Board Committee minutes - Kent and Medway NHS and Social Care

Transcription

MINUTES OF THE FINANCE AND PERFORMANCE
COMMITTEE MEETING
13.00 hours on 22 March 2016, Boardroom B, Farm Villa
Present:
Mark Bryant
Malcolm McFrederick
Ivan McConnell
Philip Cave
Ada Foreman
John Carey
Lynda Day
Non Executive Director (Chair)
Executive Director of Operations
Executive Director of Commercial
Developments and Transformation
Executive Director of Finance
Deputy Director of Finance
Director of Capital Planning & Estates
Secretary to the Committee
Apologies:
Anne-Marie Dean
Vicky Boswell
Philip Lawrence
Non Executive Director (Vice Chair)
Director of Performance
Deputy Director of Transformation
In attendance:
Les Manley
Director ICT
Non
attendance:
Richard Page
Non Executive Director
Minutes and
Rosanna Roughley
Papers sent to:
Trust Secretary
Chairman’s Welcome, Introductions and Health and Safety Briefing
FPC/16/153 APOLOGIES
Apologies were received from Anne-Marie Dean, Richard Page,
Vicky Boswell and Philip Lawrence
FPC/16/154 NOTIFICATION OF ITEMS FOR DISCUSSION NOT ON THE
AGENDA
None
FPC/16/155 DECLARATIONS OF INTERESTS
None
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FPC/16/156 MINUTES OF THE MEETING HELD ON 25 JANUARY 2016
The minutes of the last meeting held on 25 January 2016 were
ACCEPTED and signed as a correct record.
FPC/16/157 MATTERS ARISING (ACTION LOG – 25 JANUARY 2016)
The Committee NOTED the outstanding items set out in the action
log dated 25 January 2016.
FPC/16/158 FINANCE
M10 Finance Reports
The Committee confirmed that the following papers had been read
and NOTED:
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Finance Report M10
Finance Recovery Plan M10
Cash Analysis M10
Trust Financial Risks M10
Capital Plan M10
Estates Progress Report M10
Medway Hub Business Case M10
Draft Trust Capital Group Minutes 20.01.16
M11 Finance Reports
(a) Finance
(i)
Finance Reports M10 and M11
Month 10
The Committee NOTED that the M10 position met expectations. The
key concerns related to (1) the cash position which continued to be
challenging with continued large receivables balances and deferred
payments and (2) re-negotiations regarding the Trust’s income
position for FY16/17.
Month 11
The Committee NOTED that the Trust made a loss to date of £4,751k
which was £3,027k worse than plan, a movement of £1.4m in month.
This position included Capital to Revenue support income totalling
£2,825k which was received in January 2016. The underlying trend,
therefore, would have been a loss to date of £7,576k which was
£5,852k worse than plan if this had not been included. The month 11
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position was consistent with expectations and with the achievement
of the year end forecast of £4.3m deficit.
(ii) Finance Recovery Plan M11 (update 5)
The Committee NOTED that the final Annual Financial plan for
2016/17 was due to the TDA on 11 April 2016. These plans were to
include monthly phasing for 2016/17 and outturn for 2015/16. The
first draft plan was submitted on 8 February 2016 and there had been
no material changes since then.
The Committee discussed and NOTED that significant work was still
required to (1) finalise the bottom up budget setting which would
identify other cost pressures and non recurring items (2) ensure that
the CRES plan was fully developed and embedded within service line
plans and (3) contract negotiations with Kent CCGs and NHS
England were finalised. (The TDA had written to the Trust requesting
a control deficit total of £2.4m in 2016/17. At this stage the plan
reflected a deficit of £7.3m.)
The Committee was also informed that the Trust had been set a total
agency cap of £7.1m for 2016/17, which was 31% lower than the
£10.4m expected in 2015/16. The current run rate was indicating a
position of £8.1m but there were several CRES schemes which
would impact on agency spend to reduce this in year.
The Committee also NOTED that the first draft plan and final plan
indicated a CRES target of £4m, based upon £3.5m additional
income being gained through contract negotiations. This represented
a significant challenge as these needed to be owned by the service
lines, defined in detail, signed off, tracked and realised. Failure to do
so would risk the planned deficit.
(iii) Cash M11
The Committee discussed and NOTED that the cash book balance
was currently £6.9m and was £2.1m adverse to revised plan of £9m
(the original plan was £11.2m). This was due to considerably fewer
debtors making payment than planned (£0.3m) and increase in
Creditor Payments compared to plan (£2.6m). However, the Trust
had secured an advance of £3.3m against March block contract.
The TDA had agreed an amended External Financing Limit for the
Trust which had decreased the cash required in the Trust bank
account at the end of March by £5.6m. The revised EFL target for
the Trust of £2m in the bank at year end meant that supplier
payments could be managed to ensure the target was met and most
outstanding supplier payments both Trade and NHS could be made
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before year end. The Trust would require a loan for working capital
to avoid being overdrawn, planned at £2.3m.
The required recovery of old debt was being monitored very closely
and £1,761k had been received. £2,588k was still being pursued.
(iv) Trust Costing Data
The Committee discussed the report which provided an update on
Trust comparisons for reference costs, education and training costs
and the progress and development made on service line reporting.
The Committee NOTED that the Trust was well benchmarked on
these three areas.
The report also highlighted the areas for possible efficiencies and
gave the Trust the ability to make comparisons across the teams and
better understand the business/contracts and where the Trust was
making gains or losses. One key highlight identified that if the Trust
was not on a cap and collar cost and volume contract there would be
additional income of £12m generated by expenditure of £7.6m.
The Committee NOTED the progress made in providing a robust cost
breakdown for national comparison and the initial outcomes from
service line reporting.
(b) Trust Financial Risks M11
The Committee reviewed the Trust financial risks and NOTED that
only one new risk had been added to the register. Risk 4692 was a
CRES risk on the Forensic register which was currently rated at 9.
The Committee also NOTED that the three key risks for the Trust’s
P&L were: (1) CRES achievement, (2) revised (higher) contracted
income baseline reflecting actual activity and (3) the challenging cash
position in FY16/17.
(c) Capital
(i)
Capital Plan M11
The Committee NOTED that capital spend was £303k lower than
revised plan at month 11. The planned spend continued to reflect the
change in priorities in response to the CQC visits. The Trust was
forecast to deliver on the revised plan.
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(ii) Capital Programme 2016/17
The Committee discussed and APPROVED the indicative capital
plan for 2016/17 in the context of the Trust’s 5 year plan. It was
noted that an extraordinary Trust Capital Group meeting had been
held on 9 February 2016 for all Directors to agree priorities. These
proposals were then discussed and ratified by the Operations Board
and EMT. The TDA had made clear the need to prioritise backlog
investment over strategic initiatives in 2016/17.
The Committee NOTED that the revised capital plan was for
£2,889m. This may increase by a further £0.843m to £3,732m if
Laurel House was sold (likely Q4, if at all).
The Committee reviewed the revised 5 year capital plan and NOTED
that it was dependent on the Trust achieving breakeven in all years
from FY17/18 onwards.
(d) Estates
(i) Estates Progress Report M11
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Disposals Programme
The Committee discussed and NOTED that the disposals
programme had progressed well:
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Stanley House, Chartham – sold for £499.5k
Elmsleigh Lodge land, Chatham – sold at auction for £280k
Elmsleigh building, Chatham – sold at auction for £650k
Union Street, Maidstone – sold for £1.9m
Currently the only property featured in the 2016/17 plan was
Laurel House in Canterbury and capital spend reliant on this
source would not commence until the receipt was banked.
The Committee also discussed the Homeopathic Hospital in
Tunbridge Wells and NOTED there was a risk that, if declared
surplus, either of the current occupiers could express an interest
in acquisition. Under NHS rules this would mean no capital
receipt. Clarification of the options and risks was being sought.
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Estates Transformation Programme - Medway Strategic Hub
FBC
The Committee NOTED that most of the accommodation in
Medway used by the Trust was in need of substantial capital
investment if retained. This left the Trust open to significant
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disadvantage in terms of securing any long term business in
Medway, new or existing, and the time was now right to identify a
long term solution.
The Committee NOTED that GPIC, a specialist developer who
had worked with the Trust on the Albion Place hub, had indicated
a willingness to refurbish the preferred option, Sovereign House,
using developer capital. This would be a significant benefit given
the Trust’s capital position.
After discussion, the Committee AGREED that there was now a
need for an extremely robust and compelling Full Business Case
for the preferred Sovereign House option. The Trust Board
would be asked to consider the OBC in May following FPC
scrutiny.
ACTION: JC
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Capital Programme
The Committee NOTED that, in the light of restricted access to
capital in future years, the Trust should prioritise its backlog
maintenance investment programme.
The Trust had comprehensive 6 facet survey information on all its
main estate buildings, alongside the KMF maintenance team
reports, and this had been used to compile a list of critical
backlog projects estimated to total over £1.6m.
The Committee also NOTED that not all the projects identified
could be undertaken next year due to the financial constraints so
the list had been prioritised and the current range of reactive
solutions would continue for those not prioritised.
•
Cranmer Ward and St Martins Disposal Business Cases
The Committee discussed and NOTED that it was clear that
neither of these schemes would happen in 2016/17. The focus
was now on achieving a Cranmer re-provision and subsequent
site disposal in 2017/18, which was subject to agreeing strategic
bed requirements for both younger and older adults with the local
CCGs.
•
KMF Review
The Committee NOTED that the overdue NHSPS report on the
KMF review was expected to recommend changes in hosting
arrangements that would need to be considered by the
Consortium members.
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(ii) Draft Trust Capital Group Minutes 20 January 2016
The Committee NOTED the draft Trust Capital Group Minutes
dated 20 January 2016.
FPC/16/159 PERFORMANCE
The Committee confirmed that the following papers had been read
and NOTED:
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IQPR M10
Contracts 2016/17 M10
Contract Negotiation M10
M11 Performance Reports
(a) Integrated Quality and Performance Report M11
The Committee NOTED that:
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7 out of 8 of the regulatory targets were achieved Trust wide.
Despite the recent change to the DToC definition the Trust had
marginally breached the 7.5% threshold at 8.4%.
The
performance levels for 3 of the 8 Monitor targets reduced
during January. A further reduction in performance for CPA
reviews resulted in the Trust only being 0.1% above target at
the end of February.
In February 10 of the RAG rated quality targets were achieved
and 8 of the RAG rated indicators had improved from the
January position.
5 of the 7 workforce targets were achieved Trust wide in
February and there had been an improvement in the
performance levels of 3 of the RAG rated workforce targets.
The agency spend target of 5% was not met Trust wide and
increased to 6.1% from 4.9% in January.
CRSL had met 85% to 90% of its targets at year end.
(b) Contracts 2016/17 M11
The Committee NOTED the 2016/17 contract discussions, the key
milestones required to reach contract signature and the associated
disputes resolution process. The Committee also NOTED the
potential impact that the revised dates may have on the 2016/17
business planning process should agreement of the contract not be
reached before the start of the 2016/17 financial year.
The Committee discussed in detail the daily negotiations around
activity, risk share and the mediation/arbitration process.
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The Committee NOTED the progress to date and the fluidity of the
negotiation position.
FPC/16/160 TRANSFORMATION - ICT
Les Manley joined the meeting
(i)
ICT Report M11
The Committee NOTED that ICT capital was now fully spent although
requests for additional equipment continued. The HIS transition was
well underway, was within the financial contract and the risks were
being managed.
The Committee also NOTED that NHSmail2 would be available after
its launch on 4 June 2016 and that a trial of the Mobile Device
Management software technology would assess the impact of the
creation of a highly secure ‘bubble’ for information through a web
based management tool.
(ii) South of England Network (SEEN) Strategic Outline Case
The Committee NOTED that NHS providers and commissioners in
Kent jointly procured a shared N3 network infrastructure (Kent COIN)
and Sussex procured network services from BT(N3). Both counties
were approaching the end of their contracts and were now working
together on a replacement network infrastructure with a working title
of the South East of England Network (SEEN).
This project would put in place a contract for a managed service that
delivered wide area connectivity to an agreed specification for a
defined customer-base. It was expected to take between 5 and 10
years to implement the new technology. £100k was already in this
year’s capital budget for ICT to cover the costs of the business case
and procurement.
