public, patient or out of area membership category with at least one year’s experience”
Governors Questions at Board Meetings
As agreed with Governors, the process to include Governors’ questions at the end of the public Board meeting will be included in the Terms of Reference of Board meetings. This had previously been noted as requiring a change to the Constitution but in fact the Board meeting protocols form part of the Trust’s Standing Orders. This document will be presented to the Board in November for approval.
Gateshead Health NHS Foundation Trust
(A Public Benefit Corporation)
Constitution
201 76
October 2017September 2016
1 Table of Contents
Paragraph Page
1 Definitions 3
2 Name 4
3 Principal Purpose 4
4 Powers 4
5 Members 5
6 Council of Governors 7
7 Board of Directors 15
8 Declaration of Interest of Directors 19
9 Meetings of Directors 20
10 Registers 20
11 Documents available for Public Inspection 21
12 Panel for Advising Governors 22
13 Auditor 23
14 Accounts 23
15 Annual Reports and Forward Plans and non-NHS Work 23
16 Indemnity 25
17 Instruments etc 25
18 Dispute Resolution Procedures 25
19 Amendment of the Constitution 25
20 Dissolution of the Trust 26
21 Mergers and Significant Transactions 26
22 Foundation Trust Head Office 26
Annex 1 Public Constituencies of the Trust 28
Annex 2 Council of Governors’ Standing Orders 29
Annex 3 The Rules for Elections 36
Annex 4 Governor’s Code of Conduct 83 2
Unless the contrary intention appears or the context otherwise requires, words or expressions contained in this constitution bear the same meaning as in the 2003 Act.
References in this constitution to legislation include all amendments, replacements, or re-enactments made.
References to legislation include all regulations, statutory guidance or directions.
Headings are for ease of reference only and are not to affect interpretation.
Words importing the masculine gender only shall include the feminine gender; words importing the singular shall include the plural and vice-versa.
1. Definitions
1.1 In this Constitution:-
“the 2012 Act” is the Health and Social Care Act 2012 “the 2006 Act” is the National Health Service Act 2006 "the 2003 Act" is the Health and Social Care (Community Health and Standards) Act 2003;
“the 1977 Act” is the National Health Service Act 1977;
“applicant NHS means the NHS Trust which made the application to become an Trust” NHS Foundation Trust;
“area of the means the area consisting of all the areas specified in Annex 1 as Trust” an area for a Public Constituency;
“Board of means the Board of Directors as constituted in accordance with Directors” this Constitution;
“Council of means the Council of Governors as constituted in accordance Governors ” with this Constitution;
"Director" means a Director on the Board of Directors;
“Financial year” means:
(a)the period beginning with the date on which the Trust is authorised and ending with the next 31st March; and
(b) each successive period of twelve months beginning with 1 st April. “Local Authority means a Member of the Council of Governors appointed by one Governor” or more Local Authorities whose area includes the whole or part of an area specified in Annex 1 as an area for a Public Constituency;
"Member" means a Member of the Trust;
“Monitor” Is the body corporate known as Monitor, as provided by Section 61 of the 2012 Act; “other means a Member of the Council of Governors appointed by a partnership partnership organisation other than a Clinical Commissioning 3 Governor” Group or university providing a medical or dental school to the Trust specified in paragraph 6.3;
“CCG Governor” means a Member of the Council of Governors appointed by a Clinical Commissioning Group for which the Trust provides goods or services;
“Public means a Member of the Council of Governors elected by the Governor” Members of the Public Constituency;
“Patient Means a Member of the Council of Governors elected by the Governor” Members of the Patient Constituency;
"Secretary" means the Secretary of the Trust or any other person appointed to perform the duties of the Secretary of the Trust, including a joint, assistant or deputy Secretary;
“Staff means a Member of the Council of Governors elected by the Governor” Members of the Staff Constituency
“the Trust” means the Gateshead Health NHS Foundation Trust;
2. Name
2.1 The name of this Trust is to be “Gateshead Health NHS Foundation Trust”.
3. Principal Purpose
3.1 The Trust’s principal purpose is the provision of goods and services for the purposes of the Health Service in England.
3.2 The Trust does not fulfil its principal purpose unless, in each financial year, its total income from the provision of goods and services for the purposes of the health service in England is greater than its total income from the provision of goods and services for any other purposes.
3.3 The Trust may provide goods and services for any purposes related to:
3.3.1 the provision of services provided to individuals for or in connection with the prevention, diagnosis or treatment of illness, and
3.3.2 the promotion and protection of public health.
3.4 The Trust may also carry on activities other than those mentioned in the above paragraph for the purpose of making additional income available in order better to carry on its principal purpose.
4. Powers
4.1 The Trust is to have all the powers of an NHS Foundation Trust as set out in the 2003 Act, subject to the terms of authorisation.
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5. Members
5.1 Representative Membership
The Trust must take steps to secure that (taken as a whole) the actual membership of any public constituency and patient’s constituency is representative of those eligible for such membership.
5.2 The Trust is to have five Membership Constituencies, namely:
(a) Four “Public Constituencies” (including the “Out of Area Constituency), and
(b) One “Staff Constituency”
5.3 Public Constituencies (other than “Out of Area”):
5.3.1 An individual who lives in an area specified in Annex 1(a), (b) or (c) as an area for a public constituency may become or continue as a member of the Foundation Trust.
5.3.2 Those individuals who live in an area specified in an area for any public constituency are referred to collectively as the Public Constituency
5.3.3 The minimum number of members in each area for the Public Constituency is specified in Annex 1.
5.4 Out of Area Constituency:
5.4.1 Members of the Trust who are Members of the Out of Area Constituency are to be:
(a) Individuals who live in the area of the Trust listed in Annex 1 (d) or
(b) Individuals who live outside the area of the Trust listed in Annex 1 (a), (b), (c) or (d) and who have used any of the Trust’s services within the 7 years immediately preceding the date of their application for membership and had domestic responsibility for the care of the patient once they have received their treatment from the Trust (other than an individual providing care in pursuance of a contract (including a contract of employment) or as a volunteer for a voluntary organisation.
Those individuals who are eligible for membership of the Trust by reason of the previous provisions are referred to collectively as the Patient & Out of Area Constituency.
5.4.2 The minimum number of Members required for the Out of Area Constituency is to be the number given for that Constituency in column 3 of Annex 1 of the Public Constituencies.
5.5 Staff Constituency:
5.5.1 Members of the Trust who are Members of the Staff Constituency are to be individuals:
5 (a) who are employed under a contract of employment by the Trust or a wholly- owned subsidiary of the Trust; or
(b) who are not so employed but who nevertheless exercise functions for the purposes of the Trust; and
(c) who satisfy the minimum duration requirements set out in paragraph 3(3) of Schedule 1 to the 2003 Act, that is to say:
(i) in the case of individuals described at (a) above:
(aa) who are employed by the Trust under a contract of employment which has no fixed term or a fixed term of at least 12 months, or
(bb) who have been continuously employed by the Trust for at least 12 months;
(ii) in the case of individuals described at (b) above, who have exercised the functions for the purposes of the Trust for a continuous period of 12 months; and
(d) who are not disqualified for Membership under paragraph 6.4 below; and who have been invited by the Trust to become a Member of that Constituency and have not informed the Trust that they do not wish to do so.
5.5.2 The minimum number of Members required for the Staff Constituency is 2,000.
5.5.3 A person who is eligible to be a Member of the Staff Constituency (see paragraph 5.4.1 above) may not become or continue as a Member of any Constituency other than the staff Constituency.
5.6 Disqualification for Membership:
5.6.1 A person may not be a Member of the Trust if they are under 16 years of age.
5.6.2 It is the responsibility of Members to ensure their eligibility and not the Trust, but if the Trust is on notice that a Member may be disqualified from Membership, they shall carry out all reasonable enquiries to establish if this is the case.
5.7 Termination of Membership:
5.7.1 A Member shall cease to be a Member if he/she:
(a) resigns by notice to the Trust Secretary;
(b) ceases to fulfil the requirements of paragraphs 5.3, 5.4 or 5.5;
(c) dies;
(d) is disqualified from membership under paragraph 5.6.
6 5.8 Voting at Governor Elections:
5.8.1 A person may not vote at an election for a Public Governor unless within the specified period he/she has made a declaration in the specified form stating the particulars of his/her qualification to vote as a Member of the constituency, identifying the section for which he/she is a Member, for which an election is being held. It is an offence knowingly or recklessly to make such a declaration which is false in a material particular.
6. Council of Governors
6.1 The Trust is to have a Council of Governors. It is to consist of Public Governors, Staff Governors, Clinical Commissioning Group Governors, Local Authority Governors, Patient & Out of Area Governors, and other Partnership Governors.
6.2 The Council of Governors of the Trust is to include:
(a) 17 Public Governors
(b) 6 Staff Governors
(C) 1 Clinical Commissioning Group Governor
(d) 1 Local Authority Governor
(e) 7 Partnership Governors
The number of Public Governors comprise more than half the total Membership of the Council.
Partnership Governors
6.3 The specified partnership organisations below may appoint one Member of the Council of Governors: (a) Newcastle University (b) Northumbria University (c) Gateshead College (e) Gateshead Jewish Community Council (f) Gateshead Diversity Forum (g) Gateshead Youth Assembly
In addition one member of the Council of Governors will be appointed from a voluntary organisation working within the community.
6.4 Public Governors:
6.4.1 Members of the Public Constituencies may elect any of their number to be a Public Governor.
6.4.2 If contested, the election must be by secret ballot.
6.4.3 The Election Scheme including the specified forms of and periods for declarations to be made by candidates standing for office and Members as a condition of voting and the process if the election is uncontested, is set out in Annex 3, Part 4
6.4.4 A person may not stand for election to the Council as a Public Governor unless, within the period specified in Annex 3, Part 4, he/she has made a declaration in the form specified in 7 that Part of that Annex of his/her qualification to vote as a Member of the Public Constituency for which the election is being held and is not prevented from being a Member of the Council by paragraph 8 to Schedule 1 of the 2003 Act or paragraph 6.11 below (disqualification). It is an offence to knowingly or recklessly make a declaration under section 36 of the 2003 Act which is false in a material particular.
6.4.5 Paragraph 5.8 (voting at Governor elections) applies.
6.5 Staff Governors:
6.5.1 Members of the staff Constituency may elect any of their number to be a staff Governor.
6.5.2 If contested, the election must be by secret ballot.
6.5.3 The Election Scheme, including the process if the election is uncontested, is set out in Annex 3, Part 4.
6.6 Clinical Commissioning Group Governors
6.6.1 Newcastle Gateshead Clinical Commissioning Group is authorised to appoint one Clinical Commissioning Group Governor pursuant to a process agreed by the Clinical Commissioning Group and the Trust. Where a Clinical Commissioning Group Governor post falls vacant, the CCG will appoint another Governor within three months of the Trust Secretary having received notification that the post is vacant.
6.7 Local Authority Governors
6.7.1 Gateshead Council are authorised to appoint one Local Authority Governor pursuant to a process agreed by that Local Authority and the Trust. Where a Local Authority Governor post falls vacant, the Local Authority will appoint another Governor within three months of the Trust Secretary having received notification that the post is vacant.
6.8 Other Partnership Governors:
6.8.1 Newcastle University, Northumbria University, Gateshead College and Gateshead Voluntary Organisation Council, Gateshead Jewish Community Council, Gateshead Diversity Council, and Gateshead Youth Assembly are authorised to appoint one Governor each pursuant to a process agreed by those organisations and the Trust. Where a Partnership Governor post falls vacant, the relevant organisation will appoint another Governor within three months of the Trust Secretary having received notification that the post is vacant.
6.9 Terms of Office:
6.9.1 Public and Out of Area Governors:
(a) may hold office for a period of three years;
(b) are eligible for re-election at the end of that period;
(c) may not hold office for longer than nine consecutive years;
(d) cease to hold office if they cease to be a Member of the Constituency to which they are elected.
8
6.9.2 Staff Governors:
(a) may hold office for a period of three years;
(b) are eligible for re-election at the end of that period;
(c) may not hold office for longer than nine consecutive years;
(d) cease to hold office if they cease to be a Member of the staff Constituency.
6.9.3 Clinical Commissioning Group Governors:
(a) may hold office for a period of three years;
(b) are eligible for reappointment at the end of that period;
(c) cease to hold office if the sponsoring Clinical Commissioning Group withdraws its sponsorship of them.
6.9.4 Local Authority Governors:
(a) may hold office for a period of three years;
(b) are eligible for reappointment at the end of that period;
(c) cease to hold office if the sponsoring Local Authority withdraws its sponsorship of them.
6.9.5 Other Partnership Governors:
(a) may hold office for a period of three years;
(b) are eligible for reappointment at the end of that period;
(c) cease to hold office if the sponsoring partnership organisation withdraws its sponsorship of them.
6.10 Termination of Tenure:
6.10.1 A Governor may resign from that office at any time during the term of that office by giving notice in writing to the Trust Secretary.
6.10.2 If a Governor fails to attend three consecutive meetings of the Council of Governors, his/her tenure of office is to be immediately terminated unless the other Governors are satisfied that:
(a) the absence was due to a reasonable cause; and
(b) he/she will be able to start attending meetings of the Trust again within such a period, as they consider reasonable.
9
6.10.3 A Governor’s tenure of office may be terminated if he/she declines to submit to a DBS check and/or if the Council of Governors reasonably considers, after due consideration in accordance with the procedures set out in its standing orders, and the requirements of Annex 4 Code of Conduct, that he/she is unfit to discharge the functions of a Governor.
6.11 Disqualification
6.11.1 A person may not become or continue as a Governor of the Trust if:
(a) in the case of a staff Governor or public Governor, he/she ceases to be a member of the constituency he/she represents;
(b) in the case of a CCG Governor, Local Authority Governor or other partnership Governor, the sponsoringCCG, Local Authority, or partnership organisation withdraw their sponsorship of him/her;
(c) he/she has been adjudged bankrupt or his/her estate has been sequestrated and in either case he/she has not been discharged;
(d) he/she has made a composition or arrangement with, or granted a trust deed for, his/her creditors and has not been discharged in respect of it;
(e) he/she has within the preceding five years been convicted in the British Islands of any offence, and a sentence of imprisonment (whether suspended or not) for a period of three months or more (without the option of a fine) was imposed on him/her;
(f) he/she has within the preceding two years been dismissed, from any paid employment for misconduct with a health service body;
(g) he/she is a person whose tenure of office as the chairman or as a member or director of a health service body has been terminated on the grounds that his/her appointment is not in the interests of the health service, for non attendance at meetings, or for non-disclosure of a pecuniary/non-pecuniary interest;
(h) he/she is an Executive or Non-Executive Director of the Trust, or a Governor, Non-Executive Director, Chairman or Chief Executive officer of another NHS Trust;
(i) he/she has had his/her name removed, by a direction under section 46 of the 1977 Act from any list prepared under Part II of that Act, and has not subsequently had his/her name included in such a list;
(j) he/she is incapable by reason of mental disorder, illness or injury of managing and administering his/her property and affairs;
(k) he/she has failed to comply with the required standard of behaviour as per the Trust policy for withholding treatment from violent and abusive patients;
(l) he/she has been placed on the Registers of schedule 1 Offenders pursuant to the Sex Offenders Act 1977 and /or the Children & Young Person Act 1933;
(m) he/she fails to abide by the constitution as set out in this document;
10 (n) in the case of a staff Governor who has been suspended from duties for any reason, they will also be suspended from their role as Governor for the duration of their suspension;
(o) he/she is under 16 years of age;
(p) he/she has failed to undertake the required mandatory training for Governors;
(q) 3/4 of all governors agree, they can exclude anyone so disqualified from standing from re-election to be a governor of the Foundation Trust for up to a maximum of 5 years. Any such exclusion will take immediate effect and must then be confirmed in writing to the person excluded within 15 working days. At the end of an exclusion period, the exclusion must be explicitly reconsidered if the person so excluded indicates to the Trust Secretary that they wish to stand again for election to become a governor of the Foundation Trust. If the exclusion is then reaffirmed, the reasoning and length of exclusion should be given in writing to the person excluded and also included in the public papers of the Council of Governors.
6.11.2 Where a person has been elected or appointed to be a Governor and he/she becomes aware that he/she is disqualified for appointment under paragraph 6.11.1, he/she shall notify the Trust Secretary in writing of such disqualification.
If it comes to the notice of the Trust Secretary at the time of his/her appointment or later that the Governor is so disqualified, he/she shall immediately declare that the person in question is disqualified and notify him/her in writing to that effect.
Upon receipt of any such notification, that person’s tenure of office, if any, shall be terminated and he/she shall cease to act as a Governor.
6.12 Appointment of a Lead Governor
6.12.1 The Trust will appoint a Lead Governor
6.12.2 The Lead Governor will be appointed to carry out the role described in Appendix B of Monitor’s FT Code of Governance 2010 or any subsequent amendments.
6.12.3 He/she will be appointed from those in the public, patient or out of area membership category with at least 12 years’ experience as a Governor.
6.12.4 The Lead Governor will be appointed by the Council of Governors for a period of one year, but may be re-appointed annually up to a maximum of three years.
6.12.5 The Lead Governor will, via the Trust Secretary, pass on to Governors within five days any communication received directly from Monitor and, where the Chairman of the Board of Governors is conflicted, shall via the Vice-Chairman, convene a meeting of the Board of Governors at the earliest opportunity – but only in respect of communications received from Monitor.
6.12.6 Where any Governor – including the Lead Governor – wishes to contact Monitor, he/she will first discuss this with the SID (Senior Independent Director). Contact thereafter with Monitor, will be via the Lead Governor. This presupposes that matters have not been resolved locally, either through the Chairman or the Board of Governors.
6.12.7 Removal of the Lead Governor will require the approval of three-quarters of the members of the whole membership of the Council of Governors. 11
6.13 Vacancies:
6.13.1 Where membership of the Council of Governors ceases for one of the reasons set out in paragraphs 6.10 or 6.11 or through death in service:
(a) public and staff Governors shall be replaced at the next annual election in accordance with the relevant Electoral Scheme set out in Annex 3.
(b) should the vacancy affect the quorum or representation of a constituency for a period exceeding six months, a by-election shall be held in accordance with the relevant Electoral Scheme set out in Annex 3.
(c) Clinical Commissioning Group, Local Authority and Partnership Governors shall be replaced in accordance with the processes agreed pursuant to paragraphs 6.6 to 6.8.
6.14 Casual Vacancies:
6.14.1 A casual vacancy is a vacancy that arises because a Governor does not complete his term of office for any reason. A vacancy that arises because the term of office of a governor has expired and he has not been re-elected or re-appointed is not a casual vacancy.
6.14.2 The validity of any act of the Council of Governors is not affected by any vacancy amongst the Council of Governors or by any defect in the appointment of any Governor.
6.14.3 Where there is a casual vacancy of the Council of Governors for whatever reason:
(a) Where the vacancy is for an appointed Governor, the appointing organisation will be requested to appoint a replacement to hold office for the remainder of the term in accordance with the agreed appointment processes; and
(b) Where the vacancy is for an elected Governor, the next highest polling candidate at the most recent elections to fill the seat may be invited to take up the seat for the remainder of the period of office at which time he may seek re-election.
6.15 Roles and Responsibilities of Governors:
6.15.1 The roles and responsibilities of the Governors are:
(a) At a General meeting:
(i) to appoint or remove the Chairman and the other Non-Executive Directors. The initial Chairman appointed by the Council of Governors is to be the Chairman of the applicant NHS Trust if he/she wishes to be appointed. The other initial Non–Executive Directors appointed by the Council of Governors are, so far as possible, to be Non-Executive Directors (other than the Chairman) of the applicant Trust who wish to be appointed. The removal of a Non-Executive Director requires the approval of three-quarters of all the Council of Governors;
(ii) to decide the remuneration and allowances, and the other terms and conditions of office, of the Non-Executive Directors made by the Governors Remuneration Committee (after taking appropriate 12 independent advice). Details of the remuneration and allowances of Non-Executive Directors will be published in the Trust’s annual accounts.
(iii) The remuneration and allowances for Non-Executive Directors are to be set by the Council of Governors (after taking independent advice) and are also to be published in the Trust’s annual accounts.
(iv) to appoint or remove the Trust’s auditor at a general meeting of the Board;
(v) to be presented with and consider the annual accounts, any report of the auditor on them and the annual report;
(b) to approve (by a majority of the Council of Governors voting) an appointment (by the Chairman and Non-Executive Directors) of the Chief Executive other than the initial Chief Executive of the Trust appointed in pursuance of paragraph 19(6) of Schedule 1 to the 2003 Act;
(c) to give the views of the Council of Governors to Directors for the purposes of the preparation (by the Directors) of the document containing information as to the Trust’s forward planning in respect of each financial year to be given to Monitor;
(d) to hold the Non-Executive Directors individually and collectively to account for the performance of the Board of Directors
(e) to represent the interests of the members of the corporation as a whole and the interests of the public
(f) to respond as appropriate when consulted by the Directors;
(g) to carry out other duties as agreed with Directors from time to time.
6.15.2 The Trust must take steps to secure that the Governors are equipped with the skills and knowledge they require in their capacity as such.
6.15.3 For the purpose of obtaining information about the Trust’s performance of its functions or the Directors’ performance of their duties (and deciding whether to propose a vote on the Trust’s or Director’s performance), the Council of Governors may require one or more of the Directors to attend a meeting.
6.16 Expenses:
6.16.1 The Trust may reimburse Governors for travelling and other costs and expenses incurred in carrying out their duties as the Board of Directors decides.
6.17 Remuneration:
6.17.1 Governors are not to receive remuneration.
6.18 Meetings:
6.18.1 The Chairman of the Trust or, in his/her absence, another Non-Executive Director will preside at meetings of the Council of Governors. The Chairman or Non-Executive Director may have a casting vote, provided that he/she may not exercise that casting vote if he/she is conflicted on an issue. If this is the case, the Council of Governors shall elect a
13 public Governor from their number to preside over the meeting who shall exercise the casting vote.
6.18.2 Meetings of the Council of Governors are to be open to members of the public except in the following circumstances:
(a) during the consideration of any material or discussion in relation to a named person employed by or proposed to be employed by the Trust;
(b) during the consideration of any material or discussion in relation to a named person who is or has been or is likely to become a patient of the Trust or a carer in relation to such patient;
(c) during the consideration of any matter, which, by reason of its nature, the Council is satisfied, should be dealt with on a confidential basis.
6.18.3 Members of the Council of Governors will only receive patient and staff identifiable level information where the Council of Governors has satisfied itself that this is necessary for it to be able to meet its responsibilities and duties.
6.18.4 The Council of Governors is to meet at least four times a year.
6.18.5 At a general meeting in September, the Council of Governors is to receive and consider the annual accounts, any report of the auditor on them, and the annual report.
(a) Nothing in sub-paragraph 6.16.5 prevents the Council of Governors from holding a general meeting more than once a year.
6.18.6 The Council of Governors will adopt its own standing orders for its practice and procedure, in particular for its procedure at meetings (including general meetings), but these shall be in accordance with Annex 2.
6.19 Committees and sub-committees:
6.19.1 The Council of Governors may appoint committees consisting of its Members to assist it in carrying out its functions. A committee appointed under this paragraph may appoint a sub-committee.
6.19.2 These committees or sub-committees may call upon outside advisers to help them in their tasks.
6.20 Declaration of Interests of Governors:
6.20.1 Declaration of Interests:
If a Governor has a pecuniary or non-pecuniary interest, whether direct or indirect, in any contract, proposed contract or other matters which are under consideration by the Council of Governors, he/she shall disclose that to the rest of the Council of Governors as soon as he/she is aware of it. The Council of Governors shall adopt standing orders specifying the arrangements for excluding Governors from discussion or consideration of the contract or other matter, as appropriate.
6.20.2 For avoidance of doubt, interests that should be disclosed include, but are not limited to:
14 (a) directorships, including Non-Executive directorships held in private companies or PLCs with the exception of those of dormant companies;
(b) ownership, part ownership or directorship of private companies, business or consultancies likely or possibly seeking to do business with the NHS;
(a) majority or controlling shareholdings in organisations likely or possibly seeking to do business with the NHS;
(d) a position of authority in a charity or voluntary organisation in the field of health and social care;
(e) any connection with a voluntary or other organisation in the field of health and social care;
(f) to the extent not covered above, any connections with an organisation, entity or company considering entering into or having entered into a financial arrangement with the Trust, including but not limited to, lenders or banks
6.20.3 If a Governor has any doubt about the relevance or materiality of an interest, the Governor shall discuss this with the Chairman.
6.20.4 At the time the interests are declared, they shall be recorded in the minutes of the Council of Governors meeting as appropriate. Any changes of interests of a Governor shall be officially declared at the next meeting of the Council as appropriate, following the change occurring. It is the obligation of the Governor to inform the Trust Secretary in writing within seven days of becoming aware of the existence of a relevant or material interest. The Trust Secretary will amend the register within three working days.
