TRUST BOARD A meeting of the Board of Directors will be held at 10.30am on Tuesday 25 September 2012, in Room 3, 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 Board of Directors held on 25 July 2012 5 Matters Arising from the Minutes: Items for Decision:- 6 Charitable Funds Annual Report and Accounts: Enclosure To approve the Annual Report and Accounts presented by the Director of Finance and Information 7 Calendar of Board Meetings: Enclosure To approve the calendar of Board meeting dates for 2013 presented by the Trust Secretary Items for Assurance:- 8 Performance Report: Enclosure To receive the routine briefing report presented by the Director of Transformation and Compliance 9 Finance and Activity Report: Enclosure To receive the Finance and Activity Report for the period ended 31 August 2012 presented by the Director of Finance and Information 10 Annual Management Letter 2011/12 Enclosure To receive the annual management letter from the Director of Finance and Information. 11 Healthcare Associated Infections: Enclosure To receive an update report from the Director of Nursing, Midwifery and Quality 12 PQRS Compliance Report: Enclosure To receive the report from the Director of Nursing, Midwifery and Quality Items for Discussion:- 13 Audit Committee Annual Report Enclosure To receive the annual report from the Chair of the Audit Committee 14 Energy Conservation Update Enclosure To provide an update presented by The Director of Estates and Facilities Items for Information:- 15 Trust Branding Enclosure To receive an update from the Head of Communications 16 South of Tyne and Wear Serious Incident Enclosure Reporting and Management Policy To be presented by the Director of Nursing, Midwifery and Quality 17 Minutes of Meetings: Enclosure To receive for information, the minutes of the following meetings: i) Audit Committee held on 21 May 2012 ii) Charitable Funds Committee held on 14 June 2012 iii) Human Resources Committee held on 11 June 2012 iv) Patient, Quality, Risk and Safety Committee held on 20 July 2012 vi) Mental Health Committee held on 27 April 2012 18 Date & Time of the next Meeting The next meeting of the Board of Directors will be held at 10.30am on Thursday 25 October 2012 in Room 3, Education Centre, Queen Elizabeth Hospital 19 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. Trust Board Minutes of a meeting of the Board of Directors held at 10.30am on Wednesday 25 July 2012, in Room 3, Education Centre, Queen Elizabeth Hospital Present: Mrs J E A Hickey Chairman Dr D M Beaumont Medical Director Mr M Brown Non-Executive Director Dr J Bryson Non-Executive Director Mr J Connolly Director of Finance and Information Dr A Fairbairn Non-Executive Director Mr K Godfrey Deputy Medical Director Mr M Graham Non-Executive Director Mr P Harding Director of Estates and Facilities Mrs G MacArthur Director of Nursing, Midwifery and Quality Mrs Y Ormston Deputy Chief Executive Mr I D Renwick Chief Executive Mr R Simpson Non-Executive Director In Attendance: Mrs D Atkinson Trust Secretary Mrs D Renwick Strategic Lead for Performance (12/146) Miss D Waites Personal Assistant Apologies: Mr F Major Non-Executive Director (Deputy Chairman) Agenda Discussion and Action Points Action Item by 12/141 Chairman’s Business: The Board welcomed Mrs J E A Hickey to her first meeting as Chairman to the Trust. She requested Board members present to report any revisions to their declared interests or any declarations in the items on the agenda. The Chairman highlighted to the Board that the deadline for contacting the relevant Foundation trusts had passed, which indicated that the Trust would not be subject to an Annual Plan Stage 2 Review this year. Mr I D Renwick, Chief Executive, reported that the Trust had been contacted to arrange a Relationship visit in October 2012 which provides an opportunity to meet Jay Mistry, Senior Compliance Manager, and John Plumer, Compliance Manager. Mr Renwick informed the Board that the Bigger Picture group had submitted a nomination for Partnership of the Year in the Leadership in Healthcare Awards. 12/142 Minutes of the Previous Meeting: The minutes of the last meeting held on 27 June 2012 were approved as a true record. 1 Agenda Discussion and Action Points Action Item by 12/143 Matters arising from the Minutes: The new Board Action Plan was updated accordingly to reflect matters arising from the minutes. It was agreed to separate the action plan in accordance with Part I and Part II of the meeting from September 2012. 