The Committee APPROVED the direction of travel and the Strategic
Outline Case for a replacement network infrastructure.
Les Manley left the meeting
FPC/16/161 SERVICE LINE REPORT
Deferred to April meeting.
FPC/16/162 POLICIES REVIEW
Deferred to May meeting.
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FPC/16/163 ANY OTHER BUSINESS
None
FPC/16/164 FPC REPORTS TO THE BOARD/OTHER COMMITTEES
(a)
Key Issues to Trust Board Meeting on 24 March 2016
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(b)
Finance Report M11
Finance Recovery Plan M11(update 5)
CRES M11
Cash Position M11
Trust Financial Risks M11
Capital Plan M11
Capital Programme 2016/17
Estates Report – Disposals Programme
Medway Strategic Hub FBC
Integrated Quality and Performance Report M11
Contracts 2016/17
ICT/HIS Transition
Items to be referred to other Committees
None
FPC/16/165 FPC MEETINGS 2016/17
26 April – 1 pm to 5 pm – Boardroom B, Farm Villa
24 May – 1 pm to 5 pm – Boardroom B, Farm Villa
28 June – 1 pm to 5 pm – Boardroom B, Farm Villa
26 July – 1 pm to 5 pm – Boardroom B, Farm Villa
No meeting in August
27 September – 1 pm to 5 pm – Boardroom B, Farm Villa
25 October – 1 pm to 5 pm – Boardroom B, Farm Villa
22 November – 1 pm to 5 pm – Boardroom B, Farm Villa
No meeting in December
24 January – 1 pm to 5 pm – Boardroom B, Farm Villa
28 February – 1 pm to 5 pm – Boardroom B, Farm Villa
28 March – 1 pm to 5 pm – Boardroom B, Farm Villa
Signed: ………………………………………………………….
(Chair of Finance and Performance Committee)
Dated:……………………………………………………………..
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TB/16-17/25.4
Confirmed copy
Minutes of the Workforce and Organisational Development Committee Meeting
held at 1300 hrs on Wednesday, 16 March 2016
In the Boardroom A, Farm Villa, Maidstone
Present:
Mr R Ashurst
Ms A M Dean
Mr M McFrederick
Sandra Goatley
Non-Executive Director, Chairman
Non-Executive Director
Director of Operations
Director of Workforce and OD
Claire Trevill
Ms L Hunt
Assistant Director OD
Head of Learning and Development
(via spyderphone)
Head of Workforce Information
Executive Assistant to Angus Gartshore, Acting
Director of Operations and Sandra Goatley, Director
of Workforce and OD
Trust Secretary
In Attendance:
Sherry Marchant
Trish Rabbitt
Rosanna Roughley
Apologies:
Ms R Bailey
Ms T Wells
Angus Gartshore
Justine Leonard
Lona Lockerbie
Dr Aamer Sarfraz
Tracey Wells
Deputy HR Director
Recruitment Manager
Service Line Director CRSL
Service Line Director Older Adults
Service Line Director Forensic and Specialist
Services
Director of Medical Education
Recruitment Manager
MIN NO
WF/16/143 CHAIRMAN’S WELCOME, INTRODUCTIONS AND HEALTH AND SAFETY
The Chairman welcomed members to the meeting. The Health and Safety and fire
evacuation arrangements for the building were not explained as all those attending
were familiar with the arrangements.
WF/16/144 APOLOGIES FOR ABSENCE
Apologies for absence were received as noted above.
WF/16/145 NOTIFICATION OF ITEMS FOR DISCUSSION NOT ON THE AGENDA
There were no items notified for discussion which were not on the agenda.
WF/16/146 CONFLICTS OF INTERESTS
There were no declarations of a conflict of interest.
Workforce & OD Committee March 2016
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WF/16/147 MINUTES OF THE LAST MEETING HELD ON 20 JANUARY 2016
The minutes of the last meeting, held on 20 January 2016, were accepted and
signed as a correct record.
WF/16/148 ACTION SHEET AND MATTERS ARISING
The Committee noted the updates on the action sheet.
WF/16/149 PRESENTATION – SINGLE POINT OF ACCESS
It was agreed to defer this item to a future meeting as Sam Spence, HR Business
Partner for Community Recovery Service Line was unable to attend to present it.
WF/16/150 LISTENING GROUPS
The Committee received a presentation from Claire Trevill which highlighted the
results of the Listening Groups, conducted last November and December. People
who attended the Listening Groups were asked for their feedback on the following
questions:
 What is going well?
 What is not going so well?
 What could we do differently to improve?
The listening groups gave staff the opportunity to give honest feedback and in the
process generated some constructive ideas and suggestions. Sandra Goatley and
Claire Trevill will be working with the Service Lines to look at the suggestions and
to give feedback where requested. The Committee expressed concern this was
yet another forum for staff to feedback how they were feeling and it was now
imperative that the information collected was acted upon. The Committee
discussed the possibility of small locality groups getting together regularly, with
senior managers attending discreetly to listen, as an alternative to the current
methods of collecting this information. This would allow staff to speak freely, thus
allowing managers to utilise the information gathered to implement improvements
where necessary. It was agreed an action plan was needed to address the large
scale issues and a checklist devised with a list of the themes to be addressed.
Feedback will be made to the Board who will hold the Executive Team
accountable.
WF/16/151 INSIGHTS DISCOVERY PSYCHOMETRIC TOOL
The Committee received a copy of the Insights Discovery Psychometric tool and
were asked to consider the recommendation this tool is used by the Trust for team
building and training. The tool has so far been used for approximately 600 staff,
including all Service Lines, Corporate Leadership Teams and EMT at a cost of £38
per person.
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The Committee supported the use of this tool and await the decision by EMT with
regard to the future use.
WF/16/152 LEARNING AND DEVELOPMENT REPORT
The Committee received the latest Learning and Development Report from Mrs
Hunt and noted the contents. Attention was drawn to the compliance figures for
mandatory training and the Committee discussed the possibility of conducting the
Fire Warden training during induction. Planned changes to the Corporate
Induction day were developing and Sandra Goatley and Ms Trevill were keen to
feedback to the L&D team having recently the gone through Corporate Induction
themselves.
The Committee were informed that the Annual Statement of Quality was discussed
at the recent meeting of the Quality Committee and the nationally set figure of 95%
for information governance training had not been achieved by the Trust. It was
suggested that taking figures for those on maternity leave and long term sickness
out of the compliance figures would show an improvement. Mrs Hunt and Ms
Marchant agreed to meet to discuss this and revised figures would be submitted
for the committee’s consideration at the next meeting. Malcolm McFrederick
agreed to take the matter forward and asked Mrs Hunt to keep him updated on
how the rewrite of the information governance training was progressing. It was
noted that staff from the Community Recovery Service Line were not engaged in
the infection control training, and along with staff in the Acute Service Line, were
also behind on a number of other safeguarding areas. Ms Holmes-Smith informed
the Committee that staff would benefit from training being taken to the wards as it
was difficult to release people for training when some wards were short of staff. A
targeted approach was needed. It was agreed that she would meet with Mrs Hunt
to discuss this further. The Committee asked for a special report to be compiled to
include more detail regarding training compliance for each of the Service Lines
and asked for this to be provided at the next meeting.
ACTION: Mrs Hunt
WF/16/153 SAFE STAFFING REPORT
Mr McFrederick presented the headline figures of the safer staffing report noting
the highlights for each of the Service Lines. Mr McFrederick re-iterated that the
format of the national template report did not provide a full picture as it did not
reflect occupancy and patient acuity. Showing bed by bed data, rather than ward
by ward, would be more informative.
 Community Recovery Service Line – headlines included the numbers for
Davison Ward coming down and an increase in the number of registered
staff rather than unregistered staff on Ethelbert Ward and The Grove.
 Forensic and Specialist Service Line – It was noted that some beds were
not filled in Bridge House and night-time cover was being shared for
Groombridge, Penshurst and Riverhill by floating staff who were covering
breaks.
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
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Older Adults Service Line – Hearts Delight Ward and Woodstock Ward
are both filled with people past the point of mental health care and require
end of life care. They need double handling due to their physical health
needs. New entrance requirements are needed and in some cases patient
require nursing home care. These are high dependency units and show a
high usage of HCAs. Littlestone and Ruby Wards also show a higher use
of non-registered staff.
Acute Service Line – Therapeutic staffing is in place on all East Kent
wards and, as a result, we should start seeing a difference. Need to look at
twilight shift as alternative to current shift patterns.
Action:
Cohesion update to be given at the next meeting.
WF/16/154 HR WORKFORCE METRICS AND TRENDS REPORT
The Committee received the report and noted the following:
 The total headcount and FTE for February 2016 has increased and a trend
shows a steady increase over the past 5 years, with February’s figures
mirroring those of 2012
 The current turnover rate is currently 15.99% which is slightly above NHS
National average, with the highest turnover in the Forensic Service Line
 The majority of leavers have less than 5 years’ service and in particular
those with less than 1 years’ service. Recruitment and retention strategies
are required to address this. Mrs Goatley informed the Committee that she
would be looking at succession planning and would add this to the agenda
for the next Recruitment and Retention Group meeting. A report will be
commissioned and will be brought back to this Committee at a future date.
 There is a jump in the sickness absence figures for IM&T which is
understood to be as a result of the significant changes going on in the
Directorate. The Committee were keen to know what sort of help the Trust
offers to staff during times of major change. Mrs Goatley agreed to
ascertain if support was available and would report back to the Committee
in due course.
 The figures for long term and short term sickness were discussed. It was
noted that there was more long term sickness in the Service Lines. A list of
the top 10 reasons for sickness absence did not reveal any surprises. It
was acknowledged that preventative measures could be brought in to tackle
this. It was also acknowledged that a lot of work has been done across the
Service Lines to tackle sickness absence.
 Appraisal performance figures were very good with the February figure
showing 99.19% completion rate and all Directorates being over target.
The Committee asked for clarification of the release date for the appraisal targets
for next year. Ms Roughley agreed to obtain this information and report back to
the Committee at the next meeting. The Committee were also keen to see the
comparison figures for this year and 2012. Ms Marchant was asked to provide the
data at the next meeting.
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WF/16/155 OFF PAYROLL STAFF REPORT
The Committee received the latest Off Payroll Staff Report and noted the contents.
A breech was identified for the outgoing Interim Director of HR and the Committee
asked for an investigation to be conducted to ascertain why the breach occurred
and what action was taken to avoid it.
Action:
Mrs Bailey was asked to investigate how the breech occurred and whether it
was escalated by the Hiring Manager.
The Committee were informed that a list had been compiled of staff able to make
major financial decisions on behalf of the Trust. The Committee asked for
clarification of what a ‘major financial decision’ was.
The Committee noted the Report.
WF/16/156 MEDICAL STAFFING REPORT
The Committee received the Medical Staffing Report from Jacqui Dixon and noted
the contents. The Committee were informed that adverts for 16 Consultant
vacancies closed on 31st January with 5 applicants. 4 applicants have since
withdrawn their applications and 1 was appointed. The closing date for
applications has been extended to 13th March to encourage further applications.
The Committee were concerned that Higher Trainees were not being encouraged
to advance into Consultant positions. Working with them and mentoring them
when they come to the Trust as Trainees may go some way to explaining why they
leave. The Committee considered the possibility of engaging an external
organisation to speak to the Trainees to find out why they are not staying and
considered seeking college advice to address the problem. The Committee were
informed that most of the vacancies were in the Community Recovery Service
Line.
Action:
Mrs Dixon was asked to talk to other Mental Health Trusts to ascertain if they
are experiencing the same difficulties.
Ms Marchant was asked to look at the figures for all Consultant leavers in
the last 12-14 months and present them to the Committee at the next
meeting.
Sandra Goatley agreed to discuss the situation with the Executive Medical
Director to see if anything could be done to address this problem.
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WF/16/157 WHISTLEBLOWING AND CONCERNS REPORT
It was noted that there were no new incidents reported.
The Committee received an update on the incidents of drug taking and distribution
of drugs at TGU and were informed that the investigation was almost completed.
The main protagonist has resigned and details have been sent to DBS. There are
implications for 3 separate members of staff as a result of the investigation. The
Committee were keen to receive feedback on completion of the investigation.