6.20.5 Directorships of companies in 6.18.2 (a) above or in companies likely or possibly seeking to do business with the NHS in 6.18.2 (b) above should be published in the Trust’s annual report. The information should be kept up to date for inclusion in succeeding annual reports.
7. Board of Directors:
7.1 The Trust is to have a Board of Directors. It is to consist of Executive and Non-Executive Directors.
7.2 The Board is to include:
(a) the following Non-Executive Directors:
(i) a Chairman;
(ii) seven other Non-Executive Directors;
(b) the following Executive Directors:
(i) a Chief Executive;
(ii) a Finance Director;
(iii) four other Executive Directors, one of whom is to be a registered medical practitioner or a registered dentist (within the meaning of the Dentists Act 1984) and another of whom is to be a registered nurse or registered midwife.
15 7.3 Subject to paragraph 7.3.1 below, only a Member of the Public Constituency or Out of Area Constituency is eligible for appointment as a Non-Executive Director.
7.3.1 Paragraph 7.3 above does not apply to the appointment of any initial Non-Executive Director in pursuance of paragraph 19 of Schedule 1 to the 2003 Act.
7.4 Subject to the provisions in paragraph 7.5.1 regarding initial appointments, Non-Executive Directors are to be appointed in accordance with a process that may include open competition. This process will be agreed by the Council of Governors.
7.4.1 The validity of any act of the Trust is not affected by any vacancy among the Directors or by any defect in the appointment of any Director.
7.5 Terms of Office:
7.5.1 The Chairman and the Non-Executive Directors are to be appointed for a period of office in accordance with the terms and conditions of office decided by the Council of Governors at a general meeting.
7.5.2 The Chief Executive (and accounting officer) shall hold office for a period in accordance with the terms and conditions of office decided by the relevant committee of Non- Executive Directors; (or, pending the establishment of such a committee, in accordance with the terms and conditions decided by the applicant NHS Trust Board of Directors). The appointment requires the approval of the Council of Governors.
7.5.3 The Executive Directors, other than the Chief Executive shall hold office for a period in accordance with the terms and conditions decided by the relevant committee of Non- Executive Directors; (or, pending the establishment of such a committee, in accordance with the terms and conditions decided by the applicant NHS Trust Board of Directors).
7.6 Disqualification:
7.6.1 A person may not be a Director of the Trust if:
(a) in the case of a Non-Executive Director, he/she no longer satisfies paragraph 7.3.
(b) he/she is a person whose tenure of office as a Chairman or as a Member or Director of a Health Service body has been terminated on the grounds that his/her appointment is not in the interests of public service, for non attendance at meetings, or for non-disclosure of a pecuniary/non-pecuniary interest;
(c) he/she has within the preceding two years been dismissed, from any paid employment for misconduct with a Health Service body;
(d) he/she is an Executive Director of the Trust, or a Governor, Non-Executive Director, Chairman, Chief Executive officer of another NHS Trust;
(e) he/she is incapable by reason of mental disorder, illness or injury of managing and administering his/her property and affairs;
(f) he/she brings the Board of Directors or any of its Member organisations into disrepute;
(g) he/she has failed to comply with the required standard of behaviour as per the Trust policy for withholding treatment from violent and abusive patients;
16 (h) he/she has had his name removed, by a direction under section 46 of the 1977 Act from any list prepared under Part II of that Act, and has not subsequently had his/her name included in such a list;
(i) he/she has been placed on the Registers of schedule 1 Offenders pursuant to the Sex Offenders Act 1977 and/or the Children & Young Person Act 1933;
(j) he/she fails to abide by the Constitution as set out in this document;
(k) he/she has failed to undertake the required training for Directors.
7.6.2 In accordance with the Health and Social Care Act 2014 Regulation 5 “Fit and Proper Persons as Directors” the Trust shall also ensure that no person who is an unfit person may become or continue as a Director, except with the approval of Monitor.
In this condition an unfit person is:
(a) An individual;
(i) Who has been adjudged bankrupt or whose estate has been sequestrated and (in either case) has not been discharged; or
(ii) Who has made a composition or arrangement with, or granted a trust deed for, his creditors and has not been discharged in respect of it; or
(iii) Who within the preceding five years has been convicted in the British Islands of any offence and a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him; or
(iv) Who is subject to an unexpired disqualification order made under the Company Directors’ Disqualification Act 1986; or
(b) A body corporate with a parent body corporate:
(i) Where one or more of the Directors of the body corporate or of its parent body corporate is an unfit person under the provisions of sub- paragraph (a) of this paragraph or,
(ii) In relation to which a voluntary arrangement is proposed under section 1 of the Insolvency Act 1986, or
(iii) Which has a receiver (including an administrative receiver within the meaning of section 29(2) of the 1986 Act) appointed for the whole or any material part of its assets or undertaking, or
(iv) Which has an administrator appointed to manage its affairs, business and property in accordance with Schedule B1 to the 1986 Act, or
(v) Which passes any resolution for winding up, or
(vi) Which becomes subject to an order of a Court for winding up.
7.7 Roles and Responsibilities:
7.7.1 The powers of the Trust are to be exercisable by the Board of Directors on its behalf. 17
7.7.2 Any of those powers may be delegated to a committee of Directors or to an Executive Director.
7.7.3 A committee of Non-Executive Directors established as anAudit Committee is to monitor, review and carry out such other functions as may be delegated to it by the Board as referenced in 13.3.
7.7.4 It is for the Chairman and Non-Executive Directors to appoint (subject to the approval of the Council of Governors) or remove the Chief Executive (and accounting officer). The initial Chief Executive (and accounting officer) is to be the chief officer of the applicant NHS Trust if he/she wishes to be appointed.
7.7.5 A panel comprising the Chairman, Chief Executive other Non-Executive Directors and external advisors as appropriate will appoint the Executive Directors.
7.7.6 It is for the Governors at a meeting of the Council of Governors to appoint or remove the Chairman or other Non-Executive Director/s. The removal of the Chairman or a Non- Executive Director requires the approval of three-quarters of the Council of Governors.
7.7.7 The Trust is to establish a committee of Non-Executive Directors to decide the remuneration and allowances, and the other terms and conditions of office, of the Executive Directors (Remuneration Committee). Pending the establishment of such a committee, Executive Directors of the applicant NHS Trust appointed to the Trust will be appointed on their current terms and conditions at the point at which the Trust is established.
7.7.8 The Directors, having regard to the views of the Council of Governors, are to prepare the information as to the Trust’s forward planning in respect of each financial year to be given to Monitor.
7.7.9 The Directors are to present to the Council of Governors at a general meeting the annual accounts, any report of the auditor on them, and the annual report.
7.7.10 The functions of the Trust under paragraph 14.5 below are delegated to the Chief Executive as accounting officer.
7.7.11 The general duty of the Board of Directors, and of each Director individually, is to act with a view to promoting the success of the corporation so as to maximize the benefits for the members of the corporation as a whole and for the public
7.7.12 (1) The duties that a director of a public benefit corporation has by virtue of being a director include in particular –
(a) a duty to avoid a situation in which the Director has (or can have) a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the corporation;
(b) a duty not to accept a benefit from a third party by reason of being a director or doing (or not doing) anything in that capacity.
(2) The duty referred to in sub-paragraph 7.7.12 (1) (a) is not infringed if –
(a) the situation cannot reasonably be regarded as likely to give rise to conflict of interest, or
18 (b) the matter has been authorised in accordance with the constitution.
(3) The duty referred to in sub-paragraph 7.7.12 (1) (b) is not infringed if acceptance of the benefit cannot reasonably be regarded as likely to give rise to a conflict of interest.
(4) In sub-paragraph (1) (b)”third party” means a person other than –
(a) the Trust or (b) a person acting on its behalf.
8. Declaration of Interest of Directors
The functions of the Trust under paragraph 14.5 below are delegated to the Chief Executive as accounting officer.
8.1 Declaration of Interests:
If a Director has a pecuniary or non-pecuniary interest, whether direct or indirect, in any contract, proposed contract or other matter which is under consideration by the Board, he/she shall disclose that to the rest of the Board as soon as he/she is aware of it. The Board of Directors, in consultation with the Council of Governors, shall adopt Standing Orders specifying the arrangements for excluding Directors from discussion or consideration of the contract or other matter, as appropriate. If a declaration becomes inaccurate or incomplete, a further declaration must be made.
8.1.1 For avoidance of doubt, interests that should be disclosed include, but are not limited to are:
(a) directorships, including Non-Executive directorships held in private companies or PLCs with the exception of those of dormant companies;
(b) ownership, part ownership or directorship of private companies, business or consultancies likely or possibly seeking to do business with the NHS;
(c) majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS;
(d) a position of authority in a charity or voluntary organisation in the field of health and social care;
(e) any connection with a voluntary or other organisation in the field of health and social care;
(f) to the extent not covered above, any connections with an organisation, entity or company considering entering into or having entered into a financial arrangement with the Trust, including but not limited to, lenders or banks.
8.1.2 If a Director has any doubt about the relevance or materiality of an interest, the Director shall discuss this with the Chairman.
8.1.3 At the time the interests are declared, they shall be recorded in the minutes of the Board of Directors meeting as appropriate. Any changes of interests of a Director shall be officially declared at the next meeting of the Board as appropriate, following the change 19 occurring. It is the obligation of the Director to inform the Trust Secretary in writing within seven days of becoming aware of the existence of a relevant or material interest. The Trust Secretary will amend the register within three working days.
8.1.4 Directorships of companies in 8.1.1 (a) above or in companies likely or possibly seeking to do business with the NHS in 8.1.1 (b) above should be published in the Trust’s annual report. The information should be kept up to date for inclusion in succeeding annual reports.
9. Meetings of Directors
9.1 The Board of Directors, in consultation with the Council of Governors, is to adopt Standing Orders covering the proceedings and business of its meetings. These are to include setting a quorum for meetings, both of Executive and Non-Executive Directors. The proceedings shall not however be invalidated by any vacancy of its Membership, or defect in a Director’s appointment.
9.2 The Chairman may have a casting vote, provided that he/she may not exercise it if he/she is conflicted on an issue. If this is the case the meeting of the Board of Directors shall be presided over by another Non-Executive Director and that Non-Executive Director shall exercise the casting vote provided he/she is not conflicted on that issue.
9.3 (1) Before holding a public meeting, the Board of Directors must send a copy of the agenda of the meeting to the Council of Governors
(2) As soon as practicable after holding a public meeting, the Board of Directors must send a copy of the minutes of the meeting to the Council of Governors.
9.4 Meetings of the Board of Directors shall be open to members of the public. Members of the public may be excluded from a meeting for special reasons These would include Freedom of Information Act 2000 Exemptions:
Section 30 Investigations Section 36 Effective conduct of public affairs Section 40 Personal data Section 43 Commercial Interests
10. Registers
10.1 The Trust is to have:
(a) a register of Members showing, in respect of each Member, the Constituency and where there are classes within it, the class to which he belongs;
(b) a register of Members of the Council of Governors;
(c) a register of interests of the Council of Governors;
(d) a register of Directors;
(e) a register of interests of the Directors.
10.2 The Trust Secretary will set out and agree the format of the Members register with the Council of Governors. The register will list names and Constituency for each Member. The Trust Secretary will be responsible for making arrangements for additions and removals from the register. The register will be reviewed annually for completeness and accuracy .
20 The Trust Secretary will also set out and agree the format of the register of Governors and their interests and will be responsible for additions and removals from the register.
The Trust Secretary will also set out and agree the format of the register of Directors and their interests and will be responsible for additions and removals from the register.
10.3 The Trust is to send to Monitor a list of the persons who were first elected or appointed:
(a) the Members of the Council of Governors;
(b) the Directors.
11. Documents available for public inspection
11.1 The Trust shall make the following documents available for inspection by members of the public free of charge at all reasonable times:
11.1.1 a copy of the current constitution
11.1.2 a copy of the latest annual accounts and any report of the auditor on them;
11.1.3 a copy of the latest annual report.
11.2 The Trust shall also make the following documents relating to a special administration of the Trust available for inspection by members of the public free of charge at all reasonable times:
11.2.1 a copy of any order made under section 65D (appointment of Trust special administrator), 65J (power to extend time), 65KC (action following Secretary of State’s rejection of final report), 65L (Trusts coming out of administration) or 65LA (Trusts to be dissolved) of the 2006 Act.
11.2.2 a copy of any report laid under section 65D (appointment of Trust special administrator) of the 2006 Act.
11.2.3 a copy of any information published under section 65D (appointment of Trust special administrator) of the 2006 Act.
11.2.4 a copy of any draft report published under section 65F (administrator’s draft report) of the 2006 Act.
11.2.5 a copy of any statement provided under section 65F (administrator’s draft report) of the 2006 Act.
11.2.6 a copy of any notice published under section 65F (administrator’s draft report), 65G (consultation plan), 65H (consultation requirements), 65J (power to extend time), 65KA (Monitor’s decision), 65KB (Secretary of State’s response to Monitor’s decision), 65KC (action following Secretary of State’s rejection of final report) or 65KD (Secretary of State’s response to re-submitted final report) of the 2006 Act.
11.2.7 a copy of any statement published or provided under section 65G (consultation plan) of the 2006 Act.
11.2.8 a copy of any final report published under section 65I (administrator’s final report).
11.2.9 a copy of any statement published under section 65J (power to extend time) or 65KC (action following Secretary of State’s rejection of final report) of the 2006 Act. 21
11.2.10 a copy of any information published under section 65M (replacement of Trust special administrator) of the 2006 Act.
11.3 Any person who requests a copy or extract from any of the above documents is to be provided with a copy.
11.4 If the person requesting a copy or extract is not a member of the Trust, the Trust may impose a reasonable charge for doing so.
12. Panel for Advising Governors
12.1 The regulator may appoint a panel of persons to which a Governor may refer a question as to whether the Trust has failed or is failing –
(a) to act in accordance with its constitution, or (b) to act in accordance with provision made by or under Chapter 7 of the Health Act 2006.
12.2 A Governor may refer a question to the panel only if more than half of the members of the Council of Governors voting approve the referral.
12.3 The panel –
(a) may regulate its own procedure, and
(b) may establish such procedures, and make such other arrangements, as it considers appropriate for the purpose of determining questions referred to it under this section.
12.4 The panel may decide whether, or to what extent, to carry out an investigation on a question referred to it under this section.
12.5 The panel may for that purpose, or for the purpose of carrying out such an investigation, request information or advice.
12.6 Where the panel has carried out such an investigation, it must publish a report of its determination of the question referred to it.
12.7 If a person refuses to comply with a request made under subsection 12.5, the report under subsection 12.6 may refer to the refusal.
12.8 On any proceedings before a court or tribunal relating to a question referred to the panel under this section, the court may take the panel’s report of its determination of the question into account.
12.9 The regulator –
(a) must pay expenses properly incurred by the panel and (b) must make administrative support available to the panel
12.10 Regulations may make provision as to –
(a) eligibility for membership of the panel; (b) the number of persons that may be appointed as members; (c) the terms of appointment of members; (d) circumstances in which a person ceases to be a member or may be suspended.
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13. Auditor
13.1 The Trust will appoint an auditor and will provide the auditor with every facility and all information, which he/she may reasonably require for the purposes of his/her functions under Part 1 of the 2003 Act.
13.2 A person may only be appointed auditor if he/she (or in the case of a firm each of its Members) is a Member of one or more of the bodies referred to in paragraph 23(4) of Schedule 1 to the 2003 Act.
13.3 Appointment of the auditor by the Council of Governors is covered in paragraph 6.13.1, and monitoring of the auditor’s function by a committee of Non-Executive Directors is covered in paragraph 7.7.3.
13.4 An officer of the Audit Commission may be appointed with the agreement of the Commission.
13.5 The auditor is to carry out his/her duties in accordance with Schedule 5 to the 2003 Act and in accordance with any directions given by Monitor on standards, procedures and techniques to be adopted.
14. Accounts
14.1 The Trust must keep proper accounts and proper records in relation to the accounts.
14.2 Monitor may with the approval of the Secretary of State give directions to the Trust as to the content and form of its accounts.
14.3 The accounts are to be audited by the Trust’s auditor.
14.4 The Trust shall prepare in respect of each financial year annual accounts in such form as Monitor may with the approval of the Secretary of State direct.
14.5 The functions of the Trust with respect to the preparation of the annual accounts shall be delegated to the Accounting Officer.
15. Annual reports, forward plans and non-NHS work
15.1 The Trust shall prepare an Annual Report and send it to Monitor.
15.2 The reports must give –
15.2.1 information on any steps taken by the corporation to secure that (taken as a whole) the actual membership of any public constituency and patients’ constituency is representative of those eligible for such membership
15.2.2 information on any occasions in the period to which the report relates on which the Council of Governors exercised its power under paragraph 6.13.3
15.2.3 information on the Trust’s policy on pay and on the work of the Trust Remuneration Committees established under paragraph 7.7.7 and such other procedures as the Trust has on pay,
23 15.2.4 information on the remuneration of the Directors and on the expenses of the Governors and the Directors.
15.2.5 (i) any other information the regulator requires
(ii) before imposing a requirement under subparagraph 15.2.5 (i) that the regulator considers is sufficiently significant to justify consultation, the regulator must consult such persons as it considers appropriate.
15.3 The Trust shall give information as to its forward planning in respect of each financial year to the Secretary of State.
15.4 The document containing the information with respect to forward planning (referred to above) shall be prepared by the directors.
15.5 In preparing the document the directors shall have regard to the views of the Council of Governors.
15.6 Each forward plan must include information about –
15.6.1 the activities other than the provision of goods and services for the purposes of the health service in England that the Trust proposes to carry on, and
15.6.2 the income it expects to receive from doing so.
15.7 Where a forward plan contains a proposal that the Trust carry on an activity of a kind mentioned in sub-paragraph 15.6.1 the Council of Governors must –
15.7.1 determine whether it is satisfied that the carrying on of the activity will not to any significant extent interfere with the fulfilment by the Trust of its principal purpose or the performance of its other functions, and
15.7.2 notify the directors of the Trust and its determination.
15.8 A Trust which proposes to increase by 5% or more the proportion of its total income in any financial year attributable to activities other than the provision of goods and services for the purposes of the health service in England may implement the proposal only if more than half of the members of the Council of Governors of the Trust voting approve its implementation.
15.9 Annual Meeting of Members
15.9.1 The Trust must hold an annual meeting of its members.
15.9.2 The meeting must be open to members of the public.
15.9.3 At least one member of the Board of Directors of the corporation must attend the meeting and present the following documents to the members at the meeting –
(a) the annual accounts (b) any report of the auditor on them (c) the annual report
15.9.4 Where an amendment is made to the constitution in relation to the powers or duties of the Council of Governors -
24 (a) at least one member of the Council of Governors must attend the next annual meeting of members and present the amendment, and
(b) the Trust must give the members an opportunity to vote on whether they approve the amendment.
15.9.5 If more than half of the members voting approve the amendment, the amendment continues to have effect; otherwise it ceases to have effect and the Trust must take such steps as are necessary as a result.
16. Indemnity
16.1 Members of the Council of Governors and Board of Directors who act honestly and in good faith will not have to meet out of their personal resources any personal civil liability which is incurred in the execution or purported execution of their Board functions, except where they have acted recklessly. Any costs arising in this way will be met by the Trust. The Trust may purchase and maintain insurance against this liability.
17. Instruments etc
17.1 A document purporting to be duly executed under the Trust’s seal or to be signed on its behalf is to be received in evidence and, unless the contrary is proved, taken to be so executed or signed.
17.2 The Trust is to have a seal, but this is not to be affixed except under the authority of the Board of Directors.
18. Dispute Resolution Procedures
18.1 The Trust Secretary shall be the custodian of membership documentation and the membership database. The Trust Secretary shall be responsible for dealing with queries or disputes regarding membership with a right of appeal to a committee of the Council of Governors convened for this purpose, whose decision shall be final and binding.
18.2 In the event of a dispute between the Council of Governors and the Board of Directors, the Council and Board shall meet and attempt to resolve the dispute by negotiation. If agreement cannot be reached then, subject to paragraph 18.3, the dispute shall be referred to the Chairman, whose decision shall be final.
18.3 In the event that a dispute is referred to the Chairman under paragraph 18.3 and the Chairman considers that he/she has a perceived or real interest in the outcome of that dispute and the dispute would be better resolved externally, then the Chairman may refer the dispute for resolution by arbitration.
18.4 All other disputes shall be referred in the first instance to the Chief Executive who will deal with them in accordance with an appropriate dispute resolution procedure.
19. Amendment of the Constitution
19.1 (1) The Trust may make amendments to this Constitution only if –
(a) more than half of the members of the council of governors of the Trust voting approve the amendments, and
(b) more than half of the members of the Board of Directors of the Trust voting approve the amendments.
25 (2) Amendments made under this section take effect as soon as the conditions in subsection 19.1 (1) (a) and (b) are satisfied
(3) But an amendment is of no effect in so far as the constitution would, as a result of the amendment, not accord with Schedule 7 of the Health Act 2006.
(4) The Trust must inform the regulator of amendments made under this section; but the regulator’s functions do not include a power or duty to determine whether or not the constitution as a result of the amendments, accords with Schedule 7 of the Health Act 2006.
19.2 Subject to clause 19.1, this Constitution will be reviewed by the Council of Governors no sooner than the expiry of one year from the date of approval of the previous revisions and no later than two years from such date.
20. Dissolution of the Trust
20.1 The Trust may not be dissolved except by order of Monitor, in accordance with Section 54 of the 2006 Act following authorisation of a relevant application by the Council of Governors in Accordance with Para 21.1 below.
21. Mergers etc and significant transactions
21.1 The Trust may only apply for a merger, acquisition, separation or dissolution with the approval of more than half of the members of the Council of Governors.
21.2 The Trust may enter into a significant transaction only if more than half of the members of the Council of Governors of the Trust voting approve entering into the transaction
21.3 “Significant transaction” will be defined by the criteria set out by Monitor below:
Reporting requirements Ratio Description Non-healthcare/ UK Healthcare international Assets The gross assets* subject to the >5% >10% transaction, divided by the gross assets of the foundation trust Income The income attributable to the: >5% >10% • assets or • contract associated with the transaction, divided by the income of the foundation trust Consideration to The gross capital** or >5% >10% toal foundation consideration associated with the trust capital transaction divided by the total capital*** of the foundation trust following completion or the effects on the total capital of the foundation trust resulting from a transaction *Gross assets are the total of fixed assets and current assets. ** Gross capital equals the market value of the target’s shares and debt securities, plus the excess of current liabilities over current assets. ***Total capital of the foundation trust equals taxpayers’ equity.
26 22. Foundation Trust Head Office
22.1 The Foundation Trust Head Office may be contacted:
Trust Secretary Trust Headquarters Queen Elizabeth Hospital Sheriff Hill Gateshead NE9 6SX
Tel: 0191 4820000 or 0191 4453713 Fax: 0191 4826001
Email: [email protected]
Website: www.qegateshead.nhs.uk
27 Annex 1
Public Constituencies Of The Trust
Name of Constituency Area Minimum number of Number of Governors Members
(a) Western Gateshead The Western area will 600 6 consist of Prudhoe, Crawcrook & Greenside, Chopwell & Rowlands Gill, Winlaton & High Spen, Blaydon, Ryton, Crookhill & Stella, Whickham North, Whickham South & Sunniside, Dunston & Teams, Dunston Hill & Whickham East.
(b) Central Gateshead The Central area will 700 7 consist of Lamesley, Birtley, Lobley Hill & Bensham, Bridges, Saltwell, Deckham, Low Fell, Chowdene, High Fell Chester-Le-Street, Ouston and Pelton, Washington.
(c) Eastern Gateshead The Eastern area will 300 3 consist of Felling, Windy Nook & Whitehills, Pelaw & Heworth, Wardley and Leam Lane and parts of Jarrow & Hebburn.
(d) Out of Area County Durham, 100 1 Newcastle upon Tyne, North Tyneside, Northumberland,South Tyneside and Sunderland other than any areas noted above and users of Trust services living outwith the areas (a) (b) (c) and (d)
28 Annex 2
COUNCIL OF GOVERNORS’ STANDING ORDERS
1. Meetings of the Council of Governors
1.1 Admission of the Public and the Press :
It is proposed that all meetings will be held in public unless the Council of Governors decides otherwise in relation to part of a meeting for reasons of confidentiality. The Chairman may exclude any member of the public from a meeting if they are interfering with or preventing the proper conduct of the meeting.
The Chairman shall give such directions as she/he thinks fit in regard to the arrangements for meetings and accommodation of the public and representatives of the press such as to ensure that the Council’s business shall be conducted without interruption and disruption and, without prejudice to the power to exclude on grounds of the confidential nature of the business to be transacted (see 6.16.2).
