Minutes of the Integrated Audit and Risk Committee Meeting
held 16 July 2015 in Boardroom B, Farm Villa, Maidstone, ME16 9PH
Present:
Integrated Audit and Risk Committee Members
Mr T Phillips
Non-Executive Director (Chairman)
Mr R Page
Non-Executive Director
Professor M Andrews Non-Executive Director
Tiaa
Mrs R Goodall
Audit Manager
Grant Thornton
Ms L Robertson
Manager, Assurance
KMPT
Mrs P Barber
Mr P Cave
Mr I McConnell
Mr S Guile
Mrs A Foreman
Mrs S Chalmers
Ms C Robson
In Attendance:
Miss A Bedford
Director of Nursing and Governance
Director of Finance
Director of Transformation and Commercial Development,
for items IARC/15/122 & 132
Interim Company Secretary
Deputy Director of Finance
Trust Risk Manager and Health and Safety Lead,
up to item IARC/15/124
Trust Records Manager, for item IARC/15/132
Assistant Trust Secretary, Minutes
MIN NO
IARC/15/116 CHAIRMAN’S WELCOME AND INTRODUCTIONS
The Chairman welcomed those present to the meeting and apologised for the late
start to the meeting.
IARC/15/117 APOLOGIES FOR ABSENCE
There were no apologies from members of the Committee.
IARC/15/118 DECLARATIONS OF INTEREST
There were no declarations of interest.
IARC/15/119 NOTIFICATION OF ITEMS FOR DISCUSSION NOT ON THE AGENDA
There were no items notified for discussion not on the agenda.
Integrated Audit and Risk Committee Meeting – 16 July 2015
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IARC/15/120 MINUTES OF THE INTEGRATED AUDIT AND RISK COMMITTEE MEETING
HELD ON 29 JUNE 2015
The minutes of the Integrated Audit Committee and Risk Committee meeting held
on 29 June 2015 were accepted and signed as a correct record.
IARC/15/121 ACTION SHEET
The Committee noted the updates to items on the action sheet and agreed the
proposed closures of outstanding items. The following issues were noted:
IARC/15/98 Prevention of Salaries Overpayment: Mrs Goodall confirmed that she
would be providing an analysis of overpayments for the Committee. Professor
Andrews suggested that this should look into errors in payroll in general, rather than
over payments specifically. Mrs Foreman asked that it be made clear where the
errors have originated; the majority of mispayments were due to delays in workforce
data being provided to the payroll team.
IARC/15/99a Risk Registers: The Chairman noted that the requested data had not
been included in the Transformation Risk Register. Mrs Chalmers said that she had
not been involved in the drafting of this report.
IARC/15/99b&c Risk Registers: the Chairman asked that an update be provided to
the next meeting.
IARC/15/104a/tiaa update: completed.
IARC/15/104b tiaa update: to be brought to the September meeting.
IARC/15/82a Draft Annual report: Mr Cave confirmed that this action had been
completed.
IARC/15/44b Local Counter Fraud Specialist Report: the Committee asked that Dr
Kinane be invited to attend the next meeting.
ACTION: Miss Bedford, agenda
RISK
IARC/15/122 TRANSFORMATION RISK REGISTER
Mr McConnell reminded the meeting that the risk registers had been presented to
the January meeting when he had been asked to provide an update to this meeting.
He noted the following:
Transformation programme: this was managed by the Project Management Office
(PMO), reporting to the Transformation Board and then into the Finance and
Performance Committee (FPC). The process had been audited by TIAA. The key
red risk was patient flow management, with associated contractual and operational
risks.
Information and Communication Technology (ICT): this risk register was review at
both the Transformation Board and the ICT Programme Boards and monthly within
the team. There were currently no red rated risk; the revised Patient Administration
System (PAS) was on target to go on line in September.
Communications Team: Mr McConnell noted that the key issue for the team had
been staff changes over the last year. These were now bedding in well and the
Integrated Audit and Risk Committee Meeting – 16 July 2015
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team were in a position to focus on the communications strategy, which would
include a social media strand.
Professor Andrews commented that the Non-Executive Directors would welcome
some form of regular briefings from the Executive Management Team giving
information about the national and local issues and advance warnings of potential
media interest. This would be in addition to receiving the monthly Flash Report.
Mrs Goodall noted that her teams had observed that there was a lot of information
displayed on notice boards around the Trust and asked whether the
Communications Team reviewed this. Mr McConnell said that the preference now
was for electronic communication. Mrs Barber said that a physical review had been
undertaken prior to the CQC inspection.
Performance Team: Mr McConnell explained that the team were working on rolling
out the web-based INSIGHT system across the operational teams. Work was
underway to include finance data on the system to all a greater degree of
granulation and also ensure consistency of reporting. Mr McConnell noted that
KMPT was the only Mental Health Trust to be developing such a system; it was
more normally used in acute Trusts.
Professor Andrews commented that it was not always clear where ownership of
risks fell between operational teams and the Transformation team. Mr McConnell
said that he would expect to see some risks appearing on a number of department
or Service Line registers. Mrs Barber commented that the Transformation
Programme Risk Register should include elements of reputational and financial risk
and suggested that this be reviewed. Professor Andrews noted that she had
expected to see some reference to the strategic plan; Mr McConnell concurred and
said he would review.
ACTION: Mr McConnell
In response to a question from Mr Page, Mr McConnell confirmed that discussions
were ongoing with the CCGs about funding work to improve patient flow, given how
high a priority this was. He said that these were focussed on whole systems
solutions.
Mrs Chalmers said that her team had not had the capacity to provide training to Mr
McConnell’s team on the use of the risk calibration tool, but that this would be done.
It was agreed that the risk register would be re-circulated to members once the tool
had been applied.
ACTION: Mr McConnell
The Chairman questioned why two risks were owned by Mr McFrederick. Mrs
Chalmers said that this had been discussed and these were similarly assigned to Mr
McFrederick within the BAF. It was agreed that Mr McFrederick would be asked to
attend either the September or November IARC meeting to discuss his corporate
approach to risk management for the Service Line teams.
ACTION: Miss Bedford, schedule
The Committee noted and discussed the report.
IARC/15/123 FINANCE AND PERFORMANCE RISK REGISTER
Mr Cave explained that the risk register was discussed as a regular item at monthly
team meetings and that he and Mrs Foreman met separately with Mrs Chalmers or
her team. The register was also reviewed at each meeting of the Finance and
Performance Committee (FPC). Mrs Foreman said that she had now had training
Integrated Audit and Risk Committee Meeting – 16 July 2015
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on the use of the risk calibration tool and that this would be incorporated into the
register in the future. The Chairman suggested that risk movement should be
identified in future reports. Mrs Foreman acknowledged that the target dates in the
current report should read 2016, not 2015.
Mr Cave noted that the key financial risk was 4190, Financial Overspend; this was
also on the Trust Risk Register and the BAF and he believed was probably the most
critical risk facing the Trust at present. However, actions and mitigation plans were
in place to reach green by March 2016.
Mrs Barber noted that for some of the risks the controls had been marked as
inadequate and she asked what actions the team were taking to improve this. Mrs
Foreman said that she expected this to change now that she understood how to
apply the risk calibration tool.
The Chairman thanked Mr Cave for presenting the register, which he felt was
progressing well. He asked that an updated version be brought to a future meeting
once use of the risk calibration tool had been incorporated.
ACTION: Miss Bedford, agenda
The Committee noted and discussed the report.
IARC/15/124 HSE UPDATE REPORT
Mrs Chalmers explained that the Health and Safety (H&S) review had been received
and the Trust had opted for option 1: restructuring of the existing team and the
addition of an extra H&S Officer, creating a hub and spoke model to combine site
management and safety management across all Trust sites. All site managers and
safety support team members would undergo a four day training programme. The
team would report to Mrs Chalmers and to the Board via Mrs Barber. The report
had been clear that the team needed to be built within the organisation, using
ground staff, rather than create a large corporate team. Mrs Chalmers reminded the
meeting that there had been delegated action from the Board to the Chief Executive
and Chairman to implement the report recommendation re health and safety
staffing.
Mrs Barber noted that additional resources had been brought into the team to
provide cover until the substantive changes were made; these were expected to be
completed by November. The Trust was meeting with the HSE the following week
and it was anticipated that the proposed changes would result in a lifting of the
improvement notice.
In response to a question from Professor Andrews, Mrs Chalmers confirmed that the
report had provided a comprehensive review of health and safety requirements; the
new Health and Safety manager would be looking at this in depth and making
proposals for how the trust could implement the full recommendations from the
report, in addition to those relating to structure changes.
Mr Page asked whether there had been any benchmarking as part of the process;
Mrs Barber noted that this was difficult to do as no two organisations were facing
the same risks and those chosen had to be exemplar organisations, not easy to
identify.
Mr Cave advised that he had worked in an organisation which had used the bar
code system and would be talking with Mrs Foreman about scoping out the potential
for use in KMPT.
Integrated Audit and Risk Committee Meeting – 16 July 2015
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Mrs Chalmers confirmed that the vacancies for posts within the new structure were
being processed. She advised that the new Datix Manager, Katy Wheeler, was now
in post.
The Committee noted and discussed the report.
INTEGRATED AUDIT
IARC/15/124 EXTERNAL AUDITORS: GRANT THORNTON
Mrs Robertson noted that the external auditors report provided a summary of the
plans for 2015/16 and formally presented the Annual Audit letter, which the
Committee had previously received in draft.
The Chairman noted the reference to controlling agency spend, which had emerged
as a key issue for the Government. The Committee asked that the FPC ensure that
this issue is being scrutinised within their agenda and the outcomes reported to the
Board.
ACTION: Miss Bedford, FPC schedule
The Committee noted and discussed the report.
IARC/15/125 INTERNAL AUDITORS: TIAA
Mrs Goodall advised that the Clinical Record Keeping audit had just been presented
to the EMT meeting. The audit of the Transformation terms of reference would
come to the next meeting. There were a few audits outstanding from the previous
year’s schedule.
Mrs Goodall noted that there were no changes proposed to the audit plan, although
an additional day may be requested in the future to complete work on looking at
patient monies.
In response to a question from the Chairman, Mrs Goodall confirmed that she would
be visiting Amblewood ward the following week as Mrs Holmes-Smith had not been
satisfied with their initial responses to the recommendations made in the report.
She would be escalating the matter to Mrs Barber if she was not satisfied with the
discussions and to the IARC meeting if required.
The Committee noted and discussed the report.