For the period of 2 January to 29 February 2016, 64 concerns were received via
the Raising Concerns Button. 39 concerns were raised anonymously and contact
details were provided by 25 employees. There were two key themes; these were
staffing and the impact of the no smoking policy on both patients and staff.
Incidents with regard to smoking cessation are now on the decrease but it was
acknowledged that this is a factor affecting staffing too. The Committee were
advised that the Smoking Cessation Group had been resurrected and the Non
Smoking Policy will be looked at again in detail.
WF/16/158 F REEDOM TO SPEAK UP GUARDIAN
The Committee were informed that following discussion by EMT it was agreed that
the Freedom to Speak up Guardian position will be taken up by the Assistant
Director of HR’s replacement when she leaves the Trust in May. The Committee
expressed their concern that the Trust has been very slow in appointing a
Guardian and were disappointed at EMT’s decision to place this responsibility with
the Assistant Director of HR rather than making it a separate role. The role could
potentially require 8 – 18 ½ hours commitment which would mean it is
inappropriate for someone to take on as well as their existing role. It was
suggested that the Trust contacts the National Patient Champion at Ashley Brooks
Hospital to see if we can tap in to their expertise. It was agreed that Mrs Goatley
and Mr McFrederick would discuss this matter further and report back to the
Committee at the next meeting.
Action:
Mr McFrederick and Sandra Goatley to meet to discuss this matter further.
WF/16/159 WORKFORCE RISK REGISTER REPORT
Ms Marchant presented the latest Risk Register and noted that she would be
meeting with Mrs Goatley to go through this in detail.
The Committee went through the Risk Register and were asked to consider
whether details of the Off Payroll interims could be removed and also if the recent
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problems with Consultant recruitment should be included. Mrs Goatley was
planning to go through the Risk Register with the appropriate people to ensure all
entries were up to date.
ACTION: Sandra Goatley.
The Committee NOTED the report.
WF/16/160 INTERNAL AUDIT REPORTS
Safer Staffing Report: The Committee received the report provided by tiaa and
considered the contents. It was noted that as the review of the safer staffing level
arrangements was still taking place, an update would be provided at the next
meeting.
Annual leave planning: The Committee received the report provided by tiaa and
considered the contents. Mrs Goatley reported that the review of annual leave
planning went to IARC on 3rd March and she would be meeting with staff to ensure
the recommended actions from the report were actioned.
The Committee NOTED and DISCUSSED the reports.
WF/16/161 FLEXIBLE WORKING POLICY
The Committee received the Flexible Working Policy which has recently been
amended to include secondment arrangements and employment breaks. The
Policy was ratified at the last meeting of the Joint Negotiating Forum (JNF). The
Policy was AGREED by the Committee.
WF/16/162 COMMITTEE TERMS OF REFERENCE REVIEW
The Committee received the updated Terms of Reference for discussion.
Discussion centred on who should form the core Committee members and
configuration of future committee meetings. It was agreed that Mrs Goatley would
look at the current Terms of Reference and suggest amendments accordingly.
WF/16/163 COMMITTEE EFFECTIVENESS REVIEW
The Committee were informed that the Committee Effectiveness Review
Questionnaire was discussed at the last meeting of the Integrated Audit and Risk
Committee (IARC) where it was agreed that it should come to this meeting for
information.
The Committee NOTED and DISCUSSED the questionnaire.
WF/16/164 ANY OTHER BUSINESS
Page 7 of 9
TB/16-17/25.4
Confirmed copy

Learning from mistakes league. The Committee received the presentation
from Mr McFrederick and heard that the presentation was produced by the
TDA, MONITOR and NHS England. Each Trust is ranked against 140
others in terms of their openness and transparency, with the latest Staff
Survey results being used as a benchmark. Following discussion at the last
meeting of the Quality Committee, it was agreed that the Workforce
Committee should consider the findings with regard to under-reporting. It
was agreed that the slides would be appended to the next report to the
Trust Board. Both the Chairman and the Deputy Chairman of the
Committee asked for the staff survey slides to be sent to them for
information. It was suggested that the HRBPs look at local trends and
issues and draw up action plans for dealing with the highlighted issues.
One way of tackling issues would be by improving the skills of Managers
when dealing with difficult situations. It was agreed that it was important to
provide a safe place for staff to tell us how they are feeling and this should
be linked to the Speak Up Guardian report to the Trust Board.
The Committee NOTED and DISCUSSED the presentation and took the
presentation for further consideration.
Action: The Committee recommended that this item be referred back to
the Quality Committee to find out where they are getting their reporting
data from.
WF/16/165 NEXT AGENDA REVIEW
The Committee agreed that the following items should be added to the Agenda for
the next meeting:
 Single Point of Access
 Organisational Development
 Learning and Development Integrated Education Strategy
 Recruitment
 Terms of Reference – via email
WF/16/166 MATTERS TO BE REPORTED TO TRUST BOARD
The items to be taken to the Board were agreed:






Listening Groups (Director of Workforce and OD to look at best way to
engage with staff)
Whistleblowing (incidents of drug theft and concerns)
Freedom to Speak Up Guardian (EMT to look at again – Committee sees
this as an urgent requirement)
Psychometric Testing (Ops Management/EMT to make decision)
Safer Staffing (Acute Service Line Director reported improvement with
Therapeutic staffing in East)
Workforce Information and Trends (Starters/Leavers trend and vacancy rate
reducing. Staff Sickness - month and year to date)
Page 8 of 9
TB/16-17/25.4
Confirmed copy


Medical Staffing – detailed discussion (Consultant Recruitment - Committee
asked for more detail on number of Consultants who have left in the last 5
years. Committee suggested a task force be set up to look at this.
Learning from mistakes – Trust position is determined by having two ‘red
flags’
WF/16/167 DATE OF NEXT MEETING
The next meeting would be held on the 18th May 2016 at 13:00 in Boardroom A,
Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, ME16 9PH
Signed: Rod Ashurst… ……………….
Mr R Ashurst Non-Executive Director
Chairman
Date: 18th May 2016…………………
Page 9 of 9
Minutes of the Quality Committee Meeting Part I
held at 1300 hrs on Tuesday 19th April 2016
in Boardroom A, Trust Headquarters, Farm Villa,
Hermitage Lane, Maidstone, ME16 9PH
Present:
Margaret Andrews
Debbie Bray
Steve Norman
Sophie Williams
Non-Executive Director, Chairman
Trust Professional Lead for Allied Health
Professions
Patient Safety Manager
Quality Intelligence Analyst
In Attendance:
Donna Eldridge
Vicky Boswell
Rosanna Roughley
Angie Lehman
Sarah Holmes-Smith
Jenny Deacon
Rosarii Harte
Carrie McLean
Jill Lethbridge
Apologies:
Rod Ashurst
Catherine Kinane
Samantha Chalmers
Nikki Oatham
Jon Stock
Active Executive Director of Nursing & Governance
Trust Secretary
Assistant Director of Information and Performance
(by phone for item 8c, Medicines Omissions)
Acute Service Line Director (item 7a only)
Risk Emergency Planning Lead (item 7b only)
Deputy Medical Director
Complaints/Serious Incidents Facilitator
Temporary Assistant to the Trust Secretary
(minutes)
Executive Medical Director, Quality
Risk Manager and Health & Safety Lead
Head of Psychological Services
Chief Pharmacist
MIN NO
QC/16-17/1
CHAIRMAN’S WELCOME, INTRODUCTIONS AND HEALTH AND SAFETY
The Chairman welcomed members to the meeting. The Health and Safety and
fire evacuation arrangements for the building were not explained as all those
attending were familiar with the arrangements.
QC/16-17/2
APOLOGIES FOR ABSENCE
Apologies for absence were received as noted above.
QC/16-17/3
NOTIFICATION OF ITEMS FOR DISCUSSION NOT ON THE AGENDA
There were no items notified for discussion which were not on the agenda.
QC 19 April 2016
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QC/16-17/4
CONFLICTS OF INTERESTS
There were no declarations of interest.
QC/16-17/5
MINUTES OF THE LAST BOARD MEETING HELD ON 16TH FEBRUARY
AND 15TH MARCH 2016
Sophie Williams, Quality Intelligence Analyst, was omitted from the draft
minutes of 15 March 2016 circulated for approval. It was agreed that her
details would be added, and then the minutes of the last two meetings held on
16th February 2016 and 15th March 2016 were agreed and signed by the
Chairman as a correct record.
QC/16-17/6
MATTERS ARISING
194: To consider the triangulation of complaint(s) & serious incidents (SI)
information into one report
The triangulation of complaints data with the SI data had been requested to
ascertain whether there was any correlation between an increased number of
complaints in one location, with Sis and/or service line. The Chairman asked
that Ms Williams to consider the request with her colleagues and report back
as to whether the current system of reporting was the best way of presenting
the information in the Quality Digest or whether alternative presentations of the
information could be introduced to enable a more meaningful analysis of the
data.
Action: Sophie Williams to investigate and report back.
194: To discuss training priorities and targets and report back
Donna Eldridge, Acting Director of Nursing & Governance, to discuss
complaints training with Sandra Goatley, Director of Workforce &
Organisational Development and outcome to be reviewed at next meeting.
Action: Donna Eldridge to report back to Quality Committee on 17th May
2016.
QC/16-17/7
RISK REPORTS
7a Service Line: Acute Service Line (ASL)
The report and associated risk register were presented to, and discussed by,
the Quality Committee. Sarah Holmes-Smith, Acute Service Line Director,
pointed out that although the register is reviewed monthly, the register is
dynamic and updated regularly, as required. The key improvements were:
 A better clinical engagement at all levels in the management of risks
which had, and continues to drive, improvements across the Acute
Service Line.
 A rise in the attendance at clinically-led quality meetings.
 Review and monitoring of risk data at a “granular level”.
 A greater understanding of the mechanisms of risk management at a
local level throughout the organisation, including the ownership of risk
registers
 A closer working relationship with the Trust’s health and safety team to
improve attention on outstanding risks at an operational level.
QC 19 April 2016
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There are 15 risks noted on the register of which 7 are currently red.
Risk4163, Patient flow, is now an operational risk. It cannot sit on the ASL
register on its own; consequently it has been put onto the Operational risk
register.
Risk, 3448, Section 136
The Crisis Concordat steering group is discussing the creation of a facility for
people who are under the influence of alcohol and drugs to be taken other than
a Section 136 suite or into custody. If the proposal was to go ahead it would
make quite a lot of difference. From a Quality perspective it is necessary to
make sure that someone does not have a mental health issue that is masked
by the alcohol or drugs but at the moment assessments can not be made until
the individual is no longer under the influence which can result in poor quality
experience, potential escalation of incidents and long waiting times.
Risk 3954, Inability to recruit an effective workforce.
It was explained that, in addition to a national survey regarding staff morale,
the Trust undertook its own survey in 2015 and will be undertaking another
next month and so will be able to compare the results. It was observed that if
staff is happy this would reflect on the quality of service they provide.
Therapeutic staffing has been successfully introduced at Canterbury; one of
the key contributors to this was some key leaders – local clinical leaders who
are able “to engage with staff every step of the way”. The Chairman
commented that she had visited Samphire Ward a couple of weeks ago and
she got a very positive view from the staff about where they were in terms of
therapeutic staffing and that they have no vacancies. It was noted that there
were Quality and Development leads in each site which was proving very
useful.
It was highlighted that a pilot scheme where parking bays are to be reserved
for people on late shift would start this week to enable staff to get to their shifts
on time. This should help boost their morale as they should not have to arrive
an hour earlier than their contractual start time.
Action: to refer the issue of car parking to Finance & Performance Committee
(FPC) and the Workforce & Organisational Development Committee (WFOD)
to review the impact on people visiting in-patients and staff morale of the
availability/lack of on-site parking car parking and policy of fining employees. It
was understood that the fines do not go into developing more facilities for staff
and visitor parking but to a private car parking contractor. Clarification would
be sought from FPC and WFOD. Action: Secretary to refer to FPC and WFOD
and report back.