1.2 Nothing in these Standing Orders shall require the Council of Governors to allow members of the public or representatives of the press to record proceedings in any manner whatsoever, other than writing, or to make any oral report of proceedings as they take place without the prior agreement of the Council of Governors.
1.3 Calling meetings :
Meetings of the Council of Governors shall be held at least four times each year, inclusive of an Annual General Meeting, at times and places that the Council of Governors may determine.
Ordinary meetings of the Council of Governors shall be held at such times and places as the Council may determine.
1.4 The Chairman may call a meeting of the Council of Governors at any time. If the Chairman refuses to call a meeting after a requisition for that purpose, signed by at least one-third of the whole number of Governors, has been presented to him/her, or if, without so refusing, the Chairman does not call a meeting within seven days after such requisition has been presented to him, at the Trust’s Headquarters, such one third or more Governors may forthwith call a meeting.
1.5 Notice of meetings:
Before each meeting of the Council of Governors, a notice of the meeting, specifying the business proposed to be transacted at it, and signed by the Chairman or by an officer of the Trust authorised by the Chairman to sign on his behalf shall be issued to every Governor, or sent by post to the usual place of residence of such Governor, so as to be available to him at least five clear working days before the meeting.
1.6 Lack of service of the notice on any Governor shall not affect the validity of a meeting.
1.7 In the case of a meeting called by Governors in default of the Chairman, the notice shall be signed by those Governors and no business shall be transacted at the meeting other than that specified in the notice.
1.8 Failure to serve such a notice on more than three Governors will invalidate the meeting. A notice shall be presumed to have been served at the time at which the notice would be delivered in the ordinary course of the post.
29
1.9 Setting the agenda:
The Council of Governors may determine that certain matters shall appear on every agenda for a meeting of the Council of Governors and shall be addressed prior to any other business being conducted. (Such matters may be identified within these Standing Orders or following subsequent resolution shall be listed in an Appendix to the Standing Orders).
1.10 A Governor desiring a matter to be included on an agenda shall make his/her request in writing to the Chairman at least ten clear days before the meeting, subject to Standing Order 1.5. Requests made less than five days before a meeting may be included on the agenda at the discretion of the Chairman.
1.11 Chairman of meeting :
At any meeting of the Trust, the Chairman, if present, shall preside. If the Chairman is absent from the meetingeither in whole or temporarily on the grounds of a declared conflict of interest, the Non-Executive Director, shall preside
1.12 Annual public meeting :
The Trust will publicise and hold an annual public meeting in accordance with the NHS Trusts (Public Meetings) Regulations 1991 (SI(1991)482).
1.13 Notices of motion :
A Governor of the Trust desiring to move or amend a motion shall send a written notice thereof at least ten clear days before the meeting to the Chairman, who shall insert in the agenda for the meeting all notices so received subject to the notice being permissible under the appropriate regulations. This paragraph shall not prevent any motion being moved during the meeting, without notice on any business mentioned on the agenda subject to Standing Order 1.7.
1.14 Withdrawal of motion or amendments :
A motion or amendment once moved and seconded may be withdrawn by the proposer with the concurrence of the seconder and the consent of the Chairman.
1.15 Motion to rescind a resolution :
Notice of motion to amend or rescind any resolution (or the general substance of any resolution) which has been passed within the preceding six calendar months shall bear the signature of the Governors who gives it and also the signature of three other Governors. When any such motion has been disposed of by the Trust, it shall not be competent for any Governor other than the Chairman to propose a motion to the same effect within three months; however the Chairman may do so if he/she considers it appropriate.
1.16 Motions:
The mover of a motion shall have a right of reply at the close of any discussion on the motion or any amendment thereto.
30 1.17 When a motion is under discussion or immediately prior to discussion it shall be open to a Governor to move:
• an amendment to the motion
• the adjournment of the discussion or the meeting
• that the meeting proceed to the next business (*)
• the appointment of an ad hoc committee to deal with a specific item of business
• that the motion be now put (*)
• in the case of sub-paragraphs denoted by (*) above to ensure objectivity motions may only be put by a Governor who has not previously taken part in the debate
No amendment to the motion shall be admitted if, in the opinion of the Chairman of the meeting, the amendment negates the substance of the motion.
1.18 Chairman’s ruling :
Statements of Governors made at meetings of the Trust shall be relevant to the matter under discussion at the material time and the decision of the Chairman of the meeting on questions of order, relevance, regularity and any other matters shall be observed at the meeting.
1.19 Voting :
Save where all public Governors present are unanimous in opposing a motion, every question at a meeting shall be determined by a majority of the votes of the Governors present and voting on the question and, in the case of any equality of votes, the person presiding shall have a second or casting vote. In the event that a motion is opposed by all public Governors present, that motion shall not be passed.
1.20 All questions put to the vote shall, at the discretion of the Chairman of the meeting, be determined by oral expression or by a show of hands. A paper ballot may also be used if a majority of the Governors present so request.
1.21 If at least one-third of the Governors present so request, the voting (other than by paper ballot) on any question may be recorded to show how each Governor present voted or abstained.
1.22 If a Governor so requests, his/her vote shall be recorded by name upon any vote (other than by paper ballot).
1.23 In no circumstances may an absent Governor vote by proxy. Absence is defined as being absent at the time of the vote.
1.24 Minutes :
The Minutes of the proceedings of a meeting shall be drawn up and submitted for agreement at the next ensuing meeting where they will be signed by the person presiding at it.
1.25 No discussion shall take place upon the minutes except upon their accuracy or where the Chairman considers discussion appropriate. Any amendment to the minutes shall be agreed and recorded at the next meeting.
31 1.26 Minutes shall be circulated in accordance with Governors' wishes. Where providing a record of a public meeting the minutes shall be made available to the public (required by the Code of Practice on Openness in the NHS).
1.27 Suspension of Standing Orders :
Except where this would contravene any statutory provision or any direction made by the Secretary of State and/or Monitor, any one or more of the Standing Orders may be suspended at any meeting, provided that at least two-thirds of the Council of Governors are present, including one staff Governor and one public Governor, and that a majority of those present vote in favour of suspension.
1.28 A decision to suspend Standing Orders shall be recorded in the minutes of the meeting.
1.29 A separate record of matters discussed during the suspension of Standing Orders shall be made and shall be available to the Governors.
1.30 No formal business may be transacted while Standing Orders are suspended.
1.31 The Audit Committee shall review every decision to suspend Standing Orders.
1.32 Variation and amendment of Standing Orders :
These Standing Orders shall be amended only if:
• a notice of motion under Standing Order 1.14 has been given; and
• no fewer than half the total of the Trust’s public Governors vote in favour of amendment; and
• at least two-thirds of the Governors are present; and
• the variation proposed does not contravene a statutory provision or direction made by the Secretary of State.
1.33 Record of attendance :
The names of the Governors present at the meeting shall be recorded in the minutes.
1.34 Quorum :
No business shall be transacted at a meeting of the Council of Governors unless at least one-third of the whole number of the Governors are present including on or after the operational date at least nine Public Governors plus three other Governors .
1.35 If a Governor has been disqualified from participating in the discussion on any matter and/or from voting on any resolution by reason of the declaration of a conflict of interest he/she shall no longer count towards the quorum. If a quorum is then not available for the discussion and/or the passing of a resolution on any matter, that matter may not be discussed further or voted upon at that meeting and the decision to that effect shall be recorded.
32 2. Committees
2.1 Appointment of committees :
Subject to such directions as may be given by the Secretary of State and/or any requirements of Monitor, the Council of Governors may and, if directed by him/her, shall appoint committees of the Council of Governors, consisting wholly or partly of Governors.
2.2 A committee appointed may, subject to such directions as may be given by the Secretary of State or the Council of Governors appoint sub-committees consisting wholly or partly of members of the committee (whether or not they include Governors).
2.3 The Standing Orders of the Trust, as far as they are applicable, shall apply with appropriate alteration to meetings of any committees or sub-committee established by the Council of Governors.
2.4 Each such committee or sub-committee shall have such terms of reference and powers and be subject to such conditions (as to reporting back to the Council of Governors), as the Council of Governors shall decide. Such terms of reference shall have effect as if incorporated into the Standing Orders.
2.5 Committees may not delegate their executive powers to a sub-committee unless expressly authorised by the Council of Governors.
2.6 Confidentiality :
A member of a committee shall not disclose a matter dealt with by, or brought before, the committee without its permission until the committee shall have reported to the Council of Governors or shall otherwise have concluded on that matter.
2.7 A Governor or a member of a committee shall not disclose any matter reported to the Council of Governors or otherwise dealt with by the committee, notwithstanding that the matter has been reported or action has been concluded, if the Council of Governors or committee shall resolve that it is confidential.
3. Declarations of interests and register of interests
3.1 Declaration of interests :
The Trust’s constitution requires Governors to declare interests which are relevant and material to the Council of Governors of which they are a member. All existing Governors should declare such interests. Any Governors appointed subsequently should do so on appointment.
3.2 For avoidance of doubt, interests that should be disclosed include, but are not limited to are:
a) Directorships, including Non-Executive directorships held in private companies or PLCs (with the exception of those of dormant companies).
b) Ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS.
c) Majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS.
d) A position of authority in a charity or voluntary organisation in the field of health and social care.
33 e) Any connection with a voluntary or other organisation contracting for NHS services.
f) to the extent not covered above, any connections with an organisation, entity or company considering entering into or having entered into a financial arrangement with the Trust, including but not limited to, lenders or banks.
3.3 If Governors have any doubt about the relevance of an interest, this should be discussed with the Chairman.
3.4 At the time Governors' interests are declared, they should be recorded in the Council of Governors minutes of the relevant meeting. Any changes in interests should be declared at the next Council of Governors’ meeting following the change occurring.
3.5 Governors’ directorships of companies likely or possibly seeking to do business with the NHS should be published in the Council of Governors' annual report. The information should be kept up to date for inclusion in succeeding annual reports.
3.6 During the course of a Council of Governors’ meeting, if a conflict of interest is established, the Governor concerned should withdraw from the meeting and play no part in the relevant discussion or decision.
3.7 Register of interests :
The Trust Secretary will ensure that a Register of Interests is established to record formally declarations of interests of Governors. In particular the Register will include details of all directorships and other relevant and material interests which have been declared by Governors.
3.8 These details will be kept up to date by means of an annual review of the Register in which any changes to interests declared during the preceding twelve months will be incorporated.
3.9 The Register will be available to the public and the Trust Secretary will take reasonable steps to bring the existence of the Register to the attention of the local population and to publicise arrangements for viewing it.
4. Disability of Governors in proceedings on account of pecuniary interest
4.1 Subject to the following provisions of this Standing Order, if a Governor has any pecuniary interest, direct or indirect, in any contract, proposed contract or other matter and is present at a meeting of the Council of Governors at which the contract or other matter is the subject of consideration, he shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not take part in the consideration or discussion of the contract or other matter or vote on any question with respect to it.
4.2 Monitor may, subject to such conditions as that organisation may think fit to impose, remove any disability imposed by this Standing Order in any case in which it appears to Monitor in the interests of the National Health Service that the disability shall be removed.
4.3 The Council of Governors shall exclude a Governor from a meeting of the Trust while any contract, proposed contract or other matter in which he/she has a pecuniary interest, is under consideration.
4.4 Any expenses payable to a Governor shall not be treated as a pecuniary interest for the purpose of this Standing Order.
4.5 For the purpose of this Standing Order the Chairman or a Governor shall be treated, as having indirectly a pecuniary interest in a contract, proposed contract or other matter, if:
34 (a) he/she, or a nominee of his, is a director of a company or other body, not being a public body, with which the contract was made or is proposed to be made or which has a direct pecuniary interest in the other matter under consideration; or
(b) he/she is a partner of, or is in the employment of a person with whom the contract was made or is proposed to be made or who has a direct pecuniary interest in the other matter under consideration;
and in the case of married persons living together the interest of one spouse shall, if known to the other, be deemed for the purposes of this Standing Order to be also an interest of the other.
4.6 A Governor shall not be treated as having a pecuniary interest in any contract, proposed contract or other matter by reason only:
(a) of his membership of a company or other body, if he/she has no beneficial interest in any securities of that company or other body;
(b) of an interest in any company, body or person with which he is connected which is so remote or insignificant that it cannot reasonably be regarded as likely to influence a Governor in the consideration or discussion of or in voting on, any question with respect to that contract or matter.
4.7 Where a Governor:
(a) has an indirect pecuniary interest in a contract, proposed contract or other matter by reason only of a beneficial interest in securities of a company or other body; and
(b) the total nominal value of those securities does not exceed £5,000 or one-hundredth of the total nominal value of the issued share capital of the company or body, whichever is the less; and
(c) if the share capital is of more than one class, the total nominal value of shares of any one class in which he has a beneficial interest does not exceed one-hundredth of the total issued share capital of that class;
this Standing Order shall not prohibit him/her from taking part in the consideration or discussion of the contract or other matter or from voting on any question with respect to it without prejudice however to his/her duty to disclose his/her interest.
35 ANNEX 3 GATESHEAD HEALTH NHS FOUNDATION TRUST (COUNCIL OF GOVERNORS) RULES FOR THE CONDUCT OF ELECTIONS FOR PUBLIC AND STAFF GOVERNORS
PART 1: INTERPRETATION
1. Interpretation
PART 2: TIMETABLE FOR ELECTION
2. Timetable 3. Computation of time
PART 3: RETURNING OFFICER
4. Returning officer 5. Staff 6. Expenditure 7. Duty of co-operation
PART 4: STAGES COMMON TO CONTESTED AND UNCONTESTED ELECTIONS
8. Notice of election 9. Nomination of candidates 10. Candidate’s particulars 11. Declaration of interests 12. Declaration of eligibility 13. Signature of candidate 14. Decisions as to validity of nomination forms 15. Publication of statement of nominated candidates 16. Inspection of statement of nominated candidates and nomination forms 17. Withdrawal of candidates 18. Method of election
PART 5: CONTESTED ELECTIONS
19. Poll to be taken by ballot 20. The ballot paper 21. The declaration of identity (public constituencies)
Action to be taken before the poll
22. List of eligible voters 23. Notice of poll 24. Issue of voting information by returning officer 25. Ballot paper envelope and covering envelope 26. E-voting systems
The poll
36
27. Eligibility to vote 28. Voting by persons who require assistance 29. Spoilt ballot papers and spoilt text message votes 30. Lost voting information 31. Issue of replacement voting information 32. ID declaration form for replacement ballot papers (public and patient constituencies) 33 Procedure for remote voting by internet 34. Procedure for remote voting by telephone 35. Procedure for remote voting by text message
Procedure for receipt of envelopes, internet votes, telephone vote and text message votes
36. Receipt of voting documents 37. Validity of votes 38. Declaration of identity but no ballot (public constituencies) 39. De-duplication of votes 40. Sealing of packets
PART 6: COUNTING THE VOTES
STV41. Interpretation of Part 6 42. Arrangements for counting of the votes 43. The count STV44. Rejected ballot papers and rejected text voting records FPP44. Rejected ballot papers and rejected text voting records STV45. First stage STV46. The quota STV47 Transfer of votes STV48. Supplementary provisions on transfer STV49. Exclusion of candidates STV50. Filling of last vacancies STV51. Order of election of candidates FPP51. Equality of votes
PART 7: FINAL PROCEEDINGS IN CONTESTED AND UNCONTESTED ELECTIONS
FPP52. Declaration of result for contested elections STV52. Declaration of result for contested elections 53. Declaration of result for uncontested elections
PART 8: DISPOSAL OF DOCUMENTS
54. Sealing up of documents relating to the poll 55. Delivery of documents 56. Forwarding of documents received after close of the poll 57. Retention and public inspection of documents 58. Application for inspection of certain documents relating to election
37 PART 9: DEATH OF A CANDIDATE DURING A CONTESTED ELECTION
FPP59. Countermand or abandonment of poll on death of candidate STV59. Countermand or abandonment of poll on death of candidate
PART 10: ELECTION EXPENSES AND PUBLICITY
Expenses
60. Election expenses 61. Expenses and payments by candidates 62. Expenses incurred by other persons
Publicity
63. Publicity about election by the corporation 64. Information about candidates for inclusion with voting information 65. Meaning of “for the purposes of an election”
PART 11: QUESTIONING ELECTIONS AND IRREGULARITIES
66. Application to question an election
PART 12: MISCELLANEOUS
67. Secrecy 68. Prohibition of disclosure of vote 69. Disqualification 70. Delay in postal service through industrial action or unforeseen event
38 PART 1: INTERPRETATION
1. Interpretation
1.1 In these rules, unless the context otherwise requires:
“2006 Act ” means the National Health Service Act 2006;
“corporation ” means the public benefit corporation subject to this constitution;
“council of governors ” means the council of governors of the corporation;
“declaration of identity ” has the meaning set out in rule 21.1;
“election ” means an election by a constituency, or by a class within a constituency, to fill a vacancy among one or more posts on the council of governors;
“e-voting ” means voting using either the internet, telephone or text message;
“e-voting information ” has the meaning set out in rule 24.2;
“ID declaration form ” has the meaning set out in Rule 21.1; “internet voting record” has the meaning set out in rule 26.4(d);
“internet voting system ” means such computer hardware and software, data other equipment and services as may be provided by the returning officer for the purpose of enabling voters to cast their votes using the internet;
“lead governor ” means the governor nominated by the corporation to fulfil the role described in Appendix B to The NHS Foundation Trust Code of Governance (Monitor, December 2013) or any later version of such code.
“list of eligible voters ” means the list referred to in rule 22.1, containing the information in rule 22.2;
“method of polling ” means a method of casting a vote in a poll, which may be by post, internet, text message or telephone;
(5) “Monitor ” means the corporate body known as Monitor as provided by section 61 of the 2012 Act; (6) “numerical voting code ” has the meaning set out in rule 64.2(b)
“polling website ” has the meaning set out in rule 26.1;
“postal voting information ” has the meaning set out in rule 24.1;
“telephone short code” means a short telephone number used for the purposes of submitting a vote by text message;
“telephone voting facility ” has the meaning set out in rule 26.2;
“telephone voting record ” has the meaning set out in rule 26.5 (d);
“text message voting facility ” has the meaning set out in rule 26.3;
39 “text voting record ” has the meaning set out in rule 26.6 (d);
“the telephone voting system ” means such telephone voting facility as may be provided by the returning officer for the purpose of enabling voters to cast their votes by telephone;
“the text message voting system ” means such text messaging voting facility as may be provided by the returning officer for the purpose of enabling voters to cast their votes by text message;
“voter ID number ” means a unique, randomly generated numeric identifier allocated to each voter by the Returning Officer for the purpose of e-voting,
“voting information ” means postal voting information and/or e-voting information
1.2 Other expressions used in these rules and in Schedule 7 to the NHS Act 2006 have the same meaning in these rules as in that Schedule.
40 PART 2: TIMETABLE FOR ELECTIONS
2. Timetable
2.1 The proceedings at an election shall be conducted in accordance with the following timetable:
Proceeding Time
Not later than the fortieth day before the Publication of notice of election day of the close of the poll. Final day for delivery of nomination forms to Not later than the twenty eighth day before returning officer the day of the close of the poll.
Publication of statement of nominated Not later than the twenty seventh day candidates before the day of the close of the poll.
Final day for delivery of notices of withdrawals Not later than twenty fifth day before the by candidates from election day of the close of the poll.
Not later than the fifteenth day before the Notice of the poll day of the close of the poll.
Close of the poll By 5.00pm on the final day of the election.
3. Computation of time
3.1 In computing any period of time for the purposes of the timetable:
(a) a Saturday or Sunday; (b) Christmas day, Good Friday, or a bank holiday, or (c) a day appointed for public thanksgiving or mourning,
shall be disregarded, and any such day shall not be treated as a day for the purpose of any proceedings up to the completion of the poll, nor shall the returning officer be obliged to proceed with the counting of votes on such a day.
3.2 In this rule, “bank holiday” means a day which is a bank holiday under the Banking and Financial Dealings Act 1971 in England and Wales.
41 PART 3: RETURNING OFFICER
4. Returning Officer
4.1 Subject to rule 69, the returning officer for an election is to be appointed by the corporation.
4.2 Where two or more elections are to be held concurrently, the same returning officer may be appointed for all those elections.
5. Staff
5.1 Subject to rule 69, the returning officer may appoint and pay such staff, including such technical advisers, as he or she considers necessary for the purposes of the election.
6. Expenditure
6.1 The corporation is to pay the returning officer:
(a) any expenses incurred by that officer in the exercise of his or her functions under these rules, (b) such remuneration and other expenses as the corporation may determine.
7. Duty of co-operation
7.1 The corporation is to co-operate with the returning officer in the exercise of his or her functions under these rules.
42 PART 4: STAGES COMMON TO CONTESTED AND UNCONTESTED ELECTIONS
8. Notice of election
8.1 The returning officer is to publish a notice of the election stating:
(a) the constituency, or class within a constituency, for which the election is being held, (b) the number of members of the council of governors to be elected from that constituency, or class within that constituency, (c) the details of any nomination committee that has been established by the corporation, (d) the address and times at which nomination forms may be obtained; (e) the address for return of nomination forms (including, where the return of nomination forms in an electronic format will be permitted, the e-mail address for such return) and the date and time by which they must be received by the returning officer, (f) the date and time by which any notice of withdrawal must be received by the returning officer (g) the contact details of the returning officer (h) the date and time of the close of the poll in the event of a contest.
9. Nomination of candidates
9.1 Subject to rule 9.2, each candidate must nominate themselves on a single nomination form.
9.2 The returning officer:
(a) is to supply any member of the corporation with a nomination form, and (b) is to prepare a nomination form for signature at the request of any member of the corporation, but it is not necessary for a nomination to be on a form supplied by the returning officer and a nomination can, subject to rule 13, be in an electronic format.
10. Candidate’s particulars
10.1 The nomination form must state the candidate’s:
(a) full name, (b) contact address in full (which should be a postal address although an e-mail address may also be provided for the purposes of electronic communication), and (c) constituency, or class within a constituency, of which the candidate is a member. 11. Declaration of interests
11.1 The nomination form must state: 43
(a) any financial interest that the candidate has in the corporation, and (b) whether the candidate is a member of a political party, and if so, which party, and if the candidate has no such interests, the paper must include a statement to that effect.
12. Declaration of eligibility
12.1 The nomination form must include a declaration made by the candidate:
(a) that he or she is not prevented from being a member of the council of governors by paragraph 8 of Schedule 7 of the 2006 Act or by any provision of the constitution; and, (b) for a member of the public or patient constituency, of the particulars of his or her qualification to vote as a member of that constituency, or class within that constituency, for which the election is being held.
13. Signature of candidate
13.1 The nomination form must be signed and dated by the candidate, in a manner prescribed by the returning officer, indicating that:
(a) they wish to stand as a candidate, (b) their declaration of interests as required under rule 11, is true and correct, and (c) their declaration of eligibility, as required under rule 12, is true and correct.
13.2 Where the return of nomination forms in an electronic format is permitted, the returning officer shall specify the particular signature formalities (if any) that will need to be complied with by the candidate.
14. Decisions as to the validity of nomination
14.1 Where a nomination form is received by the returning officer in accordance with these rules, the candidate is deemed to stand for election unless and until the returning officer:
(a) decides that the candidate is not eligible to stand, (b) decides that the nomination form is invalid, (c) receives satisfactory proof that the candidate has died, or (d) receives a written request by the candidate of their withdrawal from candidacy.
14.2 The returning officer is entitled to decide that a nomination form is invalid only on one of the following grounds:
(a) that the paper is not received on or before the final time and date for return of nomination forms, as specified in the notice of the election, (b) that the paper does not contain the candidate’s particulars, as required by rule 10; (c) that the paper does not contain a declaration of the interests of the candidate, as 44 required by rule 11, (d) that the paper does not include a declaration of eligibility as required by rule 12, or (e) that the paper is not signed and dated by the candidate, if required by rule 13.
14.3 The returning officer is to examine each nomination form as soon as is practicable after he or she has received it, and decide whether the candidate has been validly nominated.
14.4 Where the returning officer decides that a nomination is invalid, the returning officer must endorse this on the nomination form, stating the reasons for their decision.
14.5 The returning officer is to send notice of the decision as to whether a nomination is valid or invalid to the candidate at the contact address given in the candidate’s nomination form. If an e-mail address has been given in the candidate’s nomination form (in addition to the candidate’s postal address), the returning officer may send notice of the decision to that address.
15. Publication of statement of candidates
15.1 The returning officer is to prepare and publish a statement showing the candidates who are standing for election.
15.2 The statement must show:
(a) the name, contact address (which shall be the candidate’s postal address), and constituency or class within a constituency of each candidate standing, and (b) the declared interests of each candidate standing,
as given in their nomination form.