IARC/15/126 VAT SAVING ON MEDICAL AGENCY STAFFING
Mr Cave presented the report explaining that this proposal had been developed in
liaison with Price Waterhouse Coopers and could lead to a saving of £647K; it was
a national initiative. There would be no changes in the methods used to choose the
agency staff employed. EMT had considered and approved the proposal
Mr Page said that he was concerned that there could be ramifications for the Trust
with respect to pensions. Mrs Foreman noted that the HMRC had raised questions
about the scheme and whether individuals would need to opt out from pension
rights. She added that work would be done to ensure that VAT experts had
confirmed that the proposal was compliant with law. Mr Cave advised that staff
would be employed individually on a daily contract so would not accrue employment
rights. Professor Andrews welcomed confirmation that the proposal applied to
medical staff only, however she would only wish to see this used in the short term
with each individual to avoid any risk of failing to focus on developing substantive
Integrated Audit and Risk Committee Meeting – 16 July 2015
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teams. Professor Andrews said that she would want assurance that there was HR
support for this approach and legal confirmation that it was lawful.
The Committee noted and discussed the report.
IARC/15/127 STATUS OF INCOME CONTRACTS REGISTER
Mr Cave said that the headline from the report was that negotiations were still
ongoing with three of the CCGs; he expected these to be concluded in the next few
weeks. The final step would be sign off from NHS England. The next key target to
achieve was around PTPS, which was being processed via the FPC.
Mr Cave advised that NHS Property Company had served notice on the Trust and
withdrawn. Mrs Barber confirmed that there was no residual risk. Mrs Foreman
said that the impact for the Trust was the loss of economies of scale and a local
solution was being sought.
In response to a question from Mrs Barber, Mr Cave confirmed that discussion were
ongoing in relation to the Ogden beds; the CCGs were managing a disagreement
with the Council about who had responsibility for payment.
Mr Cave said that an update would be provided to the next IARC meeting to confirm
full sign off.
ACTION: Mr Cave
The Committee noted and discussed the report.
IARC/15/128 SINGLE TENDER WAIVER REPORT
The Committee noted and discussed the report which provided details of the single
tender waivers since the last meeting, highlighting those of greatest value. The
Chairman asked that Mr Cave and the Procurement Board continue to apply tight
controls.
IARC/15/129 LOSES AND COMPENSATION REGISTER: QUARTER 4 2014/15 & QUARTER 1
2015/16
Mr Cave drew the Committee’s attention to the largest item on the report relating to
a write off of £64K as a result of poor management of a credit note involving the now
disbanded Medway PCT. The total for Quarter 1 of 2015/16 was much smaller.
The Committee noted and discussed the report.
IARC/15/130 REVISION OF KEY TRUST DOCUMENTS
Mr Guile explained that the paper summarised the changes being recommended
following a full review of the Trust’s Standing Orders, Standing Financial Instructions
and the Table of Detailed Delegation of Powers from the Scheme of Reservation of
Powers to the Board undertaken by Bevan Brittan, external legal advisors.
Mr Page noted that there were some minor inconsistencies between some of the
recommendations and content of the documents; it was agreed that he would raise
these with Mr Guile outside of the meeting.
ACTION: Mr Guile
Integrated Audit and Risk Committee Meeting – 16 July 2015
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Mrs Foreman drew attention to one key change in the Standing Financial
Instructions, paragraph 8.4, which proposed raising the approval limits for Service
Level Agreements.
The Committee considered and agreed the proposals made in the report, which
would be recommended for approval at the next meeting of the Trust Board.
STANDING ITEMS
IARC/15/131 POLICY GROUP REPORT
Mr Guile advised that a report would be brought to the next meeting of the IARC.
IARC/15/132 INFORMATION GOVERNANCE GROUP REPORT AND SIRO ANNUAL REPORT
Ms Robson noted that the Senior Information Risk Owner (SIRO) Annual Report
followed the national format. The SIRO role had been taken by Mr McConnell at the
start of the year, she remained as Deputy. The SIRO reports to the Information
Governance Group at each of their meetings. Ms Robson explained that the SIRO
role had four main functions: information systems accreditation, information assets,
information sharing & information flows and information incidents. The report
provides a summary of the work in each area over the year.
Mr McConnell noted that one key project undertaken by Ms Robson and her team
related to working with colleagues in local NHS Trusts for Acute and Community to
ensure that systems were fully compliant with IG and Security arrangements for the
implementation of the West Kent CCG Care Plan Management Service. He had
had feedback from the whole systems team that the Trust’s contribution had been
invaluable and was influencing the way that care would be provided. There was a
similar project developing in East Kent. The Chairman suggested that the Board
could be updated on these projects at a Board meeting.
Ms Robson advised that there had been fewer reportable information governance
incidents logged in year; the Information Commissioner had not taken any further
action and all recommendations he had made had already been identified by the
Trust team and already taken forward.
The Committee discussed and agreed the report.
IARC/15/133 GIFTS AND HOSPITALITY REVIEW
Mr Guile presented the report on the Gifts and Hospitality Register noting that
confirmation was still awaited from the Forensic and Specialist Services Service
Line. In response to concerns previously raised about the absence of returns for
estates staff, Miss Bedford reported that Mr Carey, Estates Manager, had confirmed
that there was zero tolerance for accepting gifts and hospitality in his team. The
Committee were pleased to note the level of returns from medical staff. Mrs Goodall
noted that there would be a follow up audit on this item.
The Committee agreed to revert to six monthly reporting on the register.
ACTION: Miss Bedford, schedule
The Committee noted and discussed the report.
IARC/15/134 IARC ANNUAL REPORT TO THE TRUST BOARD
Integrated Audit and Risk Committee Meeting – 16 July 2015
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Mr Guile presented the draft report. He confirmed that the Trust included external
review within the Board and Board Effectiveness Review every three years and
agreed to ensure that Department of Health Recommendations were adhered to. It
was agreed to delete the word ‘sound’ from the final sentence so that it reads: ‘…
the Trust has systems in place …’.
The Committee noted and agreed the draft Annual Report for presentation to the
Board.
IARC/15/135 FEEDBACK ON COMMITTEE REPORT FORM TRUST BOARD
No feedback was received.
IARC/15/136 MATTERS TO BE REFERRED TO THE TRUST BOARD
The Committee report would refer the Standing Orders etc and their Annual Report
to the Board for approval.
IARC/15/137 MATTERS TO BE REFERRED TO BOARD COMMITTEES AND GOVERNANCE
SUB-GROUPS
The Committee requested that the FPC monitor the Trust’s agency spend and
report to the Board (IARC/15/124 above).
IARC/15/138 MATTERS TO BE NOTED FOR INCLUSION IN THE AGS
The Committee agreed that the following items should be included in the Trust’s
Annual Governance Statement (AGS):


Review and update of Governance documents
The action against the HSE improvement notice
It was also agreed that a summary table of key items to be included in the AGS
would be presented to the next meeting.
ACTION: Miss Bedford
IARC/15/139 INTEGRATED AUDIT AND RISK COMMITTEE SCHEDULE
The Committee noted the schedule of items for the September meeting.
IARC/15/140 DATE OF NEXT MEETING
The next meeting will be held at 10.00 on 3 September 2015 at t Martin’s
Canterbury. This will be preceded at 0945 hours by a Confidential Meeting of the
Integrated Audit and Risk Committee members with the Auditors.
Integrated Audit and Risk Committee Meeting – 16 July 2015
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Minutes of the Quality Committee Meeting
held at 1300 hrs on Tuesday 21 July 2015
in Boardroom, Trust Headquarters, Farm Villa,
Hermitage Lane, Maidstone, ME16 9PH
Present:
Margaret Andrews
Rod Ashurst
Pippa Barber
Steve Norman
Nikki Oatham
Debbie Bray
Amanda Bedford
Stephen Guile
Non-Executive Director, Chairman
Non-Executive Director
Director of Nursing and Governance
Patient Safety Manager
Head of Psychological Services, video link
Trust Professional Lead for Allied Health
Professions
Deputy Medical Director
Complaints/SI facilitator
PCCI Manager,
for items QC/15/132 - 135, via phone link
Director of Operations, for item QC15/137
Interim Adult Service Line Improvement Specialist
for item QC15/137
Assistant Trust Secretary (minutes)
Interim Company Secretary
Catherine Kinane
Jon Stock
Srilatha Sadasivam
Executive Medical Director, Quality
Chief Pharmacist
Quality Intelligence Analyst
In Attendance: Rosarii Harte
Carrie McLean
Janet Lloyd
Malcolm McFrederick
Colin Edwards
Apologies:
MIN NO
QC/15/126 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/15/127 APOLOGIES FOR ABSENCE
Apologies for absence were received as noted above.
QC/15/128 NOTIFICATION OF ITEMS FOR DISCUSSION NOT ON THE AGENDA
There were no items notified for discussion which were not on the agenda.
QC/15/129 CONFLICTS OF INTERESTS
There were no declarations of interest.
QC/15/130 MINUTES OF THE LAST BOARD MEETING HELD ON 16 JUNE 2015
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The minutes of the last meeting held on 16 June 2015 were accepted and signed
as a correct record, with the following amendment - bullet point 3 for item
QC/15/114 should read:

In response to an enquiry from Mr Ashurst, Dr Lockerbie confirmed that she
would have capacity to continue her existing governance and risk duties as
well as undertake the interim Director role; skills were being developed among
other members of the team to provide the necessary support.
QC/15/131 MATTERS ARISING
The updates to the action table and completed actions were agreed and the
following noted:
QC/15/114a & b Forensic & Specialist Services Risk Register: to be resolved by
the next meeting.
QC/15/27b & g Patient Safety Group: Miss Bedford confirmed that the
Assessment in the Community Policy had been subsumed into the Community
Mental Health Operation Policy, which was up to date. The Committee noted that
the remaining actions under these items must be responded to by the next
meeting.
Reports from Sub-Groups
QC/15/132 TRUSTWIDE PATIENT EXPERIENCE GROUP REPORT
Mrs Lloyd advised the Committee that the fieldwork for the National Patient Survey
would be completed by the following Friday with the initial management report from
Quality Health expected on 28 July. The full report, including all the national data,
would be issued two months after this. Mrs Lloyd noted that the questions being
used were the same as the previous year, which would allow for direct
comparisons. A full report would be brought to the Committee.
Mrs Lloyd noted that the response rate to the Friends and Family test had fallen in
April; her team were working with ward teams to understand the reason for this for
future improvement.. Mrs Barber asked that the Trust wide score be included in
future reports. Mrs Lloyd said that there were also plans to improve the report to
show ongoing performance.
ACTION: Mrs Lloyd
In response to a question from Mr Ashurst, Mrs Lloyd explained that when specific
concerns were raised in a response to the questionnaire these were immediately
forwarded to the relevant team and action taken. Such instances were rare and
feedback was provided to the teams concerned when it did happen.
