Meeting of the Board of Directors in Public Wednesday 25 November 2015 from 09.00am Chelm sford City Council, Civic Centre, Duke Street, Chelmsford, Essex CM1 1JE 1 This Page Deliberately Blank 2 North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors to be held in Public on Wednesday 25 November 2015 in the Marconi Room, Civic Centre, Chelmsford City Council, Civic Centre, Duke Street, Chelmsford, Essex CM1 1JE at 09.00am Declarations and Minutes Lead Time Page 1. Apologies for Absence [Receive] CP 09.00 005 2. Declarations of Interest in Agenda Items [Receive] CP 09.00 006 3. a) Minutes of the Meeting held on 23 September 2015 CP 09.05 007 [Receive & Approve] b) Matters arising from the Minutes of the Meeting held CP 09.10 019 on 23 September 2015 [Discuss] 4. Chief Executive’s Report [Receive] AG 09.15 022 Quality 5. CQC Improvement Plan and Framework - Update [Receive] NH 09.25 024 6. Ligature Point Management and Removal [Receive] NH 09.40 032 7. Patient Survey 2015 – Results [Receive] MC 09.50 044 8. Service User and Patient Experience and Involvement MC 10.00 045 [Receive] Setting Strategy 9. Mental Health Strategic review - Update [Discuss & Note] MC 10.15 053 Comfort Break 10.30 Monitoring 10. Finance Report for the Seven Months Ending 31 October DG 10.45 054 2015 (Month 7) [Note] 11. Performance: a) Operational Performance Summary to 31 October VM 10.55 069 2015 [Receive & Note] b) Workforce Report [Receive & Note] LA 11.05 075 12. Nursing Agency Rules LA/DG 11.10 097 3 13. Quality Report [Note] NH 11.20 102 14. Ward Staffing Levels – September 2015 [Discuss & Note] NH 11.30 118 Governance 15. Nurse Revalidation NH 11.40 131 16. Monitor Compliance Report Quarter 2, 2015/16 [Note] DG 11.50 135 17. Board Committees - Verbal Reports [Note]: 11.55 a) Quality & Risk Committee (14 October 2015) BJ 144 b) Audit Committee (15 October 2015) CB c) Nominations Committee (21 October 2015) CP 18. Risk & Governance Annual Report 2015/16 [Receive] NH 12.05 145 19. Charitable Funds Accounts and Annual Report 2014/15 CP 12.15 153 [Approve] 20. Charitable Funds Forum Policy [Approve] DG 12.20 167 21. Medical and Non-Medical Education Update - Verbal Report MF 12.25 178 [Receive] 22. Reservation of Powers and Scheme of Delegation [Approve] DMc 12.30 179 23. Standing Financial Instructions [Approve] DG 12.35 200 24. Terms of Reference [Approve] 12.40 a) Audit Committee DMc/CB 237 b) Nominations Committee DMc/CP 243 Items for Noting 25. Summary of Board Decisions [Note] DMc 12.45 247 26. Execution of Deeds [Note] DMc 12.50 280 Other Items 27. Any Other Notified Business [Discuss] CP 12.50 281 28. Questions from members of the public relating to items on the CP 13.00 282 agenda only [Discuss] Date of Next Meeting in Public: 27 January 2016 from 09.00 at Stapleford House, 103 Stapleford Close, Chelmsford, Essex CM2 0QX 4 North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 1 Date: 25 November 2015 Title of Report: Apologies for absence Lead: Chris Paveley, Chairman Subject, Purpose and Recommendation: The Board of Directors is invited to receive any apologies for absence. Finance Implications: N/A Clinical Implications: N/A HR Implications: N/A Legal and/or Regulatory Implications: N/A Equality Implications: N/A Risks: N/A 5 North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 2 Date: 25 November 2015 Title of Report: Declarations of Interest in Agenda Items Lead: Chris Paveley, Chairman Subject, Purpose and Recommendation: In accordance with Standing Orders the Board of Directors is asked to receive any declarations of interest from Board members relating to items on the agenda. Finance Implications: N/A Clinical Implications: N/A HR Implications: N/A Legal and/or Regulatory Implications: N/A Equality Implications: N/A Risks: N/A 6 North Essex Partnership University NHS Foundation Trust Meeting of the Board of Directors in Public Agenda item No: 3a Date: 25 November 2015 Title of Report: Minutes of the Meeting held on 23 September 2015 Lead: Chris Paveley, Chairman Subject, Purpose and Recommendation: The Board of Directors is asked to receive and approve the minutes of the meeting held on 23 September 2015. Any items of a non-material nature e.g. typographical errors should be communicated to the Trust Secretary in advance of the meeting. Finance Implications: N/A Clinical Implications: N/A HR Implications: N/A Legal and/or Regulatory Implications: N/A Equality Implications: N/A Risks: N/A 7 NORTH ESSEX PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST MINUTES OF THE MEETING OF THE BOARD OF DIRECTORS IN PUBLIC HELD ON 23 SEPTEMBER 2015 AT STAPLEFORD HOUSE, 103 STAPLEFORD CLOSE, CHELMSFORD, ESSEX CM2 0QX Present: Chris Paveley, Chairman Andrew Geldard, Chief Executive Mike Chapman, Director of Strategy Dr Malte Flechtner, Medical Director David Griffiths, Director of Resources Natalie Hammond, Director of Nursing & Quality Jan