15.3 The statement must list the candidates standing for election in alphabetical order by surname.
15.4 The returning officer must send a copy of the statement of candidates and copies of the nomination forms to the corporation as soon as is practicable after publishing the statement.
16. Inspection of statement of nominated candidates and nomination forms
16.1 The corporation is to make the statement of the candidates and the nomination forms supplied by the returning officer under rule 15.4 available for inspection by members of the corporation free of charge at all reasonable times.
16.2 If a member of the corporation requests a copy or extract of the statement of candidates or their nomination forms, the corporation is to provide that member with the copy or extract free of charge.
17. Withdrawal of candidates
17.1 A candidate may withdraw from election on or before the date and time for withdrawal by
45 candidates, by providing to the returning officer a written notice of withdrawal which is signed by the candidate and attested by a witness.
18. Method of election
18.1 If the number of candidates remaining validly nominated for an election after any withdrawals under these rules is greater than the number of members to be elected to the council of governors, a poll is to be taken in accordance with Parts 5 and 6 of these rules.
18.2 If the number of candidates remaining validly nominated for an election after any withdrawals under these rules is equal to the number of members to be elected to the council of governors, those candidates are to be declared elected in accordance with Part 7 of these rules.
18.3 If the number of candidates remaining validly nominated for an election after any withdrawals under these rules is less than the number of members to be elected to be council of governors, then:
(a) the candidates who remain validly nominated are to be declared elected in accordance with Part 7 of these rules, and (b) the returning officer is to order a new election to fill any vacancy which remains unfilled, on a day appointed by him or her in consultation with the corporation.
46 PART 5: CONTESTED ELECTIONS
19. Poll to be taken by ballot
19.1 The votes at the poll must be given by secret ballot.
19.2 The votes are to be counted and the result of the poll determined in accordance with Part 6 of these rules.
19.3 The corporation may decide that voters within a constituency or class within a constituency, may, subject to rule 19.4, cast their votes at the poll using such different methods of polling in any combination as the corporation may determine.
19.4 The corporation may decide that voters within a constituency or class within a constituency for whom an e-mail address is included in the list of eligible voters may only cast their votes at the poll using an e-voting method of polling.
19.5 Before the corporation decides, in accordance with rule 19.3 that one or more e-voting methods of polling will be made available for the purposes of the poll, the corporation must satisfy itself that:
(a) if internet voting is to be a method of polling, the internet voting system to be used for the purpose of the election is: (i) configured in accordance with these rules; and (ii) will create an accurate internet voting record in respect of any voter who casts his or her vote using the internet voting system; (b) if telephone voting to be a method of polling, the telephone voting system to be used for the purpose of the election is: (i) configured in accordance with these rules; and (ii) will create an accurate telephone voting record in respect of any voter who casts his or her vote using the telephone voting system; (c) if text message voting is to be a method of polling, the text message voting system to be used for the purpose of the election is: (7) (i) configured in accordance with these rules; and (8) (ii) will create an accurate text voting record in respect of any voter who casts his or her vote using the text message voting system.
20. The ballot paper
20.1 The ballot of each voter (other than a voter who casts his or her ballot by an e-voting method of polling) is to consist of a ballot paper with the persons remaining validly nominated for an election after any withdrawals under these rules, and no others, inserted in the paper.
20.2 Every ballot paper must specify:
47 (a) the name of the corporation, (b) the constituency, or class within a constituency, for which the election is being held, (c) the number of members of the council of governors to be elected from that constituency, or class within that constituency, (d) the names and other particulars of the candidates standing for election, with the details and order being the same as in the statement of nominated candidates, (e) instructions on how to vote by all available methods of polling, including the relevant voter’s voter ID number if one or more e-voting methods of polling are available, (f) if the ballot paper is to be returned by post, the address for its return and the date and time of the close of the poll, and (g) the contact details of the returning officer.
20.3 Each ballot paper must have a unique identifier.
20.4 Each ballot paper must have features incorporated into it to prevent it from being reproduced.
21. The declaration of identity (public constituencies)
21.1 The corporation shall require each voter who participates in an election for a public or patient constituency to make a declaration confirming:
(a) that the voter is the person: (i) to whom the ballot paper was addressed, and/or (9) (ii) to whom the voter ID number contained within the e-voting information was allocated, (b) that he or she has not marked or returned any other voting information in the election, and
(c) the particulars of his or her qualification to vote as a member of the constituency or class within the constituency for which the election is being held,
(“declaration of identity”)
and the corporation shall make such arrangements as it considers appropriate to facilitate the making and the return of a declaration of identity by each voter, whether by the completion of a paper form (“ID declaration form”) or the use of an electronic method.
21.2 The voter must be required to return his or her declaration of identity with his or her ballot.
21.3 The voting information shall caution the voter that if the declaration of identity is not duly returned or is returned without having been made correctly, any vote cast by the voter may be declared invalid.
48 Action to be taken before the poll
22. List of eligible voters
22.1 The corporation is to provide the returning officer with a list of the members of the constituency or class within a constituency for which the election is being held who are eligible to vote by virtue of rule 27 as soon as is reasonably practicable after the final date for the delivery of notices of withdrawals by candidates from an election.
22.2 The list is to include, for each member:
(a) a postal address; and,
(b) the member’s e-mail address, if this has been provided
to which his or her voting information may, subject to rule 22.3, be sent.
22.3 The corporation may decide that the e-voting information is to be sent only by e-mail to those members in the list of eligible voters for whom an e-mail address is included in that list.
23. Notice of poll
23.1 The returning officer is to publish a notice of the poll stating:
(a) the name of the corporation, (b) the constituency, or class within a constituency, for which the election is being held, (c) the number of members of the council of governors to be elected from that constituency, or class with that constituency, (d) the names, contact addresses, and other particulars of the candidates standing for election, with the details and order being the same as in the statement of nominated candidates, (e) that the ballot papers for the election are to be issued and returned, if appropriate, by post, (f) the methods of polling by which votes may be cast at the election by voters in a constituency or class within a constituency, as determined by the corporation in accordance with rule 19.3, (g) the address for return of the ballot papers, (h) the uniform resource locator (url) where, if internet voting is a method of polling, the polling website is located; (i) the telephone number where, if telephone voting is a method of polling, the telephone voting facility is located, (j) the telephone number or telephone short code where, if text message voting is a method of polling, the text message voting facility is located, (k) the date and time of the close of the poll, (l) the address and final dates for applications for replacement voting information, and (m) the contact details of the returning officer. 49
24. Issue of voting information by returning officer
24.1 Subject to rule 24.3, as soon as is reasonably practicable on or after the publication of the notice of the poll, the returning officer is to send the following information by post to each member of the corporation named in the list of eligible voters:
(a) a ballot paper and ballot paper envelope, (b) the ID declaration form (if required), (c) information about each candidate standing for election, pursuant to rule 61 of these rules, and (d) a covering envelope;
(“postal voting information”).
24.2 Subject to rules 24.3 and 24.4, as soon as is reasonably practicable on or after the publication of the notice of the poll, the returning officer is to send the following information by e-mail and/ or by post to each member of the corporation named in the list of eligible voters whom the corporation determines in accordance with rule 19.3 and/ or rule 19.4 may cast his or her vote by an e-voting method of polling:
(a) instructions on how to vote and how to make a declaration of identity (if required), (b) the voter’s voter ID number, (c) information about each candidate standing for election, pursuant to rule 64 of these rules, or details of where this information is readily available on the internet or available in such other formats as the Returning Officer thinks appropriate, (d) contact details of the Returning Officer,
(“e-voting information”).
24.3 The corporation may determine that any member of the corporation shall:
(a) only be sent postal voting information; or (b) only be sent e-voting information; or (c) be sent both postal voting information and e-voting information;
for the purposes of the poll.
24.4 If the corporation determines, in accordance with rule 22.3, that the e-voting information is to be sent only by e-mail to those members in the list of eligible voters for whom an e- mail address is included in that list, then the returning officer shall only send that information by e-mail.
24.5 The voting information is to be sent to the postal address and/ or e-mail address for each member, as specified in the list of eligible voters.
25. Ballot paper envelope and covering envelope
50 25.1 The ballot paper envelope must have clear instructions to the voter printed on it, instructing the voter to seal the ballot paper inside the envelope once the ballot paper has been marked.
25.2 The covering envelope is to have:
(a) the address for return of the ballot paper printed on it, and (b) pre-paid postage for return to that address.
25.3 There should be clear instructions, either printed on the covering envelope or elsewhere, instructing the voter to seal the following documents inside the covering envelope and return it to the returning officer – (a) the completed ID declaration form if required, and (b) the ballot paper envelope, with the ballot paper sealed inside it.
26. E-voting systems
26.1 If internet voting is a method of polling for the relevant election then the returning officer must provide a website for the purpose of voting over the internet (in these rules referred to as "the polling website").
26.2 If telephone voting is a method of polling for the relevant election then the returning officer must provide an automated telephone system for the purpose of voting by the use of a touch-tone telephone (in these rules referred to as “the telephone voting facility”).
26.3 If text message voting is a method of polling for the relevant election then the returning officer must provide an automated text messaging system for the purpose of voting by text message (in these rules referred to as “the text message voting facility”).
26.4 The returning officer shall ensure that the polling website and internet voting system provided will:
(a) require a voter to: (i) enter his or her voter ID number; and (ii) where the election is for a public constituency, make a declaration of identity; in order to be able to cast his or her vote; (b) specify: (i) the name of the corporation, (ii) the constituency, or class within a constituency, for which the election is being held, (iii) the number of members of the council of governors to be elected from that constituency, or class within that constituency, (iv) the names and other particulars of the candidates standing for election, with the details and order being the same as in the statement of nominated candidates, (v) instructions on how to vote and how to make a declaration of identity, 51 (vi) the date and time of the close of the poll, and (vii) the contact details of the returning officer;
(c) prevent a voter from voting for more candidates than he or she is entitled to at the election;
(d) create a record ("internet voting record") that is stored in the internet voting system in respect of each vote cast by a voter using the internet that comprises - (i) the voter’s voter ID number; (ii) the voter’s declaration of identity (where required); (iii) the candidate or candidates for whom the voter has voted; and (iv) the date and time of the voter’s vote,
(e) if the voter’s vote has been duly cast and recorded, provide the voter with confirmation of this; and (f) prevent any voter from voting after the close of poll .
26.5 The returning officer shall ensure that the telephone voting facility and telephone voting system provided will:
(a) require a voter to (i) enter his or her voter ID number in order to be able to cast his or her vote; and (ii) where the election is for a public or patient constituency, make a declaration of identity; (b) specify: (i) the name of the corporation, (ii) the constituency, or class within a constituency, for which the election is being held, (iii) the number of members of the council of governors to be elected from that constituency, or class within that constituency, (iv) instructions on how to vote and how to make a declaration of identity, (v) the date and time of the close of the poll, and (vi) the contact details of the returning officer;
(c) prevent a voter from voting for more candidates than he or she is entitled to at the election; (d) create a record ("telephone voting record") that is stored in the telephone voting system in respect of each vote cast by a voter using the telephone that comprises : (i) the voter’s voter ID number; (ii) the voter’s declaration of identity (where required); (iii) the candidate or candidates for whom the voter has voted; and (iv) the date and time of the voter’s vote
52 (e) if the voter’s vote has been duly cast and recorded, provide the voter with confirmation of this; (f) prevent any voter from voting after the close of poll .
26.6 The returning officer shall ensure that the text message voting facility and text messaging voting system provided will:
(a) require a voter to: (i) provide his or her voter ID number; and (ii) where the election is for a public or patient constituency, make a declaration of identity; in order to be able to cast his or her vote; (b) prevent a voter from voting for more candidates than he or she is entitled to at the election; (d) create a record ("text voting record") that is stored in the text messaging voting system in respect of each vote cast by a voter by text message that comprises : (i) the voter’s voter ID number; (ii) the voter’s declaration of identity (where required); (ii) the candidate or candidates for whom the voter has voted; and (iii) the date and time of the voter’s vote (e) if the voter’s vote has been duly cast and recorded, provide the voter with confirmation of this; (f) prevent any voter from voting after the close of poll .
The poll
27. Eligibility to vote
27.1 An individual who becomes a member of the corporation on or before the closing date for the receipt of nominations by candidates for the election, is eligible to vote in that election.
28. Voting by persons who require assistance
28.1 The returning officer is to put in place arrangements to enable requests for assistance to vote to be made.
28.2 Where the returning officer receives a request from a voter who requires assistance to vote, the returning officer is to make such arrangements as he or she considers necessary to enable that voter to vote.
29. Spoilt ballot papers and spoilt text message votes
29.1 If a voter has dealt with his or her ballot paper in such a manner that it cannot be accepted as a ballot paper (referred to as a “spoilt ballot paper”), that voter may apply to the returning officer for a replacement ballot paper.
53 29.2 On receiving an application, the returning officer is to obtain the details of the unique identifier on the spoilt ballot paper, if he or she can obtain it.
29.3 The returning officer may not issue a replacement ballot paper for a spoilt ballot paper unless he or she:
(a) is satisfied as to the voter’s identity; and
(b) has ensured that the completed ID declaration form, if required, has not been returned.
29.4 After issuing a replacement ballot paper for a spoilt ballot paper, the returning officer shall enter in a list (“the list of spoilt ballot papers”):
(a) the name of the voter, and
(b) the details of the unique identifier of the spoilt ballot paper (if that officer was able to obtain it), and
(c) the details of the unique identifier of the replacement ballot paper.
29.5 If a voter has dealt with his or her text message vote in such a manner that it cannot be accepted as a vote (referred to as a “spoilt text message vote”), that voter may apply to the returning officer for a replacement voter ID number.
29.6 On receiving an application, the returning officer is to obtain the details of the voter ID number on the spoilt text message vote, if he or she can obtain it.
29.7 The returning officer may not issue a replacement voter ID number in respect of a spoilt text message vote unless he or she is satisfied as to the voter’s identity.
29.8 After issuing a replacement voter ID number in respect of a spoilt text message vote, the returning officer shall enter in a list (“the list of spoilt text message votes”):
(a) the name of the voter, and
(b) the details of the voter ID number on the spoilt text message vote (if that officer was able to obtain it), and
(c) the details of the replacement voter ID number issued to the voter.
30. Lost voting information
30.1 Where a voter has not received his or her voting information by the tenth day before the close of the poll, that voter may apply to the returning officer for replacement voting information.
30.2 The returning officer may not issue replacement voting information in respect of lost voting information unless he or she:
(a) is satisfied as to the voter’s identity,
54 (b) has no reason to doubt that the voter did not receive the original voting information, (c) has ensured that no declaration of identity, if required, has been returned.
30.3 After issuing replacement voting information in respect of lost voting information, the returning officer shall enter in a list (“the list of lost ballot documents”):
(a) the name of the voter (10) (b) the details of the unique identifier of the replacement ballot paper, if applicable, and (c) the voter ID number of the voter.
31. Issue of replacement voting information
31.1 If a person applies for replacement voting information under rule 29 or 30 and a declaration of identity has already been received by the returning officer in the name of that voter, the returning officer may not issue replacement voting information unless, in addition to the requirements imposed by rule 29.3 or 30.2, he or she is also satisfied that that person has not already voted in the election, notwithstanding the fact that a declaration of identity if required has already been received by the returning officer in the name of that voter.
31.2 After issuing replacement voting information under this rule, the returning officer shall enter in a list (“the list of tendered voting information”):
(a) the name of the voter, (b) the unique identifier of any replacement ballot paper issued under this rule; (c) the voter ID number of the voter.
32. ID declaration form for replacement ballot papers (public and patient constituencies)
32.1 In respect of an election for a public or patient constituency an ID declaration form must be issued with each replacement ballot paper requiring the voter to make a declaration of identity.
Polling by internet, telephone or text
33. Procedure for remote voting by internet
33.1 To cast his or her vote using the internet, a voter will need to gain access to the polling website by keying in the url of the polling website provided in the voting information.
33.2 When prompted to do so, the voter will need to enter his or her voter ID number.
33.3 If the internet voting system authenticates the voter ID number, the system will give the voter access to the polling website for the election in which the voter is eligible to vote.
33.4 To cast his or her vote, the voter will need to key in a mark on the screen opposite the particulars of the candidate or candidates for whom he or she wishes to cast his or her
55 vote.
33.5 The voter will not be able to access the internet voting system for an election once his or her vote at that election has been cast.
34. Voting procedure for remote voting by telephone
34.1 To cast his or her vote by telephone, the voter will need to gain access to the telephone voting facility by calling the designated telephone number provided in the voter information using a telephone with a touch-tone keypad.
34.2 When prompted to do so, the voter will need to enter his or her voter ID number using the keypad.
34.3 If the telephone voting facility authenticates the voter ID number, the voter will be prompted to vote in the election.
34.4 When prompted to do so the voter may then cast his or her vote by keying in the numerical voting code of the candidate or candidates, for whom he or she wishes to vote.
34.5 The voter will not be able to access the telephone voting facility for an election once his or her vote at that election has been cast.
35. Voting procedure for remote voting by text message
35.1 To cast his or her vote by text message the voter will need to gain access to the text message voting facility by sending a text message to the designated telephone number or telephone short code provided in the voter information.
35.2 The text message sent by the voter must contain his or her voter ID number and the numerical voting code for the candidate or candidates, for whom he or she wishes to vote .
35.3 The text message sent by the voter will need to be structured in accordance with the instructions on how to vote contained in the voter information, otherwise the vote will not be cast.
Procedure for receipt of envelopes, internet votes, telephone votes and text message votes
36. Receipt of voting documents
36.1 Where the returning officer receives: (a) a covering envelope, or (b) any other envelope containing an ID declaration form if required, a ballot paper envelope, or a ballot paper, before the close of the poll, that officer is to open it as soon as is practicable; and rules 37 and 38 are to apply.
36.2 The returning officer may open any covering envelope or any ballot paper envelope for the purposes of rules 37 and 38, but must make arrangements to ensure that no person
56 obtains or communicates information as to: (a) the candidate for whom a voter has voted, or (b) the unique identifier on a ballot paper.
36.3 The returning officer must make arrangements to ensure the safety and security of the ballot papers and other documents.
37. Validity of votes
37.1 A ballot paper shall not be taken to be duly returned unless the returning officer is satisfied that it has been received by the returning officer before the close of the poll, with an ID declaration form if required that has been correctly completed, signed and dated.
37.2 Where the returning officer is satisfied that rule 37.1 has been fulfilled, he or she is to:
(a) put the ID declaration form if required in a separate packet, and (b) put the ballot paper aside for counting after the close of the poll.
37.3 Where the returning officer is not satisfied that rule 37.1 has been fulfilled, he or she is to:
(a) mark the ballot paper “disqualified”, (b) if there is an ID declaration form accompanying the ballot paper, mark it “disqualified” and attach it to the ballot paper, (c) record the unique identifier on the ballot paper in a list of disqualified documents (the “list of disqualified documents”); and (d) place the document or documents in a separate packet.
37.4 An internet, telephone or text message vote shall not be taken to be duly returned unless the returning officer is satisfied that the internet voting record, telephone voting record or text voting record (as applicable) has been received by the returning officer before the close of the poll, with a declaration of identity if required that has been correctly made .
37.5 Where the returning officer is satisfied that rule 37.4 has been fulfilled, he or she is to put the internet voting record, telephone voting record or text voting record (as applicable) aside for counting after the close of the poll.
37.6 Where the returning officer is not satisfied that rule 37.4 has been fulfilled, he or she is to:
(a) mark the internet voting record, telephone voting record or text voting record (as applicable) “disqualified”, (b) record the voter ID number on the internet voting record, telephone voting record or text voting record (as applicable) in the list of disqualified documents; and (c) place the document or documents in a separate packet.
38. Declaration of identity but no ballot paper (public constituency) 1
1 It should not be possible, technically, to make a declaration of identity electronically without also submitting a vote. 57 38.1 Where the returning officer receives an ID declaration form if required but no ballot paper, the returning officer is to:
(a) mark the ID declaration form “disqualified”, (b) record the name of the voter in the list of disqualified documents, indicating that a declaration of identity was received from the voter without a ballot paper, and (c) place the ID declaration form in a separate packet.
39. De-duplication of votes
39.1 Where different methods of polling are being used in an election, the returning officer shall examine all votes cast to ascertain if a voter ID number has been used more than once to cast a vote in the election.
39.2 If the returning officer ascertains that a voter ID number has been used more than once to cast a vote in the election he or she shall:
(a) only accept as duly returned the first vote received that was cast using the relevant voter ID number; and (b) mark as “disqualified” all other votes that were cast using the relevant voter ID number
39.3 Where a ballot paper is disqualified under this rule the returning officer shall:
(a) mark the ballot paper “disqualified”, (b) if there is an ID declaration form accompanying the ballot paper, mark it “disqualified” and attach it to the ballot paper, (c) record the unique identifier and the voter ID number on the ballot paper in the list of disqualified documents; (d) place the document or documents in a separate packet; and (e) disregard the ballot paper when counting the votes in accordance with these rules.
39.4 Where an internet voting record, telephone voting record or text voting record is disqualified under this rule the returning officer shall:
(a) mark the internet voting record, telephone voting record or text voting record (as applicable) “disqualified”, (b) record the voter ID number on the internet voting record, telephone voting record or text voting record (as applicable) in the list of disqualified documents; (c) place the internet voting record, telephone voting record or text voting record (as applicable) in a separate packet, and (d) disregard the internet voting record, telephone voting record or text voting record (as applicable) when counting the votes in accordance with these rules.
40. Sealing of packets
40.1 As soon as is possible after the close of the poll and after the completion of the 58 procedure under rules 37 and 38, the returning officer is to seal the packets containing:
(a) the disqualified documents, together with the list of disqualified documents inside it, (b) the ID declaration forms, if required, (c) the list of spoilt ballot papers and the list of spoilt text message votes, (d) the list of lost ballot documents, (e) the list of eligible voters, and (f) the list of tendered voting information and ensure that complete electronic copies of the internet voting records, telephone voting records and text voting records created in accordance with rule 26 are held in a device suitable for the purpose of storage.
59 PART 6: COUNTING THE VOTES
STV41. Interpretation of Part 6
STV41.1 In Part 6 of these rules:
“ballot document ” means a ballot paper, internet voting record, telephone voting record or text voting record.
“continuing candidate ” means any candidate not deemed to be elected, and not excluded,
“count ” means all the operations involved in counting of the first preferences recorded for candidates, the transfer of the surpluses of elected candidates, and the transfer of the votes of the excluded candidates,
“deemed to be elected ” means deemed to be elected for the purposes of counting of votes but without prejudice to the declaration of the result of the poll,
“mark ” means a figure, an identifiable written word, or a mark such as “X”,
“non-transferable vote ” means a ballot document: (a) on which no second or subsequent preference is recorded for a continuing candidate, or (b) which is excluded by the returning officer under rule STV49,
“preference ” as used in the following contexts has the meaning assigned below:
(a) “first preference” means the figure “1” or any mark or word which clearly indicates a first (or only) preference,
(b) “next available preference” means a preference which is the second, or as the case may be, subsequent preference recorded in consecutive order for a continuing candidate (any candidate who is deemed to be elected or is excluded thereby being ignored); and
(c) in this context, a “second preference” is shown by the figure “2” or any mark or word which clearly indicates a second preference, and a third preference by the figure “3” or any mark or word which clearly indicates a third preference, and so on, (11) “quota ” means the number calculated in accordance with rule STV46,
“surplus ” means the number of votes by which the total number of votes for any candidate (whether first preference or transferred votes, or a combination of both) exceeds the quota; but references in these rules to the transfer of the surplus means the transfer (at a transfer value) of all transferable ballot documents from the candidate who has the surplus, “stage of the count ” means: 60
(a) the determination of the first preference vote of each candidate, (b) the transfer of a surplus of a candidate deemed to be elected, or (c) the exclusion of one or more candidates at any given time,
“transferable vote ” means a ballot document on which, following a first preference, a second or subsequent preference is recorded in consecutive numerical order for a continuing candidate,
“transferred vote ” means a vote derived from a ballot document on which a second or subsequent preference is recorded for the candidate to whom that ballot document has been transferred, and
“transfer value ” means the value of a transferred vote calculated in accordance with rules STV47.4 or STV47.7.
42. Arrangements for counting of the votes
42.1 The returning officer is to make arrangements for counting the votes as soon as is practicable after the close of the poll.
42.2 The returning officer may make arrangements for any votes to be counted using vote counting software where:
(a) the board of directors and the council of governors of the corporation have approved: (i) the use of such software for the purpose of counting votes in the relevant election, and (ii) a policy governing the use of such software, and (b) the corporation and the returning officer are satisfied that the use of such software will produce an accurate result.
