POOLE HOSPITAL NHS FOUNDATION TRUST COUNCIL OF GOVERNORS

POOLE HOSPITAL NHS FOUNDATION TRUST COUNCIL OF GOVERNORS Part 1 minutes of the Council of Governors of Hospital NHS Foundation Trust held at 4.30pm on Thursday 15 October 2015, in the Board Room. Present: Mrs A Schofield Chairman AVM G Carleton Purbeck, East Dorset and Christchurch Mrs L Cherrett Clinical Staff Mr A Creamer Mrs V Duckenfield Mrs R Gould Purbeck, East Dorset and Christchurch Ms K Knudsen Clinical Staff Mrs C Morgan Dr S Minocha Bournemouth University Mr B Newman Bournemouth Mrs L Nother Mrs E Purcell Mr J Pride Mr T Purnell Bournemouth Dr D Richardson Dorset Clinical Commissioning Group Dr S Sen Purbeck, East Dorset and Christchurch Mrs A Stribley Borough of Mr G Whittaker Non-Clinical Staff Mrs S Yeoman In attendance: Ms V Fenton TIAA Internal Audit Mrs D Fleming Chief Executive Mr J Harding HR Business Partner Mr P Miller Director of Strategy Major J Myles Governor Delegate Ms T Nutter Director of Nursing Miss K Nye Board and Council Administrator Mr M Orchard Director of Finance Mr M Stabb TIAA Internal Audit Mrs C Stone Company Secretary Mr R Talbot Medical Director Mr N Ziebland Non-Executive Director The chairman welcomed Dr David Richardson and Dr Sonal Minocha to the meeting who had recently joined the Council as the nominated governor from the Dorset Clinical Commissioning Group and Bournemouth University respectively. The chairman also welcomed Major James Myles who had recently been elected unopposed for the North Dorset, West Dorset, Weymouth, Portland & the Rest of England constituency. Mr Mark Stabb and Ms Virginia Fenton from TIAA were also welcomed to the meeting who were in attendance to present the Internal Audit Assurance Report. CoG 112/15 Apologies for Absence Apologies for absence were received from Mr P Chappell;, Ms S Lowrey; Clinical Staff Governor, Mr D Jones; Dorset County Council and Ms J Saunders; Director of HR and Organisational Development. 1

CoG 113/15 Declarations of Interest There were no declarations of interest pertaining to the agenda. CoG 114/15 Draft Minutes of the Meeting held on 30 July 2015 (paper A) The minutes were AGREED as a correct record of the meeting. CoG 115/15 Matters Arising - Action List (paper B) 92/15: The chairman noted that a board displaying the Council of Governor photos will be placed in the dome area and in the main entrance. ACTION: AB/CS 98/15: The chairman noted that the issues relating to the acoustics in the Board Rooms had been reviewed. It was noted that solutions involving the use of microphones may limit an open discussion. The chairman noted that the board rooms will be organised into a horseshoe shape for future Board meetings to see if this improves the acoustics for the governors sat in the public seats. Item closed. 98/15: Mrs Stone noted that options for a paperless system for Council of Governor meetings had been considered. The council noted that all governors will be provided with an NHS Net email account if they do wish to have the papers sent to them electronically. Mrs Stone reminded the governors that part 1 papers are available on the website one week prior to the meeting. Item closed. It was NOTED and AGREED that all actions, unless subject to this or future Council of Governors agenda, had been executed. CoG 116/15 Chairman s Comments The chairman reported that: This was the last meeting of Mr Creamer, AVM Carleton, Mr Pride, Ms Knudsen and Ms Lowrey. She thanked them for their excellent contribution to the Council and wished them well for the future. Dr David Richardson was attending his first meeting as the appointed governor from the Dorset Clinical Commissioning Group. Dr Sonal Minocha was also attending her first meeting as the appointed governor from Bournemouth University. The recent governor elections had closed on 14 October and the chairman was pleased to noted that Brian Newman has been elected unopposed for the Bournemouth constituency and James Myles had been elected unopposed for the North Dorset, West Dorset, Weymouth, Portland & the Rest of England constituency. There had been three newly elected governors for the Constituency, Sarah Holmes MBE, Richard Negus and Sandra Yeoman. The chairman further noted that Marilyn Osner had been elected as governor for the Purbeck, East Dorset and Christchurch constituency. The chairman gave thanks to all members who had put themselves forward for election. 2