QC/15/133 CLINICAL EFFECTIVENESS GROUP REPORT
Mrs Oatham said that she had included the full summary report from the Clinical
Audit group on their work from 1 November 2014 to provide the Quality Committee
with a good understanding of the range of the work carried out. Mrs Oatham
confirmed that there were no issues which needed highlighting to the Committee;
QC July 2015
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the level of re-audits was high and this provided assurance to CEOG that
appropriate action was taken when there were concerns.
Mrs Oatham noted that the other key item discussed at the meeting was the gap
analysis on adherence to NICE guidance. It had been noted that some service
lines were falling behind and Dr Kinane had contacted their Directors asking for
action to be taken. Mrs Oatham agreed to liaise with Dr Kinane about the
timescales for the work and that the Service Line Directors would be asked to
provide a report on their action plans, including timeframes, to a future meeting of
the Quality Committee.
ACTION: Mrs Oatham / Miss Bedford - agenda
Mrs Oatham advised that Lona Lockerbie would be taking over as Chairman of
CEOG with Debbie Bray as the Deputy Chair. The Chairman thanked Mrs Oatham
for her contribution to the work of the Group.
The Committee discussed and noted the report.
QC/15/134 TRUSTWIDE PATIENT SAFETY GROUP (TWPSG) REPORT
Dr Harte presented the report which highlighted key issues from the last meeting of
the TWPSG, including:







safeguarding issues – in particular the Did Not Attend (DNA) Policy;
changes in the Care Act;
improvements in recording data in cases where children are involved or the
patient is pregnant;
Sign up to safety plan;
discharge summaries – the next report to the Quality Committee was due in
August;
the pressures of meeting high level of requests for S136 assessments; and
use of seclusion rooms across the Trust – report due to the August Quality
Committee meeting.
Mr Norman commented that there was a common theme developing within SI and
complaints. This was concerned with problems arising because the DNA Policy
was not being followed. Mrs Barber said that it was important that patients’ GPs
were provided with this information, therefore sharing the risk. Mr Norman was
asked to liaise with Mr Bean to arrange for an audit to be carried out on DNA
cases and a report provided to the October meeting of the Committee. The terms
of reference for the audit to be brought to the next meeting.
ACTION: Mr Norman
The Committee discussed and noted the report.
QC/15/135 QUALITY DIGEST
Integrated Complaints and SI Data:
Mrs Barber presented both sections of the report which summarised the action
taken in relation to Complaints and SIs since the last meeting. Mrs Lloyd noted
that the out of time complaints mentioned in the report had now been completed.
Mrs Lloyd noted that the table at the top of page 5 should have been on page 3.
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Mrs Barber commented that the learning item about copying correspondence to
service users and their GPs was something that should have been happening
automatically. Mrs Lloyd agreed and said that a reminder had been circulated to
staff; Mrs Barber asked that the Community Recovery Service Line be requested
to confirm that the policy was now being followed.
ACTION: Mrs Lloyd
Mrs Barber noted that the draft report from the CQC Inspection indicated that there
was a lack of awareness about the management of low level complaints. Mrs
Lloyd said that members of her team attended Service Line Patient experience
Groups and reminded staff of the process. The new web based datix system
enabled mangers to log their own complaints, which she felt would improve the
process.
Mrs Lloyd said that satisfaction surveys were now being sent to all complainants
when their cases were closed. Replies had been received from 11 complainants
with 13% saying that they were very satisfied with the way their complaint had
been handled. Three complainants (30%) were dissatisfied and an analysis had
been done of these cases; Mrs Lloyd agreed to share this analysis with members,
she noted that two had said that the process had taken too long. Mrs Bray
suggested including the question ‘What would have made a difference’ to the form
and Mrs Barber said that asking ‘what part of the process was good’ would also
provide useful feedback. Mrs Lloyd confirmed that information from the survey
was fed back to service lines where possible.
ACTION: Mrs Lloyd
Mrs Barber noted that Medway Community Health Team had not received any
complaints in the period and the Committee agreed that this should be
acknowledged formally to the team.
ACTION: Mrs Lloyd
Mrs Lloyd provided confirmation that the final sentence on page 3 should read:
Maidstone, Ashford and DGS CMHTs have received the highest number of
complaints this month which is 3 cases each, whilst Medway recorded the
highest number of complaints for last month (5 cases).
The Committee discussed and noted the report.
Nursing metrics:
Mrs Barber noted that the data was mixed for this period; explanations were
provided within the report. Two wards had missed the 72 hour physical health
check target, in Amberwood this was thought to be linked to the high usage of
agency staff. Mrs Barber drew the Committee’s attention to the inclusion of the
National Safety Thermometer data in the report and agreed that more explanations
would be included in the next report.
ACTION: Mrs Barber
The Chairman asked for assurances that the data was accurate. Mrs Barber said
that the majority of the information was taken from the Business Information data.
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It was noted that the restraint data, shown as zero, seemed unlikely to be correct;
Mrs Barber agreed to check this.
ACTION: Mrs Barber
The Chairman noted that the Metrics report was in the development phase and
asked about future plans. Mrs Barber said that it had been recognised that the
metrics for Older Adults services needed to be different to take into account the
element of continuing care. Undertaking deep dives into care planning across the
service lines would provide more information than simple audits and the
Committee may wish to consider specifically requesting this in the future.
Mr Ashurst asked why physical health checks might be affected because there
were agency staff on the ward. Mrs Barber explained that this was most likely
when the agency staff changed frequently and there was little time for them to
become familiar with local practices. Mrs Barber confirmed that the Trust did not
run 12 hours shifts any longer and that time was set aside to ensure that hand
overs between shifts were carried out correctly. Mrs Eldridge had also introduced
a developmental programme for all new ward managers.
The Committee noted that Medication Omissions report data and that a full
narrative report was expected at the August meeting. The response rate was low,
at 67%, and Mrs Barber said that this was being addressed.
The Committee discussed and noted the report.
QC/15/136 LISTENING LEARNING AND IMPROVING PLAN
Mrs Barber reminded the Committee that the plan had been reformatted in the new
year with any outstanding items carried forward and captured actions arising from
reviews of national and local reports. It was agreed that timeframes would be
included in the next report and each service line director would be asked to submit
a summary report on how they were managing the plan.
ACTION: Mrs Barber
QC/15/137 CQC THEMATIC REPORT
Mr McFrederick reminded the Committee that the Trust had led on the CQC
Thematic Review on behalf of health and social care agencies across Kent. The
action plan arising from the report was being managed by the Crisis Concordat
Steering Group, which was jointly chaired by Chief Superintendent Ann Lisseman
and David Holman, West Kent CCG.
Mr McFrederick said that the report had been positive about the Crisis teams and
record keeping, while recognising that information sharing between agencies was
a problem, which was a national issue, and that there was a high usage of S136s
in Kent. The report focussed on the national picture with respect to A&E care and
noted that Kent services were relatively good, although Dartford was not 24/7 and
the East Kent Services were seen as fragile. Mr McFrederick said that the Crisis
Concordat was focussing their actions on reducing the high levels of S136s,
particularly as there was a less than 20% conversion rate. This was supported by
the Police, who recognised that the numbers needed to fall. The Concordat was
encouraging NHS England to meet with the CCGs to promote a more cohesive
approach.
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Mr McFrederick advised that different models for managing potential S136 patients
were being explored, as the Police had pulled out of the Street Triage project. It
was noted that the report was inaccurate in this respect as it indicated that the
project would continue. The Police were in favour of having a member of KMPT
staff based in their control room, which was not seen as an option by the Trust.
Use of cameras was one option being explored, as was an agreement with the
Ambulance Service.
The Committee discussed and noted the report.
QC/15/138 SIB QIA
Mrs Barber said that the group were now trying to work remotely where possible so
that decisions were not delayed. Virtual decisions taken were ratified at the formal
meetings. She brought the following to the attention of the Committee:
June meeting
2.2.5 Transport review – the arrangements made for public transport provision
between Medway and Maidstone following the transfer of services were being
discontinued as the uptake was minimal. Quality indicators would be monitored
quarterly and the decision reviewed if these fell.
2.3.2 Personality Disorder Therapeutic House - this initiative was reviewed, having
been in place for nine months; the SIB noted the positive reduction in S136
presentations although there was concern admissions to psychiatric beds during
crisis had increased. The SIB requested clarification of some of the data and
requested that the service line attend the 12 month review in October.
The Chairman said that the information provided in this report, around bed usage,
seemed to conflict with her recollection of data presented in another report to the
Board, possibly related to Transformation. She asked that this be checked.
ACTION: Mrs Barber
July Meeting
2.1.2 Review of Medical Posts (Forensic) – this QIA was closed.
2.2.2 Ruby Ward - Mrs Barber advised that this QIA was on the SIB agenda to
ensure that it was tracked as Ruby was now a stand alone ward. The Chairman
commented that it would be important for staff on the ward to maintain their
professional links with colleagues to avoid becoming isolated.
Mrs Barber noted that the SIB had considered a number of submissions relating to
therapeutic staffing; the majority had been referred back as it was too early.
The Chairman thanked Mrs Barber for the report, noting that the format and
content was now much clearer and helpful.
The Committee discussed and noted the report.
QC/15/139 QUALITY COMMITTEE ANNUAL REPORT
QC July 2015
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It was agreed to defer this item to the next meeting due to the late circulation of the
draft report.
ACTION: Miss Bedford, Agenda
QC/15/140 ITEMS FOR AUGUST AGENDA
The Committee considered the initial list of items for the August meeting and had
nothing to add. The Chairman commented that she was concerned about the
length of agendas for the meetings; these needed to be controlled better to make
sure that the Committee were clear about what was being asked of them and that
this fitted with its responsibilities for governance and assurance. Where
appropriate actions should be dealt with within the Management line.
QC/15/141 ITEMS REFERRED TO OTHER COMMITTEES
No items were referred.
QC/15/142 ITEMS TO REPORT TO THE BOARD
It was agreed to report the following items in the Committee’s report to the Board:
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clinical audit and the need to raise its profile in the Board
national patient survey and the timescales
DNA audit
Developing the Nursing Metrics
Medical audits.
That the CQC report would be considered at the next meeting, following its
publication
Update on managing S136 presentations and the work in the Crisis
Concordat.
QC/15/143 ANY OTHER BUSINESS
Mrs Barber advised the Committee that, due to changes in the focus of her role at
Kent County Council (KCC), Mrs Fenton would no longer be their representative
on the Committee. The Committee noted their thanks to Mrs Fenton for her
contribution to the work of the group and agreed that the Chairman should
acknowledge this formally by letter. Mrs Barber updated the Committee on the
changes occurring within KCC in response to new legislation and the practical
impact this was having on the details of the partnership between KCC. The
Committee agreed that representation from KCC was most valuable and they
would welcome a replacement for Mrs Fenton.
