Agenda Group Name: Trust Board – Open Session Date of Meeting: 26 May 2016 Venue: Conference Room, Heartbeat Education Centre, F Level, North Wing, SGH Time: 9.00am Apologies to: Sue Diduch, Corporate Affairs Administrator 9.00 1. Chair’s Welcome, Apologies and Declarations of Interest 2. Minutes of Previous Meeting held on 28 April 2016 Enclosure 1 3. Matters Arising/Summary of Agreed Actions 9.10 4. Integrated Performance Report for Month 1 including: Enclosure 2 • Access Performance • Nursing & Midwifery Staffing • Clinical Outcomes (PIF) • Infection Prevention & Control • Quarterly UHS Maternity Dashboard • Any other items of concern (Jane Hayward, Director of Transformation & Improvement/ Caroline Marshall, Chief Operating Officer) 5. Finance Discussion Items 9.45 5.1 Finance Report for Month 1 Enclosure 3 (David French, Chief Financial Officer) 6. Operational Performance Discussion Items 9.55 6.1 Informatics 6-monthly Report Enclosure 4 (Jane Hayward, Director of Transformation & Improvement/ Adrian Byrne, Director of Informatics) 10.05 6.2 Human Resources 6-monthly Report Enclosure 5 (Fiona Dalton, Chief Executive/Steve Harris, Associate Director of Human Resources) 7. Governance Decision Items 10.15 7.1 Chief Executive’s Report including items for ratification Enclosure 6 (Fiona Dalton, Chief Executive) 10.20 7.2 Briefing from Co-Chair of Audit & Assurance Committee Oral (Simon Porter, Co-Chair A&AC) Discussion Items 10.25 7.3 Briefing from Chair of Strategy & Finance Committee Oral (David Price, Chair, S&FC) 10.30 7.4 Briefing from Chair of Quality & Performance Committee Oral (Mike Sadler, Chair, Q&PC) 10.35 7.5 Emergency Planning Response and Resilience Annual Enclosure 7 Report 2015-16 (Caroline Marshall, Chief Operating Officer/Sandra Hodgkyns, Head of Security/Emergency Planning Response and Resilience) 10.45 7.6 Security Annual Report 2015/16 Enclosure 8 (Caroline Marshall, Chief Operating Officer/Sandra Hodgkyns, Head of Security/Emergency Planning Response and Resilience) 10.55 8. Any other business 9. Comments and Questions from the public on items received or considered by the Board of Directors at the meeting 10. To note the date of the next meeting: Tuesday 28 June 2016 in Lecture Room A, Education Centre, C Level, South Academic Block, SGH In Attendance: Adrian Byrne, Director of Informatics Steve Harris, Associate Director of Human Resources Sandra Hodgkyns, Head of Security/Emergency Planning Response and Resilience EXCLUSION OF PRESS, PUBLIC AND OTHERS The public and representatives of the press may attend all meetings of the Trust, but shall be required to withdraw upon the Board of Directors resolving as follows “that representatives of the press, and other members of the public, be excluded from the remainder of this meeting as publicity would be prejudicial to the public interest by reason of the confidential nature of the business to be transacted” UHSFT – Directors’ Actions Summary for 26 May 2016 Trust Board – Open session ___________________________________________________________________________________________________________________________________________ Action & Minute Reference By whom Target Date Current Status Trust Board 28 April 2016 Review of Processes for Learning from Unexpected Deaths (Minute Ref 56/16) A flowchart to be developed outlining the Trust’s process for DS/GB reviewing and reporting unexpected deaths. Equality, Diversity & Inclusivity (EDI) Action Plan Quarter Report (Minute Ref 58/16) Links to be made with local organisations to identify best GB practice and shared learning relating to EDI. UHS Clinical Strategy 2016 (Minute Ref 61/16) The Clinical Strategy to be updated to reflect the following amendments: · Diagram on page 2 to be amended to include R&D DS · Remove the duplication of people strategy Chief Executive’s Report (Minute Ref 63/16) Discussion to be held with outlets in the main entrance FD regarding Southampton Hospital/Children’s Hospital Charity collection boxes. Draft Annual Report 2015/16 (Minute Ref 64/16) The Annual Report to be amended to reflect feedback AL Complete. received. Assurance Framework & Corporate Risk Register 2015/16 Quarter 4 Report (Minute Ref 65/16) A single page risk dashboard to be developed for inclusion AL 18/7/16 To be included in next quarter report to Audit & Risk Committee within future risk reports. 18/7/16. as at 17/5/16 Page 1 of 1 Trust Board Minutes – Open Session Minutes of the Open Trust Board meeting held on Thursday, 28 April 2016, in the Conference Room, Heartbeat Education Centre, North Wing, University Hospital Southampton, commencing at 0900 and concluding at 1110. Present: Mr P Hollins, Trust Chair PH Ms F Dalton, Chief Executive FD Mr D French, Chief Financial Officer DAF Dr C Marshall, Chief Operating Officer CM Ms J Hayward, Director of Transformation & Improvement JH Mrs G Byrne, Director of Nursing & Organisational Development GB Dr D Sandeman, Medical Director DS Mr S Porter, Senior Independent Director/Deputy Chair SP Prof I Cameron, Non-Executive Director IC Ms L Lockyer, Non-Executive Director LL Dr D Price, Non-Executive Director DP Dr M Sadler, Non-Executive Director MS Ms J Douglas-Todd, Non-Executive Director JD-T In Attendance: Ms A Lowe, Associate Director: Corporate Affairs AL Ms J Pearce, Head of Patient Safety JP Maria Dore, Head of Midwifery MD Ms V Boland, Corporate Affairs & Policy Manager (minutes) Mr L Spender, Lead Governor Mr B Bird, Governor 2 members of the public 51/16 Apologies None. Action By 52/16 Chair’s Welcome, Opening Comments and Declarations of Interest The Chair welcomed everyone to the meeting. There were no declarations of a conflict of interest with any item on the agenda. 