There are two staff governor vacancies and elections will be held early in 2016 to fill these positions. The chairman noted that interviews had been held for two new nonexecutive directors and a paper would be presented at the part 2 meeting with the proposed candidates. The chairman thanked members of the interview panel for their contribution. The chairman thanked members for their attendance to the Annual Members Meeting. Thanks were also given to Dr Angus Wood, Dr Gary Cumberbatch and Geoffrey Walker for their presentations and to the organisers of the event. The chairman noted that Mrs Gould had been asked to be a member of the Clinical Excellence Awards panel as a governor representative. The governors expressed their support and thanked Rosemary for her participation. At the private Council of Governor meeting in July the following was Approved: The outcome of the Chairman s and Non-Executive Director 2014/15 Annual Performance Evaluation Reappointment of External Auditors Received: 2014/15 Board Assurance Framework Annual Report CoG 117/15 Council of Governor Dates (paper C) Mrs Stone presented the report which provided the Council with the revised Council of Governors meeting schedule for 2016. Mrs Stone highlighted the amendments to the schedule and these were noted. The council noted that the revised schedule would be sent in the weekly governor email. ACTION:KN The governors UNANIMOUSLY APPROVED the Council of Governor schedule for 2016 subject to amending the August 2016 Informal Governor Briefing to 31 August. CoG 118/15 Appointment of a New Vice Chairman of the Hospital NHS Foundation Trust Board of Directors and Council of Governors. (paper D) The chairman presented the report which provided the Council of Governors with the opportunity to appoint a new Vice Chairman of the Hospital NHS Foundation Trust Board of Directors and Council of Governors. The chairman noted that with the cessation of the term of office of Mrs Jean Lang on 30 November 2015, the Council of Governors is asked to appoint non-executive director Philip Green to the role of Vice Chairman with effect from 1 December 2015. The item was discussed and the Council UNANIMOUSLY APPROVED the appointment of Philip Green to the role of new Vice Chairman. 3

CoG 119/15 Annual Complaints Report (paper E) Mr Talbot presented the Annual Complaints Report which described how complaints had been managed in the Trust during 2014/15. The report was discussed with a particular focus on the number, type and outcome of complaints. Mr Talbot noted that for the year ending 31 March 2015 the Trust received 493 complaints, of which 34% were sent via email. Mr Talbot noted that there had been 7 referrals to the Health Service Ombudsmen during the year and there are currently 4 outstanding cases for which the Trust is awaiting the outcomes. The common themes arising from complaints were discussed and Mr Talbot noted that 16% were due to staff attitude. Mr Talbot noted that complaints relating to staff attitude are taken very seriously and consultants do have to reflect on complaints in their annual appraisal. The council suggested that the tables relating to complaints by staff type and complaints relating to clinical care be combined to highlight any comparisons. ACTION: TN/MD The Council noted that out of 2250 enquiries received by the Patient Advice and Liaison Service (PALS), 1731 were enquiries resolved and 338 were defused complaints. Mr Talbot noted the important contribution of PALS in resolving issues at an early stage. Mr Talbot thanked Mrs Stone for her work as this was her final annual complaints report. The Council noted that complaints are now managed by the Patient Experience Team. The report was discussed and NOTED CoG 120/15 Report from Nominations, Remuneration and Evaluation Committee Meeting 15 October 2015. The chairman noted that an NREC meeting had been held on 15 October 2015. The chairman noted that the committee had made a recommendation to the Council of Governors relating to the appointment of two new Non-Executive Directors which would be discussed later in the meeting. CoG 121/15 2015/16 Board Assurance Framework ( paper F) Ms Nutter presented the report providing the Council with the Board Assurance Framework for 2015/16. Ms Nutter noted that the Board Assurance Framework enables the Trust to monitor risks and gaps in control which may have an impact on reaching organisational objectives. Ms Nutter noted that the Board Assurance Framework is a working document and is monitored on a quarterly basis by the relevant Board sub-committees. A summary report is also provided to the Board in October and April of each year. The report was discussed. Mrs Cherrett noted that the report is useful and informative for the Council of Governors, and it provides assurance that the 4