12/144 Monitor Q1 Governance: Mr I D Renwick, Chief Executive, presented the Quarter 1 2012/13 Governance Declaration and Quality Board Statement. He informed the Board that some of the figures contained in the report may have changed since the time of writing the paper and asked the Board to refer to the figures presented in the Performance Report, Agenda Item 8, for the Trust’s definitive position. He added that these changes would not affect the recommendation to the Board. The Board acknowledged that all targets had been achieved and following consideration, it was: RESOLVED: i) to approve that the Trust signs Declaration 1 for the Quarter 1 Declaration for 2012/13 ii) to sign Declaration 1 of the Quality Board Statement at Quarter 1 of 2012/13. 12/145 Research & Development Operational Capability Statement: Dr D M Beaumont, Medical Director, presented the Research and Development Operational Capability Statement for approval by the Board. He explained that following approval, this statement will be available on the external website to attract more portfolio studies, industry studies and researchers which in turn will attract more research funding to the Trust. The Board supported the need for further research but felt that the current template was difficult to read and queried how this would be presented within the website. Mrs Y Ormston, Deputy Chief Executive, agreed to discuss with YO Lucia Hiden, Head of Communications for her to clarify this with Alison Harvey, Governance, Research and Development Manager. After further discussion, it was: RESOLVED: to approve the Research and Development Operational Capability Statement. 12/146 Performance Report: Mrs D Renwick, Strategic Head of Performance, updated the Board on performance against national and local targets. Mrs Renwick reminded the Board of the detailed discussion at the last meeting in relation to the under performance against the A&E 4 hour waiting time target 2 Agenda Discussion and Action Points Action Item by and was pleased to report that despite this, the Trust has achieved quarterly compliance with a final position of 95.03%. She explained that fortnightly review meetings are taking place within the team and this has instigated work across the patch to fully understand this and provide detailed learning. Mr I D Renwick, Chief Executive, reported that all clinical Divisions within the organisation have worked together around this issue and an action plan is being developed and implemented. This is providing a positive impact within the decision support unit and easing the overall position. She also highlighted that following the Medway/PAS implementation, ongoing data validation is being undertaken on a weekly basis to review the management of data quality and compliance across the suite of indicators. The Chairman commented on the programme for Improving Clinical Performance and whether this work was still being focussed on following the introduction of the Strategic Transformation Improvement Programme. Mrs Y Ormston, Deputy Chief Executive reported that a framework is being developed and the Chairman felt that a focus paper would be beneficial to show the Board the type of data being collated and how this will be included within strategic developments. Dr J Bryson, Non Executive Director, raised an issue to the Board on requests for orthopaedic and gynaecology intervention being referred through A&E rather than directly to the appropriate speciality and Mrs Ormston agreed to investigate YO this further. Mr M Brown, Non Executive Director, also raised concerns on the percentage of Personal Development Plans falling from 53% to 48% and felt that the importance of completion may need to be reinforced across the organisation. Mrs Ormston highlighted that an action plan had been presented at the last Human Resources Committee and further details from managers will be requested. The Board discussed the report in detail and acknowledged the hard work being undertaken by all those involved in achieving all the targets currently covered in the Compliance Framework. It was therefore: RESOLVED: to receive the report as assurance of full compliance against the governance indicators in the Compliance Framework and local supporting measures of improvement management in Quarter 1 Mrs D Renwick left the meeting. 12/147 Finance and Activity Report: Mr J Connolly, Director of Finance and Information, provided the Board with details of performance against activity and financial plans as at the end of June 2012 (Month 3). Mr Connolly reported that the Trust had a planned surplus of £1,360k at Month 3 and Quarter 1 however the actual position is a surplus of £212.1k. He explained that this was mainly due to a fall in operating income. The Board discussed the overspend in expenditure for temporary staff and Mr Connolly reported that the rate had fallen but still had a large impact on the 3 Agenda Discussion and Action Points Action Item by Efficiency Programme.