Risk 4694: Staffing levels in Priority House. The Chair questioned whether this
risk related only to services provided at Priority House. The Quality Committee
was informed that it is not only staffing levels at Priority House but links to Risk
3954 Inability to recruit and effective workforce.
The Chairman asked what impact the proposed provision of psychiatric
services by the Kent Institute of Medical Science (KIMS) would have on the
Trust’s Acute services. It might certainly reduce the number of out of area
beds and our contract to identify such beds. In relation to staff, the Chairman
QC 19 April 2016
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enquired where KIMS would source their mental health trained staff from,
including consultants, and whether from the Trust with consequent impact on
the Trust’s ability to recruit. KIMS is investing £18m and has decided on
Maidstone as the location where it proposed, subject to planning permission,
to build mental health services provision. A view was expressed that
consideration should be given to discussions with KIMS in respect of
partnering and collaborating with the Trust.
Action: Donna Eldridge, Acting Director of Nursing & Governance, to speak
with Ivan McConnell, Executive Director, Commercial Development &
Transformation, to ascertain whether discussions are taking place/scheduled
with KIMS, the Chairman of Quality Committee would raise this matter with the
Trust Chairman, Andrew Ling, for consideration by the Board.
It was noted that the number of patients smoking had reduced a little, and that
there were many actions being taken to reduce the number further... Donna
Eldridge said that she would send to Sarah Holmes-Smith and the Chairman
Public Health England’s tracking maps which show all the Trusts that are
actually now either smoke free or going to be smoke free by 2018 as required
by the legislation. The “telling” data would be the physical health data because
an improvement in physical health was the driver for the Trust to go smoke
free earlier than the statutory deadline. Trust patients had as much right to
health education and promotion. The Quality Committee enquired as to data
about the use of nicotine replacement therapy to reduce smoking and that
might be useful, if available. The support for people, at often a time of
maximum stress, in reducing their smoking habit was discussed...
7b Quality Risk Register
The report was presented to the Committee giving a snapshot as at 31st March
2016 showing that movement in the right direction in ensuring the adequacy of
controls, noting there had been a slight reduction in risks that are inadequately
controlled and also a slight reduction in uncertain risks.
The Chair mentioned that on the last page it reported an increase of risks
reported by the Acute Older Adult Inpatient Services. This arose
from the recent CQC compliance inspection in March 2016.
Staffing (3954) on the acute risk register (3954) has been upgraded to red
rated risk as discussed earlier in the meeting.
Rosarii Harte commented that the Executive Management Team has been
asked to put the issue of the junior doctors on the Trust risk register because
there are a high number of vacancies in training posts, plus the risk arising
from strike action. It was confirmed that this has been done.
The Chair mentioned that for the last few months, other than matters noted
above, there did not appear to have been any noticeable movement of risks.
Ms Deacon replied that things were static at the moment. The training to use
the new calibration tool was ongoing (training started in November 2015) and
once the use of this tool is more widespread the risk ratings would change.
QC 19 April 2016
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It was noted that Risks 3723 and 3353 were new Forensic Risks. The wording
required clarification, as otherwise, it suggested that there were limited
measures for effective measuring and monitoring and reviewing clinical
practice. Action: Jenny Deacon to raise this with Lona Lockerbie, Forensics &
Specialist Service Line Director and Peter Griffin, who had responsibilities for
the risk, for clarification and reword.
The Committee discussed and noted the report
QC/16-17/8
QUALITY DIGEST
8a: Integrated Complaints and Serious Incidents (SI) Data:
Dr Rosarii Harte drew the Quality Committee’s attention to the headline
statistics on complaints and SIs received and closed in March 2016, as
detailed in the report. There were 33 reportable complaints and three MP
enquiries. Forty Five cases were closed during the month. Duty of Candour
letters have gone out. It was noted that there was still a large gap between the
number of open and closed cases. Donna Eldridge has spoken to the Patient
Experience Team (PET) team and that the team had confirmed it was very
difficult get people to get the reports back in a timely manner from those asked
to investigate the complaints. The gap is, however, much smaller than it used
to be and the PET Team is continually striving to reduce this further.
From data there still appeared to be quite a large gap between the open and
closed Serious Incidents. In September 2015 the Quality Committee was
advised that closing SIs was a national problem and the CCGs had each been
given targets to work to. Mrs Eldridge said that she had not seen these
targets, but would find out what they were.
Action: Closure of serious Incidents should be raised at Board to Board with
CCGs. Secretary to note. Donna Eldridge, Acting Director of Nursing &
Governance, to determine the Serious Incident closure targets for CCGs in
Kent.
Mr Norman commented that there had been further work with data and Datex
so that reporting for closed cases was much more accurate. The Trust’s gap
analysis following the Southern Health report would come to Quality
Committee via Trust Wide Patient Safety and Mortality Review Group (formerly
the TWPSG). Any issues that need to be taken to the Board would be
highlighted in the paper so that they could be noted, agreed or recommended
for approval, as appropriate.
Chairman mentioned that the Medway area is highest for complaints and
Serious Incidents. There had been a review of Medway and the action plan
discussed in January 2016. The Chairman enquired to know when there
would be a report back to Quality Committee and it was agreed to check this.
Action: Steve Norman to check and find out when the report would come back
to Quality Committee.
At the Quality Committee on 15 March 2016 there was discussion around
restraint for the purpose of injections. This was discussed at length in the
QC 19 April 2016
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Violence Restraint and Seclusion Group and the actions discussed were
summarised on page 25 of the Quality Digest. As the training was ongoing
this would be reviewed again in a couple of months. New NICE guidelines
require that a post restraint debrief (outside of the clinical area debrief), by
someone external to that ward, (modern matrons, Pharmacy Team) needs to
be completed within 72 hours.
8b: Nursing metrics:
The monthly report was presented to the Committee. On Page 2 under
‘analysis’ there is an error – VTW should read VTE. The report showed an
improvement on last month in respect of the staffing levels and especially
lower sickness absence although it remains very challenging. All the
assessments were “going in the right direction” even though they might not
have met the targets except for the VTE assessment.
Donna Eldridge has had a meeting with Vicky Boswell, Director of
Performance. There will be a report for the 72 hours and in addition there will a
report provided next to it on the week and then the month position to show that
within that month that person has received the appropriate assessment. This
would be done by July 2016. The CCGs had been told and they welcome he
proposal.
The Chairman asked that, in relation to the safety thermometer, it was noticed
that most of the community mental health teams are not making submissions
The initial response is either “we do it” or “we don’t” across the Trust and if it is
not seen as useful across the Trust then we should not do it, or if it is seen as
important then the community teams must respond. (The comment from
Andrew Dickers on page 6 refers). Donna Eldridge concurred. It was
questioned that if there is such a large group of staff not seeing the relevance
it is worth questioning whether “we are doing it for the sake of doing it or if
there is something that we get from it that would be enhanced by the
community also doing it”. It was noted that everything in the report was
duplicated on the Quality Digest. Nationally the trusts that are not reporting
are not receiving any penalties.
Action: Donna Eldridge, Acting Director of Nursing & Governance, to take this
to Trust wide Patient Safety Group in May 2016 with a report back to Quality
Committee in June 2016.
The Committee discussed and noted the report.
8c: Medicines Omissions
The report was presented to the Committee. There has been a great
improvement in the number of wards which have submitted data this month,
43% last month to 81% this month and all the Forensic Service Line units had
submitted data. The window for the submission of data has been extended
and it was thought this would improve the level of reporting even further and
this would show in the figures within a couple of months.
Angie Lehman, Assistant Director of Information and Performance, also
highlighted that the number of incidents is still generally very low, however
QC 19 April 2016
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there is one ward within the Acute Service Line (Foxglove ward in East Kent)
that appears to have a lot more incidents reported this month than previously,
and compared to other comparable units. It is believed that this gives a much
more realistic picture of what actually happens on a ward rather than this ward
having a high incidence of omissions against other wards.
Currently there is a good process in place for when administration type
incidents occur in that the incident will be referred to the ward manager, and
the ward manager will then raise it with nurse that was involved and take
appropriate action. One of the issues that has been raised to Angie Lehman is
that a similar process for prescribing incidents – does this need to be
discussed at either this Quality Committee or the Trust wide Patient Safety and
Mortality Group as to ensure appropriate governance of this issue and to
enable the learning the lessons from prescribing incidents as well as from the
administration ones.
The Chairman suggested that the matter be raised with Trust wide Patient
Safety and Mortality Group and report back to the Quality Committee. Rosarii
Harte, Deputy Medical Director, suggested that she might also take it to the
Medical Managers’ meeting.
Action: Rosarii Harte, Deputy Medical Director, to meet with Angie Lehman,
Assistant Director of Information & Performance, to advise her of the reporting
structure, and what is decided will be taken to the next Trust wide Patient
Safety and Mortality Group.
QC/16-17/9
QUALITY IMPACT ASSESSMENTS (QIAs)
The report was presented to the Committee. The Chair raised a question
about closure of Davidson Ward (2.2.2) and the reinvestment in establishing a
Community Rehabilitation Service. “The Trust Board, Finance and
Performance and Committee…” Should have read:” the Trust Board’s finance
and Performance Committee…” and this was noted.
QC/16-17/10
CQC QUALITY IMPROVEMENT PLAN (QIP)
The March report was presented to the Quality Committee. It was noted that
a few “must do’s” were outstanding. The Chairman sought assurance that the
Trust was meeting the timetable and if not, the Quality Committee needs to be
aware of this. Donna Eldridge provided this assurance and replied that actions
were being taken within agreed timetables and where items had been put
back, mainly the capital ones, where the timeframe had been exceeded, this
had been factored into the Quality Improvement Plan.
The Chairman’s report to the Board would highlight that not all the timescales
in the Quality Improvement Plan had been met in relation to Estates and that
this was borne out by the Chairman’s recent clinical visits.
QC 19 April 2016
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The Quality Committee was reminded that the Trust submitted a monthly
report to the CQC regarding the QIP. The CQC had not replied with comments
or raised any issues and so the understanding was the CQC was in agreement
with the QIP and in particular the timetable.
The red item on page 7 with regard to care planning would turn amber for next
month because a template had been introduced for use in care planning and
very positive feedback had bene received.
QC/16-17/11
QUALITY ACCOUNT PRIORITIES: 2015/16 and 2016/17 - UPDATE
The update was presented to the Committee. The Chairman reminded the
Committee that the Quality Account priorities had been to the Committee at
various stages, they have been to IARC for review. The Board had seen the
draft for review and are on target in terms of our timescale and the
amendments requested have been made now. The IARC Committee had
some discussion and agreed with the priorities but was interested in the
number of cancelled appointments.
The report had been to a number of Committees, group meetings and the
Board and this was the latest version. The priorities reflected matters that the
Committee had highlighted during the last six months. There had been
discussions about changing the approach and not having very aspirational
targets or performance targets and this possibly was not in Trust’s best
interest. Lou Bean had checked what other Trusts were doing and believed
that the Trust had got more meaningful priorities now. Debbie Bray, Trust
Professional Lead for Allied Health Professions, commented on the process for
determining the priorities in future, how to get the priorities’ owned’ and how to
drive changes in practice. The Quality Committee was invited to consider
whether the process was right and it was agreed that in September 2016 the
approach that would be used to develop the quality account be reviewed.
Once the priorities had been set the dashboard should be reviewed in detail
every quarter in terms of “where we are up to, but what we do not do (rightly).
Action: Secretary to diarise the review of the approach to the Quality
Accounts process for September 2016.
QC/16-17/12
DUTY OF CANDOUR - AUDIT
The TIAA Duty of Candour paper was presented to the Committee, it had
previously been received by the Integrated Audit & Risk Committee (IARC).
The number of cancellations was raised and would be investigated. The
Internal Auditors (TIAA) had prepared a paper on the implementation of Duty
of Candour Requirements and IARC asked for it is submitted to the Quality
Committee for review and action, as required. It was understood that Catherine
Kinane has also instructed Steve Norman, Patient Safety Manager with Lou
Bean Clinical Audit and Effectiveness Manager, amongst others, to undertake
a Duty of Candour Audit. The scope of that audit would be undertaken and
reported back to either the May or June Quality Committee with a view then of
QC 19 April 2016
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Page 8 of 10
possibly bringing a report back to the Committee in the Autumn (by October
2016).
Action: Steve Norman.