ACTION: Chairman
QC/15/144 DATE OF NEXT MEETING
The next meeting would be held at 1.00pm on 18 August 2015 in the Boardroom,
Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, ME16 9PH
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Minutes of the Quality Committee Meeting
held at 1300 hrs on Tuesday 18 August 2015
Boardroom, Trust Headquarters, Farm Villa,
Hermitage Lane, Maidstone, ME16 9PH
Present:
Margaret Andrews
Rod Ashurst
Catherine Kinane
Donna Eldridge
Steve Norman
Debbie Bray
Jon Stock
Srilatha Sadasivam
Non-Executive Director, Chairman
Non-Executive Director
Executive Medical Director, Quality
Deputy Director of Nursing
Patient Safety Manager
Trust Professional Lead for Allied Health
Professions, absent for items QC/15/151
Chief Pharmacist
Quality Intelligence Analyst
In Attendance:
Samantha Chalmers
Sheila Wilkinson
Sarah Holmes Smith
Apologies:
Amanda Bedford
Dan Stark
Vicky Boswell
Josie Broady
Justine Leonard
Risk Manager and Health & Safety Lead
Consultant, for item QC/15/153 & 160
Director, Acute Service Line,
for item QC/15/151 & 158
Assistant Trust Secretary (minutes)
Lead Nurse, OPMH, for item QC/15/157
Director of Performance, for item QC/15/161
Medical Records Manager, for item QC/15/162
Director, Older Adults Service Line, for item QC/15/
Pippa Barber
Nikki Oatham
Executive Director of Nursing and Governance
Head of Psychological Services
MIN NO
QC/15/145 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/15/146 APOLOGIES FOR ABSENCE
Apologies for absence were received as noted above.
QC/15/147 NOTIFICATION OF ITEMS FOR DISCUSSION NOT ON THE AGENDA
There were no items notified for discussion which were not on the agenda.
QC/15/148 CONFLICTS OF INTERESTS
There were no declarations of interest.
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QC/15/149 MINUTES OF THE LAST QUALITY COMMITTEE MEETING HELD ON 21 JULY
2015
The minutes of the last meeting held on 21 July 2015 were accepted and signed
as a correct record.
QC/15/150 MATTERS ARISING
The following updates were noted:
134 Trust Wide Patient Safety Group report – Mr Norman advised the meeting that
Ms McClean had started an audit of a sample set of case notes against the DNA
policy and would be reporting the results to the October meeting. Action closed.
135a Quality Digest – Mrs Eldridge agreed to liaise with the CRSL to confirm that
GP letters were being copied to patients.
ACTION: Mrs Eldridge
138 SIB QIA report – confirmation that data on bed usage is consistent across
Board and Board Committees, to be carried forward to the next meeting.
114a add the issue relating to blank boxes on medication charts to service line risk
register – Miss Bedford advised the Committee that Mr Halpin had confirmed by
email that this had been done. Action closed.
114b Share risk re MIMHS (Mother and Infant Mental Health Service) with the
CCGs - Miss Bedford advised the Committee that Mr Halpin had confirmed by
email that this had been done, The lead for the MIMHS would be attending the
August performance meeting with CCG colleagues to provide an update. Action
closed.
115 Review risk rating for risk 3736, medicines management Mrs Chalmers
confirmed that the risk had been reviewed. The rating had remained the same; the
inherent risk had been increased although this was balanced by the mitigated risk.
Action closed.
The updates due to the meeting on the following items:
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discussion re Ashford Deep Dive next steps
intramuscular injection audit
duty of candour
were deferred to the next meeting.
ACTION: Miss Bedford
RISK
QC/15/151 ACUTE SERVICE LINE RISK REGISTER
Ms Holmes-Smith advised the Committee that the risk register was discussed with
the Risk team each month. The following points were noted during the discussion:
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Ms Holmes-Smith said that one of the high risks remained staff morale (5136)
and that this was critical to performance in the service line. If the staff team
were not stable and permanent this impacted significantly on quality.
The risk relating to patients choosing to smoke in unsafe areas had been
identified and was being approached on the basis that patient safety had to be
the highest priority.
Ms Holmes-Smith noted that capturing in the records that a patient had been
offered support to cease smoking was not always done. Mr Ashurst suggested
that some information would be available from comparing patient details on
repeat admissions.
Patient flow, 4163, remained a critical issue.
Monitoring patient safety when care was contracted from a private provider,
3367, was an issue, which needed to be mitigated via visits from discharge
care co-ordinators. The service provided had to deliver value for money.
In response to a question from Dr Kinane, Ms Holmes-Smith said that she
would confirm that the risk register included the issues raised in the CQC
report.
ACTION: Ms Holmes-Smith
QC/15/152 QUALITY RISK REGISTER
Mrs Chalmers advised the meeting that the risk profile had shown little change
since the last meeting. Several new risks had been added to the register; the
related risk ratings were artificially high as it was Trust policy for the inherent and
mitigated risks to be the same value until the first review point, at which time the
risk rating would be expected to fall.
Dr Kinane advised the meeting that the register had been reviewed at the
Executive Management Team (EMT) meeting on Monday 16 August and some
changes had been suggested, so the document presented to the meeting did not
correctly reflect the current situation.
Mr Ashurst observed that the risks listed in the Acute Service Line risk register,
which was also being considered at the meeting, did not accurately reflect the
related items in the Quality Risk Register and he wondered how old the ASL risk
register paper was.
Mrs Eldridge asked the Committee to consider the implications of developments
with the Trust’s implementation of the Smoke Free Policy. She explained that in a
few locations patients were going off site so that they could smoke and were
congregating in unsafe areas to do so, for example by the side of a busy road.
The suggestion had been made that smoking shelters should be introduced on
these sites to mitigate the risk, however this would break the policy guidance. Mrs
Eldridge sought the view of the Committee.
Mr Stock commented that the key objective of the policy had been to improve
patient health by offering smoking cessation support. The amount of nicotine
replacement therapy medication used since the introduction of the policy was
much less than anticipated, suggesting that this objective was not being achieved.
Mrs Eldridge acknowledged that staff needed to be more pro-active to encourage
patients to stop smoking.
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Dr Kinane noted that removing the risk of secondary smoking from Trust buildings
had been another objective; this would still be met if smoking shelters were
positioned carefully. She wondered what action other Trusts were taking. Mrs
Eldridge said that some had followed a totally smoke free approach, others
allowed smoking area in the grounds.
Mrs Chalmers said that from a health and safety point of view, knowingly allowing
patients to leave the grounds to smoke in an area that was deemed unsafe was
unacceptable. She suggested that there would be no debate about mitigating the
risk immediately if it was arising from any other driver than smoking. Dr Kinane
said that the safety of patients had to be the Trust’s priority.
It was agreed that the Smoking Group would be asked to review the situation and:
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ensure patient safety is a priority;
determine how effective the policy had been in reaching the primary
objective of improving patient health; and
consider whether smoking was being treated differently to other addictions,
such as alcohol, and, if so, did this need to be addressed.
The Committee asked for an update to their October meeting.
ACTION: Mrs Eldridge / Miss Bedford, schedule
The Committee DISCUSSED and AGREED the report.
CQC INPSECTION
QC/15/153 CQC REPORT ACTION PLAN
Mrs Wilkinson reported that the CQC Quality Summit had taken place on 24 July
and an action plan had been developed by consolidating the individual action plans
subsequently developed by each service line. This had been shared with the TDA
and the CCGs who had asked that it be divided into categories:
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purely internal actions
actions involving capital expenditure
system wide actions.
As the plan was being revised to meet this requirement, and to include clear
timeframes, the Committee had been provided with a dashboard to show progress.
A follow-up meeting was scheduled with the TDA for 4 September. Mrs Wilkinson
agreed to provide a copy of the revised action plan for the non-executive directors
to consider at their meeting on 26 August. Monthly meetings were planned to
review the plan, involving the TDA, NHS England, the CCGs and the Trust. The
focus of the meeting was to ensure that the CCGs were able to meet their
obligations. It was agreed that a dashboard providing an update on progress
against the plan would be brought to each Quality Committee.
ACTION: Mrs Wilkinson / Miss Bedford, schedule
The Chairman noted that the Committee had received regular reports on the
Littlestone action plan, following the CQC visit, and suggested that a report from
the Rehabilitation Services should be brought to the next meeting; to be presented
by Mr Gartshore and Mr McFrederick.
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ACTION: Miss Bedford, schedule
Mr Ashurst noted that the Committee could not agree the action plan as this had
not been provided, but would be able to confirm that monitoring arrangement had
been agreed.
The Committee DISCUSSED the report and AGREED monitoring arrangements
for the CQC Quality Improvement Plan.
QC/15/154 CQC INSPECTION: LITTLESTONE ACTION PLAN
Mrs Leonard advised the Committee that the action plan was reviewed regularly in
the service line; she was meeting with colleagues later in the week to agree
whether the action plan should be transferred to the Trust CQC QIP action plan.
The following points were noted:
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Dan Stark, Lead Nurse, was now satisfied with pain management
arrangements. Dr Kinane noted that staff on the ward had asked for further
training on the principles behind pain management, which was positive.
Use of the dementia mapping tool was now embedded in the ward, again Mr
Stark was pleased with progress.
A revised version of the MEWS chart was being used which staff found easier
to complete and more informative. Mrs Eldridge advised that this was to be
rolled out across other wards.
The ward now had a continence care champion and audits on continence care
confirmed that process were being followed.
All the health care assistants had undertaken appropriate training.
The one case where family engagement was proving to be difficult to achieve
had moved to the stage of writing to the family members concerned.
End of life care was firmly in place in the ward.
Mrs Wigley had advised that she was satisfied with the responses from KCC in
relation to the three safeguarding incidents reported.
Mrs Leonard provided details of the staffing changes being made on the ward.
As yet it had not been possible to appoint a nurse with general nursing
qualifications, the post was being covered by a bank staff worker on a regular
basis.
A decision would be taken at the September meeting about using the CQC
Action Plan to monitor progress on Littlestone.
ACTION: Miss Bedford, schedule
The Committee DISCUSSED and AGREED the report.
QC/15/155 CQC FOLLOW-UP REPORT ON LITTLESTONE RE-VISIT
The Committee noted the report.
QUALITY DIGEST
QC/15/156 QUALITY DIGEST
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Integrated Complaints and SI Data: Dr Kinane advised the Committee that the
report provided the headline figures for complaints and serious incidents in period.