43. The count
43.1 The returning officer is to:
(a) count and record the number of: (iii) ballot papers that have been returned; and (iv) the number of internet voting records, telephone voting records and/or text voting records that have been created, and (b) count the votes according to the provisions in this Part of the rules and/or the provisions of any policy approved pursuant to rule 42.2(ii) where vote counting software is being used.
43.2 The returning officer, while counting and recording the number of ballot papers, internet voting records, telephone voting records and/or text voting records and counting the votes, must make arrangements to ensure that no person obtains or communicates information as to the unique identifier on a ballot paper or the voter ID number on an internet voting record, telephone voting record or text voting record. 61
43.3 The returning officer is to proceed continuously with counting the votes as far as is practicable.
STV44. Rejected ballot papers and rejected text voting records
STV44.1 Any ballot paper:
(a) which does not bear the features that have been incorporated into the other ballot papers to prevent them from being reproduced, (b) on which the figure “1” standing alone is not placed so as to indicate a first preference for any candidate, (c) on which anything is written or marked by which the voter can be identified except the unique identifier, or (d) which is unmarked or rejected because of uncertainty,
shall be rejected and not counted, but the ballot paper shall not be rejected by reason only of carrying the words “one”, “two”, “three” and so on, or any other mark instead of a figure if, in the opinion of the returning officer, the word or mark clearly indicates a preference or preferences.
STV44.2 The returning officer is to endorse the word “rejected” on any ballot paper which under this rule is not to be counted.
STV44.3 Any text voting record:
(a) on which the figure “1” standing alone is not placed so as to indicate a first preference for any candidate, (b) on which anything is written or marked by which the voter can be identified except the unique identifier, or (c) which is unmarked or rejected because of uncertainty,
shall be rejected and not counted, but the text voting record shall not be rejected by reason only of carrying the words “one”, “two”, “three” and so on, or any other mark instead of a figure if, in the opinion of the returning officer, the word or mark clearly indicates a preference or preferences.
STV44.4 The returning officer is to endorse the word “rejected” on any text voting record which under this rule is not to be counted.
STV44.5 The returning officer is to draw up a statement showing the number of ballot papers rejected by him or her under each of the subparagraphs (a) to (d) of rule STV44.1 and the number of text voting records rejected by him or her under each of the sub- paragraphs (a) to (c) of rule STV44.3.
62 FPP44. Rejected ballot papers and rejected text voting records
FPP44.1 Any ballot paper:
(a) which does not bear the features that have been incorporated into the other ballot papers to prevent them from being reproduced, (b) on which votes are given for more candidates than the voter is entitled to vote, (c) on which anything is written or marked by which the voter can be identified except the unique identifier, or (d) which is unmarked or rejected because of uncertainty,
shall, subject to rules FPP44.2 and FPP44.3, be rejected and not counted.
FPP44.2 Where the voter is entitled to vote for more than one candidate, a ballot paper is not to be rejected because of uncertainty in respect of any vote where no uncertainty arises, and that vote is to be counted.
FPP44.3 A ballot paper on which a vote is marked:
(a) elsewhere than in the proper place, (b) otherwise than by means of a clear mark, (c) by more than one mark,
is not to be rejected for such reason (either wholly or in respect of that vote) if an intention that the vote shall be for one or other of the candidates clearly appears, and the way the paper is marked does not itself identify the voter and it is not shown that he or she can be identified by it.
FPP44.4 The returning officer is to:
(a) endorse the word “rejected” on any ballot paper which under this rule is not to be counted, and (b) in the case of a ballot paper on which any vote is counted under rules FPP44.2 and FPP 44.3, endorse the words “rejected in part” on the ballot paper and indicate which vote or votes have been counted.
FPP44.5 The returning officer is to draw up a statement showing the number of rejected ballot papers under the following headings:
(a) does not bear proper features that have been incorporated into the ballot paper, (b) voting for more candidates than the voter is entitled to, (c) writing or mark by which voter could be identified, and (d) unmarked or rejected because of uncertainty,
and, where applicable, each heading must record the number of ballot papers rejected in part. FPP44.6 Any text voting record:
63 (a) on which votes are given for more candidates than the voter is entitled to vote, (b) on which anything is written or marked by which the voter can be identified except the voter ID number, or (c) which is unmarked or rejected because of uncertainty,
shall, subject to rules FPP44.7 and FPP44.8, be rejected and not counted.
FPP44.7 Where the voter is entitled to vote for more than one candidate, a text voting record is not to be rejected because of uncertainty in respect of any vote where no uncertainty arises, and that vote is to be counted.
FPP448 A text voting record on which a vote is marked:
(a) otherwise than by means of a clear mark, (b) by more than one mark,
is not to be rejected for such reason (either wholly or in respect of that vote) if an intention that the vote shall be for one or other of the candidates clearly appears, and the way the text voting record is marked does not itself identify the voter and it is not shown that he or she can be identified by it.
FPP44.9 The returning officer is to:
(a) endorse the word “rejected” on any text voting record which under this rule is not to be counted, and (b) in the case of a text voting record on which any vote is counted under rules FPP44.7 and FPP 44.8, endorse the words “rejected in part” on the text voting record and indicate which vote or votes have been counted.
FPP44.10 The returning officer is to draw up a statement showing the number of rejected text voting records under the following headings:
(a) voting for more candidates than the voter is entitled to, (b) writing or mark by which voter could be identified, and (c) unmarked or rejected because of uncertainty,
and, where applicable, each heading must record the number of text voting records rejected in part.
STV45. First stage
STV45.1 The returning officer is to sort the ballot documents into parcels according to the candidates for whom the first preference votes are given.
STV45.2 The returning officer is to then count the number of first preference votes given on ballot documents for each candidate, and is to record those numbers.
STV45.3 The returning officer is to also ascertain and record the number of valid ballot documents.
64 STV46. The quota
STV46.1 The returning officer is to divide the number of valid ballot documents by a number exceeding by one the number of members to be elected.
STV46.2 The result, increased by one, of the division under rule STV46.1 (any fraction being disregarded) shall be the number of votes sufficient to secure the election of a candidate (in these rules referred to as “the quota”).
STV46.3 At any stage of the count a candidate whose total votes equals or exceeds the quota shall be deemed to be elected, except that any election where there is only one vacancy a candidate shall not be deemed to be elected until the procedure set out in rules STV47.1 to STV47.3 has been complied with.
STV47. Transfer of votes
STV47.1 Where the number of first preference votes for any candidate exceeds the quota, the returning officer is to sort all the ballot documents on which first preference votes are given for that candidate into sub- parcels so that they are grouped:
(a) according to next available preference given on those ballot documents for any continuing candidate, or (b) where no such preference is given, as the sub-parcel of non-transferable votes.
STV47.2 The returning officer is to count the number of ballot documents in each parcel referred to in rule STV47.1.
STV47.3 The returning officer is, in accordance with this rule and rule STV48, to transfer each sub- parcel of ballot documents referred to in rule STV47.1(a) to the candidate for whom the next available preference is given on those ballot documents.
STV47.4 The vote on each ballot document transferred under rule STV47.3 shall be at a value (“the transfer value”) which:
(a) reduces the value of each vote transferred so that the total value of all such votes does not exceed the surplus, and (b) is calculated by dividing the surplus of the candidate from whom the votes are being transferred by the total number of the ballot documents on which those votes are given, the calculation being made to two decimal places (ignoring the remainder if any).
STV47.5 Where at the end of any stage of the count involving the transfer of ballot documents, the number of votes for any candidate exceeds the quota, the returning officer is to sort the ballot documents in the sub-parcel of transferred votes which was last received by that candidate into separate sub-parcels so that they are grouped:
(a) according to the next available preference given on those ballot documents for any continuing candidate, or (b) where no such preference is given, as the sub-parcel of non-transferable votes.
65 STV47.6 The returning officer is, in accordance with this rule and rule STV48, to transfer each sub- parcel of ballot documents referred to in rule STV47.5(a) to the candidate for whom the next available preference is given on those ballot documents.
STV47.7 The vote on each ballot document transferred under rule STV47.6 shall be at:
(a) a transfer value calculated as set out in rule STV47.4(b), or (b) at the value at which that vote was received by the candidate from whom it is now being transferred,
whichever is the less.
STV47.8 Each transfer of a surplus constitutes a stage in the count.
STV47.9 Subject to rule STV47.10, the returning officer shall proceed to transfer transferable ballot documents until no candidate who is deemed to be elected has a surplus or all the vacancies have been filled.
STV47.10 Transferable ballot documents shall not be liable to be transferred where any surplus or surpluses which, at a particular stage of the count, have not already been transferred, are:
(a) less than the difference between the total vote then credited to the continuing candidate with the lowest recorded vote and the vote of the candidate with the next lowest recorded vote, or (b) less than the difference between the total votes of the two or more continuing candidates, credited at that stage of the count with the lowest recorded total numbers of votes and the candidate next above such candidates.
STV47.11 This rule does not apply at an election where there is only one vacancy.
STV48. Supplementary provisions on transfer
STV48.1 If, at any stage of the count, two or more candidates have surpluses, the transferable ballot documents of the candidate with the highest surplus shall be transferred first, and if:
(a) The surpluses determined in respect of two or more candidates are equal, the transferable ballot documents of the candidate who had the highest recorded vote at the earliest preceding stage at which they had unequal votes shall be transferred first, and (b) the votes credited to two or more candidates were equal at all stages of the count, the returning officer shall decide between those candidates by lot, and the transferable ballot documents of the candidate on whom the lot falls shall be transferred first. STV48.2 The returning officer shall, on each transfer of transferable ballot documents under rule STV47:
(a) record the total value of the votes transferred to each candidate, (b) add that value to the previous total of votes recorded for each candidate and record 66 the new total, (c) record as non-transferable votes the difference between the surplus and the total transfer value of the transferred votes and add that difference to the previously recorded total of non-transferable votes, and (d) compare: (i) the total number of votes then recorded for all of the candidates, together with the total number of non-transferable votes, with (ii) the recorded total of valid first preference votes.
STV48.3 All ballot documents transferred under rule STV47 or STV49 shall be clearly marked, either individually or as a sub-parcel, so as to indicate the transfer value recorded at that time to each vote on that ballot document or, as the case may be, all the ballot documents in that sub-parcel.
STV48.4 Where a ballot document is so marked that it is unclear to the returning officer at any stage of the count under rule STV47 or STV49 for which candidate the next preference is recorded, the returning officer shall treat any vote on that ballot document as a non- transferable vote; and votes on a ballot document shall be so treated where, for example, the names of two or more candidates (whether continuing candidates or not) are so marked that, in the opinion of the returning officer, the same order of preference is indicated or the numerical sequence is broken.
STV49. Exclusion of candidates
STV49.1 If:
(a) all transferable ballot documents which under the provisions of rule STV47 (including that rule as applied by rule STV49.11) and this rule are required to be transferred, have been transferred, and (b) subject to rule STV50, one or more vacancies remain to be filled,
the returning officer shall exclude from the election at that stage the candidate with the then lowest vote (or, where rule STV49.12 applies, the candidates with the then lowest votes).
STV9.2 The returning officer shall sort all the ballot documents on which first preference votes are given for the candidate or candidates excluded under rule STV49.1 into two sub-parcels so that they are grouped as:
(a) ballot documents on which a next available preference is given, and (b) ballot documents on which no such preference is given (thereby including ballot documents on which preferences are given only for candidates who are deemed to be elected or are excluded). STV49.3 The returning officer shall, in accordance with this rule and rule STV48, transfer each sub-parcel of ballot documents referred to in rule STV49.2 to the candidate for whom the next available preference is given on those ballot documents.
STV49.4 The exclusion of a candidate, or of two or more candidates together, constitutes a further stage of the count.
67
STV49.5 If, subject to rule STV50, one or more vacancies still remain to be filled, the returning officer shall then sort the transferable ballot documents, if any, which had been transferred to any candidate excluded under rule STV49.1 into sub- parcels according to their transfer value.
STV49.6 The returning officer shall transfer those ballot documents in the sub-parcel of transferable ballot documents with the highest transfer value to the continuing candidates in accordance with the next available preferences given on those ballot documents (thereby passing over candidates who are deemed to be elected or are excluded).
STV49.7 The vote on each transferable ballot document transferred under rule STV49.6 shall be at the value at which that vote was received by the candidate excluded under rule STV49.1.
STV9.8 Any ballot documents on which no next available preferences have been expressed shall be set aside as non-transferable votes.
STV49.9 After the returning officer has completed the transfer of the ballot documents in the sub- parcel of ballot documents with the highest transfer value he or she shall proceed to transfer in the same way the sub-parcel of ballot documents with the next highest value and so on until he has dealt with each sub-parcel of a candidate excluded under rule STV49.1.
STV49.10 The returning officer shall after each stage of the count completed under this rule:
(a) record: (i) the total value of votes, or (ii) the total transfer value of votes transferred to each candidate, (b) add that total to the previous total of votes recorded for each candidate and record the new total, (c) record the value of non-transferable votes and add that value to the previous non- transferable votes total, and (d) compare: (i) the total number of votes then recorded for each candidate together with the total number of non-transferable votes, with (ii) the recorded total of valid first preference votes.
STV49.11 If after a transfer of votes under any provision of this rule, a candidate has a surplus, that surplus shall be dealt with in accordance with rules STV47.5 to STV47.10 and rule STV48.
STV49.12 Where the total of the votes of the two or more lowest candidates, together with any surpluses not transferred, is less than the number of votes credited to the next lowest candidate, the returning officer shall in one operation exclude such two or more candidates.
STV49.13 If when a candidate has to be excluded under this rule, two or more candidates each have the same number of votes and are lowest:
68 (a) regard shall be had to the total number of votes credited to those candidates at the earliest stage of the count at which they had an unequal number of votes and the candidate with the lowest number of votes at that stage shall be excluded, and (b) where the number of votes credited to those candidates was equal at all stages, the returning officer shall decide between the candidates by lot and the candidate on whom the lot falls shall be excluded.
STV50. Filling of last vacancies
STV50.1 Where the number of continuing candidates is equal to the number of vacancies remaining unfilled the continuing candidates shall thereupon be deemed to be elected.
STV50.2 Where only one vacancy remains unfilled and the votes of any one continuing candidate are equal to or greater than the total of votes credited to other continuing candidates together with any surplus not transferred, the candidate shall thereupon be deemed to be elected.
STV50.3 Where the last vacancies can be filled under this rule, no further transfer of votes shall be made.
STV51. Order of election of candidates
STV51.1 The order in which candidates whose votes equal or exceed the quota are deemed to be elected shall be the order in which their respective surpluses were transferred, or would have been transferred but for rule STV47.10.
STV51.2 A candidate credited with a number of votes equal to, and not greater than, the quota shall, for the purposes of this rule, be regarded as having had the smallest surplus at the stage of the count at which he obtained the quota.
STV51.3 Where the surpluses of two or more candidates are equal and are not required to be transferred, regard shall be had to the total number of votes credited to such candidates at the earliest stage of the count at which they had an unequal number of votes and the surplus of the candidate who had the greatest number of votes at that stage shall be deemed to be the largest.
STV51.4 Where the number of votes credited to two or more candidates were equal at all stages of the count, the returning officer shall decide between them by lot and the candidate on whom the lot falls shall be deemed to have been elected first.
69 FPP51. Equality of votes
FPP51.1 Where, after the counting of votes is completed, an equality of votes is found to exist between any candidates and the addition of a vote would entitle any of those candidates to be declared elected, the returning officer is to decide between those candidates by a lot, and proceed as if the candidate on whom the lot falls had received an additional vote.
70 PART 7: FINAL PROCEEDINGS IN CONTESTED AND UNCONTESTED ELECTIONS
FPP52. Declaration of result for contested elections
FPP52.1 In a contested election, when the result of the poll has been ascertained, the returning officer is to:
(a) declare the candidate or candidates whom more votes have been given than for the other candidates, up to the number of vacancies to be filled on the council of governors from the constituency, or class within a constituency, for which the election is being held to be elected, (b) give notice of the name of each candidate who he or she has declared elected: (i) where the election is held under a proposed constitution pursuant to powers conferred on the [Gateshead Health ] NHS Foundation Trust by section 33(4) of the 2006 Act, to the chairman of the NHS Foundation Trust, or (ii) in any other case, to the chairman of the corporation; and (c) give public notice of the name of each candidate whom he or she has declared elected.
FPP52.2 The returning officer is to make:
(a) the total number of votes given for each candidate (whether elected or not), and (b) the number of rejected ballot papers under each of the headings in rule FPP44.5, (c) the number of rejected text voting records under each of the headings in rule FPP44.10,
available on request.
STV52. Declaration of result for contested elections
STV52.1 In a contested election, when the result of the poll has been ascertained, the returning officer is to:
(a) declare the candidates who are deemed to be elected under Part 6 of these rules as elected, (b) give notice of the name of each candidate who he or she has declared elected – (i) where the election is held under a proposed constitution pursuant to powers conferred on the [Gateshead Health ] NHS Foundation Trust by section 33(4) of the 2006 Act, to the chairman of the NHS Foundation Trust, or (ii) in any other case, to the chairman of the corporation, and (c) give public notice of the name of each candidate who he or she has declared elected. STV52.2 The returning officer is to make:
(a) the number of first preference votes for each candidate whether elected or not,
71 (b) any transfer of votes, (c) the total number of votes for each candidate at each stage of the count at which such transfer took place, (d) the order in which the successful candidates were elected, and (e) the number of rejected ballot papers under each of the headings in rule STV44.1, (f) the number of rejected text voting records under each of the headings in rule STV44.3,
available on request.
53. Declaration of result for uncontested elections
53.1 In an uncontested election, the returning officer is to as soon as is practicable after final day for the delivery of notices of withdrawals by candidates from the election:
(a) declare the candidate or candidates remaining validly nominated to be elected,
(b) give notice of the name of each candidate who he or she has declared elected to the chairman of the corporation, and
(c) give public notice of the name of each candidate who he or she has declared elected.
72 PART 8: DISPOSAL OF DOCUMENTS
54. Sealing up of documents relating to the poll
54.1 On completion of the counting at a contested election, the returning officer is to seal up the following documents in separate packets:
(a) the counted ballot papers, internet voting records, telephone voting records and text voting records, (b) the ballot papers and text voting records endorsed with “rejected in part”, (c) the rejected ballot papers and text voting records, and (d) the statement of rejected ballot papers and the statement of rejected text voting records,
and ensure that complete electronic copies of the internet voting records, telephone voting records and text voting records created in accordance with rule 26 are held in a device suitable for the purpose of storage.
54.2 The returning officer must not open the sealed packets of:
(a) the disqualified documents, with the list of disqualified documents inside it, (b) the list of spoilt ballot papers and the list of spoilt text message votes, (c) the list of lost ballot documents, and (d) the list of eligible voters,
or access the complete electronic copies of the internet voting records, telephone voting records and text voting records created in accordance with rule 26 and held in a device suitable for the purpose of storage.
54.3 The returning officer must endorse on each packet a description of:
(a) its contents, (b) the date of the publication of notice of the election, (c) the name of the corporation to which the election relates, and (d) the constituency, or class within a constituency, to which the election relates.
55. Delivery of documents
55.1 Once the documents relating to the poll have been sealed up and endorsed pursuant to rule 56, the returning officer is to forward them to the chair of the corporation.
56. Forwarding of documents received after close of the poll
56.1 Where:
(a) any voting documents are received by the returning officer after the close of the
73 poll, or (b) any envelopes addressed to eligible voters are returned as undelivered too late to be resent, or (c) any applications for replacement voting information are made too late to enable new voting information to be issued,
the returning officer is to put them in a separate packet, seal it up, and endorse and forward it to the chairman of the corporation.
57. Retention and public inspection of documents
57.1 The corporation is to retain the documents relating to an election that are forwarded to the chair by the returning officer under these rules for one year, and then, unless otherwise directed by the board of directors of the corporation, cause them to be destroyed.
57.2 With the exception of the documents listed in rule 58.1, the documents relating to an election that are held by the corporation shall be available for inspection by members of the public at all reasonable times.
57.3 A person may request a copy or extract from the documents relating to an election that are held by the corporation, and the corporation is to provide it, and may impose a reasonable charge for doing so.
58. Application for inspection of certain documents relating to an election
58.1 The corporation may not allow:
(a) the inspection of, or the opening of any sealed packet containing – (i) any rejected ballot papers, including ballot papers rejected in part, (ii) any rejected text voting records, including text voting records rejected in part, (iii) any disqualified documents, or the list of disqualified documents, (iv) any counted ballot papers, internet voting records, telephone voting records or text voting records, or (v) the list of eligible voters, or (12) (b) access to or the inspection of the complete electronic copies of the internet voting records, telephone voting records and text voting records created in accordance with rule 26 and held in a device suitable for the purpose of storage, by any person without the consent of the board of directors of the corporation.
58.2 A person may apply to the board of directors of the corporation to inspect any of the documents listed in rule 58.1, and the board of directors of the corporation may only consent to such inspection if it is satisfied that it is necessary for the purpose of questioning an election pursuant to Part 11.
58.3 The board of directors of the corporation’s consent may be on any terms or conditions that it thinks necessary, including conditions as to – 74
(a) persons, (b) time, (c) place and mode of inspection, (d) production or opening,
and the corporation must only make the documents available for inspection in accordance with those terms and conditions.
58.4 On an application to inspect any of the documents listed in rule 58.1 the board of directors of the corporation must:
(a) in giving its consent, and (b) in making the documents available for inspection
ensure that the way in which the vote of any particular member has been given shall not be disclosed, until it has been established –
(i) that his or her vote was given, and (ii) that Monitor has declared that the vote was invalid.
75 PART 9: DEATH OF A CANDIDATE DURING A CONTESTED ELECTION
FPP59. Countermand or abandonment of poll on death of candidate
FPP59.1 If at a contested election, proof is given to the returning officer’s satisfaction before the result of the election is declared that one of the persons named or to be named as a candidate has died, then the returning officer is to:
(a) countermand notice of the poll, or, if voting information has been issued, direct that the poll be abandoned within that constituency or class, and (b) order a new election, on a date to be appointed by him or her in consultation with the corporation, within the period of 40 days, computed in accordance with rule 3 of these rules, beginning with the day that the poll was countermanded or abandoned.
FPP59.2 Where a new election is ordered under rule FPP59.1, no fresh nomination is necessary for any candidate who was validly nominated for the election where the poll was countermanded or abandoned but further candidates shall be invited for that constituency or class.
FPP59.3 Where a poll is abandoned under rule FPP59.1(a), rules FPP59.4 to FPP59.7 are to apply.
FPP59.4 The returning officer shall not take any step or further step to open envelopes or deal with their contents in accordance with rules 38 and 39, and is to make up separate sealed packets in accordance with rule 40.
FPP59.5 The returning officer is to:
(a) count and record the number of ballot papers, internet voting records, telephone voting records and text voting records that have been received, (b) seal up the ballot papers, internet voting records, telephone voting records and text voting records into packets, along with the records of the number of ballot papers, internet voting records, telephone voting records and text voting records and
ensure that complete electronic copies of the internet voting records telephone voting records and text voting records created in accordance with rule 26 are held in a device suitable for the purpose of storage.
FPP59.6 The returning officer is to endorse on each packet a description of:
(a) its contents, (b) the date of the publication of notice of the election, (c) the name of the corporation to which the election relates, and (d) the constituency, or class within a constituency, to which the election relates.
FPP59.7 Once the documents relating to the poll have been sealed up and endorsed pursuant to rules FPP59.4 to FPP59.6, the returning officer is to deliver them to the chairman of the corporation, and rules 57 and 58 are to apply. 76
STV59. Countermand or abandonment of poll on death of candidate
STV59.1 If, at a contested election, proof is given to the returning officer’s satisfaction before the result of the election is declared that one of the persons named or to be named as a candidate has died, then the returning officer is to:
(a) publish a notice stating that the candidate has died, and (b) proceed with the counting of the votes as if that candidate had been excluded from the count so that – (i) ballot documents which only have a first preference recorded for the candidate that has died, and no preferences for any other candidates, are not to be counted, and (ii) ballot documents which have preferences recorded for other candidates are to be counted according to the consecutive order of those preferences, passing over preferences marked for the candidate who has died.
STV59.2 The ballot documents which have preferences recorded for the candidate who has died are to be sealed with the other counted ballot documents pursuant to rule 54.1(a).
77 PART 10: ELECTION EXPENSES AND PUBLICITY
Election expenses
60. Election expenses
60.1 Any expenses incurred, or payments made, for the purposes of an election which contravene this Part are an electoral irregularity, which may only be questioned in an application made to Monitor under Part 11 of these rules.
61. Expenses and payments by candidates
61.1 A candidate may not incur any expenses or make a payment (of whatever nature) for the purposes of an election, other than expenses or payments that relate to:
(a) personal expenses, (b) travelling expenses, and expenses incurred while living away from home, and (c) expenses for stationery, postage, telephone, internet(or any similar means of communication) and other petty expenses, to a limit of £100.