Duty of Candour would continue to be reported via the Quality Digest and it
was anticipated that the audit would use information provided in the Quality
Digest. The audit could also try to gather where we are failing to record duty of
candour information. An audit would look at the high SIs, complaints and
correlate this information with what is already on Datex to ensure consistent
reporting between letter, phone calls and visits. It was suggested that a review
as to how Duty of Candour was reported by other Trusts to their Boards and
this was agreed.
Action: Catherine Kinane/Steve Norman/Lou Bean.
QC/16-17/13
COMMITTEE EFFECTIVENESS REVIEW
This item was deferred and would be discussed at June meeting.
QC/16-17/14
ITEMS TO REFER OR REFERRED FROM BOARD/OTHER COMMITTEES
 Duty of Candour paper referred from IARC as mentioned above.
 Issue of car parking to Finance & Performance Committee and the
Workforce & Organisational Development Committee.
 Closure of Serious Incidents to be raised at Board to Board meetings with
CCGs.
 Submissions for Safety Thermometer to be referred to Trust wide Patient
Safety and Mortality Group in May 2016
 Governance with regards to prescribing incidents be taken to Trust wide
Patient Safety and Mortality Group in May 2016
QC/16-17/15
ITEMS TO REPORT TO BOARD
The items for the Board report were:
 Acute Service Line Risk Register
 CQC QIP –including monitoring by Quality Committee, noting all the
timescales in the QIP had not been met in relation to Estates and that
CQC had not respond to our monthly submissions, therefore trust
assumption was the CQC was in agreement with actions in the QIP .
 Final Quality Account priorities for 2016/17
 Duty of Candour Audit, and acknowledgement of tiaa report on subject
from IARC
QC/16-17/16
REVIEW OF NEXT AGENDA
There was nothing to be added. Donna Eldridge, Acting Director of Nursing &
Governance, asked that it be noted that she would not been attending the next
meeting, unless she was asked to by Mary Mumvuri, who was to take up her
appointment as Director of Nursing & Governance, on 6 May 2016.. As the
Chairman would not be at the next meeting in May and his would probably be
QC 19 April 2016
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Donna Eldridge’s’ last meeting she thanked her for her contribution to the
Committee.
QC/16-17/17
ANY OTHER BUSINESS
There was no other business.
QC/16-17/18
DATE OF NEXT MEETING
The next meeting would be held on Tuesday 17th May 2016 in Boardroom A,
Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, ME16 9PH
Signed: …………………….……………………………. Date: ………………………….
Rod Ashurst, Non-Executive Director
Vice- Chairman
QC 19 April 2016
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TB16-17/25.2 – Conformed copy
Minutes of the Integrated Audit and Risk Committee Meeting
held 3rd March 2016
in Boardroom A, Farm Villa,
Present:
Integrated Audit Committee Members
Mr T Phillips
Professor M Andrews
Mr R. Page
Non-Executive Director (Chairman)
In Attendance:
Grant Thornton
Ms L. Olive
Ms L Leka
Director
Manager
Tiaa
Ms N. Meeks
Mrs R Goodall
Head of Internal Audit
Audit Manager
KMPT
Mrs. D. Eldridge
Mr P Cave
Miss R. Roughley
Ms S Chalmers
Dr L. Lockerbie
Mr. I McConnell
Apologies:
Mrs J. Lethbridge
Acting Director of Nursing and Governance
Executive Director of Finance and Resources
Trust Secretary
Trust Risk Manager, Health and Safety Lead
FSSL Service Line Director (items 153 and 154)
Director of Commercial Development and
Transformation
Temporary Assistant Trust Secretary, Minutes
Mrs M Alflatt
Local Counter Fraud Specialist
MIN NO
IARC/15-16/219 CHAIRMAN’S WELCOME AND INTRODUCTIONS
The Chairman welcomed those present to the meeting. Donna Eldridge was
welcomed as the Acting Director of Nursing and Governance, and Liz Olive was
introduced as a new member of the directors of Grant Thornton.
IARC/15-16/220 APOLOGIES FOR ABSENCE
Apologies for absence were received from Mrs M. Alflatt
IARC/15-16/221 DECLARATIONS OF INTEREST
There were no declarations of interest.
Integrated Audit and Risk Committee Meeting – 3 March 2016
Page 1 of 14
IARC/15-16/222 NOTIFICATION OF ITEMS FOR DISCUSSION NOT ON THE AGENDA
There were no items notified for discussion not on the agenda.
IARC/15-16/223 MINUTES OF THE INTEGRATED AUDIT AND RISK COMMITTEE MEETING
HELD ON 7th JANUARY 2016
The minutes of the Integrated Audit Committee and Risk Committee meeting held
on 7th January 2016 were accepted and signed as a correct record.
IARC/15-16/224 ACTION SHEET AND MATTERS ARISING
The Committee noted the updates to items on the action sheet and agreed the
proposed closures of outstanding items.
Action Point 196 Risk Register Nursing and Governance, Mrs Eldridge gave a
verbal update to the Committee. She had been trying to find out in which ward
hanging rails had been removed from patients’ wardrobes. She had been in
contact with lead nurses and service managers all of whom seemed unaware of
any issue. She said she would continue her investigations to ascertain the ward
name so that further actions could be taken to resolve this matter. Mr Page
asked about the level of risk associated with the rails as they should all be
collapsible.
Action: Mrs Eldridge to confirm all rails in wardrobes on wards are
collapsible
196 Risk Register Nursing and Governance – Executive Director of Nursing
Vacancy.
Although there were succession planning concerns as both the CEO post and the
Director of Nursing post were vacant it was considered and rated as a low risk on
the register as the posts were filled quickly.
197(and 155) Transformation Risk Register
Mr McConnell informed the Committee that there had been a deferral of the
internal audit and transformation audit. It could go ahead now but given the
changes in the economy and the timing of the review all the feedback would be
the same as last year, and not a cost effective exercise. He felt it was therefore
better to carry out the audit at the end of May, with the results to be presented
either July or September 2016 which will still fit in ok with the tenders. The 16/17
internal audit plan will move forward to accommodate this delay in progressing
15/16 work.
198 Risk Management Strategy and Policy
This came to IARC in January to be considered, and will be reviewed in IARC on
7th July 2016.
201 Internal Auditor’s report
Salary benchmarking. The chair asked how KMPT were fairing regarding this.
Mrs Goodall said that the average number of overpayments was 321 and the
Trust had 158, the Trust was also below (£108,773) the average (£270,604) in
value. The lowest Trust was £105,106. However, overpayments were not
detected quickly enough and the Trust needs to concentrate on preventative
controls. Audit and Fraud reviews have shown that the majority of overpayments
relate to late notification to Payroll Services. This is because payment is an
Page 2 of 14
automatic process unless notification is received to stop payment. The question
was raised as to whether the problems were caused because a paper system
was still being used. The Committee was informed that with an electronic system
information should be sent direct to Payroll Services and that it would be good
practice to stop using the paper based system. The Committee were informed
that with the current system documents should be printed, completed, signed,
scanned and returned. The Committee suggested that managers may need
support and training to be able to manage the paperwork in a timely manner.
The Committee members assumed that the system would be that as soon as
someone starts or leaves that information would be passed to Payroll Services to
ensure that the appropriate action would occur. HR and Finance systems need
to be integrated systems. Mrs Goodall mentioned that the E-rostering system
has the facility to insert leaving dates. This system is not fully utilised across the
Trust and currently does not include medical staff.
Action: Mrs Eldridge would ask Sherry Marchant, Head of Workforce Information
to investigate the potential for using the e-rostering system to record staff leaving
dates.
Action: It was agreed that managers need to be encouraged to follow process
and use the e-rostering system and if they needed more training this needed to
be addressed, and to make sure that they have the necessary support and are
made aware of the consequences of failing to notify staff termination dates
resulting in over-payments. Mr McConnell and Mr Cave would follow up the
systems integration issues and Mr McFrederick would discuss with the Service
Lines managers how to address this avoidable risk. The new HR Director will
also be asked to review the current system. TIAA will look at this again at the end
of the year when they look at payroll checks.
203 Counter Fraud Update Report
This was presented by Rosamond Goodall in the absence of Ms Alflatt. Ms
Goodall stated that the problem of immigration status related to one person, and
although the manager had completed the form, they had not alerted HR that the
status needed to be validated. It is the responsibility of the manager to ensure
that the correct information is given to HR. The Committee was concerned that
managers may not have the experience to undertake employment checks, and
felt that the control could be better exercised by HR. Checks such as immigration
status, qualifications etc. ready for interview.
Action: HR to come up with an action plan to check new staff.
Refer to WF&OD Committee with a strong steer for HR not to devolve its
responsibilities with regards to checks on staff prior to employment.
205 Losses and Compensation Report: Quarter 3 – October to December 2015
173 External Auditor’s Report
174b Internal auditors report
It was agreed that there was no further action needed on these items and they
were duly noted as completed.
Page 3 of 14
RISK REGISTERS
IARC/15-16/225 RISK REGISTER: FORENSIC AND SPECIALIST SERVICE LINE
Lona Lockerbie and Ivan McConnell joined the meeting to present the report on
the Forensic & Specialist Service Line.
The red flag issues which were raised in the report were brought to the attention
of the Committee:
Risk 3723 – Uncertainty around commissioning arrangements
If we do not have plans and resources to meet NHS England Tendering
processes and we are unable to demonstrate compliance with service
specifications then we may be unsuccessful in tendering for existing and new
business including medium secure inpatient services.
The Committee were informed that there was uncertainty around commissioning
arrangements, these had gone out to procurement. Currently there is an existing
annual rolling contract, not a fixed term contract. The Trust may loose out if the
contract goes out to tender. We need to prepare for potential need to build on
what is already an excellent service. There is a potential £29m of business and
price is a key driver. We are considered outstanding with the CQC and we need
to maintain this.
The CQC are due to visit again in the Autumn, possibly October or November but
this is to be confirmed.
A group has been established to look into how to develop this further in Forensic
Learning Disabilities and other gaps in the market to build credibility. Currently
Learning Disabilities has 30 beds. We also need to create a community forensic
outreach programme which would target women, and medium and enhanced
care, which would improve and support the tender.
The Chair asked Dr Lockerbie if she felt supported by the Executive Management
Committee. Dr Lockerbie replied that she did, she had had meeting with Mrs
Barber around CQC and believes she will be listened to and encouraged to
escalate any issues to Management. She did however recognise that the web
site and advertising were an area of weakness and that Marketing still needed to
be reviewed.
The risk identified was that when moving to large scale beds there would need to
be dedicated bed resources which would need a marketing resource. Dr
Lockerbie said that in the past an external writer had been used which had not
been helpful or useful and this needed to be developed in-house, for which she
would need support and finance.
This is a BAF risk. Mr McConnell as the responsible Executive Director will keep
the Board informed.
Risk 3353 – CQC Compliance
The CQC visit in March 2015 gave the Medium Secure services an overall rating
of excellent. One domain, safety was found to require improvement. Specifically
the CQC found that our ICU area fell short of the required standards – particularly
size and seclusion facilities. Failure to address these issues exposes us to the
risk of enforcement action by the CQC, damages the Service Line’s ability to win
any potential tender for Medium Secure services and exposes patients to
Page 4 of 14
potential harm. The seclusion facilities at the Allington Centre and Tarentforth
also require improvement. Controls include the production of a business case to
obtain funding for the required work. Ultimately however, unless the money can
be found to make the necessary improvements to our seclusion facilities the risk
will remain.
Dr Lockerbie explained that at present the seclusion rooms do not meet the
current standards and will require a major redesign which will require substantial
capital resource. Even the one in Penshurst which is top of the range needs to
be brought up to date. The cost to update the ordinary rooms is £250k per room
and Penshurst will cost 400k. This is because the new guidance says that the
rooms need to move from the middle of a ward to the end which means a
complete rebuild, not just an internal refurbishment.
The Chair asked what the impact of the rebuild would be on the patients. Dr
Lockerbie explained that not all rooms were used on a daily basis, nor would they
all be done at the same time so there would still be rooms for patient use.
The Chair asked whether the Business Case would be going to the Board. Dr
Lockerbie said that it would be, there is a capital expenditure plan but there were
no revised figures. The refurbishment of Penshurst may mean that money is
taken from elsewhere. It needs to be established what money is necessary for
compliance.