Hutchinson, Non Executive Director Peter Little, Non Executive Director Amanda Sherlock, Non Executive Director and Deputy Chairman In Attendance: Lisa Anastasiou, Director of Workforce & Development David Bamber, Public Governor, Harlow Sarah Burtenshaw, Member of the Public Martin Cresswell, Associate Director Communications Sydney Dyne, Member of the Public Adrian Faiers, Public Governor, Chelmsford Ray Hardisty, Deputy Lead Governor and Public Governor, Colchester Pippa Ecclestone, Public Governor Uttlesford 1 Elizabeth Mabbutt, Executive Assistant to CEO & Chairman (Minutes) Melanie Leahy, Member of the Public Rachel Lucas, Member of the Public Vince McCabe, Director of Operations Dermot McCarthy, Trust Secretary Lisa Morris, Member of the Public Nigel Mountford, Public Governor, Colchester David Paramore, Heart Essex Linda Pearson, Public Governor, Mid Gary Rayment, North East Essex CCG Paul Sargent, Nominated Governor, HMP & YOI Chelmsford Andrew Smith, Public Governor, Epping Forest Rita Usitalo, NEP Brian Weavers, Public Governor, Harlow Clive White, Lead Governor and Public Governor Colchester 1 = Part of Meeting 2015/098 Apologies for Absence Chris Paveley welcomed everyone to the meeting. Apologies for absence were received from: • Charles Beaumont, Non Executive Director • Brian Johnson, Non Executive Director and Senior Independent Director. 8 2015/099 Declarations of Interest There were no Declarations of Interest. 2015/100 Minutes of the Meeting held on 29 July 2015 The minutes of the meeting held on 29 July 2015 were agreed as a correct record and signed by the Chairman. 2015/101 Matters Arising from the Minutes of the Meeting held on 29 July 2015 The Matters Arising were: a) Update on Commissioning for Quality & Innovation Payments (CQUINs), Dr Malte Flechtner confirmed that an action plan was in place to deliver the CQUIN re Cardio Metabolic Assessment b) People Strategy – Lisa Anastasiou advised NEP’s People Strategy had been launched c) Serious Incident Reporting – Natalie Hammond reported on the development of a new reporting format, centring on actions taken and shared learning. d) Medical and Non-Medical Education – Dr Malte Flechtner advised that this was on the agenda e) Finance Report – David Griffiths advised that an update re the cash position was included in this month’s finance report f) Introduction of Inpatient Staffing Tool – Natalie Hammond reported that this was being tested in inpatient areas g) Monitor Compliance – David Griffiths advised that as agreed the relevant note re property disposals had been added to the Monitor finance and governance return for Quarter 1 (Q1) h) Research and Development (R&D) Annual Report 2014/15 – Dr Malte Flechtner commented that funding was dependent on the success of research grant applications; the amount received by NEP was proportionate, and in line with expectations. The Board of Directors noted progress re the Matters Arising. 2015/102 Chief Executive’s Report Andrew Geldard presented this item and highlighted: a) Regulatory issues: NEP’s Monitor Risk Ratings were Continuity of Service Risk (CoSRR) ‘3’ and Governance ‘Under Review’, pending feedback from the CQC inspection b) CQC Inspection: Verbal feedback had been received at end of process; the focus was on adult inpatient facilities c) Finance: as at the end of August the Trust had an EBITDA of £1.6m and a deficit of £0.9m d) Assurance: Board to Ward visits were scheduled for rest of the year e) Contracts: Discussions with Commissioners for second part of the year continued f) Council of Governors – A successful Annual Members’ meeting had been held on 10 September 2015. Discussions continued with the relevant Governor committees regarding the proposed merger 9 g) Journeys – a post-implementation review process was underway. Andrew Geldard had written a letter of thanks to all community staff h) External Relations – The Boston Consulting Group had undertaken a piece of work centring on the sustainability of mental health services in Essex and the associated commissioning framework. In answer to questions from Brian Johnson and Amanda Sherlock, Vince McCabe confirmed that a Board report on the implementation of Journeys would be brought to the next Board meeting. Action: Vince McCabe, Director of Operations The Board of Directors noted the Chief Executive’s Report. 2015/103 CQC Improvement Plan and Framework Natalie Hammond presented a detailed report regarding the Care Quality Commission (CQC) inspection process and outcomes. The CQC’s inspection of the Trust was conducted over five days from 24 August 2015 by a team comprising the Chair of Inspection Team, CQC lead inspector, Mental Health Act Commissioners, analysts, external advisors and experts through experience. The inspection process included reviews of the environment, clinical documentation, data and interviews with executive and non-executive directors.