Luton & Dunstable University Hospital Board of Directors Board of Directors COMET Lecture Hall 7 February 2018 10:00 - 7 February 2018 12:00 Overall Page 1 of 124 Overall Page 2 of 124 AGENDA # Description Owner Time 1 Chairman's Welcome & Note of Apologies S Linnett 10.00 2 Any Urgent Items of Any Other Business and Declaration S Linnett 10.05 of Interest on Items on the Agenda and/or the Register of Directors Interests 3 Minutes of the Previous Meeting: Wednesday 1 November S Linnett 10.10 2017 (attached) To approve 3 Minutes BoD 011117 version 1.doc 7 4 Matters Arising - Action Log (no actions) S Linnett 10.15 To note 5 Chairman's Report (verbal) S Linnett 10.20 To note 6 Merger Update (attached) D Carter 10.25 To note 6 Merger Update.docx 15 6 i Merger Update app.pptx 17 7 Executive Board Report (attached) D Carter 10.30 To note 7 Executive Board Report February 2018.doc 21 8 Performance Reports (attached) To note 8 Performance Reports Header.doc 49 8.1 S Oke/C 10.45 Quality & Performance Jones 8.1 Quality Performance Report.ppt 51 8.2 Finance A Harwood 10.55 8.2 Board Finance Paper.docx 79 Overall Page 3 of 124 # Description Owner Time 8.3 Workforce A Doak 11.05 8.3 Workforce Boardreport_February 2018_FINAL.... 87 9 Clinical Outcome, Safety & Quality Report (attached & A Clarke 11.15 verbal) To note 9 COSQ Report November.doc 93 10 Finance, Investment & Performance Committee Reports A Harwood 11.20 (attached) To note 10 FIP Committee Report.docx 99 11 Audit & Risk Committee Reports (attached) D Hendry 11.25 To note 11 Audit and Risk Committee Report January 2018.... 107 12 Charitable Funds Committee Reports (attached) C Bygrave 11.30 To note 12 Charitable Fund Committee Report January 201... 111 13 Hospital Redevelopment Programme Board Report D Hendry 11.35 (attached) To note 13 Hospital Redevelopment Report - February 18.d... 115 14 Risk Register (attached) V Parsons 11.40 To approve 14 RR February 2018.doc 119 15 Board Secretary Report (attached) V Parsons 11.50 To ratify 15 Board Secretary Report January 2018.doc 123 16 Details of Next Meeting: Wednesday 2 May 2018 at 10.00am in COMET Lecture Hall 17 CLOSE 12.00 Overall Page 4 of 124 INDEX 3 Minutes BoD 011117 version 1.doc.............................................................................................7 6 Merger Update.docx....................................................................................................................15 6 i Merger Update app.pptx............................................................................................................17 7 Executive Board Report February 2018.doc...............................................................................21 8 Performance Reports Header.doc...............................................................................................49 8.1 Quality Performance Report.ppt..............................................................................................51 8.2 Board Finance Paper.docx.......................................................................................................79 8.3 Workforce Boardreport_February 2018_FINAL.pptx.................................................................87 9 COSQ Report November.doc......................................................................................................93 10 FIP Committee Report.docx....................................................................................................99 11 Audit and Risk Committee Report January 2018.doc................................................................107 12 Charitable Fund Committee Report January 2018.doc.............................................................111 13 Hospital Redevelopment Report - February 18.doc..................................................................115 14 RR February 2018.doc.............................................................................................................119 15 Board Secretary Report January 2018.doc...............................................................................123 Overall Page 5 of 124 Overall Page 6 of 124 BOARD OF DIRECTORS Agenda item 3 Category of Paper Tick Minutes of the Meeting held on Paper Title To action Wednesday 1 November 2017 Date of Meeting Wednesday 7 February 2018 To note Lead Director David Carter For Information Paper Author David Carter To ratify Indicate the impact of the paper: Financial Quality/Safety Patient Experience Equality Clinical Governance History of Committee N/A Reporting and Date Links to Strategic All objectives Board Objectives Links to Regulations/ CQC Outcomes/Extern Monitor al Assessments Links to the Risk All Board Level Risks rated High Risk (15+) Register PURPOSE OF THE PAPER/REPORT To provide an accurate record