Finance and Performance Committee needs to look at capital expenditure plans
from a quality issue.
Action: Finance and Performance Committee needs to look at capital
expenditure plans from a quality issue for the rebuild of the seclusion rooms
Risk 3811: Demand for the ASD service exceeds commissioned level
This is a long-running risk and may move up the risk register. This is an
assessment only service not a follow-up service. This has made it difficult to
attract and retain clinicians. Currently services are being delivered by agency
and contract staff. Other Trusts are either not buying our services or have been
given extra money to provide their own services. If we are unable to deliver the
service adequately we will be asked to give back £70k. The services are in high
demand, our income is £52k for 60 assessments, but there are 396 demands.
This issue and dilemma is that we need to maintain market presence.
ADHD, Neuropsychology and CAMHS is open to tender. The question is how
realistic is it for us to grow this business. As it currently stands it is only a
diagnostic service, and there is a waiting list for this service. We could potentially
offer a wider service as opposed to not offering any service. Understanding what
is needed to support the service and what is not will help to decide whether or not
we should we pull out.
Peter Griffin and Kate Bisham are overseeing the risk register in relation to SI
and complaints and report an improvement from 18 months ago.
IARC/15-16/226 CHILDREN AND YOUNG PEOPLE’S SERVICE (CHYPS) PROCUREMENT
UPDATE
The report was presented to the Committee. The main points are summarised:
West Kent CCG is leading on behalf of the health economy.
Page 5 of 14
The proposed contract start date is April 2017 – mobilisation from late 2016. To
meet the go live timescale procurement will need to commence in early 2016.
The West Kent contract is currently out to tender but all CCGs will be testing the
market to see if they can get it cheaper.
We currently provide mental health services for ages 18-25. We also provide
EDS for ages 14+. The CAMHS Tender will cover these services. We would like
to continue providing these services and have the opportunity to develop the
pathway further.
We currently provide in-patient services so we have the infrastructure and build
costs. If someone else gets the contract could they use our facilities?
CAMHS does not currently include children in care. The new contracts will, as
well as 925 asylum seekers, therefore we need a multi-agency response. The
current political view is that the current model does not work – what is the right
model. We need big scale thinking. There is an opportunity for preservation of
income for the 18-25 group which is 15% of income at £10m.
It is thought that KMPT should partner in order to provide comprehensive
CAMHS services to ensure we have the expertise required. Options are
Portman/Tavistock which provide academic expertise and systems, and family
work expertise. The Priory already delivers CAMHS services and has a good
working model – they also run schools. Sussex NHS Trust currently provides up
to 18 years CAMHS and is well thought of, or Cygnet which currently provides
some in-patient services. It was confirmed that the 18-25 age group is where the
effort would be targeted as this is 15% of business.
Working groups need to be established, as well as putting together clinical
reference groups. There is a section 75 agreement in place with KCC – we could
collaborate with KCC.
It was recognised that this risk could be a major piece of work.
The Chair asked whether Dr Lockerbie would be the clinical lead. Dr Lockerbie
said no, there would need to be a medical/clinical lead and she would ask for Dr
Kinane’s input. Dr Kinane’s view is that a CAMHS consultant is needed to run it.
To provide this technical knowledge, a partnership would be important.
The new model also needs to have the support of clinicians. The Sheffield model
is well thought of.
Although we have been lead to believe that there is not a substantial problem
with the bid, other bids may be more favourable because of cost.
This will be a development topic for the Board after further work. It was decided it
should go to Board in about 3 months time – June or July. The Executive
Management Team to propose a course of action to the Board.
IARC/15-16/227 RISK REGISTER: TRANSFORMATION
The report was presented to the Committee.
A number of audit reviews have been completed which were satisfactory, risks
have been reviewed and triangulated. Any concerns are escalated directly to the
overarching Estates and ICT Programme Board.
Page 6 of 14
The major red risk is the termination of Health Informatics Services (HIS) on 31st
March 2016. Two weekly sessions have been held in regard to this, interviews
have been completed, 3 people have to move from HIS and ¾ of the posts have
been filled. This is, however, a post merger integration risk. There will be a
transition director in post for one month.
Mr McConnell informed the Committee that there were currently no red risk within
the Communications or Performance and Information functions.
IARC/15-16/228 BOARD ASSURANCE FRAMEWORK (BAF)
The Board Assurance Framework report was presented to the Committee. Two
new risks have been added, there are now 13 in the higher extreme range. To
support the target rating a Performance Metric against each entry has been
identified. The aim of this is to provide a recognisable measure with which to set
achievable targets.
There have been some staff movements since the Frank Lloyd unit report. The
Orchard ward manager has move to Ruby and the deputies have been stepping
up. There is concern around continuing bed care. In Ogden wing, this comes
under KCC for the building but the staff and patients are ours. The Littlestone
warning notice said that stronger leadership was needed. Mrs Chalmers said
that the CQC was triggering a fully focussed inspection across all older adult
services.
Professor. Andrews asked if focus inspections were across the whole trust.
Mrs Chalmers said that there was potentially another Chief Inspectors
comprehensive review coming up towards the end of the year. There was nothing
regarding Woodchurch. Jasmine was a concern and Dartford generally was
experiencing staffing difficulties, they are in a position of transition re key
members of the team. It is a significant risk and regulatory visits are planned by
Corporate Nursing team. The outcome of the Dartford review will be presented to
the Quality Committee.
The CCG visit and report on FLU will be followed up by Internal team review of
state of services. The Lead nurse and quality leads will undertake a mini
inspection and fix any problems whilst they are there rather than just do a report
highlighting issues. The objective is to prevent the problems in the Frank Lloyd
Unit happening elsewhere.
Action: The Director of Operations needs to make sure the Lead nurse and
quality leads undertake a mini inspection and fix any problems whilst they are
there rather than just do a report highlighting issues.
3753 – Care and welfare of service users. Assessing and monitoring the quality
of service provision.
This risk is rated as 3 which appeared to be low. Mrs Chalmers said agreed but
that was the way it was calculated, it would however be looked at. The level of
control being applied is an inherent risk.
Staffing was reported as an ongoing problem within the NHS, especially issues
around recruitment and retention.
Action: The WF&OD Committee will be asked to look at this issue and to review
the recruitment and retention policy and going forward Director of Nursing’s work
on the strategy for nursing revalidation. They were also asked to look at staff
Page 7 of 14
turnover and assess whether it was new staff who joined and then left relatively
swiftly or whether it was more experienced staff.
Is safer staffing also a question of competency? Not much is heard about the
skill and competencies to do the job. Although there is a high rate of appraisal,
does this mean that they are competent just because mandatory training has
been completed? Nursing staff have competency assessments done and have to
do revalidation in order to continue practicing.
The recruitment & retention and skills performance metrics have been changed.
Another question asked was if the probation period has failed or is failing? The
Committee was informed that retention rates are good against others.
No entries are recommended for removal from the BAF.
The Committee is asked to receive and note the entries on the Board Assurance
Framework.
Regarding the Health and Safety update, the short term actions have been
completed. There is a Health and Safety meeting next week which Mrl Cave will
chair
IARC/15-16/229 TRUST RISK REGISTER
Mrs Chalmers presented the Trust Risk Register report, the main points are
summarised below
The purpose of this report is to provide assurance on the range of systems in
place to identify, mitigate, monitor and manage Trust-wide risks. The report also
provides an overview of the significant corporate risks of the organisation.
The Trust operates a comprehensive internal system of control which includes
the use of Local Risk Registers and Service Risk Registers. These feed into the
Trust Risk Register (TRR).
The criteria for a risk to be escalated to the TRR are:
1. The risk has been reviewed and “finally approved” by the relevant service
line director and/or nominated risk lead
2. The current risk rating is 15 or above
3. The risk is classified at a ‘Service’, ‘Strategic’ or ‘Trust’ risk
4. Any risk held on the Board Assurance Framework that has a current rating of
12 and above.
5. Any risk outside of the escalation criteria that require monitoring at a senior
level.
The inclusion criteria has been broadened following an amendment approved by
the Integrated Audit and Risk Committee to reflect a greater level of risk maturity
and the application of the control calibration tool. The Trust Risk Register at
Appendix 1 shows the nine risks that currently meet the required criteria.
2.
Risk Movement
Data Quality continues to be reviewed to ensure that entries on the Datix Risk
Module comply with the requirements set out in both the Risk Management Policy
& Procedure and Risk Management Strategy, reflecting both the procedure for
escalation and de-escalation of risks and ensuring that the Risk Description
shows cause and effect using the ‘IF/THEN/RESULTING IN’ format.
Page 8 of 14
With the approval of the Control Calibration Tool at the Integrated Audit & Risk
Committee in January 2015, work continues to ensure that the high level risks
that are included on the Trust Risk Register have been reviewed by the Trust
Risk Manager and the respective Risk Owner.
The Risk Management team continues to work with Service Lines and
Directorates to provide support and guidance on the development of Risk
Registers, including both the escalation and de-escalation process and ensuring
that risks are worded using the agreed format.
The heat map and the rating columns on the Trust Risk Register have been
amended to reflect the four colour scheme used by the NPSA. This is to bring
the reporting mechanism into alignment with the NPSA Risk Matrix.
The layout of the Trust Risk Register has now been updated to show the
Performance Metric.
IARC/15-16/230 REPORT FROM TRUST WIDE HEALTH AND SAFETY GROUP
The Committee was informed that there would be a review of both the quantity
and quality of training provided, and that support would be given to managers
training and that Mr Cave would be responsible for this. The Risk Management
training was under attended, the reason given that a lot of the wards were busy
and staff were unable to get away to attend. Only 50% of managers had been
properly trained. The newly appointed Health and Safety Manager will be asked
to drive this forward.
Action: Mr McFrederick to be asked to ensure that operational personnel
understand the importance of statutory training.
HSE update report
It was reported that the short and medium term actions had been completed and
that there was to be a Health and Safety meeting w/c 7th March 2016 which Mr
Cave would be chairing.
There are two long-terms actions which are still on-going:
- The Trust Risk Manager and Health and Safety Lead has begun her training
and this is expected to be complete in August 2017
- Review all Health and Safety related policies and procedures to reflect the
new structures and responsibilities. On appointment the Health and Safety
Manager will prioritise a review of the strategy and core policies and
procedures. A review will be carried out in six months and again at 12
months to ensure that the new structures are functioning effectively.
TIAA report states that there is still more to be done regarding reporting and the
status against action re the board report.
The auditors stated that they are happy with the Health and Safety arrangements
and there was no need to follow-up to the Board. A new Health and Safety Manager
is in place and a health and safety report should go to the board in two meetings
time. The annual report will be presented to the to Board in June.
Page 9 of 14
INTEGRATED AUDIT
IARC/15-16/231 EXTERNAL AUDITORS: GRANT THORNTON
Ms Olive presented the External Auditors report.
There were 3 risks which were key areas of focus
- Control income
- Operating expenditure
- Payroll cost.
The External auditors to ensure that we are getting value for money, that there is
a plan of implementation for CQC, and finance position regarding setting of
budgets.
The audit work is planned for Mid May, with a report due on 20th May. The Audit
would be on the 16th May and the Audit Committee Report would be available on
the 25th May. The question was raised that this seemed a rather tight timescale,
GT reassured the committee that a lot of sampling work had already been
undertaken, and that test and risk assessments had been done.
The disclosure implication of NHS capital to revenue movements was discussed.
Ms Olive and Mr Cave would discuss further outside the meeting.
IARC/15-16/232 INTERNAL AUDITORS: TIAA
A progress report was given to the Committee. Three audits reports have been
finalised since the last meeting:
o Annual leave –
reasonable assurance
o Safer staffing –
o CRES
Discussion regarding annual leave planning. The question was raised as to who
approves the medical consultants annual leave, Medical Director or the Service
Line Director. The consultants use a paper based system. Each consultant has a
leave application form that they use to record all their annual leave. They get a
colleague to sign it to say that they will cover their absence. The form is
forwarded to Medical Staffing who maintain manual annual leave records. The
audit identified risks associated with this process and has made
recommendations for improvement. Mrs Goodall commented that progress for
some of the 2015/16 audits has been impacted by the lack of availability of
operational staff in February/March due to the need for them to use their annual
leave by the end of March.