She noted that the number of open STEISS cases continued to increase; the Trust
were submitting cases within the required timeframe and correct format. In
response to a question from The Chairman about the need for Chief Executive
level support in liaising with the CCGs to reduce the backlog, Dr Kinane said that
some of the load of open cases was the result of the Trust needing to re-submit
paperwork to a revised format. As these were processed by the CCGs the
numbers should fall. The Trust was working with the CCGs to encourage them to
adopt a standard approach and, ideally, agree a lead CCG for the future. This was
supported by the TDA.
Ms Sadasivam advised the Committee that the data on complaints had been
impacted by the change to the web-based system and it may be necessary to
revise the figures. She explained that there were slight differences in the way that
complaints were categorised on the web system that needed to be resolved before
the data could be compared historically. The Chairman noted that the levels of
complaints in Dartford, Gravesham & Swanley and Medway seemed to be
increasing, which should be monitored. Ms Sadasivam said that the corrections
being made were likely to reduce these numbers.
Dr Kinane noted that the figures showed the good progress made on reducing the
use of prone restraints.
Dr Kinane advised the Committee that she intended to revise the content of the
Quality Digest to make it more focussed; a lot of information had been added since
it was first developed and it was in need of constructive review.
Nursing metrics: Mrs Eldridge noted that incidents of prone restraints were now
all entered onto the web based datix system. A lot of work had been done to
reduce these. Mrs Eldridge said that targets for 72 hour physical health
assessments were not being met in some areas. One factor was that patients
admitted for acute mental health were sometimes not willing to agree to the
checks; it was reassuring to note that the checks were carried out later.
Mrs Eldridge explained that ward teams were focussing on the safe ward analysis,
moving towards completing the 10 modules. This was a continuous process and
the Acute Service Line were working to a completion date of December 2015. Mrs
Eldridge said that progress on the programme should be evident to those doing 15
steps visits.
Mrs Eldridge advised the Committee that wards were now required to complete
both the general and mental health national safety thermometer. The general
thermometer was designed against acute care processes so was not well suited to
mental health wards.
Dr Kinane noted that some items were being reported in the Quality Digest and
Nursing Metrics, such as restraint and violence & aggression figures. The
restraint data differed this month in the two reports and this was of concern. Mrs
Eldridge acknowledged the problem and said that she was working with Mrs
Sadasivam to ensure consistency; it was important for the data to be included in
the Nursing Metrics as it was used for performance monitoring generally.
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Medications Omissions: Mr Stock said that this was the 5th snapshot audit
undertaken and reported to the Quality Committee. Mrs Eldridge had asked that
the audit be extended across the month rather than, as now, be undertaken on just
one day. Mr Stock said that he was exploring this with the audit team. He
confirmed that an omission was defined as a drug not being administered within an
hour either side of the prescribed time. If the relevant recording box on the drug
chart was blank this would be counted as an omission as staff were required to
write in a code if a choice was made not to administer the drug. One such code
was ‘drug not available’, which meant that either it was not in stock or not available
from the manufacturer. Lloyds Pharmacy made daily deliveries.
The Chairman said that the level of omissions were worrying as this was a
fundamental and simple process. She noted the low performance on Amhurst
Ward, at 87%, and Mr Stock confirmed this had been recognised. Mrs Eldridge
noted that data had not been provided from three wards, one of which was
Littlestone Ward, and this was being addressed. The Chairman expressed
concern that data from the CRSL had not been included as the Lead Nurse was on
holiday. Mrs Eldridge said that this should not have happened; the audits had
been carried out, the failure had been in providing a narrative for the report. The
Committee noted the zero scores for the Rivendel Unit and the Chairman
commented that this site had not performed well in their 15 steps visit.
Mrs Eldridge explained that it was good practice for ward managers to check
medication charts prior to staff going off duty and this was being rolled out across
the wards. Mr Stock said that the pharmacy staff were undertaking a rolling
programme of accompanied drug rounds so that each ward was covered at either
a lunch or tea-time drug round every month.
The Committee DISCUSSED and AGREED the report.
QC/15/157 END OF LIFE CARE – POLICY UPDATE
Mr Stark explained that the policy had been updated to reflect the changes within
the NHS to move from the Liverpool Care Pathway towards ensuring that patients
in the end stage are identified and then that the care provided is appropriate for
them. Mr Stark said that the key driver was that there was only one chance to get
this right for each individual. Mr Stark explained that identifying the end stage of
life in patients with dementia presented particular challenges and the policy
extended some of the timeframes within the national guidance to ensure that this
would be achieved.
The policy also took into account the NICE guidance on care for the dying. Mr
Stark said that he was now in the process of arranging training.
The Chairman thanked Mr Stark and said that that she was pleased to note the
care being taken to get this policy right. In response to a question from Mr Stock,
Mrs Eldridge confirmed that hospice staff are invited in to assist for patients
requiring sophisticated pain relief; these were too few to make it viable to train inhouse staff.
Dr Kinane noted that the policy included the clinician’s responsibility to make
decisions taking into account, but not necessarily adhering to, the views of carers
and family. She suggested that this be cross-reference to the Mental Capacity Act
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and the Do Not Resuscitate (DNR) policy. It was agreed that the Trust Wide
Patient Experience Group should own the policy.
The Committee APPROVED the End of Life Care Policy subject to the inclusion of
cross referencing to the Mental Capacity Act
QC/15/158 SECTION 136 UPDATE REPORT
Ms Holmes-Smith introduced this item as Ms Dorey-Rees was unwell. She
reminded the Committee that seclusion rooms had been raised as an issue in the
CQC report. The Dartford area was undergoing refurbishment, which should be
completed by the end of the month; to meet the Trust’s committeemen to have four
sites available, extra capacity had been arranged at Canterbury. The Canterbury
refurbishment would take place in November.
Ms Holmes-Smith noted that the rooms were subject to damage due to violence on
a regular basis and one had been closed over the weekend. In response to a
question from Dr Kinane, Ms Holmes-Smith confirmed that patients were
sometimes charged for the damage depending on the circumstances of the case.
Mrs Chalmers advised that the Local Security Management Services were
developing protocols to be used in such circumstances to help determine the
viability of cost recovery.
Ms Holmes-Smith confirmed that the demographic data for use of the suites in the
North reflected the population demographics. It was noted that there had been a
slight spike in use in July and this was being looked at to see whether this showed
any correlation with factors such as staff leave, the temperature or number of
patients in private beds.
Ms Holmes-Smith noted that the conversion rate for admission remained low at 10
– 20%. The high number of S136s in the county had been recognised by the CQC
review and acknowledged by the Crisis Care Concordat. Negotiations were
ongoing with partner organisations about the model to be adopted to address this
issue. The police were less favourable towards the street triage model, and had
withdrawn support. Alternatives were being considered.
The Committee DISCUSSED and AGREED the report.
QC/15/159 15 STEPS PROGRAMME
Mrs Eldridge presented the 15 Steps Annual Report and reminded the Committee
that the visiting teams looked at the wards from the patient experience view and
covered the four CQC domains. The visits were unannounced and two were made
to each ward annually, unless specific concerns were raised. Mrs Eldridge
commented that it had been difficult to find lay members for all the visits that year.
The Chairman suggested that it would be helpful if visit dates could be set quickly
once availability was provided to the co-ordinator, if there was a delay the date
may have been lost.
The Chairman said that it was pleasing to note the amount of positive results. The
principle for the visits was for staff to receive feedback from the visit team and
produce a quick action plan to address any issues raised. The team will then revisit the ward area to assess the changes made.
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Dr Kinane suggested that the checklist could be extended to include signage
relating to use of CCTVs and viewing seclusion rooms. Mrs Eldridge emphasised
that the areas covered by the 15 steps visit have to be based on patient
experience; she felt that the areas suggested by Dr Kinane could be included and
she would look at some wording; for example the test for the seclusion rooms
could be about there being a calming environment and having a clock and
calendar in the room.
In response to a question from the Chairman, Mrs Eldridge said that the
programme was sustainable with effort. The intelligence gained was shared with
senior managers in the service line and Directors.
The Committee DISCUSSED and AGREED the report.
QC/15/160 WELL LED ORGANISATION
Mrs Wilkinson reminded the Committee that the guidelines for the Well Led
Framework had been issued in April 2015 and discussed at an informal meeting of
the Board. It had been agreed that the Quality Committee would look at the
Quality Module and that IARC would look at the Governance module. A report
would then go to the Board for agreement.
The Committee first discussed the rationale for completing the framework and
agreed that more detail in the text about the evidence considered when assessing
the ten sections would help in judging the assessment. Dr Kinane suggested that
the evidence would support a positive response, detract or indicate a developing
area. Mr Ashurst commented that if gaps were identified as part of the process,
then confirmation that there were appropriate action plans in place was needed.
The Chairman asked the Committee whether there were any areas where
members thought that the assessment did not provide a proper reflection of the
Trust’s performance. Mr Ashurst said that he did not have a level of concern that
would support a change in the rating given, however, there were some areas
where he felt there was a lack of evidence. He gave the examples of an absence
of succession planning in relation to a robust leadership and also asked whether
360° peer reviews were part of the appraisal system. Mrs Wilkinson confirmed that
the assessment was in keeping with the issues highlighted in the CQC report.
The Committee DISCUSSED and AGREED the ratings proposed in the paper prior
to a full Board self-assessment of the Well Led Framework.
QC/15/161 QUALITY ACCOUNTS 2015/16 PERFORMANCE REPORT QUARTER 1
The Chairman thanked Mrs Boswell for the useful report, noting that it was the first
time it had been presented to the meeting for the 2015/16 Quality Account targets.
The following points were noted:
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the target for the number of SI and suspected suicides was an annual one so
the data included the numbers from the previous year as a comparator.
The safeguarding targets were challenging, staff were being supported to
achieve the year end 85% target
The figures on attending case conferences involving children had improved.
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Recording information on RiO remained an issue for some of the targets.
Recording of data on smoking cessation by the wards would be reviewed on a
monthly basis. As this was linked to a CQUIN measure accurate data
collection was important and may need manual collection until electronic
collection was considered robust. The key element was to evidence whether
the measures were working. Mrs Boswell said that this would continue to be
refined.
The Committee noted that work on the drafting of the discharge letters for
patients had slowed and requested that this be addressed.
ACTION: Mrs Lloyd
Mrs Eldridge advised that there was now a task and finish group working on
person centred care planning. She advised that the digital pen project had
been cancelled. The Committee were surprised to hear that this step had
been taken and decided to refer the matter for further consideration at the
Board.
Mrs Eldridge said that the task and finish group were considering whether to
use carbon copies as an interim measure; Dr Kinane said that the open RiO
would be going line in September so efforts should be focussed on getting the
care planning element of this correct.