62. Election expenses incurred by other persons
62.1 No person may:
(a) incur any expenses or make a payment (of whatever nature) for the purposes of a candidate’s election, whether on that candidate’s behalf or otherwise, or (b) give a candidate or his or her family any money or property (whether as a gift, donation, loan, or otherwise) to meet or contribute to expenses incurred by or on behalf of the candidate for the purposes of an election.
62.2 Nothing in this rule is to prevent the corporation from incurring such expenses, and making such payments, as it considers necessary pursuant to rules 63 and 64.
Publicity
63. Publicity about election by the corporation
63.1 The corporation may:
(a) compile and distribute such information about the candidates, and (b) organise and hold such meetings to enable the candidates to speak and respond to questions,
as it considers necessary.
63.2 Any information provided by the corporation about the candidates, including information compiled by the corporation under rule 64, must be:
78 (a) objective, balanced and fair, (b) equivalent in size and content for all candidates, (c) compiled and distributed in consultation with all of the candidates standing for election, and (d) must not seek to promote or procure the election of a specific candidate or candidates, at the expense of the electoral prospects of one or more other candidates.
63.3 Where the corporation proposes to hold a meeting to enable the candidates to speak, the corporation must ensure that all of the candidates are invited to attend, and in organising and holding such a meeting, the corporation must not seek to promote or procure the election of a specific candidate or candidates at the expense of the electoral prospects of one or more other candidates.
64. Information about candidates for inclusion with voting information
64.1 The corporation must compile information about the candidates standing for election, to be distributed by the returning officer pursuant to rule 24 of these rules.
64.2 The information must consist of:
(a) a statement submitted by the candidate of no more than 250 words, (b) if voting by telephone or text message is a method of polling for the election, the numerical voting code allocated by the returning officer to each candidate, for the purpose of recording votes using the telephone voting facility or the text message voting facility (“numerical voting code”), and (c) a photograph of the candidate.
65. Meaning of “for the purposes of an election”
65.1 In this Part, the phrase “for the purposes of an election” means with a view to, or otherwise in connection with, promoting or procuring a candidate’s election, including the prejudicing of another candidate’s electoral prospects; and the phrase “for the purposes of a candidate’s election” is to be construed accordingly.
65.2 The provision by any individual of his or her own services voluntarily, on his or her own time, and free of charge is not to be considered an expense for the purposes of this Part.
79 PART 11: QUESTIONING ELECTIONS AND THE CONSEQUENCE OF IRREGULARITIES
66. Application to question an election
66.1 An application alleging a breach of these rules, including an electoral irregularity under Part 10, may be made to Monitor for the purpose of seeking a referral to the independent election arbitration panel ( IEAP).
66.2 An application may only be made once the outcome of the election has been declared by the returning officer.
66.3 An application may only be made to Monitor by:
(a) a person who voted at the election or who claimed to have had the right to vote, or (b) a candidate, or a person claiming to have had a right to be elected at the election.
66.4 The application must:
(a) describe the alleged breach of the rules or electoral irregularity, and (b) be in such a form as the independent panel may require.
66.5 The application must be presented in writing within 21 days of the declaration of the result of the election. Monitor will refer the application to the independent election arbitration panel appointed by Monitor.
66.6 If the independent election arbitration panel requests further information from the applicant, then that person must provide it as soon as is reasonably practicable.
66.7 Monitor shall delegate the determination of an application to a person or panel of persons to be nominated for the purpose.
66.8 The determination by the IEAP shall be binding on and shall be given effect by the corporation, the applicant and the members of the constituency (or class within a constituency) including all the candidates for the election to which the application relates.
66.9 The IEAP may prescribe rules of procedure for the determination of an application including costs.
80 PART 12: MISCELLANEOUS
67. Secrecy
67.1 The following persons:
(a) the returning officer, (b) the returning officer’s staff,
must maintain and aid in maintaining the secrecy of the voting and the counting of the votes, and must not, except for some purpose authorised by law, communicate to any person any information as to:
(i) the name of any member of the corporation who has or has not been given voting information or who has or has not voted, (ii) the unique identifier on any ballot paper, (iii) the voter ID number allocated to any voter, (iv) the candidate(s) for whom any member has voted.
67.2 No person may obtain or attempt to obtain information as to the candidate(s) for whom a voter is about to vote or has voted, or communicate such information to any person at any time, including the unique identifier on a ballot paper given to a voter or the voter ID number allocated to a voter.
67.3 The returning officer is to make such arrangements as he or she thinks fit to ensure that the individuals who are affected by this provision are aware of the duties it imposes.
68. Prohibition of disclosure of vote
68.1 No person who has voted at an election shall, in any legal or other proceedings to question the election, be required to state for whom he or she has voted.
69. Disqualification
69.1 A person may not be appointed as a returning officer, or as staff of the returning officer pursuant to these rules, if that person is:
(a) a member of the corporation, (b) an employee of the corporation, (c) a director of the corporation, or (d) employed by or on behalf of a person who has been nominated for election.
81 70. Delay in postal service through industrial action or unforeseen event
70.1 If industrial action, or some other unforeseen event, results in a delay in:
(a) the delivery of the documents in rule 24, or (b) the return of the ballot papers,
the returning officer may extend the time between the publication of the notice of the poll and the close of the poll by such period as he or she considers appropriate.
82 Annex 4
Gateshead Health NHS Foundation Trust
Governors’ Code of Conduct
PART 1
In undertaking the role of Governor of Gateshead Health NHS Foundation Trust, at a personal level, Governors will:
1. respect that Gateshead Health NHS Foundation Trust is an apolitical organisation;
2. if they are a member of any trade union, political party of other organisation, recognise that should they be elected, they will not be representing those organisations (or the views of those organisations) but will be representing the constituency that elected them;
3. be honest and act with integrity at all times;
4. accept responsibilities for their own actions;
5. show their commitment to working as a team member by working with all their colleagues in the NHS and the wider community;
6. seek to ensure that the membership of the constituency they represent is properly informed and able to influence services;
7. seek to ensure that no-one is discriminated against because of their religion, belief, race, colour, gender, marital status, disability, sexual orientation, age, social and economic status or national origin; and
8. uphold the seven principles of public life as detailed by the Nolan Committee (see Part 4).
As part of Gateshead Health NHS Foundation Trust Council of Governors, Governors will:
9. actively support the vision and aims of Gateshead Health NHS Foundation Trust in developing as a successful NHS Foundation Trust;
10. contribute to the work of the Council of Governors in order for it to fulfil its role as defined in the Trust’s constitution;
11. recognise that the Council of Governors exercises collective decision-making;
12. acknowledge that, other than when attending meetings and events as a Governor, they have no rights or privileges over any other member. Governors wishing to visit the Trust in a formal capacity shall liaise with the Trust Secretary to make the necessary arrangements and must wear their ID badge when undertaking such visits and at all other times when carrying out duties as a Governor
13. recognise that the Council of Governors does not exercise a managerial role within Gateshead Health NHS Foundation Trust;
14. value and respect all colleagues and members of staff and the opinions of individuals;
15. recognise and help the Council of Governors to balance the priorities across the full range of health needs of those we serve; 83
16. respect the confidentiality of information they receive in their role as a Governor. Governors should ensure that documents sent to them are carefully retained and ensure other people do not have access to them. Confidential papers, will be on pink paper and must not be shared with any third party. Once records are no longer needed they should be destroyed by shredding or returned to the Trust
17. act with integrity and objectivity and in the best interests of Gateshead Health NHS Foundation Trust, without any expectation of personal benefit;
18. attend meetings of the Council of Governors, member meetings and training events, on a regular basis. Some training will be defined as mandatory and Governors must attend these sessions;
19. conduct themselves in a manner that reflects positively on Gateshead Health NHS Foundation Trust; and
20. abide by the Trust’s policies and procedures, including its standing orders and standing financial instructions. Trust policies and procedures also cover equity regarding sex, disability and other types of discrimination.
PART 2 – ELIGIBILITY
Potential Governors (members wishing to stand for election) will openly declare to the Trust matters which would affect their eligibility under paragraph 6.11.1 of the constitution.
Where a person has been elected or appointed to be a Governor and he/she becomes aware that he/she is disqualified for appointment under paragraph 6.11.1 of the constitution he/she shall notify the Trust Secretary in writing of such disqualification.
If it comes to the notice of the Trust Secretary at the time of his/her appointment or later that the Governor is so disqualified, he/she shall immediately declare that the person in question is disqualified and notify him/her in writing to that effect.
Upon receipt of any such notification, that person’s tenure of office, shall be terminated and he/she shall cease to act as a Governor.
PART 3 – CONFLICTS OF INTEREST
It is very important that Governors act and are seen to act in accordance with high standards of public office. Governors should not use their role to gain media or public attention in order to advance their personal, business or party political interests.
If a Governor has a pecuniary interest, whether direct or indirect, in any contract, proposed contract or other matters which are under consideration by the Council of Governors, he/she shall disclose that to the rest of the Council of Governors as soon as he/she is aware of it. The Council of Governors shall adopt standing orders specifying the arrangements for excluding Governors from discussion or consideration of the contract or other matter, as appropriate
Under the constitution all conflicts of interest must be declared.
PART 4 - THE SEVEN PRINCIPLES OF PUBLIC LIFE
Selflessness – Holders of public office should take decisions solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family, or their friends.
Integrity - Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might influence them in the performance of their official duties.
84 Objectivity - In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit.
Accountability - Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office.
Openness - Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands.
Honesty - Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest.
Leadership - Holders of public office should promote and support these principles by leadership and example
These principles apply to all aspects of public life.
PART 5 - Guide to Social Media for the Council of Governors
The Trust would like to make Governors aware of its position in relation to social networking sites. Governors must be mindful of the fact that posting inappropriate comments on social networking/external discussion board sites, even during their own time, relating to the Trust are a matter of concern in relation to their role as a Governor.
Social media describes the online tools, websites and services that people use to share content, profiles, opinions, insights, experiences, perspectives and media itself. These tools include social networks, blogs, message boards, podcasts, microblogs, image sharing, lifestreams, social bookmarks, wikis and vblogs.
PART 6 – Upholding this Code of Conduct
1. Following approval of this Code of Conduct by the Council, Governors agree to comply with all of its content.
2. The Constitution provides that where there are concerns as to the conduct or performance of a Governor these are to be addressed in the first instance by the Chairman, with support from the Secretary, to include training and development where this is considered relevant and necessary. Where such concerns exist the Chairman will write to the Governor concerned to set out the concerns and the action agreed to rectify or otherwise address them.
3. The Constitution provides for the cirumstances in which a Governor can be removed from office, including where any Governor fails to comply with this Code of Conduct. As required by the Constitution, it is for the Council of Governors to determine (in accordance with the rules set out in the Constitution) whether any Governor should be removed from office following a proposal from the Chairman.
I ……………………………………………………………………………. (print name) agree to abide by the Code of Conduct of the Council of Governors of Gateshead Health NHS Foundation Trust
Signed Date
85 Council of Governors
Report Cover Sheet Agenda Item: 8
Date of Meeting: Wednesday 22 nd November 2017
Report Title: Lead Governor Appointment
Purpose of Report: The Council of Governors is asked to: (i) Note the appointment process for the Lead Governor (ii) Agree to the appointment of a Lead Governor
Decision: Discussion: Assurance: Information: ☒☒☒ ☐☐☐ ☐☐☐ ☐☐☐
Brief summary to highlight key issues:
To approve the appointment of a Lead Governor.
Author: Mrs D Atkinson, Trust Secretary
Presented by : Mrs D Atkinson, Trust Secretary
Paper for Council of Governors Meeting Agenda Item: 8 22 nd November 2017
G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T
Lead Governor Appointment
Aim
To approve the appointment process for the Trust’s Lead Governor.
Process
It is a requirement of Monitor that all NHS Foundation Trusts nominate a “Lead Governor”.
At the Council of Governors’ meeting in September 2017, governors were asked to consider the job description and person specification and forward expressions of interest to the Trust Secretary.
Following a single nomination from Mr Michael Loome, Public Governor Central, all governors are asked to endorse this nomination.
Mrs D Atkinson Trust Secretary
Council of Governors
Report Cover Sheet Agenda Item: 10
Date of Meeting: Wednesday 22 nd November 2017
Report Title: Trust Performance Report
Purpose of Report: To provide an overview on performance against national and local targets, ensuring the Board receives assurance about the Trust’s performance in light of national requirements and local changes.
Decision: Discussion: Assurance: Information: ☐☐☐ ☐☐☐ ☒☒☒ ☐☐☐
Brief summary to highlight key issues:
The Council of Governors is asked to note the overall continuing good performance of the Trust - but with specific action required by Executive Team and Associate Directors in relation to the workforce metrics, as discussed at the HR Committee, and the operational metrics for A&E and diagnostics, as discussed at the Finance and Performance Committee.
The Trust is not meeting the Single Oversight Framework (SOF) requirement to report the Mental Health priority indicators. No concern has been expressed by NHSI and the revised SOF removes these indicators from the operational performance element of SOF.
The Trust has not met the SOF standard diagnostics waiting for the fourth consecutive month in September. A potential support need by NHSI under the SOF remains in place. NHSI are being updated on performance and trajectory for this standard. There are no STF or acute contract penalty implications. A return to standard is expected by end of October.
Completion of mandatory training for all staff has not reached the anticipated levels despite stringent work by all areas, thus there is a small risk that some staff are not up-to-date with essential training.
Significant work is on-going to maintain the steady decline in sickness absence (there has been a constant downward trend over the past 18 months) and therefore increased staff availability. The aim for all staff to have an appraisal every 12 months remains a challenge and will continue to be a focus within all teams.
Delivery of national and local targets should ensure there is no discrimination towards any particular patient group. Access to appraisals/training is non-discriminatory, with sickness absence managed fairly across all employees. Author: Steven Lawson, Head of Performance Presented by : Susan Watson, Executive Director, Strategy and Transformation
1. Single Oversight Framework:
The Trust has delivered against all standards under the operational metrics of the SOF with the exception of the MH Data Completeness priority metric for accommodation status.
2. Performance dashboard – access/outcome standards not included in the Single Oversight Framework
3. Workforce metrics
Council of Governors
Report Cover Sheet Agenda Item: 11
Date of Meeting: Wednesday 22 nd November 2017
Report Title: Learning from Serious Incidents and Duty of Candour Report (September 2016 – March 2017)
Purpose of Report: To provide an update to the Council of Governors
Decision: Discussion: Assurance: Information: ☐☐☐ ☐☐☐ ☒☒☒ ☐☐☐
Brief summary to highlight key issues:
To provide assurance to the Council of Governors in relation to the Trust’s compliance with Duty of Candour requirements and performance against the standards held within the NHS England Serious Incident Framework which are: • All serious incidents should be reported with 2 working days • Provide a 72 hour report when applicable. • Provide the RCA investigation report within 60 days
Author: Gillian Appleby, Assistant Director of Quality. Paula Brennan, SafeCare Lead – Patient Safety and Incident Management.
Presented by : Kate Jones, Head of Risk
Paper for Council of Governors Meeting Agenda Item: 11 22 nd November 2017
G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T
Learning from Serious Incidents and Compliance with Duty of Candour Requirements
1st September 2016 – 31st March 2017
1. Introduction
The purpose of this paper is to provide assurance to the Board in relation to the Trust’s compliance with Duty of Candour requirements and performance against the standards held within the NHS England Serious Incident Framework which are: • All serious incidents should be reported with 2 working days • Provide a 72 hour report when applicable. • Provide the RCA investigation report within 60 days
In line with the trust policy this report provides an update to the Board on the serious incidents that have occurred within the trust and been reported as well as compliance with Duty of Candour requirements in the period between 1st September 2016 and 31st March 2017. The previous report presented to the Board in September 2016 covered a part year of data, for this reason this report includes data up to March 2017, this will enable a complete financial year to be presented in September 2018. It also provides lessons learned from the afore mentioned incidents.
2. Serious Incident Reporting and Investigation
Serious incidents continue to be reported to the North of England Commissioning Support Unit (NECS) via the Strategic Executive Information System (StEIS), where they are monitored on behalf of the local clinical commissioning groups (CCGs). These incidents are reviewed by the Newcastle Gateshead Clinical Commissioning Group (CCG) to gain assurance that incidents are properly investigated, action is taken to improve clinical quality, and lessons are learnt in order to minimise the risk of similar incidents occurring in the future. There have been 41 serious incidents reported in the period 1 st September 2016 to 31 st March 2017.
A regular summary report on serious incidents is provided to the Commissioners at the Quality and Risk Group (QRG). This group meets to review performance in a number of areas including serious incident reporting and management. The meeting hosted by NECS, is attended by Gateshead CCG and the leads for quality, safety and risk from the Trust. Commissioners take a keen interest in the timing of the serious incident reports and ensuring that incidents are not closed on the StEIS system until they are assured that appropriate actions have been taken and lessons learned.
Regular communication between the Trust (Patient Safety Team) and staff from NECS and the CCG occurs to discuss the incidents as part of the CCG Serious Incident Review Panel. The purpose is to discuss lessons learned and provide where necessary additional information before closure of the incident.
Never Events
Never Events are a subset of serious incidents and may highlight potential weaknesses in how an organisation manages fundamental safety processes. Regardless of the outcome, Never Events are always considered serious incidents as described in the NHS England Serious Incident Framework.
As detailed in the previous report presented to the Board in September 2016 there were 5 never event reported and comprehensive investigations carried out. A robust action plan was produced and assurances have been given for this part of the work however a subsequent Perioperative Service Improvement plan has also been produced and work streams are currently undergoing carrying out improvement work. All work carried out in these work streams will be reported to Quality Governance Committee and exceptions reported to the Board.
There have been no never events in this reporting period.
Serious Incident Data
Table 1 below details the incidents reported to StEIS for the reporting period since the last Board update to date (1 st September 2016 – 31 st March 2017) by type:
Table 1 Type of incident Total Ongoing Appointment / list issues 1 0 Delay / failure to treat / monitor 3 0 Information governance 4 0 Patient falls 14 0 Pressure damage 18 0 Safeguarding 1 0 Total 41 0
Table 2 below shows an overall summary of the incidents reported to StEIS for the financial year 2016-17 and includes a comparison of the incidents reported in 2015-16. Details show incidents reported. Table 2 Type of incident 2015/2016 2016/2017 Appointment / list issues 0 1 Delay / failure to treat / monitor 2 3 Information governance 1 4 Maternity / foetal / neonatal 1 1 Medication 1 0 Operations / procedures 2 6 Non- Patient Fall 1 0 Pathology Sample 2 0 Patient falls 25 23 Results/Investigations 1 0 Pressure damage 10 18 Safeguarding 1 1 Total 47 57
The table highlights a year on year increase in the number of incidents reported to StEIS with an increase of 10 from 15/16-/16/17. There are no ongoing incidents from 16/17 that need to be closed.
Performance against Serious Incident Framework for quarter 2 (July –Sept 2016) Incidents All serious incidents should be Within 2 days Compliance reported reported with 2 working days. 9 6 67% 72 hour report Within 72 hours Compliance Supply 72 hour report . applicable 9 1 11% RCA within 60 RCA's due Compliance Supply RCA within 60 days days 9 8 89%
Performance against Serious Incident Framework for quarter 3 (October –December 2016) Incidents All serious incidents should be Within 2 days Compliance reported reported with 2 working days. 18 5 28% 72 hour report Within 72 hours Compliance Supply 72 hour report. applicable 18 6 34% RCA within 60 RCA's due Compliance Supply RCA within 60 days days 9 8 89%
Performance against Serious Incident Framework for quarter 4 (January – March 2017) Incidents All serious incidents should be Within 2 days Compliance reported reported with 2 working days. 17 8 47% 72 hour report Within 72 hours Compliance Supply 72 hour. applicable 17 13 76% RCA within 60 RCA's due Compliance Supply RCA within 60 days days 10 8 80%
2.1. Learning from incidents
Pressure Damage Whilst there was a high majority of serious incidents reported that where falls, there was also an increase in the amount of Pressure Damage Serious Incidents and an increase of 10 in 2015/16 to 18 in 2016/17. This increase was due to the Trust entering into a new partnership with Gateshead Care Partnership in October 2016.
There are two good example of learning from serious incidents highlighted below.
Case Study 1 - Incident 31928 This incident was in relation to a patient who was discharged with a grade 2 pressure damage that deteriorated in the community to a grade 3.
The RCA identified the following issues: • The Categorisation of the pressure damage was reported by community staff with a different grading process than used in the Trust. • The wound documentation was also different to the format used in QEH. • Communication with the carers could have better. • Pressure relieving advice could have been better.
Learning/Actions taken include: • Training for Community Staff for grading pressure damage to ensure a standardised approach between Trust and Community. • Work carried out to improve the wound documentation used in the Community. • Improved communication with carers regarding pressure relieving equipment.
Case Study 2 – Incident 29861 This incident was in relation to a fax regarding a different patient was added to a patient’s maternity record.
The RCA identified the following issues: • Printers within Maternity/Women’s Health did not have a secure print function. • The Maternity patient record system (Badger) was purchased to be paper light however the system needed an upgrade to ensure this was possible. • Staff did not immediately pick up their printing and this was a risk of papers being mixed up. • No final check of the documents prior to adding them to the patient records.
Learning/Actions taken include: • Review of the printers within the unit and new ones purchased so secure print can be set up. • Information Governance training/awareness for all staff to be arranged. • An upgrade to the Badger system to ensure that the department can become paper light; this will mitigate the risk of this occurring again. • A review of all the administration processes within the unit to minimise paper and the process they use when paper is needed.
2.2 Internal Audit of Incident Management
An audit of Incident Management was undertaken as part of the 2016/17 internal audit plan. The Trust should maintain an adequate and robust process to ensure incidents are identified on a timely basis and appropriately analysed to help prevent re-occurrence. The Trust should also have an active and ongoing approach to build and increase staff awareness on the consequences of not reporting and adequately dealing with incidents. The Trust uses an electronic reporting system (DATIX) to control and co-ordinate incident management.
The audit was undertaken in February 2017. Based upon the work undertaken Internal Audit were able to give significant assurance there is a generally sound system of control designed to meet the organisation’s objectives in the areas reviewed but with issues of note:
The management actions agreed are as follows: • Awareness to be rolled out to staff around the scope of the serious incident framework and their responsibilities in achieving targets. • Plans to improve the Patient Safety Culture in the Trust, this has been included as a priority in the Trust Quality Account. • Patient Safety Team to produce a monthly dashboard to show compliance of the policy and this is to be shared in QE Weekly so staff have access to it. • Policy RM04 to include the improvement to assurance work that is now carried out in the Patient Safety Team.
3. Duty of Candour
The Duty of Candour Regulations came into force in November 2014. An extensive training programme has been delivered to ensure that staff is aware of the legal obligations involved and the steps that should be taken to ensure compliance is achieved. A comprehensive policy is in place and updates were made to the electronic reporting system to support the entire Duty of Candour process and facilitate storing all relevant associated documentation. Template letters have been developed and are readily available for staff to download from the electronic reporting system. The purpose of the letter is to assist staff to produce the initial letter of notification and subsequently to share the findings following the investigation.
To date, monitoring has been undertaken to ensure that the legal requirement to provide a verbal notification has been completed. This has shown that this duty has been carried out in all cases. This information has been shared with the Commissioners, as required, who are satisfied with the level of monitoring and compliance.
3.1. Compliance
Compliance from 1 st September 2016 to 31 st March 2017 is shown below. Patient Safety Duty of Patient/appropriate Patient/appropriate Month Not applicable Candour person informed person not informed Incidents September 2016 10 10 0 0 October 2016 6 6 0 0 November 2016 11 11 0 0 December 2016 8 7 0 1 January 2017 19 19 0 0 February 2017 9 8 1 0 March 2017 18 18 0 0 TOTAL
The exceptions for the above report are below.
December 2016 – Datix 31089 – Actual Suicide – Duty of Candour not carried out as this was investigated as a police investigation.
February 2017 – Datix 32869 – Delay in duty of candour being carried out due to the patient being very ill. The patient has now been discharged and recovering and at a routine appointment on 14 th September a duty of candour discussion will be initiated with the consultant carrying out the care of the patient.
4. Conclusion
There is a significant amount of work being undertaken around serious incidents and Duty of Candour. The never events highlight some specific learning opportunities and areas for improvement within our theatre services and the associated specialities. Actions from the learning following the never events have already begun and work is undergoing and detailed in the Perioperative Service Improvement Plan. Updates will be provided to the Quality Governance Committee periodically.
5. Recommendations
The Trust Board is asked to receive this report for assurance against serious incidents and duty of candour. They are asked to receive assurance that as a trust we are reporting in the appropriate manner, ensuring learning, and undertaking positive changes/improvements to practice.