Action: It was decided that the matter would be referred to WF&OD to
investigate and provide assurances around the process for annual leave and
ensure adequate provision is in place regarding consultants.
Mrs Goodall requested confirmation that the remaining contingency could be
used for a process review of the Disablement Service at Medway Hospital. A
meeting is arranged with Dr Lockerbie for 14th March to agree the scope of the
review. Mr Cave confirmed that this is the largest area of non pay expenditure
Page 10 of 14
within the Trust. The review will establish the risks associated with the service
and the effectiveness of the controls to manage those risks. This will include
reviewing the current risk register for the service.
The 2016/17 internal audit plan was brought back to the Committee for approval.
This includes details of the reviews relating to bringing HIS back in-house.
Mrs Goodall confirmed that the review of managerial supervision does not include
clinical staff who are covered by supervision. Mrs Goodall noted that the
following wards would be considered for the Ward action plans audit. Frank
Lloyd, Amberwood, Littlestone and Jasmine would be covered when the review is
scoped and agreed with management.
Mrs Goodall asked whether Nurse Revalidation should be included in the
2016/17 plan. Mrs Eldridge felt that an audit was not required because she
confirmed that the Trust has taken action to ensure nursing staff are supported in
this new process. She told the Committee that it is in the best interests of staff to
ensure they engage in the revalidation process because it is a requirement of
their registration, and failure to do so would prevent them working. It is the
individual’s responsibility to revalidate.
The Committee DISCUSSED and AGREED the report
IARC/15-16/232 EXTERNAL AND INTERNAL AUDITORS RECOMMENDATIONS FOLLOW UP
REPORT
This report was presented to the Committee for information.
There are 30 recommendations which remain outstanding, of which 17 are from
reports that give limited assurance.
IARC/15-16/233 COUNTER FRAUD UPDATE REPORT AND 2016/17 WORK PLAN
This report was presented to the Committee and provides an update on the work
undertaken to date against the counter fraud work plan and how is it being
addressed.
The Chair commented that he was disappointed that there were still more
instances of the same thing, ie paying salaries to staff who had left. The Trust
takes a strong view in relation to fraudulent activities, there needs to be a process
in place to avoid temptation. The Committee was reassured that there were less
new cases, the last one regarding overpayments had been in September 2015.
The Fraud Stop document was well received by staff who felt able to raise
concerns. The Committee was told that the instances in the report were
cumulative rather than more being added.
There has been a national review of counter fraud. There is no direct operational
support and no training on behalf of the Trust. The question was asked as to the
impact this would have on the NHS, TIAA to clarify this.
Action: Melanie Alflatt to confirm no impact on NHS of national changes to Fraud
Services. .
IARC/15-16/234 SINGLE TENDER WAIVER REPORT
The Committee was presented with this report which informed them that there
were 21 Single Tender Waivers in the last three months, the total value of which
Page 11 of 14
amounted to £464,016. £110 was in regard to software licences, and 90k costs
for recruitment of senior executive staff with interim costs, but this will not be a
recurrent cost.
IARC/15-16/235 2015/16 YEAR END ACCOUNTS
The Committee were presented with this report which shows the draft year end
timetable and changes to accounting policies for 2015-16, and to give assurance
that resources are being allocated to achieve the target submission of accounts
by notified deadline and to seek approval of the accounting policies for 2015/16.
The timetable is on 21st April the completed accounts are to be checked, the 25th
May will be the final sign off with the accounts out on 2nd June.
Appendix C has the proposed responses to the checklist questions and the
committee are asked to agree these. Appendix D is the proposed formal
response which agreement is sought in principle to enable final agreement to be
obtained from the Committee in May 2016.
The Committee agreed in principle the proposed formal responses in Appendix D
for final agreement in May 2016.
IARC/15-16/236 2017/18 AUDIT ARRANGEMENTS
Grant Thornton left for a short while whilst the Committee discussed the audit
arrangement for 2017/18.
Mr Cave presented a report on the arrangements for the appointment of external
auditors. He informed the Committee that from 2017/18 onwards, clinical
commissioning groups and NHS trusts must have an ‘auditor panel’ to advise on
the appointment of their external auditors. As the 2017/18 appointment must be
made by the end of the preceding year (i.e. by 31st December 2016), auditor
panels need to be in place early in 2016. The guidance gave options for
procurement including soft market testing.
Mr Cave proposed that the panel should be the Integrated Audit and Risk
Committee supported by relevant Executive Directors and the Chairman.
IARC’s terms of reference would need to be amended to reflect the audit panel
responsibilities. He also proposed that the Trust used procurement option 1, soft
market testing.
There are two procurement options to consider:
The soft market exercise: Grant Thornton would undertake the audit at a market
price and the audit committee would have the assurance from current service
provision regarding client service and an added value service.
or
The full market test: a full tender exercise would be undertaken and the
shortlisted bidders would meet the audit panel and auditors would be selected.
The Chair noted that Grant Thornton had done a good job with regard to the
audit so far.
The Committee agreed that the favoured proposal would be the soft market
exercise, with a full market test in year two.
Page 12 of 14
It was agreed that the audit committee would include Mr Cave and one other
executive – possible the director of nursing.
The Committee agreed the proposal that IARC should be the “auditor panel”,
IARC terms of reference should be amended to reflect this and that option 1 soft
market testing should be used. This would be reported to Board for ratifications.
Action: the setting up of the audit panel and the amended terms of reference to
go the Board
Grant Thornton returned and the above information was imparted to them.
GOVERNANCE
IARC/1516/236 2015/16 Annual Governance Update, including draft AGS.
The report was presented to the Committee, which provided assurance that the
production of the 2015/16 year end governance documents is on schedule.
The documents required to be completed are
- Annual report (AR)
- Annual Governance Statement (AGS)
- Quality Account (QA)
- Annual Accounts (AA)
The paper provides details of the work to date and the proposed plans to ensure
that drafts of the documents pass through the correct committee in time for them
to be ratified at Board level and published within the national timeframes.
Mr McFrederick will be the acting CEO and would approach Mrs McNab for her
full input to the Governance statement as far as she is able.
IARC had no amendments to make to the AGS.
IARC/15-16/237 QUALITY COMMITTEE REPORT: INCLUDING TOP QUALITY RISKS
This was presented and agreed
IARC/15-16/238 REPORT FROM INFORMATION GOVERNANCE GROUP
The reported was presented and agreed.
IARC/15-16/239 REVIEW OF IARC TERMS OF REFERENCE (ToRs)
These are reviewed annually, there were no changes except to note the audit
panel terms of reference.
IARC/15-16/240 COMMITTEE EFFECTIVENESS REVIEW
The committee agreed to the questionnaires and these will be circulated to the
Board and Committees as appropriate.
IARC/15/-16/241 REPORT FROM POLICY MANAGER
The report was presented and agreed.
Page 13 of 14
IARC/15-16/242 FEEDBACK ON COMMITTEE REPORT FORM TRUST BOARD
No feedback was received.
IARC/1516/243 MATTERS TO BE REFERRED TO THE TRUST BOARD
Details on the following items would be included in the report of the Integrated
Audit and Risk Committee to the Trust Board:






Forensic Risk Report
Budget for the rebuilding of the Seclusion rooms
Dartford review to go to Quality or Board
Formation of the Audit Committee Panel
Committee effectiveness review
Annual Governance update, including AGS
IARC/15-16/244 MATTERS TO BE REFERRED TO BOARD COMMITTEES AND
GOVERNANCE SUB-GROUPS
As detailed in the minutes. The Committee has formally referred several items to
WFOD and Quality/Board
IARC/15-16/245 MATTERS TO BE NOTED FOR INCLUSION IN THE AGS
It was felt that this had been covered in point 236 above.
ITEMS FOR INFORMATION
IARC/15-16/246 BOARD COMMITTEE MINUTES CIRCULATED UNDER SEPARATE COVER
The Committee noted the List of Board Committee minutes circulated under
separate cover to Integrated Audit and Risk Committee members.
IARC/15-16/247 INTEGRATED AUDIT AND RISK COMMITTEE SCHEDULE
The Committee noted the annual schedule of items.
IARC/15-16/248
DATE OF NEXT MEETING
The next meeting will be held at 09.45 on 14 April 2016. This will be preceded at
09.30 hours by a Confidential Meeting of the Integrated Audit and Risk Committee
members with the Auditors.
The meeting closed at 13.05 hours.
Signed:……Mr T Phillips…………………………………… Dated: …14 April 2016………………..
Mr T Phillips
Non-Executive Director (Chairman)
Page 14 of 14
MINUTES OF THE FINANCE AND PERFORMANCE
COMMITTEE MEETING
09.00 hours on 27 April 2016, Meeting Room 1, Magnitude
Present:
Mark Bryant
Philip Cave
Angus Gartshore
Ada Foreman
John Carey
Vicky Boswell
Philip Lawrence
Lynda Day
Non Executive Director (Chair)
Executive Director of Finance
Acting Executive Director of Operations
Deputy Director of Finance
Director of Capital Planning & Estates
Deputy Director of Transformation
Secretary to the Committee
Apologies:
Anne-Marie Dean
Malcolm McFrederick
Ivan McConnell
Non Executive Director (Vice Chair)
Executive Director of Operations
Executive Director of Commercial
Developments and Transformation
In attendance:
Les Manley
Sarah Holmes-Smith
Victoria French
Matthew Chapman
Director ICT
Director – Acute Services
Associate Director of Finance
Deputy Associate Director of Finance
Richard Page
Non Executive Director
Non
attendance:
Minutes and
Rosanna Roughley
Papers sent to:
Trust Secretary
Chairman’s Welcome, Introductions and Health and Safety Briefing
FPC/
16-17/01
APOLOGIES
Apologies were received from
McFrederick and Ivan McConnell.
FPC/
16-17/02
Anne-Marie
Dean,
Malcolm
NOTIFICATION OF ITEMS FOR DISCUSSION NOT ON THE
AGENDA
None
1
FPC/
16-17/03
DECLARATION OF INTERESTS
None
FPC/
16-17/04
MINUTES OF THE MEETING HELD ON 22 MARCH 2016
The minutes of the last meeting held on 22 March 2016 were
ACCEPTED and signed as a correct record.
FPC/
16-17/05
MATTERS ARISING (ACTION LOG – 22 MARCH 2016)
The Committee NOTED the outstanding items set out in the action
log dated 22 March 2016.
FPC/
16-17/06
FINANCE
(a) Finance
(i)
Finance Report M12
The Committee NOTED that the Trust made a loss to date of £4,179k
which was an improvement of £95k on forecast. The annual plan
was adjusted to reflect the improvements required by the TDA which
moved the original plan from £2,339k to a revised plan of £1,472k
deficit (after technical adjustments). Therefore the revised plan was
missed by £2,707k. This was in line with the in year forecasts and the
revised outturn position identified in month 9.
The Trust had achieved its four statutory targets: break even duty,
EFL, CRL and 3.5% return on relevant net assets.
The EFL target was achieved due to a change in target by the TDA to
£2m. The break even duty target was achieved due to a change in
target by the TDA to £4,274m. High levels of agency staff had
impacted on the financial position for the Trust, reflecting the
challenge of recruiting permanent staff and the need to adhere to
safe staffing guidance and could impact on the quality of services. A
full quality assessment had not been made.
(ii) Finance Recovery Plan (update 6)
The Committee NOTED that the TDA had written to the Trust
requesting a control deficit total of £2.4m in 2016/17. At this stage
the plan still reflected a deficit of £7.3m as communicated previously
and agreed by the FPC and Trust Board.
2
The Committee reviewed the final plans for TDA submission.
The CRES shortfall, with regard to the original schemes, was £6.9m.
However, the Stretch schemes to be implemented as part of the
financial recovery plans indicated the potential to achieve £6.2m as:
1. The CRES process had been strengthened to reduce the risk of
non delivery from FY15/16 levels and to implement the more
robust schemes identified during the year.
2.
The process had also tightened such that there was a much
greater focus on CRES delivery from day 1 of the year, in
contrast to FY15/16.
3. The level of planned CRES set out still resulted in a deficit of
£7.3m.