The physical health check target for in patients was being impacted by the
acuity of the patient’s condition. The situation for community checks was
complex as some patients would have the checks from their GPs if they were
on medication. Mrs Boswell said that she was looking into this further.
The Committee were surprised that the recovery star was still part of the
quality accounts. Mrs Bray advised that there was now a different focus on
care planning goals being person focussed.
Mrs Boswell confirmed that the report data could be presented by service line
for the next quarter.
In her capacity as lead for the management of production of annual governance
documents, Miss Bedford asked the Committee to ensure that they began
debating the quality account priorities for 2016/17 at the earliest opportunity.
The Committee DISCUSSED and AGREED the report.
QC/15/162 MEDICAL RECORDS REPORT – QUARTERLEY UPDATE
Mrs Broady advised that there were 106 outstanding discharge letters from
2014/15 to be entered onto the system. For 2015/16 the outstanding numbers
were being kept at 3%, which was an excellent result. Validating records was also
progressing with a monthly level of 3% and the outstanding figure currently at 7%,
compared to 19% in October.
The Chairman commented that the data appeared to be volatile; she had hoped to
see more of a constant straight line, although the percentages were reassuring. Dr
Kinane said that overall the position was much more positive than in the previous
year. There had been more admissions in recent months, particularly in July. Dr
Kinane said that she was reviewing the graphs used in the report and would
update this for the next presentation.
The Committee DISCUSSED and AGREED the report.
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QC/15/163 QUALITY IMPACT ASSESSMENT REPORT
Mrs Eldridge noted that the report set out the decisions taken at the last QIA
meeting. She reported that a decision had been taken not to move to 12 hour
nursing shifts. The Chairman commented that the report provided assurance that
the group were engaged with responsible decision making on behalf of the Quality
Committee.
The Committee DISCUSSED and AGREED the report.
QC/15/164 ANY OTHER BUSINESS
There was no further business.
QC/15/165 ITEMS REFERRED TO OTHER COMMITTEES
There were no items for referral to other committees.
QC/15/166 ITEMS TO REPORT TO THE BOARD
The Committee agreed to include the following items in the report to the Board:
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CQC quality improvement plan (QIP)
Note the progress in relation to use of restraints
15 Step Annual Report
Acute Service Line risk register report.
Update on progress with S136 referrals
Progress against the quality accounts
Progress on validation of records and discharge summaries
Littlestone update, including report on the CQC re-visit
To seek guidance from the Board with respect to cancelling the digital pen
project.
Update on Trust wide medicines monitoring following CQC inspection
QC/15/167 SEPTEMBER AGENDA
The Committee noted the items proposed for inclusion in the agenda for the
September meeting.
QC/15/168 DATE OF NEXT MEETING
The next meeting would be held at 13.00 hrs on 15 September 2015 in the
Boardroom, Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, ME16
9PH
QC August 2015
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Minutes of the Workforce and Organisational Development Committee Meeting
held at 1300 hrs on Wednesday, 20 May 2015
in the Boardroom, Farm Villa, Maidstone
Present:
Mr R Ashurst
Non-Executive Director, Chairman
Ms A M Dean
Non-Executive Director
Mr P Jones
interim Director of Human Resources
In Attendance:
Ms R Bailey
Assistant Director, HR
Mrs J Leonard
Older Adults Service Line Director
Mr K Halpin
Forensic and Specialist Services SL Director
To end of formal meeting
Mrs S Holmes-Smith
Acute Service Line Director
Mrs L Hunt
Head of Learning and Development,
to item WF/15/52
Mrs T Wells
Head of Recruitment
Mrs S Marchant
Head of Workforce information and Governance
Ms C Stewart
Acute SL HR Business Partner
Ms S Spence
CRSL HR Business Partner
Miss A Bedford
Assistant Trust Secretary (minutes)
Ms Ml Brown
Interim Company Secretary
Apologies:
Mr M McFrederick
Director of Operations
MIN NO
WF/15/45 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/15/46 APOLOGIES FOR ABSENCE
Apologies for absence were received as noted above.
WF/15/47 DECLARATION OF INTERESTS
Mr Jones noted an interest in item WF&OD/15/38 Self-Employed Contractors,
given his status as an interim appointment.
WF/15/48 NOTIFICATION OF ITEMS FOR DISCUSSION NOT ON THE AGENDA
There were no items notified for discussion which were not on the agenda.
WF/15/49 MINUTES OF THE LAST BOARD MEETING HELD ON 10 MARCH 2015
The minutes of the last meeting held on 10 March 2015 were accepted and signed
as a correct record.
WF&OD 20 May 2015
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WF/15/50 MATTERS ARISING
35 NED Training: Mrs Hunt provided written details of the mandatory training
required for the Non-Executive Directors. Mr Ashurst said that he would take this
forward with his colleagues.
36a Database for Mentors: Mr Jones noted that the policy was being reviewed as
this requirement was currently beyond the resources within the HR team and
would need to be delivered in a more proportionate way.
37a Reconciling HR and Finance staffing data: Mr Jones noted that he and Mr
Cave were working to reconcile the data sets and to ensure consistent reporting.
Mrs Marchant advised that the inconsistencies between the staffing data presented
in various reports were due to the timing of when the data was pulled from different
systems.
WF/15/51 ORGANISATIONAL DEVELOPMENT (OD) STRATEGY AND LEADERSHIP
STRATEGY UPDATE
Mr Jones advised the Committee that both strategies were to undergo a revision to
migrate from the current aspirational document to a more practical version which
was within the ability of the HR Department to deliver. An interim Head of OD had
been appointed, Mr Nigel Benjamin, and provided details of his qualifications. Mr
Benjamin had been tasked with developing the revised strategies and a road map
for delivery over the next three years. Mr Jones noted that the choice of making
an interim appointment to the post would ensure that any permanent appointments
made would support the revised strategies.
The Chairman asked whether the revision was likely to be based on a scaling
down of the strategy or an increase in the Trust’s OD resources. Mr Jones said
that there were plans to expand the OD team and it was also intended to prioritise
the initiatives within the strategies to ensure that they fully support the Trust’s
transformation work. Mr Jones said that the aim was to facilitate a collegiate
approach within the organisation to deliver culture change and leadership,
ensuring that the planned deliverables were within the capacity of the HR team.
The future vision needed to be articulated more clearly and a good baseline
established to provide coherence and an agreed direction.
Mr Jones confirmed that the leadership work planned with the Pacific Institute
would be taken forward, although planned work with other organisations may be
reconsidered.
In response to a question from Mrs Dean, Mr Jones said that the OD Strategy did
need to be better aligned to the Transformation Programme and that this was key
to the revision work. The Chairman suggested that some projects within the
Programme required more OD support than others so the alignment perhaps
needed to be more to the detail than the wider picture. Mr Jones added that there
was also some overlap between projects
The Committee discussed and noted the oral report.
LEARNING AND DEVELOPMENT
WF&OD 20 May 2015
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WF/15/52 LEARNING AND DEVELOPMENT REPORT
Mrs Hunt noted that it would take time to meet the new targets for moving and
handling training, although the link trainers were now in place. If required, some
extra external support would be arranged.
The Committee agreed the proposal that provision of library services be moved to
Maidstone and Tunbridge Wells NHS Trust. Mrs Hunt said that the move would be
made in July and confirmed that the change would be seamless for users of the
service.
Mrs Hunt drew the Committee’s attention to the report on Allied Health
Professionals Placement and noted that it was a requirement to bring this
information to Board level attention. Mr Jones confirmed that he would work with
Mr Cave to resolve an ongoing financial issue relating to purchasing computers for
the use of students during their placements.
The Chairman noted the data on compliance with medicines calculations and
prescribing training and commented that this had relevance to the CWF inspection
findings, which would be discussed later.
The Committee discussed and noted the report and agreed to transfer provision
of library services to Maidstone and Tunbridge Wells NHS Trust.
METRICS
WF/15/53 WORKFORCE METRICS AND TRENDS
Mrs Marchant noted the following:
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staff in post figures were showing a slight increase from the 2011/12 figures
and a slightly different staff mix;
turnover was below the national average;
the twelve month rolling figure for sickness absence was currently 3.42% the 2015/16 target was still to be set; and
appraisal levels had been consistently above the target of 90% for the last
three months.
Mrs Marchant said that for the July report the data would be linked to patient
metrics to better understand how workforce issues were impacting on
performance. The Chairman welcomed this development and suggested that this
could also be applied to the results of the national staff survey.
Mrs Dean noted that the numbers of starters and leavers were closely balanced,
which was of some concern when building the workforce. She requested that the
medicals/dental line be divided to show consultant levels and a percentage
turnover figure to show the level of loss. The Chairman commented that the level
of turnover for younger staff was surprisingly high; Mrs Marchant confirmed that
this had been noted and the exit questionnaire was to be used to try to identify
why. Mrs Leonard commented that often the younger members of staff were
moving to higher grade posts. Her concern was to understand why, when young,
newly qualified staff did not choose the Trust to build their careers within. Mrs
WF&OD 20 May 2015
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Bailey and Mrs Dean both noted that they had had some good feedback from a
recent preceptorship group.
The Committee discussed and noted the report.
STAFF CHECKLIST AND POLICY REVIEW
WF/15/54 RECRUITMENT KPIs
Mrs Wells reported that Nursing/HCA recruitment was keeping pace with the
number of leavers, noting the high level of retirees among leavers. The recent
recruitment campaign involving advertising in the Guardian had been successful,
resulting in over 300 hits to the recruitment site. Mrs Wells said that she would
report on the conversion rate for this campaign at a later meeting. Mrs Wells said
that for Q4 2014/15 there had been 204 advertisements and 258
assessment/interview processes. The Chairman asked whether the team had the
capacity to manage this level of workload; Mrs Wells acknowledged that the team
was spread thinly, although improvements were being made to streamline
processes. It was noted that Medical Staffing figures were not included in this
data.
The meeting then considered whether Medical Staffing would be better managed
outside of the HR department, given concern that the pressure of responding to
urgent, unpredictable need to find medical cover adversely impacted on
recruitment activity. Mrs Dean suggested that there was a more natural link
between Medical Education and Medical Staffing. Mr Jones said that this was
being considered as part of the overall fitness for purpose review of the HR
structure currently underway. He confirmed that the Committee would be kept
updated on this at future meetings.
The meeting discussed and noted the report.
WF/15/55 SELF EMPLOYED CONTRACTORS – GOVERNANCE ARRANGEMENTS
Mr Jones noted that this issue had been added to the HR risk register. A number
of recommendations had been made following an internal audit report on this
issue; in his view the following areas were still outstanding:
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the HR department were not capturing all instances where interim staff
were being employed;
compliance with HM Treasury guidance could not be fully evidenced;
more rigour needed to be applied to background checks; and
ensuring value for money was not a robust feature.