Gillian Appleby Assistant Director of Quality Paula Brennan – SafeCare Lead – Patient Safety
Council of Governors
Report Cover Sheet Agenda Item: 12
Date of Meeting: Wednesday 22 nd November 2017
Report Title: Summary of Assurances and Items from the Quality Governance Committee
Purpose of Report: To receive the assurance report from the Quality Governance Committee held on 18 th October 2017
Decision: Discussion: Assurance: Information: ☐☐☐ ☐☐☐ ☒☒☒ ☐☐☐
Brief summary to highlight key issues:
This report is presented by the Non-Executive Chair of the Quality Governance Committee who will highlight the assurances raised to the Board.
Author:
Presented by : Mr David Shilton, Non-Executive Director
ASSURANCE REPORT
Quality Governance Committee – 18 October 2017
The Quality Governance Committee has fulfilled its role and functions as defined within its terms of reference.
The reports received by the Quality Governance Committee and level of assurance are set out below.
ISSUES TO BE ASSURANCE RAISED TO COMMITTEE UPDATE NEXT ACTION TIMESCALE LEVEL BOARD CQC Visit – The Committee were informed CQC Action November Mental Health that good progress is being Plan will be 2017. made. discussed at The Committee agreed that the the next CQC Action Plan would be meeting of the managed at the Quality Quality Governance Committee prior to Governance being presented to the Trust Committee. Board.
Board The Committee reviewed the The Board October Assurance new version of the Board Assurance 2017.
Framework Assurance Framework. Framework will be populated further prior to this document being presented to the Trust Board.
Risks (by There are still a number of risks Ongoing. exception) over 12 and above. There is a robust process in place for reviewing risks.
Never Events The Action Plan has now been Ongoing. completed and this will be discussed on a quarterly basis at future meetings of the Quality Governance Committee.
ISSUES TO BE ASSURANCE RAISED TO COMMITTEE UPDATE NEXT ACTION TIMESCALE LEVEL BOARD Q1 LAC doctor post vacant as the Safeguarding post was not appointed to.
CQC Insights The Committee agreed to Present to Ongoing. receive this document twice a Trust Board. year and if there were any issues of exception these would be reported to the Trust Board.
Bowel Cancer The Committee received a very Screening positive report on the Bowel Cancer Screening and there are no major concerns.
PLACE Report The Committee received the Ongoing. report.
Assurance Key Level of Assurance
Assured – there are no gaps in assurance
Partially assured – there are gaps in assurance but we are assured appropriate action plans are in place to address these
Not assured – there are significant gaps in assurance and we are not assured as to the adequacy of current action plans
Council of Governors
Report Cover Sheet Agenda Item: 13
Date of Meeting: Wednesday 22 nd November 2017
Report Title: Integrated Learning Report – Q1
Purpose of Report: To receive the summary report on integrated learning
Decision: Discussion: Assurance: Information: ☐☐☐ ☐☐☐ ☒☒☒ ☐☐☐
Brief summary to highlight key issues:
The purpose of the Integrated Learning Report is to support the analysis of data, collated from Patient Safety Incidents, Patient Experience, Clinical Effectiveness, Legal and Research and Development, to facilitate effective communication Trust wide to learn from experience.
Author: Mrs P Brennan, SafeCare Lead - Patient Safety and Incident Manager
Presented by : Mrs K Jones, Head of Risk
1. Introduction
The purpose of the Integrated Learning Report is to support the analysis of data, collated from Patient Safety Incidents, Patient Experience, Clinical Effectiveness, Legal and Research and Development, to facilitate effective communication Trust wide to learn from experience. Information for Quarter 1 Integrated Learning report was extracted from Datix on 6 th September.
We continually look at ways of improving the aggregation/presentation of data to increase the value of the information provided and support improvements in patient safety and experience. Any suggestions for additional/ improved information and additional information on lessons learned would be welcomed by the Quality Team. Please contact Paula Brennan on extension 3633 or e-mail [email protected] with any suggestions or feedback.
The report is presented to the Trusts Quality Governance Committee for assurance, as well as the Risk and Safety Council and SafeCare Council to identify trends and share lessons learned across the organisation. This in turn will be a standard agenda item on SafeCare Business Unit Meetings to ensure that all learning can be shared at individual SafeCare sessions.
This document has been compiled with contributions from:
Paula Brennan, SafeCare Lead – Patient Safety Wendy McFadden – SafeCare Lead – Patient Experience Jac Reaveley, Medical Devices and Risk Manager/Matron Alison Harvey – Research and Development Manager Andrea Tweddell, Maternity Risk Manager Judith Curry, Volunteer and Patient Experience Manager Vikki Brown, Complaints Manager Sarah Grenfell/Kieran Doran – Legal Services Facilitator/Legal Services Manager Paul Matthewson – SafeCare Lead – Clinical Effectiveness Tom Monaghan – Medical BU Risk and SafeCare Manager Mike Bowe - Divisional Specialist Clinical Pharmacist - Critical Care & Theatres Nicola Allen – Community Services Business Unit
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CONTENTS PAGE
1. Introduction Page 1
2. Patient Safety and Incident Management Page 3 2.1 Patient Safety incidents 2.2 Patient Safety Themes 2.3 Near Miss Incidents 2.4 Patient Safety Incident Learning 2.5 Learning from Medical Services 2.6 Learning from Medical Devices 2.7 Learning from Medication Incidents 2.8 Learning from Community Services 2.9 Learning from Serious Incidents
3. Patient Experience Page 8 3.1 Friends and Family Test (F&FT) 3.2 Fifteen Step Challenge 3.3 Patient Advice and Liaison Service 3.4 Complaints
4. Clinical Effectiveness Page 9 4.1 Clinical Audit 4.2 Mortality & Morbidity
5. Legal Services Page 10
6. Research and Development Page 12
7. Conclusion Page 13
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2. Patient Safety and Incident Management When incidents do happen, it is important that lessons are learned to prevent the same incident occurring elsewhere. RCA is a well-recognised way of doing this. Investigations identify how and why patient safety incidents happen. Analysis is used to identify areas for change and to develop recommendations which deliver safer care for our patients.
2.1 Patient Safety incidents There have been a total of 1389 patient safety incidents reported during Q1, 1024 no harm (74%) 325 low harm(23%), 29 moderate harm (2%) and 11 severe/major harm (1%).
In each of these integrated learning reports we will monitor the amount of incidents and in time hopefully show a reduction in harmful incidents throughout the Trust as learning is implemented. An increase in the amount of no harm incidents will also confirm that patient safety culture is improving and staff are openly reporting incidents as they occur.
2.2 Patient Safety Themes The below table shows the top ten categories of patient safety incidents reported Trust wide, broken down into severity of harm, this will also be monitored in future reports.
Category Low / Minor Harm Moderate Harm Severe / Major Harm Total Patient falls 84 6 8 98 Pressure damage 64 8 1 73 Delay / failure to treat / monitor 27 2 1 30 Maternity / foetal / neonatal 23 4 1 28 Patient accident (non-fall) 19 0 0 19 Pathology sample issues 18 1 0 19 Medication 11 3 0 14 Information governance 13 0 0 13 Operations / procedures 10 1 0 11 Discharge or transfer issue 8 1 0 9
2.3 Near Miss Incidents The table below shows the top ten no harm near miss incidents that have been reported throughout Q1. There were 347 no harm near miss incidents reported in this period. Whilst there were 347 incidents recorded as near misses, it is clear some have been graded incorrectly.
The true definition of near miss is a situation in which an event or omission, or a sequence of events or omissions, fails to develop further, whether or not as a result of compensating action, thus preventing injury to a patient, visitor or member of staff. An example being a patient who fell and hit the floor but was not harmed would not be a near miss; a true near miss would be if we caught the patient before they hit the floor.
Category Apr 2017 May 2017 Jun 2017 Total Patient falls 24 25 32 81 Medication 13 22 21 56 Equipment / Medical Devices 9 7 10 26 Delay / failure to treat / monitor 10 4 11 25 Communication failure 12 7 5 24 Patient information (inc patient records) 8 9 5 22 Discharge or transfer issue 4 5 7 16
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Pathology sample issues 5 5 4 14 Appointment / list issues 4 9 1 14 Maternity / foetal / neonatal 5 2 2 9
The data confirms that not all of the incidents have learning or and root cause analysis within the investigation. Work is planned to reaffirm the importance of robust investigations with near miss incidents and future reports will detail all progress regarding this.
2.4 Patient Safety Incident Learning
Learning from Surgical Services – Maternity The below learning may come from an individual incidents or a theme that was identified and also learning that was noted as an incidental finding following an investigation/case review. Communication between Maternity and Health Visitors: • A secure email for HVs has been established to facilitate maternity staff informing the health visitors of current pregnancies Neonatal assessment : • Whereby a mother is showing signs of sepsis, screened and treated, to ensure that the neonate has the relevant investigations as soon as possible. There has been an incident where this wasn’t detected until discharge two days later, despite the mother being cultured and receiving IV Antibiotics – mandatory to use neonatal assessment documentation to enable red flag. • Please remember that the baby of any mother on IV antibiotics during labour (for suspected sepsis) requires observations at 1 and 2 hours of age followed by 2 hourly observations until 12 hours of age. Paediatric review must also be requested as baby is at risk of developing sepsis. Classification of instrumental delivery : • Please ensure that once the decision has been made to perform an instrumental delivery, that the decision is classified according to urgency. Bladder care in labour : • An incident has occurred whereby bladder care was omitted for eight hours in labour with an epidural, with an overall positive fluid balance of almost 4 litres. The woman is now seven weeks post-partum self-catheterising at home. Full investigation is to currently underway. Readmission and appropriate review : • Advice for re-admission of a neonate is through A and E not directly to the Ward. Baby re-admitted, treatment (phototherapy) started without appropriate review by the Paediatrician. In light of a baby not having a review, staff will now ensure all babies will be reviewed by Paediatrician prior to commencement of any treatment. Missing patient identifiers on samples: • Please ensure that the NHS number is included on any investigations requested by community. Failure to include this demographic causes a duplicate record to be created and information may not be available in a timely manner. Logging out / requesting investigations: • Ensure that when you have finished requesting on ICE you log out. When making a request, please confirm that you have the correct patient on the screen prior to making the request. Hourly CTG review / peer review: • All intrapartum CTGs to be assessed hourly and to have peer review performed as per Intrapartum Care guideline. Badger entries: • Please check entries made on Badger to confirm they make sense as these are now your clinical record. Faulty equipment : • Ensure any faulted or suspected faulted equipment is removed from use and reported to Medical Electronics.
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Postnatal discharge: • Please ensure that any postnatal medication required for discharge are prescribed appropriately and that women are advised of the number of days and the dose; also confirm the discharge address and GP with the mother.
2.5 Learning from Medical Business Unit. Patient Falls incidents learning • Staff are reminded that on admission patient’s that have a potential risk of falling must have lying and standing blood pressure carried out as soon as possible. • A number of incidents have highlighted problems with the position of falls alarm, staff to ensure that alarms need to be positioned in a place where they will be heard.
2.6 Learning from Medical Devices Device failures, damages or wear and tear 37 reports in this category -Refers to incidents believed to be caused by the failure, damage or wear and tear of a device; • Bed rail from a bariatric rail became dislodged and fell on a member of staff’s foot; the failure had been previously reported. • 2 failures with haemocure devices; these are now being reviewed in respect of future maintenance with QEF, and on contract maintenance. • 5 failures of biopsy consumables varying manufacturers and types
Two incidents reported in this quarter relate to failures in the paging system; however this is managed by Facilities not medical devices. Failure to decontaminate - 15 reports in this category-Refers to failure in the decontamination of medical devices; • 11 incidents report debris, staining or rust on trays opened in theatres. The Trust have begun to use surgi-stain in SSD which removes the rust and procurement are also looking at costs for refurbishment of instruments Rust on one instrument can migrate to other instruments and we can’t scratch it off or it damages the surface of the instrument therefore we have to use chemical means • 1 report of breached tray wrap • 3 Trays not processed in time.
Equipment shortage 53 incidents reported in this category- Refers to incidents occurring because devices were not available at the point of need; • 23 incidents reported relate to shortages of bed and chair alarms in the medical services. Work remains ongoing to remind staff these devices are an alerting aid not a prevention tool. • The trials of the new pads on ward 14 did not prove successful and parts of the equipment went missing. • The use of the paging system was also found to be of little advantage in some clinical areas. • A proposal to purchase 20 additional fall units has been presented to Deputy Director of Nursing and we are currently awaiting approval for funding. • 13 accounts of Theatre trays/ instruments not available at the time of need due to equipment shortages, failures in SSD (washers/ sterilisers), incomplete trays, scheduling clashes, delivery issues etc
User error 8 incidents reported in this reporting period; Refers to incidents reported due to the use of devices for which individuals have not been trained • Tourniquet left in situ on a patients arm • NIV device not plugged in, battery depleted staff unaware • Retention of biopsy sheath – led to RCA Patient entrapment 1 incident within this reporting period • During the last reporting period we identified a patient becoming entrapped within the rails of the trolleys used in EAU. Again during this reporting period we have had another incident. We need to
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ensure all staff are aware of the risks, ensure patients are fully assessed for suitability of rails on beds but also on trolleys if they are left in closed rooms. A recent meeting with clinicians, ergonomics and Health and Safety decided to look into the cost implications of trading in the current model for something that potentially eliminate such entrapment risks in the future.
Staff need to be aware of possible device failures and how to recognise these in practice; staff need to be able to identify necessary actions upon failure recognition. Medical devices need to work closely with business unit managers to ensure staff complete as much detail as possible within Datix; an essential element of the Datix report needs to be the identifying asset, serial, batch number and manufacturer or supplier so equipment can be suitably quarantined and tested.
Many incidents are categorised as equipment failure as staff believe their practice to be correct, this has on occasions been disproven at investigation. However, if equipment remains untraceable further investigation cannot determine the true cause of the incident; a significant risk is associated with this practice as potentially faulty equipment is not being quarantined for essential safety checks. If faulty equipment is placed back in circulation there is the potential for patient or user harm.
2.7 Learning form Medication Incidents The main learning point from a medication point of view was that following the integration ePMA and the Omnicell cabinets into the medication administration pathway there is a concern that staff are becoming too reliant on the expectation that the new systems will stop them from getting things wrong. Examples include not checking when previous doses have been given and selecting the wrong drug from the Omnicell but not checking the medication before administering.
The action points from this are that all staff must ensure that patients get the right medication at the right time and that self-checks must be undertaken at each step of the administration pathway.
2.8 Learning from Community Services Improvement work continues at Eastwood Unit, some important improvements/learning from Q1 is; • Collaborative approach to patient records rather than having separate notes for Local Authority staff and Gateshead staff • Implementation of a Rapid Review Document to be used when harmful incidents occur.
A recent IT system upgrade occurred and it identified that Eastwood Staff have no access to computer systems at all. Learning from this incident has resulted in; • Business continuity plan set up • Purchase of Laptops and Wi-Fi Dongles to ensure internet access at all times.
2.9 Learning from Serious Incidents During Q1 there were 25 incidents reported externally to Strategic Executive Information System (StEIS). Some of the learning is detailed below.
Communication Failure Background: It was identified during June 2017 that 31,000 discharge proformas were backlogged in the Medway system and not sent the GP, and this resulted in a delay in GP’s receiving patient discharge information.
Learning: • Consideration given to the expected level of information provided to the IT Change control group, and possible consideration be given to the representation and remit of that group. • An end-to-end test cycle be implemented for all email addresses to ensure that the appropriate recipient is actually receiving the intended messages.
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• Consideration be given to who/which department oversees the electronic patient discharge letter process from end to end as a single entity removing the split responsibility as far as reasonably possible. • Clarity is established when and how the SIRO and CSO are alerted to such incidents and what expected actions for communication would follow. • A process is clarified that escalates to the relevant team/clinician/CSO if a system fault reported by the Trust is provided by the system provider without the agreement of the Trust.
Discharge of Transfer Issue Background: This incident detailed a venerable patient who tailgated a member of staff out of a ward area and absconded. Learning: • Access to the ward environment restricted to mental health ward based clinical staff, on-call medical and other senior staff who require access and only other staff members (groups) agreed by the Ward Manager or Modern Matron. • Routine daytime access to the Ward is changed to the back entrance which has a double door airlock, thereby reducing risk of patients absconding. • Consideration to all service users admitted to the ward having a picture taken to provide a clear image of all service users to support a search in such circumstances. • Fixed notices regarding liaising with the ward team for access/egress. • Monthly audit by the Ward manager and Matron regarding staff access (via their ID badge) to the ward area. • No access for any staff via their ID badge will be granted without confirmation from the Ward Manager or Modern Matron. • Opportunities for improvements in the environment have been subject to feasibility studies by QEF and schemes drawn up.
Maternal/foetal/neonatal Background: This incident was regarding a shoulder dystocia, is a specific case of obstructed labour whereby after the delivery of the head, the anterior shoulder of the infant cannot pass below, or requires significant manipulation to pass below, the pubic symphysis. It is diagnosed when the shoulders fail to deliver shortly after the fetal head. Learning: • It is recommended that the BMI is calculated at the dating scan appointment to ensure consistency with this calculation. • The current process for requesting an OGTT may increase the risk of a non-pregnant test being selected due to there being 2 options. A review is currently underway between maternity and pathology to examine this process.
Pathology Samples Issues Background: A GP rang querying abnormal creatinine results for two patients who were relatively young and otherwise healthy. On investigation, it was discovered that 2 of the 8 modules measuring creatinine had an unacceptably poor reproducibility (precision) over the preceding 2 months. The evidence for this was a significantly greater number of quality control (QC) failures than there should have been and evidence that actions in response to QC failures were not sufficient to prevent releasing erroneous results. Learning: • Some staff do not know how to correctly perform technical checks following replacement of ISE electrodes or after a service engineer visit. • Deficiencies in the QC monitoring process were found e.g. lack of weekly review, failure to inspect trends following QC failure • A general lack of deeper understanding of how to investigate QC failures was found. • The ability to inspect previous QC trends is made more difficult because of inadequacies in the IT system (Roche CiTM) used to monitor QC results on a day to day basis.
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Patients Falls (resulting in fractured neck of femur (hip)) Background: These incidents detailed patients’ who fell whilst on a ward and this fall resulted in a fractured neck of femur. Whilst some of the investigations confirmed all necessary risks were assessed and the patients had mobilisation plans in place, they attempted to walk without assistance and fell. Learning: • Improved physiotherapy reviews for patients who are at risk of falling. • No lying and standing blood pressure recorded on admission to the wards, this is now carried out as a priority. • Improve the quality of the falls risk assessment documentation. • A review of the falls risk assessment documentation will be undertaken. This has been reviewed and will be presented to December 2017 Council for ratification. • A weekly audit to be completed on falls assessment documentation, to ensure compliance. • Falls alarms have all had new hooks fitted to them so they can hang from the patient’s bed, to ensure staff will be alerted if they sound.
Deterioration of Pressure Damage Background: These incidents detail patients’ who have had their pressure damage deteriorate to grade 3 or grade 4 whilst under the care of our teams. There were three of the incident from ward patients, and 8 from our community patients. Learning from Wards: • Improved skin care documentation, and comprehensive skin assessments to be carried out on patients. • Education on accurate record keeping. • Staff must ensure that all food charts are signed off according to the MUST tool. Learning from Community: • Improved wound assessment documentation, to standardise with the one used on our wards. • Staff reminded that incidents of pressure damage should be reported as soon as identified.
3. Patient Experience The core measures of patient experience are derived from Friends and Family Test (F&FT), 15 step Challenge, Real Time Feedback Survey and Paper Surveys, PALS and Complaints.
3.1 Friends and Family Test (F&FT) The themes identified in the ‘Extremely Likely’ Friends and Family Test recommendations are: • Quick & Efficient Service • Informative Service • Excellent care from staff • Friendly staff
The themes identified in the ‘Extremely Unlikely’ Friends and Family Test recommendations are: • Waiting times at A+E and in clinics • Poor attitude of staff • Poor care from staff • Poor communication by staff to patients and other staff
3.2 Fifteen Step Challenge During quarter 1 6 areas took part in the challenge, Urology, Ward 1, MRI, Ultrasound, Critical Care and Ward 23. There are four categories that are measured throughout the challenges; how welcoming the area is, how safe it appears to be, how caring and involving staff are and finally whether the ward seems calm and organised.
There were some really positive comments made during the challenges; staff was welcoming, wards were clean and tidy, patients dressed and comfortable and also good signage on the wards. There were some recommendations that were identified and these were time to care boards and safety cross did not include the most up to date information. This recommendation was shared with the areas and rectified.
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3.3 Patient Advice and Liaison Service During quarter 1 there were 117 informal complaints to PALS as detailed below, the majority of these contacts were resolved locally. Compliments remain the highest proportion of contacts with the service 284, followed by 43 requests for information. Other contacts remain diverse with communication, values and behaviour of staff, clinical assessment and appointments being the next largest proportion.
An example of learning from PALS; Issue: Patient concerned with the delay of results from Cardiology. Learning/Resolution: This complaint initiated a query to the department regarding the letter, and it was confirmed there had been a delay in processing responses. The letter has now been sent and the patient has confirmed receipt.
An example of a compliment from PALS: To all the wonderful staff, day and night, medical staff and support staff. I want to thank you all for the loving care you gave to my brave daddy in the last two weeks of his life. You all looked after him with care and dignity and respect. It was a great comfort to see and I to know that he was so well cared for. I admire and respect each and every one of you for your caring nature that you all have to enable you to provide a unique support to both patients and their families. Once again thank you for everything.
3.4 Complaints During quarter 1 there were 52 formal complaints reported. An example of learning from Complaints;
Issue: As part of the Trust’s Duty of Candour a letter was sent to the patient’s son in regards to an incident that had occurred. Concerns were raised as to how the patient had become dehydrated in hospital and that high sodium levels were recorded and questions were asked about how these had been monitored Learning/Response: Unfortunately it was not recognised that a patient’s blood sodium levels were rising and he continued to receive intravenous saline. As a result of this the medical and nursing team have agreed to put a process in place to ensure all pathology results are directed to one point of contact on the ward, where they can be reviewed with the drugs and fluids prescribed to a patient. This revised process was disseminated to the junior doctors on 20th March 2017. Learning/Resolution: Teaching sessions have commenced to stress the necessity for accurate record keeping and a template of accountability has been formulated for both nursing and medical teams to ensure all charts are completed. The nursing documentation has now been amended to enable more accurate and accountable record keeping for all patients including those who stay on the Ward longer than the recommended 72 hours.
3.5 Real Time Surveys Patients who took part in our Real Time Inpatient Survey programme in April, May and June told us that they felt staff had a caring and compassionate attitude, they were treat with respect and in a friendly manner and were given enough privacy and dignity during their stay. However they did tell us there was room for improvement in providing information about the ward such as meal times and visiting time and also prompt response to call bells. A piece of work is to be undertaken with the wards to look at what information is provided to patients on admission with a view to possibly standardising this.
4. Clinical Effectiveness
4.1 Clinical Audit During quarter 1 the following lessons have been highlighted through audit projects that have been completed. • It is vital to adhere to National Institute for Clinical Excellence (NICE) guidelines in each and every step during the management of patients with Acute Kidney Injury (AKI). NICE Guidance CG169 - Acute kidney injury: prevention, detection and management. There are several essential areas need to be improved
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in order to reach the best possible management of patients with AKI. Staff should be kept well-informed by all the essential guidelines and updates. This can be achieved by frequent education approaches, including regular scientific meetings, reviews, journal clubs and regular discussions during grand rounds. • A new transfusion policy is being implemented by the trust; this targets a lower transfusion threshold. It would be beneficial for a further audit to be undertaken once this policy is in place to assess practice. Current practice based on this audit, implies that patients are being over transfused, it would be interesting to assess whether this changes following a new transfusion policy.
• None of physio assessments of new stroke patients were undertaken within 24 hours, no documentation of initial swallow screening could be located in the notes. We need to improve on using compensatory strategies used in patients with unsafe swallow and develop framework for assessment and development of stroke specific competencies for Multi-Disciplinary Team (MDT). Review stroke pathway/MDT documentation to ensure appropriate documentation of assessments. • In the future, after implementation of the plans from this IBleep Out of Hours audit and the Rapid Process Improvement Workshop (RPIW) it would be necessary to re-audit the out of hour’s workload, ensuring that we sustain new ways of working and the longevity in the projects.