key controls are being identified in order to achieve the Trust s objectives. The report was discussed and NOTED CoG 122/15 Report on 2015/16 Annual Members Meeting (paper G) The chairman presented the report on the 2014/15 Annual Members Meeting and results of the questionnaire. The chairman asked the governors how they thought the meeting could have been improved. Mr Newman noted that the discussion groups had been difficult due to the seating arrangements. Mrs Cherrett noted that the question presented to members had instilled a lot of discussion, however there was some confusion relating to the question posed. Mrs Cherrett noted that the question needed to be more focused on a particular topic in the future. The chairman noted that the feedback from members had been very positive and the meeting had been a success. The chairman gave thanks to members, attendees and organisers. CoG 123/15 Register of Interests The chairman presented the Register of Interests for the Council of Governors. The chairman noted that if governors have any changes to the register they should inform the Company Secretary team for noting at the next Council of Governors meeting. CoG 124/15 Board Dates 2016 Mrs Stone presented the Board of Directors meeting schedule for 2016. The schedule was NOTED. CoG 125/15 Internal Audit Assurance and CQC Preparedness (paper J) Mr Stabb and Ms Fenton provided a presentation to brief the Council of Governors of the role of Internal Audit within the Trust and an outline of their involvement linked to the CQC (Care Quality Commission) formal inspection process. Mr Stabb outlined how the Internal Audit function operates and provided a summary of the work undertaken at the Trust during 2014/15 and to date. Ms Fenton provided the governors with a briefing of work undertaken by Internal Audit in assisting the Trust in its preparations for its CQC inspection and how this relates to the governors. The presentation was discussed and Mr Stabb and Ms Fenton were thanked for their report. 5

Mr Stabb and Ms Fenton left the meeting. Mrs Fleming and Dr Minocha joined the meeting. CoG 126/15 2015/16 Quality Accounts (paper K) Ms Nutter presented the report providing the Council with the updated Quality Account. Ms Nutter thanked the governors for developing the new Quality Reference Group which had met on 1 October. Ms Nutter noted that the meeting had been helpful and that the Quality Accounts had since been updated as a result of this meeting. A further review meeting is planned for early 2016. The governors noted that the report contained a large number of abbreviations which were not included in the glossary. It was noted that the glossary would be updated for the next meeting. ACTION: KN The report was discussed and NOTED. CoG 127/15 Integrated Trust Performance Report (paper L) Mr Orchard presented the report and highlighted the following key points: All Monitor standards were achieved in August with the exception of the 4 hour operational standard and July s 62 day cancer wait target. Mr Orchard noted that the 4 hour standard was delivered in September and the Trust therefore achieved compliance in quarter 2. The 62 day cancer wait target remains the greatest challenge due to the increase in two week wait cancer referrals. The number of referrals received in July was the highest ever reported with 728 received against a monthly average of 590. This has increased the demand for diagnostic testing, along with the unusually high number of head and neck and lung cancer treatments reported in August. The increase in referrals and funding for this activity was discussed in detail. Mr Orchard noted that an update will come to January s meeting on the funding required to undertake the additional activity. ACTION: MO In August the Trust had achieved the Referral to Treatment performance for the incomplete pathways target, all screening targets were achieved for July and there was an increase in activity levels of elective inpatient and outpatient activity compared to the previous year. Mr Orchard provided a summary of the Trust s financial performance in August and noted that the Trust had an overall 18k favourable variance against plan for the month of August with a 372k actual deficit against a planned 390k deficit. Mr Orchard noted that Clinical Directorates are overspent by 708k for the first 5 months of the financial year and which is currently offset in part by corporate and non-directorate underspends. The Trust reported 370k agency expenditure during August which the Council was pleased to note was the lowest monthly spend during the financial year to date and lower than the same month in 6