53/16 Minutes of Previous Meeting (Agenda item 2. Enclosure 1) The minutes of the meeting held on 31 March 2016 were AGREED as an accurate record. 54/16 Matters Arising/Summary of Agreed Actions (Agenda item 3) 54/16 a) The Board NOTED the latest position on the actions in summary of actions. 55/16 Integrated Performance Report for Month 12 (Agenda item 4. Enclosure 2) a) The Director of Transformation and Improvement provided an overview of the Executive Digest. DP questioned the Trust’s ability to compare complex discharge numbers given the change in analysis of this metric. FD confirmed that a single way of measuring complex discharge has now been agreed across the local health and social care system ensuring consistency with reporting across all organisations. Page 1 of 6 DP queried why elective cancellations for the quarter were red rated, despite achieving the RTT target being achieved. CM advised that there were a number of reasons for cancellations taking place, including strikes by Junior Doctors. MS provided an overview of the performance measures considered at the Quality and Performance Committee, including: • ED performance including the increase in attendances from the working age population • Sustainability of achieving the Referral to Treatment targets given the continued increase in the number of referrals received • Complex discharge • The governance arrangements for investigating and reporting Serious Incidents. Nursing and Midwifery Staffing 55/16 b) The Director of Nursing presented the report, confirming further improvement in respect of vacancy rates. The use of agency staff increased in month, reflecting an increase in ‘specialling’ due to patient acuity, the opening of the surgical day unit for some nights and the additional support and supervision provided to new nursing staff during their induction period. DP highlighted a number of wards showing less than 70% Registered Nurses and queried the action being taken to ensure that safety was not compromised. GB advised that supervisory staff were not included within these numbers, enabling flexibility between roles. In addition, support is provided to Registered Nurses through the use of Band 4 staff, however, this is subject to close monitoring to ensure this level of skill mix remains clinically appropriate. Patient Safety 55/16 c) The Director of Nursing summarised the report, highlighting that: • CQUINs for Acute Kidney Injury and Sepsis had been achieved. • 2 Never Events have been reported in this period. A Scrutiny Board has been established to ensure learning is shared and embedded. • There have been 36 avoidable grade 3 and 4 pressure ulcers; a small reduction on last year. The Trust has agreed a target of zero to be achieved in the next two years. IC queried the timescale for reporting back on the work programmes relating to Never Events. GB confirmed that the Scrutiny Board meet every 6 weeks with immediate actions already underway. LL requested further information on the actions being taken by the Trust to reduce the number of pressure ulcers. GB provided an overview of the work programmes underway. DP requested clarity regarding the medication error KPI, noting a green rating despite a 30% increase on the previous year. GB advised that the KPI is not designed to reflect the number of high harm medication errors, instead reflecting the increased reporting of medication incidents. 55/16 b) RESOLVED That the Board NOTED the content of the Integrated Performance Report. Page 2 of 6 56/16 Quality & Safety a) Review of Processes for Learning from Unexpected Deaths (Agenda item 5.1. Enclosure 3) FD introduced the report highlighting the need for the Trust Board to be assured of the processes in place for the proactive assessment of all deaths in hospital. JP confirmed that all inpatient deaths are reviewed within 48 hours in order to identify any learning or further action required. This process of review is led by the Interim Medical Examiner Group (IMEG). In addition, the Trust has reviewed existing internal processes against the recommendations arising from the Southern Health report, with no significant gaps identified. There are areas in which the Trust continue to improve, namely in respect of the timeliness of investigation reporting. In addition, the Trust is looking to develop mechanisms for the review of unexpected outpatient deaths.