of the meeting. SUMMARY/CURRENT ISSUES AND ACTION Matters arising to be addressed through the action log. ACTION REQUIRED To approve the Minutes. Public Meeting Private Meeting 3 Minutes BoD 011117 version 1.doc Overall Page 7 of 124 THE LUTON & DUNSTABLE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST BOARD OF DIRECTORS Minutes of the meeting held on Wednesday 1 November 2017 Present: Mr Simon Linnett, Chairman Mr David Carter, Acting Chief Executive Ms Cathy Jones, Deputy Chief Executive Ms Angela Doak, Director of Human Resources Mr Andrew Harwood, Director of Finance Ms Sheran Oke, Acting Director of Nursing & Midwifery Dr Danielle Freedman, Chief Medical Adviser Ms Marion Collict, Director of Operations Mr Denis Mellon, Non-Executive Director Mr John Garner, Non-Executive Director Mr David Hendry, Non-Executive Director Dr Vimal Tiwari, Non-Executive Director Mr Cliff Bygrave, Non-Executive Director Mr Mark Versallion, Non-Executive Director Mrs Alison Clarke, Non-Executive Director In attendance: Ms Philippa Graves, Director of IT Mr Ian Allen, Director of Estates Ms Victoria Parsons, Board Secretary Mrs Anne Sargent, Minute Secretary 22 non Board members, including governors 1. CHAIRMAN’S WELCOME & NOTE OF APOLOGIES The Chairman opened the meeting, welcoming governors & members of the public. With the exception of public & governors, papers would be assumed to have been read. Questions would be taken at the end of the meeting, other than points of clarity. Actions would be summarised by the Board Secretary following the meeting. The audience were reminded that this was a meeting in public, as opposed to a public meeting. No apologies were recorded. 2. ANY URGENT ITEMS OF ANY OTHER BUSINESS TO BE DECLARED AND ANY DELARATIONS OF INTEREST? No items of any other business were raised. No declarations of interest were made. 3. MINUTES OF MEETING HELD ON WEDNESDAY 26 JULY 2017 Pg 2 Needs Based Care – The Board Secretary asked that the term ‘pyjama paralysis’ be re-phrased. D Carter explained that this is a widely recognised NHS term. As a Trust, locally, we intend to brand this as ‘rise & shine’. The minutes were approved as an accurate record. 1 3 Minutes BoD 011117 version 1.doc Overall Page 8 of 124 Proposed: J Garner Seconded: V Tiwari 4. MATTERS ARISING (ACTION LOG) A Doak responded to a question from the previous meeting re exit interviews, advising that for nursing, a senior nurse now contacts those that are leaving, to identify trends. This will be introduced more widely and followed up by HR, with analysis to understand what lies beneath the reasons for leaving. 5. CHAIRMAN’S REPORT The Board received the Chairman’s report as follows: The new Chair of NHSI, Dido Harding, is now in place. Jim Mackey is leaving; we do not yet know who will replace him. A meeting is scheduled with the Director of Finance of Department of Health, to pursue the financial aspects of the proposed merger with Bedford Hospital. A recent meeting with the leader of Luton Borough Council gave positive signs in relation to help with alleviating some of our parking issues in terms of space and access. Immense gratitude was recorded to staff who worked tirelessly to overcome issues as a result of our transport provider going into liquidation, noting that EEAST are taking over the service. A meeting is planned later in the day to look at open spaces around the L&D site, with a view to improving the ambience. 6. MERGER UPDATE D Carter updated the Board that PWC had been appointed as advisers in the first instance, to set up a PMO and prepare the FBC; the PWC report included in the papers gives a flavour of the work underway. The Joint Integration Board meets weekly and on a monthly basis includes the remainder of the Executive Teams. L&D will shortly undertake a cultural baseline survey, (Bedford Hospital have already completed this) to identify values for the future. NHSI are positive in terms of our timetable. D Carter and S Conroy recently met with all CCGs to engage them. They are broadly happy but would prefer more detail in the business case in terms of how services may work in the future. We intend to do this over a period of time with input and engagement from clinicians. A Harwood added that we need to complete two standalone financial models, leading to a merged financial model being completed by 17 November. D Hendry requested feedback from the meeting with NHSI on 24 October. D Carter outlined that it was helpful in discussing capital, accumulated debt of Bedford Hospital and long term plans, noting that pressures on NHS capital are significant. We felt comfortable with their indications that the accumulated debt is an issue that can be resolved. NHSI have a process to follow but feel comfortable that we have good support.