2014. Mr Orchard reported that from 1 October 2015 Monitor has set a cap on agency expenditure for registered nurses to no more than 5%. Mr Orchard noted that the Trust reported Cost Improvement Plan (CIP) savings of 553k compared to a plan of 603k for August 2015. The Project Management Office has been set a target to identify and deliver additional savings to achieve the full 7m CIP target for 2015/16. The report was discussed and NOTED. CoG 128/15 Monitor Quarter 4 Monitoring Feedback (paper M) Mrs Fleming presented the report providing the governors with details of Monitor s Assessment of the Trust s performance for quarter 4. CoG 129/15 Vanguard Application (paper N) Mr Miller presented the report to update the Council on the position of the Vanguard Programme. Mr Miller noted that on 30 July 2015 Dorset County Hospital NHS Foundation Trust, Hospital NHS Foundation Trust and the Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust submitted an application to become a Vanguard in the national future models of acute care collaboration programme. On 25 September the new national care models team announced that the joint application Developing one NHS in Dorset was one of 13 successful applicants. Mr Miller noted that as a Vanguard, Dorset providers are committed to ensuring a programme is developed that will enable the delivery of the Dorset Clinical Services Review. Additionally, the Vanguard will assist the providers of Dorset to work together and allow learning to be shared with others. Mrs Fleming noted that a great deal of work is currently being undertaken to create an agreed programme approach to manage the development and implementation of the Trust s Vanguard vision. The council noted that the national team is visiting Dorset on 3 November 2015. The report was discussed and NOTED. CoG 130/15 Organisational Development Action Plan (paper O) Mr Harding presented the report updating the Council on the Trust s Organisational Development Plan. Mr Harding noted that the plan provides an overview of a series of interventions and initiatives to support the Trust in delivering its strategic priorities and objectives. The report was discussed and Mr Harding noted that the key focus of the plan is the development of people and system alignment to improve efficiencies and effectiveness. The Council noted that the Organisational Development Plan is monitored by the newly developed Workforce Group and the Workforce and Organisational Development 7

Committee. The report was discussed and NOTED. CoG 131/15 Reports from Reference Groups: Membership Engagement and Recruitment Mrs Yeoman noted that Mrs Bonham had liaised with the Outpatient General Manager and the self-check in machines now ask patients if they would be interested in becoming members. It is hoped that this will initiate a steady recruitment of new members. Mrs Yeoman noted that previously the council had requested a report on the effect of opening up the Purbeck, East Dorset and Christchurch constituency to include the rest of England on the membership. Mrs Yeoman reported that since the 1 September 2014 we have had 73 members join this constituency giving a total at the end of September 2015 of 334 members. The chairman thanked Mrs Yeoman for her report. Future Plans and Priorities Mr Purnell noted that the next Future Plans and Priorities meeting was on 29 October 2015. Governor Training and Development Reference Group Mr Pride noted that there was Board and Council Away Day on Tuesday 20 October. Mr Pride gave thanks to Mr Chappell for taking on the role as chairman of the Governor Training and Development Reference Group. The Council expressed appreciation to Mr Pride for his contribution as chairman of the group. Quality Reference Group Nomination for a new chairman of the group. AVM Carleton noted that the newly developed Quality Reference Group required a chairman. AVM Carleton noted that Mrs Cherrett had been nominated for the position and she had kindly agreed to chair. The Council APPROVED Mrs Cherrett as the new chairman of the Quality Reference Group. At the first meeting held on 1 October the Terms of Reference had been agreed and the Assistant Director of Nursing had given the group an overview of the Quality Account. CoG 132/15 Reports from Other Groups: Staff Governors Mrs Cherrett noted that the previous few weeks had been very busy 8

in the Trust. Mrs Cherrett noted the importance of planning for the winter months and for the CQC visit which was taking place in January. Mrs Cherrett noted that CQC preparation and training was going well. Research and Innovation Group Nomination for governor attendee for the Research and Innovation Committee. The chairman noted that due to Mr Creamer s tenure ending at the end of October, a new volunteer was required to attend the Research and Innovation Group. The chairman noted that Mrs Nother had kindly agreed to attend future meetings and the Council supported this. CoG 133/15 Board of Director s Agenda: 29.07.2015 The agenda was NOTED. 26.08.2015 The agenda was NOTED. 30.09.2015 The agenda was NOTED. CoG 134/15 Any Other Business AVM Carleton gave thanks to the chairman, the executive and non-executive directors and to his fellow governors for their hard work and support over the last several years. There was no other business. CoG 135/15 Urgent Motions or Questions The chairman noted that there were no urgent motions or questions. CoG 136/15 Reflection on Current Meeting The members agreed it had been a useful and informative meeting with a good focus on the Integrated Performance Report. CoG 137/15 Date and Time of Next Meeting Thursday 14 January, 2016, 4.30pm in the Board Rooms, Hospital NHS Foundation Trust. Agreed as a correct record of the meeting: Chairman. Date 9