Mrs Bailey noted that the process for compliance with Treasury guidance had been
made more robust; the department continued to follow up with individuals who had
been employed and were reticent in providing the required details. She confirmed
that, ultimately, reports would be made to HRMC where individuals failed to
comply; the Trust had to meet its statutory obligations. The Chairman asked that
he and Mrs Dean be provided with a list of people who had failed to provide the
required information.
ACTION: Mrs Bailey
WF&OD 20 May 2015
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The Committee discussed and noted the oral report.
WF/15/56 WHISTLEBLOWING REPORT
Mrs Bailey reported that there had been no new whistleblowing incidents since the
last meeting. Fourteen concerns had been raised, 64% anonymously. She
confirmed that anonymous concerns were investigated if possible and outcomes
reported via the monthly team briefings, sometimes the information provided was
insufficient to do so. Mrs Dean asked that a report be provided on the way in
which the Trust was responding to the TDA forward in the Francis Report,
‘Speaking out’ be included in a future agenda.
The Committee discussed and noted the report.
GOVERNANCE
WF/15/57 RISK REGISTER
Mrs Marchant noted that the HR risk Register had been reviewed and updated.
The key risks identified were:
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2193 Sickness absence target: Mrs Marchant noted that the data had been
looked at in greater depth and infections and stress related illness had been
identified as the main reasons for absence. The Chairman confirmed that the
data should continue to be presented on a Trust wide basis to allow for
comparisons to be made. He suggested that the risk should be re-worded to
show the affect of sickness absence, in particular in relation to patient safety.
3807 Failure to recruit consultants
3738 Staff engagement – the Committee noted the link to the discussion on
item WF/15/51 OD and Leadership Strategies.
3808 Failure to recruit to safer staffing levels: the risk had been revised to take
into account the therapeutic staffing project.
Mrs Marchant noted that several new risks had been identified which would be
added to the register, including:



Off payroll appointments
Lack of leadership capability
Reputational damage should the Primary Care Pilot fail.
The Committee discussed and noted the report.
WF/15/58 TERMS OF REFERENCE REVIEW
The Committee considered the Terms of Reference and agreed to amend Section
6 Quorum to read: A Quorum shall consist of one Non-Executive Director and
either the Director of HR or the Operations Director.
Section 5, Attendance b other Directors and Staff was also considered and it was
agreed that this should also include the Head of OD and Head of earning and
Development and Service Line HR Business Partners.
WF&OD 20 May 2015
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Section 14 – the reference to Terms of Reference to be reviewed annually by the
Integrated Audit and Risk Committee (IARC) should be removed unless this is
consistent with the terms of reference for other Board Committees.
It was agreed to make any necessary changes to remove references to defunct
organisations and to update staff titles.
The Committee discussed and revised the Terms of Reference.
The Formal Meeting closed at this point as Mr Jones had to leave to attend a
Consultants’ Forum meeting and it therefore ceased to be quorate. (15.45)
.
The Non-Executive Directors remained and the following items were considered:

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
The Board Effectiveness review results. The length of the agenda and the
need to ensure that all those attending were able to contribute in line with their
experience and knowledge were noted as areas where improvements might be
made. It was important that issues be delegated to sub-committees as
appropriate with the WF&OD Committee retaining the wider view. Mrs Dean
said that consideration should be given to improving the way that the work of
the Committee is communicated to staff.
ACTION
WF&OD Annual report – required greater detail – to return to the July meeting.
ACTION
The Apprenticeship Report was noted.
The Safer Staffing report was noted.
The Policies and Procedures report was noted.
Matters to be reported to the Board to include:
o
o
o
o
o
o
o
OD and Leadership Strategies review
Workforce metrics – report to be appended
Recruitment data
Off payroll contractors
Whistleblowing
Risk Register
Terms of Reference
The remainder of the meeting was given to the joint presentation from the Acute
and Community Recovery Service Lines on their response to the National Staff
Survey. Mrs Holmes-Smith explained that Mr Gartshore, CRSL Director, had
contributed to the presentation and sent his apologies that a previous appointment
prevented him from attending in person.
At the conclusion of the item the Chairman thanked the presenters for a very
useful presentation which had provided a welcome opportunity for him and Mrs
Dean to drill down into the detail of some of the cultural and staffing issues facing
the operational teams.
DATE OF NEXT MEETING
The next meeting would be held at 13.00 hours on 22 July 2015 in the Boardroom,
Trust Headquarters, Farm Villa, Hermitage Lane, Maidstone, ME16 9PH
WF&OD 20 May 2015
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Minutes of the Workforce and Organisational Development Committee Meeting
held at 1300 hrs on Wednesday, 22 July 2015
In the Boardroom, Farm Villa, Maidstone
Present:
Mr R Ashurst
Ms A M Dean
Mr M McFrederick
Mr P Jones
Dr A Sarfraz
Mrs T Wells
Mrs L Hunt
Mr G Cook
Non-Executive Director, Chairman
Non-Executive Director
Director of Operations
Interim Director of Human Resources
Director of Medical Education,
for item WF/15/68 only
Head of Recruitment
Head of L&D
Employee Relations Team Manager
In Attendance:
Mr N Benjamin
Ms C Cloud
Ms C Stewart
Ms J Leonard
Mr K Halpin
Dr L Lockerbie
Ms S Holmes-Smith
Interim Head of Organisational Development
HR Business Partner,
Forensics and Specialist Services SL
HR Business Partner, Acute SL
Director, Older Adults SL
Director, Forensic and Specialist Services SL
Forensics and Specialist Services SL
Director, Acute SL
Miss A Bedford
Mr S Guile
Assistant Trust Secretary (minutes)
Interim Company Secretary
Ms R Bailey
Mrs S Marchant
Ms L Pratt
Deputy HR Director
Head of Workforce Information & HR Governance
HR Business Partner, Oder Adults SL
Apologies:
MIN NO
WF/15/60 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/15/61 APOLOGIES FOR ABSENCE
Apologies for absence were received as noted above.
WF/15/61 DECLARATION OF INTERESTS
Mr Jones and Mr Guile reminded the Committee of their status as interim
employee.
WR&OD 22 July 2015
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WF/15/62 NOTIFICATION OF ITEMS FOR DISCUSSION NOT ON THE AGENDA
There were no items notified for discussion which were not on the agenda.
WF/15/63 MINUTES OF THE LAST BOARD MEETING HELD ON 22 JULY 2015
The minutes of the last meeting held on 22 July 2015 were accepted and signed
as a correct record with the following exceptions:

Sarah Holmes-Smith to be referred to as Ms Holmes-Smith, not Mrs HolmesSmith.
WF/15/64 ACTION SHEET AND MATTERS ARISING
Communicating the Committee’s decision to staff: it was agreed that inclusion in
the one minute read would be appropriate.
36a Mentor database: Mr Jones said that this would be developed within the HR
team as a coaching database.
NED training: The Chairman said that this had been taken forward, with his nonexecutive colleagues being encouraged to complete their required training.
SERVICE LINE PRESENTATION: RESPONSE TO NATIONAL STAFF SURVEY
WF/15/65 OLDER ADULTS
Mrs Leonard provided a summary of the results of the staff survey for the Older
Adults Service Line and the actions taken, as per the presentation at appendix A.
In the discussion on the items the following points were noted:
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Mrs Dean wondered whether the actions being taken would have time enough
to impact before the next survey was carried out.
Mrs Leonard confirmed that where possible actions around staff development
were being arranged on a county wise basis.
Mrs Dean observed that continual professional development (cpd) of clinical
staff was well managed and planned; she suggested that such rigor should be
applied to cpd for non-clinical staff. Mr Benjamin said that a key element of
the revised Organisational Development (OD) was to ensure that paperwork
was not a barrier to good practice in relation to appraisals so that the process
of setting and monitoring objectives and cpd was effective and robust. It was
acknowledged that the systems used needed to be trust wide; if these were
too complex local teams would be tempted to develop their own, Mrs Leonard
acknowledged that one team in the service line had done so. It was agreed
that Mrs Hunt, Mr Benjamin and Mrs Leonard would review the standard
documentation; Mr Ashurst suggested that the team who had developed their
own version should be represented on that group.
ACTION: Mrs Hunt.
Mr McFrederick observed that assessing staff talent, weaknesses and
strengths was a key factor in delivering the transformation
The Committee DISCUSSED and AGREED the report.
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WF/15/66 FORENSIC AND SPECIALIST SERVICES (FSSL)
Ms Cloud provided a summary of the results of the staff survey for the Forensic
and Specialist Services Service Line and the actions taken, as per the report
appended to the agenda. In discussion the following points were noted:
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Mr Halpin observed that it was important to respond to the information given
from the survey – the question should only be raised if the results are going to
be acted upon.
The Chairman asked whether any of the actions taken by the FSSL could be
copied within other service lines. Ms Holmes-Smith confirmed that the HR
business partners did share ideas and good practice. Mr Benjamin
commented that building a network to share engagement ideas and avoid
duplication was part of the OD strategy.
Mr Halpin noted that the FSSSL did not have the same physical spread as the
other service lines; their sites were discrete and self-contained so in some
respect taking action was easier.
The Chairman referred to the FSSL engagement cycle and asked whether the
consultant staff were involved in the process. Mr Halpin confirmed that this
was the case.
Mr Halpin confirmed that the service line was experiencing problems with
consultant recruitment, which was not assisted by the current recruitment
process. However retention was not such a problem.
In response to a question from Mrs Dean, Mr Halpin explained that many of
the actions taken were low cost; there was not a specified budget for staff
engagement work. He commented that a lot could be achieved with bartering
services.
Mr Guile challenged the Committee to consider whether presentations from
four service lines and the corporate team on the same issue provided value for
time taken. The Chairman and Mrs Dean agreed that the discussion gave
them the opportunity to meet with the senior operational management team
and engage in discussion about key issues. The staff could also be assured
that their views were being heard directly and fed through to the Board. The
time taken was therefore most valuable.
The Committee DISCUSSED and AGREED the report.
ORGANISATIONAL DEVELOPMENT
WF/15/67 ORGANISATIONAL DEVELOPMENT AND LEADERSHIP STRATEGY
Mr Benjamin presented the report on progress in implementing the strategy. He
explained that the strategy presented to the board had been comprehensively
reviewed and the road map provided in the report focussed on the areas seen to
be key to delivering the transformation programme. Mr Benjamin stressed that the
strategy could not be seen in isolation to the transformation programme but as
integral to its delivery. The corporate teams also needed to be seen as part of the
process rather than as delivering a back office function. The process needed to
the linked to the Trust’s values and fully embedded consistently within the
organisation. Mr Benjamin agreed with the view expressed earlier that linking the
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work to appraisals and personal development plans was essential. Mr Benjamin
said that the pathway for leadership development in the Trust was not yet clear.