4. The statutory financial requirement was for the Trust to achieve
breakeven over a 3 year period, including carried forward
cumulative surpluses. A more prudent approach would be to
target breakeven over 3 years. To achieve this meant the Trust
needed to over-deliver against the FY16/17 plan and achieve a
significant surplus in 17/18. This would help repair the financial
impact on the Trust of recent underlying operational losses, avoid
loans to fund working capital and rebuild capital balances for ongoing investment.
To breakeven in a 3 year period implied:
a. FY15/16 loss = £4.2m
b. FY16/17 planned deficit = £7.3m
c. FY17/18 required surplus = £11.5m
d. This reinforced the criticality of the Trust delivering recurrent
CRES savings from day 1, transforming the cost base over the
next 2 years and negotiating a new contract each year
consistent with the levels of activity the Trust was providing
CCGs, which was understated by over £7m in FY15/16.
e. Financial performance therefore remained the top risk for the
Trust in the context of FY16/17 and 2017/18.
5. The Finance department continued to work closely with
directorates to identify 4% CRES plans as part of the budget
setting process. This was due to be finalised shortly and would
then be reviewed and challenged by EMT plus subjected to QIAs.
3
(iii) One Year Plan Summary
The Committee discussed the Plan which was set against the
background of the instability of the Health Economy and the
overriding need for integrated working and collaboration.
The first comprehensive CIH inspection in March 2015 rated the
Trust overall as “Requires Improvement”. The refreshed and updated
plan for the year ahead would build on the Trust’s five year
projections and plans, take into account progress made against that
plan, CQC inspection report and changes that occurred both locally
and nationally.
(iv) Cash Analysis
The Committee NOTED the cash book balance was £2.1m at year
end which was a £0.1m improvement against the £2m revised
plan/EFL. The original plan was for a bank balance of £7.6m which
was revised down following the increase in deficit and the increase in
receivables due to disputes with the CCGs.
Cash remained a high risk in the new financial year because of the
planned deficit of £7.3m and slow debtor payments. The Trust was
likely to take on a loan of £2.3m to fund working capital and pay staff
in year:
1.
2.
3.
4.
5.
The plan showed no repayments to this loan being made in
FY16/17.
This further reinforced the need to negotiate tighter terms with
CCGs in the FY17/18 contracts regarding timely payment for out
of area beds.
It further reinforced the need to go to arbitration with CCGs that
failed to pay for the services they used in a timely manner.
The Finance team would maintain monthly cash flow forecasts
reflecting a “likely” scenario to ensure the Trust Board remained
sighted on this issue.
The TDA had been informed of the Trust’s low cash position
going into FY16/17.
AF agreed to clarify the Trust’s 3 year breakeven duty in the Cash
report for the May meeting.
ACTION: AF
(b) Trust Financial Risks
ACTION: AF
4
(c)
Capital
The Committee NOTED that the Trust met its capital plan and CRL
for the year ended 31 March 2016. This was mainly due to the rephasing of schemes in response to the changes in the capital
programme during the year.
The depleted capital programme for 2016/17 was already coming
under pressure from bids by services linked to concerns around H&S,
fire protection, CQC attention, etc.
(d)
Procurement
The Committee NOTED the draft Procurement Board minutes of 16
February 2016.
(e) Estates
(i)
Estates Transformation Programme
The Committee NOTED that work continued with the project teams in
Medway, Canterbury and the southeast. Additionally, the space
utilisation audit was now underway and would be reported back to the
Committee on completion.
(ii) Cranmer Ward and St Martins Disposal Business Cases
The Committee NOTED that the search for options to relocate
Cranmer Ward was ongoing and the planning application for St
Martins West redevelopment was ready but on hold pending greater
clarity on timescales for Cranmer relocation and CCG commissioning
intentions.
(iii) KMF Review
The Committee NOTED that the KMF Director had recently
resigned. Interim cover arrangements had been agreed and a
project to set out the future direction for those services was
underway.
(iv)
Disposals 2016/17
The Committee NOTED that the disposals for the financial year
totalled £4.4m which was £0.1m below plan due to a change in
valuation. JC had met with the DH lead for provider surplus
property disposal and had discussed some of the challenges
currently faced. There may be options for central DH assistance
with some of those challenges.
5
(v) Sustainability
The Committee NOTED that the annual review of the Trust’s
Sustainable Development Management Plan, including carbon
reduction, would be available at the May meeting.
ACTION: JC
(vi) Estates Strategy
The Committee NOTED that the Estates Strategy would be updated
over the next few months as part of the wider organisational work on
strategy. It would link with other NHS estates strategies/STP as
appropriate and would be a longer term plan that reflected the lack
of funds.
FPC/
16-17/07
PERFORMANCE
(a) Integrated Quality and Performance Report
The Committee NOTED that 5 out of 8 of the regulatory targets were
achieved Trust wide. Delayed Transfers of Care were slightly over
the 7.5% target at 7.84%. Performance fell under the target for CPA
12 month review at 93.1% and, for the first time since its introduction
last year, the Trust did not achieve the EIP waiting time measure for
patients to be seen within 2 weeks of referral to care co-ordinator with
compliance 36.4% against the 50% target.
In March, 13 of the RAG rated quality targets were achieved and 10
of the RAG rated indicators had improved.
In March, 3 of the 7 workforce targets were achieved Trust wide and
there was a further decrease in the performance levels of 5 of the
RAG rated workforce targets across the Trust. The sickness
absence data used in this analysis was from February 2016 as the
March position was not available.
The agency spend target of 5% was not met Trust wide and
increased to 7% from 6.1% in February. Staff turnover increased
from 16% in February to 16.2% in March against the 14% target.
Trust-wide performance for appraisals was 82.8% in March, below
the 90% target.
The Committee discussed the detail and length of the current cover
report with a view to shortening it to focus on the most material items.
It was considered a reasonable approach as the detailed IQPR sat
alongside the cover report. This exercise would evolve over the
coming months and VB agreed to draft a first example for discussion.
ACTION: VB
6
(b)
CQUIN Programme 2016/17
The Committee discussed the report and NOTED that the total
assessed financial risk for FY15/16 was £237,128:



There was an anticipated loss of £117,687 for cardiometabolic assessment across all CCG areas. The Committee
AGREED to refer this matter to the Quality Committee to ask
them to scrutinise the current approach which failed to deliver
the CQUIN target last year and this year. As the target would
recur next year (17/18), the Committee believed that the Trust
needed a credible plan, approved and monitored by the
Quality Committee, to ensure that the targets were achieved in
FY16/17 for both financial and reputational reasons.
ACTION: VB
There was an assumed risk of £65,770 for the East Kent
Dementia CQUIN relating to the Q3 milestone achievement.
2 of the 7 CQUIN milestones for the CAMHS Transition were
not met in Q1 equating to the loss of £8,053 for East Kent.
There was a further risk for the CAMHS CQUIN totalling
£53,671 for all milestones, including the Q1 shortfall of £8,053.
The current CQUIN value for 2016/17 was likely to be around £3.5m
as in 2015/16.
(c) Contracts 2016/17
The Committee NOTED the 2016/17 contract discussions. Strong
progress had been made with West Kent, North Kent and NHS
England. Negotiations with East Kent CCGs have made less
progress and arbitration proceedings have been instigated against
them for over performance of £3.9m.
FPC/
16-17/08
TRANSFORMATION
(a)
Trust Consultancy Expenditure Business Case
The Committee NOTED that the Trust was experiencing difficulty in
recruiting within the Dartford area. The project covered:


business as usual recruitment – of 36.41 FTE ranging from
Band 2 to Band 8a broken down as 35% nursing, 47% allied
health, 18% HCA all based in Dartford.
new ward recruitment – of 37 FTE ranging from Band 2 to
Band 8a broken down as 75% nursing, 19% allied health, 6%
HCA. Ward to be opened at end of June with 75% workforce
in situ with 100% workforce in situ at end of September.
7
The Committee discussed and APPROVED the business case at a
total contract value of £152,088 (including expenses and VAT) for 7
months duration. As this was within FPC limits, it did not require
additional Trust Board approval. Final approval for all expenditure
requested in this Business Case would be given by TDA Consultancy
Controls Panel.
(b)
Operations Board Minutes 10 March 2016
The Committee NOTED the Operations Board minutes of 10 March
2016.
Les Manley joined the meeting
(c)
ICT Report
The Committee NOTED that the ICT performance was being closely
monitored and had exceeded expectations for the first week of the
new service. A range of reports would be produced over the coming
weeks in line with agreed service levels and KPIs.
Les Manley left the meeting
FPC/
16-17/09
SERVICE LINE REPORT - ACUTE
Sarah Holmes-Smith joined the meeting
The Committee discussed and NOTED that the key risks identified
were (1) out of area bed usage and (2) staffing shortages/costs.
There was only one month in which the Delayed Transfer of Care
target (7.5%) was met last year and there were currently 24 acute
patients with a delayed transfer of care.
The pay costs overspend was mostly with Acute (£2,304k) and was
predominantly due to increased expenditure on medical and nursing
agency. This would need to be addressed to ensure these practices
were not replicated in 2016/17. Delays in the implementation of the
therapeutic staffing initiative had reduced the benefits realised
against assumption made for 2015/16. The Service Line Director
provided assurance that the therapeutic model piloted in East Kent
had resulted in considerable displacement of agency staff and
appointment of full time staff. Costs had reduced and morale
improved as a direct result. The detailed CRES scheme for rolling
this out across the rest of the Trust would be reviewed at next
month’s meeting.
ACTION: PC
8
The pressures on the acute inpatient service had been experienced
for a sustained period of time and additional capacity was being
discussed with CCGs as part of the contracting process. In addition,
targeted cross boundary approaches and alternative models were
being developed to ensure that sustainable solutions were found
across the health economy.
Sarah Holmes-Smith left the meeting
FPC/
16-17/10
POLICIES REVIEW
FPC/
16-17/11
ACTION: AF
TERMS OF REFERENCE REVIEW
(a)
Finance and Performance Committee
The Committee discussed and AGREED that the updated terms of
reference for the Finance and Performance Committee be forwarded
to the Trust Board for approval.
(b)
Trust Capital Group
The Committee discussed and AGREED that the Trust Capital
Group’s terms of reference be forwarded to the Trust Capital Group
for comment at their meeting on 3 May before being forwarded to the
Trust Board for approval.
(c)
Procurement Board
The Committee discussed and AGREED that no changes be made to
the terms of reference for the Procurement Board.
FPC/
16-17/12
ANY OTHER BUSINESS
None
FPC/
16-17/13
FPC REPORTS TO THE BOARD/OTHER COMMITTEES
(a)
Key Issues to Trust Board Meeting on 28 April 2016


Finance Report M12
Finance Recovery Plan (update 6)
9











(b)
CRES
One Year Summary 2016/17
Cash Position
Capital Plan
Estates Report - KMF
Integrated Quality and Performance Report
CQUIN Programme 2016/17
Contracts 2016/17
Trust Consultancy Expenditure Business Case
ICT/HIS Transition
Acute Service Line
Items to be referred to other Committees
The Committee AGREED that the Quality Committee be
requested to scrutinise the current approach to the Cardio
Metabolic Assessment CQUIN. (FPC/16-17/07(b)).
FPC/
16-17/14
FPC MEETINGS 2016/17
24 May – 1 pm to 5 pm – Boardroom B, Farm Villa
28 June – 1 pm to 5 pm – Boardroom B, Farm Villa
26 July – 1 pm to 5 pm – Boardroom B, Farm Villa – to review
No meeting in August
27 September – 1 pm to 5 pm – Boardroom B, Farm Villa
25 October – 1 pm to 5 pm – Boardroom B, Farm Villa – to review
22 November – 1 pm to 5 pm – Boardroom B, Farm Villa
No meeting in December
24 January – 1 pm to 5 pm – Boardroom B, Farm Villa
28 February – 1 pm to 5 pm – Boardroom B, Farm Villa
28 March – 1 pm to 5 pm – Boardroom B, Farm Villa
Signed: ………………………………………………………….
(Chair of Finance and Performance Committee)
Dated:……………………………………………………………..
10

Board Committee minutes - Kent and Medway NHS and Social Care

Transcription

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