4.2 Mortality & Morbidity Themes which have arisen within the mortality working undertaken within this time period are;
Do Not Attempt Resuscitation (DNAR) – Should be countersigned, ensure a form is accurately completed, document everything, patients on end of life pathways, handover of accurate information to all staff Emergency Health Care Plan (EHCP) – Appropriate wording of the plan, no discussion with the Coroner documented Place of death – Good communication, families kept fully informed, appropriate implementation of end of life, management of patients outside of the hospital Death Certificates – Ensure that the death certificate accurately reflects other co-morbidities, Complete DNAR when severity of illness is clear, No copy of the death certificate in the case notes Notification of death to the GP – Ensure that junior doctors are aware of their obligation to notify GP of the death via Medway letters, Discharge letters not complete, no cause of death recorded or Medway letters in notes Palliative Care – Good end of life recognition, good clinical management Communication – Proactive approach and management of patients with all MDT team Good practice – Appropriate bundles in place, continued good care, well documented
5. Legal Services Within the first Quarter, i.e. 1 April 2017 to 30 June 2017, the Trust received nineteen (19) notifications of potential clinical negligence claims in the form of disclosure requests. This compares to the final Quarter 4 2016 whereby the Trust received twenty eight (28) potential clinical negligence claims in the form of disclosure requests, and 1 litigated claim in the form of a Letter of Claim.
Case Background 1 The claimant was admitted to the Accident & Emergency Department complaining of acidic reflux and indigestion. However, the claimant also presented with an extremely rapid heart rate and very high blood pressure. While an ECG was undertaken there was no follow up on the results. As a result an upper gastrointestinal infection was diagnosed. However, the claimant subsequently suffered from a myocardial infarction and was hospitalised. Case Learning Points We identified that the Trust had failed to take notice and act upon an abnormal ECG in the Accident & Emergency Department and had immediate steps should have been taken to avoid the myocardial infarction. Learning has been shared with Service Line Manager’s to disseminate to relevant departments / individual healthcare professionals.
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Case Background 2 The claimant had a long history of ischaemic heart disease and hypertension, as well as diabetes. On initial admission the claimant presented with breathlessness and chest pain, and given his long medical history, complications from heart disease was diagnosed. However, the claimant’s additional medical history of smoking and working in dusty environments was eventually factored in and an x-ray was carried out on his lungs, which eventually showed up increased density on the left lung. The claimant was ultimately given a diagnosis of lung cancer. Case Learning Points We established that the reporting Radiologist should have recommended a CT scan of the chest given the evidence of increased density on the x-ray of the lung. The failure to do this led to a delay in diagnosing and treating lung cancer. Learning has been shared with Service Line Manager’s to disseminate to relevant departments / individual healthcare professionals.
Case Background 3 The claimant presented with facial palsy and headaches. The initial examination was complicated by the presence of dental abscesses and sinus pathology. The Senior Registrar involved in the initial admission ordered a Lyme disease serology and although it was given the all clear a follow up serology test was clinically indicated. As a result no further test was undertaken in time and no treatment given to address the initial symptoms and the claimant developed Lyme Disease. Case Learning Points We found in this case that whilst the Registrar correctly identified the suspicion of Lyme disease and organised a follow up serology test, antibiotic therapy should also have been commenced in the meantime as this was a suspected case of Lyme disease. Furthermore, the claimant should have been recalled and reviewed and repeat serology obtained at a later date. Also, the claimant should also have been referred to an Infectious Diseases Consultant. Learning has been shared with Service Line Manager’s to disseminate to relevant departments / individual healthcare professionals.
Case Background 4 The claimant attended an NHS Breast Screening Programme at Queen Elizabeth Hospital, having had an initial breast screening a number of years earlier. At the latter breast screening examination the claimant complained of a lump but informed the Radiographer that it was painless. The Radiographer diagnosed a non-malignant lump and discharged the claimant. However, the lump did not go away and the claimant attended for a follow up examination and a diagnosis of breast cancer was made. Case Learning Points We established that the claimant’s mammogram was incorrectly interpreted and the Radiographer failed to provide any follow up advice, which led to the delayed diagnosis of breast cancer. Learning has previously been shared with Service Line Manager’s to disseminate to relevant departments / individual healthcare professionals.
Case Background 5 The claimant was admitted for right knee replacement, which was successfully carried out. Consequently, the claimant was referred to a Physiotherapist for two (2) sessions per day for the first three (3) days post- operatively. Unfortunately, once the claimant was discharged, at his request as he was keen to go home, there was no follow up physiotherapy arranged apart from one (1) appointment a month after the procedure. Consequently, the claimant developed flexion problems in his right knee and ultimately had to attend for a further surgical procedure to address the post-operative problem of a lack of flexion in the right knee. Case Learning Points We established that there was a delay in starting the Claimant’s physiotherapy following a knee replacement. This was due to an IT system error causing the delay and therefore no lessons could be learned.
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Case Background 6 The claimant was admitted to the Accident & Emergency Department following a fall on leaving a party. As a result of the fall, the claimant trapped his left wrist in railings and his wrist began to swell up. The claimant had been drinking but was not drunk. He was then examined by the Specialist GP Trainee who was on duty at the time. A pulse was detected, the hand was warm, with good blood supply, and although there was limited range of movement of the wrist, there appeared to be no bone damage. As a result no x-ray was taken. Consequently, the claimant was discharged. However, the claimant subsequently readmitted himself to Northumbria Emergency Department as his symptoms persisted, inclusive of pain, and subsequent to an x-ray been taken, a fracture of the left wrist was diagnosed. Case Learning Points We found that there had been a failure to x-ray the Claimant’s left arm and diagnose a fracture in the Accident & Emergency Department. The medical records in this case were also of a very poor quality. Learning has previously been shared with Service Line Manager’s to disseminate to relevant departments / individual healthcare professionals.
Conclusion In the future it is the intention of the Legal Services team to continue to build on the learning points from Trust claims and develop Trust wide training programmes which will address the training requirements throughout the Trust based on the issues that have emerged in Trust claims, ranging from Clinical Record keeping to dealing with aggressive patients/family members, the implementation of the Duty of Candour to name but a few.
6. Research and Development
Recruitment
During the first quarter (April – June 2017) the R&D Team recruited 280 patients across 29 National Institute for Health Research (NIHR) portfolio studies, across many different specialties – Anaesthesia, Perioperative & Pain Management, Cancer, Critical Care, Dementias & Neurodegeneration, Health Services & Delivery Research, Metabolic & Endocrine Disorders, Musculoskeletal Disorders, Reproductive Health & Childbirth, Respiratory Disorders, Stroke & Surgery.
R&D Annual Report 2016-2017
The first R&D Annual Report went to the Quality Governance Committee in September 2017 for Assurance and to the Trust Board Meeting in September 2017 for Information.
The Annual Report highlighted the following –
In the 12 months from 1st April 2016 to 31st March 2017, we recruited 1032 patients across 60 National Institute for Health Research (NIHR) portfolio studies. The Research and Development (R&D) Department have seen many successes over the last 12 months: • Dr Ray Meleady, Consultant Cardiologist, was invited to be Chief Investigator for England for the OUTSTEP study (sponsored by Novartis Ltd.), which is a prestigious appointment. • The Gynaecological Oncology Team was the second highest recruiting team in the UK for the ROCKeTS study in February 2017. • We delivered five of the seven North East and North Cumbria Clinical Research Network (NENC CRN) Continuous Improvement targets, securing £11,111 of additional in-year funding for the Trust. • Research activity in a previously inactive area – Hepatology – took place in 2016/17, with 27 participants recruited across four studies.
• The Reproductive Health Team achieved an exceptional recruitment figure, recruiting a total of 257 participants across five studies. For the VESPA study, the team recruiting 137 patients out of 150
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patients who had to be approached consecutively. This target was achieved by all of the Research Nurses from the R&D Department working collaboratively from other clinical specialties. The team was praised for their innovative working practice which proved to be highly successful and may lead to changes in national practice.
Our aim for 2017/18 is to continue to build on our success and to further develop our reputation as a research active Trust, providing high quality research opportunities for patients.
The Annual Report was very well received by the Trust Board and further updates by the R&D Team have been scheduled at subsequent Trust Board Meetings.
7. Conclusion This is the first version of this report and the team would welcome suggestions on content for future reports.
Actions identified through the production of this report; • Trust communication detailing a true near miss and how to maximize the learning identified from these incidents. • A piece of work is to be undertaken with the wards to look at what information is provided to patients on admission with a view to possibly standardising this.
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Council of Governors
Report Cover Sheet Agenda Item: 14
Date of Meeting: Wednesday 22 nd November 2017
Report Title: Membership Strategy Sub Group Update
Purpose of Report: To receive the report for information
Decision: Discussion: Assurance: Information: ☐☐☐ ☒☒☒ ☐☐☐ ☐☐☐
Brief summary to highlight key issues:
To provide the Council of Governors with an update on membership numbers and the current and future work of the Membership Strategy Sub Group.
Author: Mrs J Williamson, Membership Co-ordinator
Presented by : Mr M Loome, public governor and Chairman of the group
Paper for Council of Governors Meeting Agenda Item: 14 22 nd November 2017
G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T
Membership Strategy Sub Group Update
1. Current Membership
Information on membership numbers is presented at each meeting and reviewed by the group. This includes breakdowns by age, gender and ethnicity.
The total number of all members (public, patient and staff) at 31 st October 2017 was 17,775. A graph showing membership totals is overleaf as Appendix 1.
A table showing the population of the three public constituencies; Central, Eastern and Western, and their membership ratio is attached as Appendix 2.
2. Recent Work
The group has met once since the last update and has continued to take part in the following activities: • met to finalise details for Membership Week 2017 • discussed, promoted and attended the Open Event • continued with recruitment and engagement in OPD • continued to attend local community groups • discussed future venues for recruitment/engagement sessions
3. Next Steps/Future Plans
The next steps/future plans for the group are to: • encourage all members of the Council of Governors to become involved in recruitment • continue to work with all governors towards the objectives and actions detailed in the Membership Strategy • continue to promote membership in the QE Outpatients department • continue to attend local engagement events
Mr M Loome Chairman of the Group and Public Governor Appendix 1 Membership by Constituency (at 31st October 2017) 7000
6000
5000
4,192 4000 3686
3000
2381
2000
1000 470
0 Eastern Central Western Out of Area Staff
Appendix 2
Population and Membership Ratio by Constituency
Western Central Eastern Overall Population 77,471 92,828 41,615 211,914 Membership 3,686 7,046 2,381 13,113 % 4.76 7.59 5.72 6.19
Council of Governors
Report Cover Sheet Agenda Item: 16
Date of Meeting: Wednesday 22 nd November 2017
Report Title: Governor Activities
Purpose of Report: To receive the report for information
Decision: Discussion: Assurance: Information: ☐☐☐ ☐☐☐ ☐☐☐ ☒☒☒
Brief summary to highlight key issues:
The report details governor activities from 16 th September 2017 to 13 th November 2017 inclusive including attendance at events and meetings and information from the online feedback form.
Author: Mrs J Williamson, Membership Co-ordinator
Presented by : Mrs D Atkinson, Trust Secretary
Paper for Council of Governors Meeting Agenda Item: 16 22 nd November 2017
G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T
Governor Activities
1. Introduction
Data for the report has been compiled from attendance at events and meetings and from the online feedback form.
The time period of the activities below covers 16 th September 2017 to 13 th November 2017 inclusive.
2. Governor Activities
During the period, 23 survey responses were received from governors after attending an event or meeting. The feedback was as follows:
What are you providing feedback about? 7
6
5
4
3
2
1
0 A public event Recruitment / A meeting or A training session *Other (internal) Engagement conference (internal) (internal)
Please let you know if you did any of the following: 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 Talked to people Recruited new Contributed your Learned more about Learned useful new about the Trust members views to a discussion the Trust skills/knowledge informally or consultation
If you were able to recruit new members, how many did you recruit? 5
4
3
2
1
0 0-5 6-10 11-20
I would be happy to do this again
Potentially, being there was of benefit to patients
I think my being there was of benefit to the Trust
I enjoyed myself
I was clear about why I was there
I was able to contribute usefully
It was worthwhile to me personally
I learned a lot
0 1 2 3 4 5 6 7 8 9 101112131415
Did Not Answer Strongly Agree Agree Not Sure
3. Recommendation
The Council of Governors is asked to note this summary and the activities report attached as Appendix 1.
Debbie Atkinson Trust Secretary Appendix 1 Governor Activities Public and Staff
Governor Name Activity Date Governors’ Workshop – Patient Flow 04/10/2017 Membership Week – Leaflet Promotion Civic Centre 09/10/2017 Eileen Adams Membership Week – Information Stand 30/10/2017 Membership Week Open Event 01/11/2017 Membership Strategy Sub Group 09/11/2017 Membership Week – Information Stand 31/10/2017 Sue Begg Membership Week Open Event 01/11/2017 Membership Strategy Sub Group 09/11/2017 Staff Governors’ Meeting 16/09/2017 Corporate Induction – Staff Governors 02/10/2017 Joanne Coleman Corporate Induction – Staff Governors 30/10/2017 Membership Week Open Event 01/11/2017 Membership Strategy Sub Group 09/11/2017 Board of Directors’ Meeting 26/09/2017 Membership Engagement – Older Person’s Forum AGM 29/09/2017 Membership Engagement – Garsfield Golf Club Men’s Group 02/10/2017 Governors’ Workshop – Patient Flow 04/10/2017 PLACE Visit – Paeds, A&E, Chapel of Rest 25/10/2017 Steve Connolly Board of Directors’ Meeting 25/10/2017 Membership Week Open Event 01/11/2017 Infection Prevention and Control Committee 02/11/2017 Membership Week – Information Stand 03/11/2017 Membership Strategy Sub Group 09/11/2017 Membership Engagement – Garsfield Golf Club Men’s Group 02/10/2017 Governors’ Workshop – Patient Flow 04/10/2017 Cecilia Coulson Board of Directors’ Meeting 25/10/2017 Membership Week Open Event 01/11/2017 Membership Strategy Sub Group 09/11/2017 Board of Directors’ Meeting 26/09/2017 Diversity Information Stand 19/09/2017 Diversity Information Stand 03/10/2017 Governors’ Seminar 04/10/2017 Alan Dougall Leaflet Distribution – Civic Centre 09/10/2017 HR Committee 10/10/2017 Board of Directors’ Meeting 25/10/2017 Membership Strategy Sub Group 09/11/2017 Staff Governors’ Meeting 16/09/2017 Claire Ellison Governors’ Workshop – Patient Flow 04/10/2017 Membership Engagement – Rowlands Gill Flu Day 22/09/2017 Board of Directors’ Meeting 26/09/2017 Jenny Gill Membership Engagement – Garsfield Golf Club Men’s Group 02/10/2017 Governors’ Workshop – Patient Flow 04/10/2017 Membership Week – Leaflet Promotion Civic Centre 09/10/2017 Governor Name Activity Date Board of Directors’ Meeting 25/10/2017 Membership Week – Information Stand 30/10/2017 Membership Week – Information Stand 31/10/2017 Membership Week Open Event 01/11/2017 Membership Strategy Sub Group 09/11/2017 Membership Week – Leaflet Promotion Civic Centre 09/10/2017 Board of Directors’ Meeting 25/10/2017 Grace Henderson Membership Week Open Event 01/11/2017 Membership Week – Information Stand 02/11/2017 Membership Week – Information Stand 03/11/2017 Board of Directors’ Meeting 26/09/2017 Council of Governors’ Remuneration Committee 27/09/2017 Governors’ Workshop – Patient Flow 04/10/2017 Human Resources Committee 10/10/2017 SafeCare Council 11/10/2017 Jim Holmes Membership Week – Information Stand 31/10/2017 Membership Week Open Event 01/11/2017 Membership Week – Information Stand 03/11/2017 Membership Strategy Sub Group 09/11/2017 Council of Governors’ Remuneration Committee 13/11/2017 Governors’ Workshop – Patient Flow 04/10/2017 Membership Engagement – OPD Recruitment 12/10/2017 Membership Engagement – OPD Recruitment 20/10/2017 Membership Engagement – OPD Recruitment 30/10/2017 Margaret Jobson Membership Engagement – OPD Recruitment 01/11/2017 Membership Week Open Event 01/11/2017 Patient, Public and Carer Involvement Meeting 07/11/2017 Membership Engagement – OPD Recruitment 07/11/2017 Membership Strategy Sub Group 09/11/2017 Helen Jones Governors’ Workshop – Patient Flow 04/10/2017 Charitable Funds Committee 21/09/2017 Jackey Lockwood Membership Week – Information Stand 02/11/2017 Membership Engagement – Rowlands Gill Flu Day 22/09/2017 Board of Directors’ Meeting 26/09/2017 Membership Engagement – Garsfield Golf Club Men’s Group 02/10/2017 Governors’ Workshop – Patient Flow 04/10/2017 Board of Directors’ Meeting 25/10/2017 Membership Week – Information Stand 30/10/2017 Michael Loome Membership Week – Information Stand 31/10/2017 Membership Week Open Event 01/11/2017 Membership Week – Information Stand 02/11/2017 Membership Week – Information Stand 03/11/2017 Membership Strategy Sub Group 09/11/2017 Council of Governors’ Remuneration Committee 13/11/2017 Abe Rabin Quality Governance Committee 20/09/2017 QE Star Awards Presentation Evening 22/09/2017 Mary Summers Safeguarding Committee 06/10/2017 Governor Name Activity Date Governors’ Workshop – Patient Flow 04/10/2017 PLACE Inspection 18/10/2017 Membership Week – Information Stand 30/10/2017 Membership Week – Information Stand 31/10/2017 Membership Week Open Event 01/11/2017 Membership Week – Information Stand 02/11/2017 Membership Week – Information Stand 03/11/2017 Diversity and Inclusion Forum 07/11/2017 QE Star Awards Presentation Evening 22/09/2017 Board of Directors’ Meeting 26/09/2017 Council of Governors’ Remuneration Committee 27/09/2017 Governors’ Workshop – Patient Flow 04/10/2017 Membership Week – Leaflet Promotion Civic Centre 09/10/2017 Janice Todd Membership Week – Information Stand 30/10/2017 Membership Week Open Event 01/11/2017 Infection Prevention and Control Committee 02/11/2017 Membership Strategy Sub Group 09/11/2017 Council of Governors’ Remuneration Committee 13/11/2017
In addition, appointed governors have also been able to attend the following events:
Governor Name Activity Date Pam Dawson Governors’ Workshop – Patient Flow 04/10/2017 Mary Foy Board of Directors’ Meeting 25/10/2017
Council of Governors
Report Cover Sheet Agenda Item: 17
Date of Meeting: Wednesday 22 nd November 2017
Report Title: Elections Update 2017
Purpose of Report: To receive the report for information
Decision: Discussion: Assurance: Information: ☐☐☐ ☐☐☐ ☐☐☐ ☒☒☒
Brief summary to highlight key issues:
The paper summarises the candidates for this year’s election.
Author: Mrs J Williamson, Membership Co-ordinator
Presented by : Mrs J Williamson, Membership Co-ordinator
Paper for Council of Governors Meeting Agenda Item: 17 22 nd November 2017
G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T
Update Report – Elections 2017
Introduction
The closing date for receipt of nominations for this year’s elections was 27th October.
Nine nominations were received for three of the constituencies; four for central, three for western, and two for staff. A full list of candidates is attached as Appendix 1.
Results
Central Constituency four nominations received for two vacancies
Western Constituency three nominations received for two vacancies
Staff Constituency Mrs Anna Richardson – elected unopposed for three years Mr Aaron Walton – elected unopposed for three years
Out of Area Patient Constituency one vacancy remains
Next Steps
The voting packs will be distributed by the ERS to all Central and Western members on Friday 17 th November 2017. The closing date for receipt of ballot papers is Tuesday 12 th December 2017, with the results announced at 12.00 noon on Wednesday 13th December 2017.
Recommendation
The Council of Governors is asked to receive for information the update report on the elections 2017.
Mrs J Williamson Membership Co-ordinator
Appendix 1
6th November 2017
GATESHEAD HEALTH NHS FOUNDATION TRUST ELECTION TO THE COUNCIL OF GOVERNORS STATEMENT OF NOMINATED CANDIDATES
Financial and Political Constituency Forename Surname Other Interest Interest In the Trust Public: Central Bob Brammer None None Public: Central Alan Crawford Wallace Campbell None None Public: Central Phil Stokoe None None Public: Central Karen Linda Tanriverdi None None Public: Western Michael Lamport None None Public: Western Warwick (Joe) Peacock None None Public: Western Janice Todd None None Staff Anna Richardson None None Staff Aaron Walton None None
Council of Governors
Report Cover Sheet Agenda Item: 18
Date of Meeting: Wednesday 22 nd November 2017
Report Title: Calendar of Events 2018
Purpose of Report: To receive and note the calendar of meetings and events for 2017
Decision: Discussion: Assurance: Information: ☐☐☐ ☐☐☐ ☐☐☐ ☒☒☒ Brief summary to highlight key issues:
The paper recaps the Council of Governors meetings held in 2017 and details the dates of all meetings and events in 2018.
Author: Mrs J Williamson, Membership Co-ordinator
Presented by : Mrs J Williamson, Membership Co-ordinator
Paper for Council of Governors Meeting Agenda Item: 18 22 nd November 2017
G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T
Calendar of Events 2018
Council of Governors Meetings:
By the end of 2017, the full Council of Governors will have met four times, as follows: • February, May, September and November
It is proposed that the Council of Governor meetings for 2018 take place as follows: • Wednesday 28 th February 2018 • Wednesday 23 rd May 2018 • Wednesday 26 th September 2018 • Wednesday 21 st November 2018
All meetings will be held in public and start at 10:00am.
Other Events:
A calendar of all events planned for the Council of Governors is overleaf. This provides dates and times for all meeting and events planned for 2018, including dates of the Board of Directors meetings.
Additional events may be planned throughout the year and Governors will be given as much notice as possible of any additional dates.
Recommendation:
The Council of Governors is asked to receive the calendar of meetings and events for 2018 and note the dates in their diaries.
Mrs Joanne Williamson Membership Co-ordinator
Council of Governors’ Calendar of Events 2018
October November December January February March April May June July August September
Council of Governors Rooms 9 & 10, 10.00 am to 1.00 pm 28 23 26 21
Board of Directors Room 3, 9.30 am to 12.00 noon 31 28 25 27 25 25 31 28
New Governors’ Induction Session Room 3, 9.30 am to 2.30 pm 10
Governors’ and NEDs’ Joint Workshop Rooms 9 & 10, 10.00 am to 4.00 pm 17
Governors’ Development Day Rooms 9 & 10, 10.00 am to 4.00 pm 4
Membership Strategy Sub Room 5, 10.00 am to 11.30 am 8 10 13 1
Seminars for Governors Room 3, 10.00 am to 12.00 noon 7 6 3 5
Medicine for Members Lecture Theatre, 6.00 pm to 8.00 pm 14 11 11 24
Council of Governors
Report Cover Sheet Agenda Item: 19
Date of Meeting: Wednesday 22 nd November 2017
Report Title: NHS Providers – Governor Advisory Committee Elections
Purpose of Report: The Council of Governors is asked to: (i) Note the Guidance for election to the NHS Providers Governor Advisory Committee (GAC)
Decision: Discussion: Assurance: Information: ☐☐☐ ☐☐☐ ☐☐☐ ☒☒☒
Brief summary to highlight key issues:
To note the guidance for election to the NHS Providers Governor Advisory Committee (GAC).
Author: Mrs D Atkinson, Trust Secretary
Presented by : Mrs D Atkinson, Trust Secretary
Paper for Council of Governors Meeting Agenda Item: 19 22 nd November 2017
G A T E S H E A D H E A L T H N H S F O U N D A T I O N T R U S T
Governor Advisory Committee Elections NHS Providers
NHS Providers have written to notify the Trust of the election of their Governor Advisory Committee (GAC), which begins on 11 th December. This committee oversees their governor support work and gives NHS Providers valuable advice on governor-specific issues.
The GAC is comprised of eight governors elected by member trusts, and two Chairs who are NHS Providers board members. The term of office to the committee is three years, and the current committee members will come to the end of their terms in March 2018.
A dedicated area has been developed on the NHS Providers website that holds all information related to this election including the GAC Terms of Reference, election rules, a general description of the committee as well as testimonials from current members and their trusts about the value the committee brings. They have also introduced Frequently Asked Questions and an election glossary to help you understand the process better. You can find this information here: http://nhsproviders.org/programmes/governwell/governor-advisory-committee-elections
Nominations Nominations will be sought for: an acute trust representative, a mental health trust representative, a community trust representative and an ambulance trust representative. Nominations will only be accepted from Councils of Governors via their Trust Secretary/Chair, who may nominate only one governor per trust for election.
On 11 th December the Trust will receive an email inviting us to nominate our Council of Governors preferred candidate. Nominations will close on 12 th January 2018.
Voting On 26 th January 2018 we will receive an email inviting us to vote. Again, Trust Secretaries will vote on the Council of Governors behalf
Final Steps The election will close at noon on Friday 30 th March 2018 and election results will be published on NHS Providers website on 4 th April 2018. Newly elected members will be invited to the first Governor Advisory Committee induction and meeting on 25 th April 2018 at their offices in London.