In response to a question from the Chairman, Mr Benjamin said that all service
lines had systems to vet the training courses staff attended. However, the
approach needed to be more consistent and linked to appraisals. It was
acknowledged that developing metrics to test the impact of training on quality of
service was difficult. The Chairman suggested that there were some measures
already included within the Integrated Quality and Performance Report to the
board which could be relevant.
Mrs Dean said that she would be interested to see how the OD Strategy and
Transformation Strategy mapped over the Clinical strategy and whether the
funding available would be sufficient at the critical points. She also questioned
whether the strategy was flexible enough to respond to sudden or unexpected
commissioning decisions.
Mr McFrederick commented that, given the large number of consultant vacancies,
depending on Local Leadership Groups (LLGs) to take the leadership pathway
forward was not practical. He suggested that care should be taken not to rely on
the Edward Jenner programme for training needs as this may be under review
nationally. Mr McFrederick added that some titles user in the report needed to be
corrected and requested that it be re-worked to ensure that there were clear OD
objectives for specific projects. The programme must be sustainable and fit for
purpose, not an impediment to change.
The Committee DISCUSSED and AGREED the report and requested that a
further update be brought to the next meeting.
LEARNING AND DEVELOPMENT
WF/15/68 DIRECTOR OF MEDICAL EDUCATION REPORT
Dr Sarfraz provided the Committee with summaries of the three items detailed in
his report and added the following information:
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
Junior Doctors’ rota – the Trust was in the top five most popular training
trusts and third in the country for core training.
Consultant recruitment and retention – it was recognised that the practice
of assigning mentors to new consultant staff had been lost and should be
re-instated; Dr Kinane was supporting this approach.
Physician associate programme
In response to a question from Mr Ashurst, Mr Jones confirmed that retention of
consultant staff had been recognised as a significant issue; there would shortly be
29 vacancies in a consultant body of 96. The HR department was looking at
various issues, such as work intensity and job satisfaction, with a view to
expediting changes to encourage retention. There was a need for job redesign to
ensure the posts were attractive. He confirmed that this had been added as a risk
on the HR risk register. Mrs Dean suggested that this should be considered for
inclusion on the Trust wide risk register.
ACTION: Mr Jones
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Mr Jones said that following the current recruitment process would mean that
these vacancies could not be filled before the New Year. The process needed to
be streamlined as some of the current steps did not add value; work on this was
underway. Another factor was the amount of HR support available; this had been
reduced as part of the de-centralisation of the HR function.
The Committee DISCUSSED and AGREED the report.
WF/15/69 LEARNING AND DEVELOPMENT – METRICS
Mrs Hunt presented the report and the following was noted:
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The team were seeking benchmarking data from other trusts in relation to the
number of trainers in L&D teams prior to a business case being submitted.
Moving and handling link trainers were in place.
A project plan was being developed to deliver HNOS training as there were no
trainers available at present.
Teams were being encouraged to back fill care support workers to ensure that
they all complete the care certificate programme.
The team were working towards making mandatory training requirements role
specific; at present the CCGs were making different requirements and
nationally several new topics, such as dementia training, were being added.
In response to a question from the Chairman about the pressures on the
trainers to deliver mandatory training, Mr Jones explained that the Trust was
reviewing what training should be included, the methods of delivery and the
frequency of the updating to help control the demand and match to the
resources of the team.
Mr Halpin said that the pressure on the operational teams to release staff for
mandatory training was also significant; the previous day he had been asked
to release all ward managers to attend a four day course on health and safety
training. Mr McFrederick said that this would be raised at the operational
board.
It was recognised that there was a growing need for role specific training also.
The Committee DISCUSSED and AGREED the report.
WF/15/70 NHS LEADERSHIP ACADEMY NATIONAL PROGRAMME
The Committee NOTED the report and asked to be kept up to date with
developments.
ACTION: Mr Benjamin
STAFFING AND METRICS
WF/15/71 HR WORKFORCE METRICS, TRENDS AND HEAT MAP
Mr Jones said that the highlights of the report were: the 9.79% year to date
turnover rate, which was below the national average; the 3.4% sickness rate for
May, with a year to date figure of 4.28 which was just above the trust target for
3.9% - in response to a question from the Chairman, Mr Jones confirmed that
sickness reporting was made against the national guidance; and appraisal rates at
94% with only IM&T being below the target rate of 90%. However, the figures
WR&OD 22 July 2015
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masked the variation within the Trust and Mr Jones explained that he was
developing a heat map to try to capture this; the first draft of which was presented
in the report.
The Chairman said that he welcomed the additional granularity that the heat map
provided. Mr McFrederick noted that it was critical that the workforce data used in
HR and Finance was consistent. The Chairman commented that he remained
unconvinced that the data on vacancies was robust. Mr Jones said that by the
end of the month the data within the ESR and Finance would be reconciled, there
was then further work to do to validate the data. Mr Jones commented that the
data had to reflect the real situation, for example in some cases there may have
been a decision not to recruit to a vacancy, in which case the establishment
figures may not match the number in post plus the vacancy number. Mr Halpin
commented that the service line teams needed to know the number of vacancies
they could recruit to. Mrs Dean suggested that it was also important for the
vacancy figures for medical staff to split out the consultant and training posts to
provide a proper picture.
The Committee DISCUSSED and AGREED the report.
WF/15/72 SAFER STAFFING
Mr McFrederick advised the Committee that the report coming to the September
meeting would be revised to reflect the therapeutic staffing plans. Formally the
Trust would report on the nursing figures but would also present the therapeutic
staffing. He agreed to talk with the Chairman and Mrs Dean outside of the
meeting to explain the details of the therapeutic staffing model.
ACTION: Mr McFrederick
WF/15/73 RECRUITMENT AND RETENTION STRATEGY
Mrs Wells explained that the Recruitment and Retention group now met monthly
and that Dr Harte, Deputy Medical Director, had joined. The action plan the group
was working to had been expanded and included:
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a new lean methodology to be adopted for recruitment;
succession planning model;
exit interviews undertaken more frequently; and
benchmarking against other trusts.
Mrs Wells noted that her team were not always aware of the work done locally
around staff retention. In response to a question from the Chairman, Mrs Wells
said that she expected the action plan to be completed within a year. Mrs Dean
asked whether the actions were being taken forward via task and finish groups to
ensure that they were completed as quickly as possible. Mrs Wells said that all
the actions were underway and were being treated as a matter of priority.
Mr McFrederick made the following points: retention and the survey results would
not necessarily equate; managing internal appointments better could improve on
consultant retention; and controlling the start dates when internal appointments
were made would reduce the potential disruption for fragile services and was
within the control of the Trust to do so.
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Mr Halpin asked whether feedback could be provided to the service line teams
when there were trust wide recruitment drives, such as the one which had taken
place in Scotland. Mrs Wells provided a brief summary of that outcome; Mrs Dean
noted how important it was to include accommodation in the recruitment package
if staff were expected to re-locate.
The Committee DISCUSSED and AGREED the report.
GOVERNANCE
WF/15/74 INTERIM “PAY OFF” APPOINTMENT PROCESS AND CONTROLS
The Chairman commented that the report was quite detailed and invited questions.
Mrs Dean said that it should be made clear which background checks must be
completed before an interim post could be commenced. It was agreed that the
declarations required by the HMRC must be provided before the contract
commenced. The Committee requested a six monthly report on off payroll staff.
The Committee DISCUSSED and AGREED the report.
WF/15/75 HR RISK REGISTER
Mr Jones explained that the risk register which had been taken to the Integrated
Audit and Risk Committee when he first joined the Trust had not, in his view,
properly reflected all the Workforce risks. Also, the risk calibration tool had not
been applied to the ratings. A lot of work had been done to improve the quality of
the register and he felt it now reflected the workforce risks more accurately. He
noted that a risk around consultant vacancies had been added.
Mr Jones noted that the register was a line document and would be reviewed
regularly. Mr Jones noted that risk 4362 Impact from Critical Reports, was
included in the Board Assurance Framework as a reputational risk.
The Committee DISCUSSED and AGREED the report.
WF/15/76 WHISTLEBLOWING AND CONCERNS RAISED
Mr Jones explained that the report included a review of the ‘Freedom to Speak Up’
guidance produced in the aftermath of the Mid Staffordshire case. The report
summarised the systems already in place in the Trust and some further work
which the Trust may wish to consider, including:



appointing a Freedom to Speak up guardian;
appointing a designated Executive Director; and
nominating a manager in each department to receive reports of concerns.
After discussion the Committee AGREED that the Trust should adopt best practice
in relation to this guidance and REQUESTED an action plan to be developed in
discussion with staff groups and an update brought to the next meeting.
ACTION: Mr Jones
WF/15/77 POLICIES AND PROCEDURES
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Mr Cook explained that the paper summarised the current position in relation to
HR policies and the plans in place to make these more flexible and responsive,
ensuring that any irrelevant policies were removed. The plan was to move forward
with tranches of five policies each time to make the work manageable; the most
urgent policies would be dealt with first.
Mrs Dean said that policies should include simple flow charts with clear timelines
to make it easy for staff to follow.
The Committee DISCUSSED and AGREED the approach to managing and
updating HR policies laid out in the report.
WF/15/78 WORKFORCE AND ORGANISATIONAL DEVELOPMENT ANNUAL REPORT
Deferred.
STANDING ITEMS
WF/15/79 MATTERS TO BE REFERRED TO TRUST BOARD
It was agreed to report the following items to the Board:







medical staffing recruitment
OPMH and FSS staff survey action plans – noting that best practice was being
shared across all service lines
OD strategy
Workforce data
Safer staffing figures
Recruitment and Retention strategy
Whistleblowing report
WF/15/80 MATTERS TO BE REFERRED TO BOARD COMMITTEES
None.
WF/15/81 ANY OTHER BUSINESS
The Chairman noted that this was the last meeting that Mr Halpin would be
attending prior to his retirement and thanked him for his considerable contribution
to the work of the Committee.
WF/15/82 REVIEW OF SEPTEMBER AGENDA
The early draft of the agenda for the September meeting was noted and agreed.
The item on Freedom to Speak to be added.
WF/15/83 DATE OF NEXT MEETING
The next meeting would be held at 16th September 2015 in Boardroom B, Trust
Headquarters, Farm Villa, Hermitage Lane, Maidstone, ME16 9PH
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