Deloitte proposal document A4 - Poole Hospital July 2014 Part 1 Board... · 2014. 7. 23. · CoG...

Top

Poole�Hospital�NHS�Foundation�Trust

Council�of�Governors

Council�of�Governors��Part�1�-�4.30pm�Thursday�31�July�2014

31�July�2014�-�16:30

Board�Room�1,�Poole�Hospital,�BH15�2JB

AGENDA

1 Apologies�for�absence

2 Declaration�of�Interests

3 Draft�Minutes�of�Meeting�held�on��1�May�2014CoG�July�14�a�Minutes�May�14�Part�1�Draft 7

4 Matters�Arising/Action�ListCoG�July�14�B�Actions 16

5 Chairman’s�Comments

6 TO�APPROVE

7 2014/15�Remunerations�and�Allowances�for�Chairman�And�Non-Executives’Owner:�NREC/Chairman

CoG�July�14�C�Renumerations�and�Allowances�for�Cha 18

8 Proposed�Changes�to�the�ConstitutionOwner:�Chairman

CoG�July�14�D1�Proposed�Changes�to�Constitution�co 19CoG�July�14�D2�Proposed�Changes�to�the�Constitutio 20CoG�July�14�D3�Report�to�Governors�on�detail�chang 24

9 TO�RECEIVE

http://www.eshareuk.com

Top

10 2013/14�Annual�Report�&�Accounts�Issued�Separately

10.1 Annual�Report�&�Accounts�(including�Audit�Opinion)Owner:�Chief�Executive/Director�of�Finance/External�Auditor

10.2 Supporting�Information

10.3 External�Audit�Report:�The�Quality�ReportOwner:�External�Auditor

CoG�July�14�F1�cover�sheet�-�Quality�report 165CoG�July�14�F2�Quality�Account�Report�-Final 166

10.4 External�Audit�Report:�Financial�StatementsOwner:�External�Auditor

CoG�July�14�G1�cover�sheet�-�Governor�finanical�st 191CoG�July�14�G2�Governor�financial�statement�report 192

11 2013/14�Annual�Council�of�Governors�Assessment�of�Collective�PerformanceOwner:�Chairman/Company�Secretary

CoG�July�14�H1�2013-14�Annual�Council�of�Governors 209CoG�July�14�H2�2013-14�Annual�CoG�Assessment�of�Co 210

12 Report�from�NREC�Meeting�31�July�2014Owner:�Chairman

13 Annual�Audit�and�Governance�ReportOwner:�Senior�Independent�Director

CoG�July�14�I1�Annual�Audit�and�Governance�Report� 229CoG�July�14�I2�AG�Annual�Report�2013-14 230

14 Updates�to�Governors�Meeting�Schedule�for�Calendar�Years�2014�and�2015Owner:�Company�Secretary

CoG�July�14�J1�Updates�to�Governors�Meeting�Schedu 228CoG�July�14�J2�CoG�2014�Meeting�Schedule 248

15 FOR�INFORMATION/SCRUTINY

16 Update�on�Non-Executive�RecruitmentOwner:�Chairman


Top

17 Trust�Performance�Report�Month�3Owner:�Chief�Executive

CoG�July�14�K�IPR�Jun�2014�MM�checked 251

18 Monitor�Quarter�4�Monitoring�FeedbackOwner:�Chief�Executive

19 FOR�REVIEW

20 Reports�from�Reference�Groups:

20.1 Membership�Engagement�and�RecruitmentOwner:�Mrs�S�Yeoman

20.2 Future�Plans�&�PrioritiesOwner:�Mr�T�Purnell

20.3 Governor�Training�and�DevelopmentOwner:�Mr�J�Pride

21 Reports�from�Other�Groups

21.1 SWGENOwner:�Attendees

21.2 Staff�GovernorsOwner:�TBC

22 Future�Agenda�ItemsOwner:�Chairman

23 Motions�on�NoticeOwner:�Chairman

24 Urgent�Motions�or�QuestionsOwner:�Chairman

25 Date�of�next�meeting:�(25/09/14�12.15-1.00)�(30/10/14�4.30pm)Owner:�Chairman


Top

26 A�glossary�of�abbreviations�that�may�be�used�in�these�papers�will�be�foundat�the�back�of�this�document

27 AGENDA�–�PART�2

28 Draft�Part�2�Minutes�of�the�Meeting�held�on�1�May�2014

29 Matters�Arising/Action�List

30 Draft�Minutes�from�Nominations,�Remuneration�and�Evaluations�Committeeheld�on�1�May�2014

31 TO�AGREE

32 Outcome�of�the�Chairman’s�and�Non-Executive�Directors’�2013/14�AnnualPerformance�EvaluationOwner:�Chairman/Senior�Independent�Director

33 Future�Engagement�with�a�Removed�GovernorOwner:�Chairman

34 TO�RECEIVE

35 Trust's�Operational�Plan�Document�2014/16Owner:�Chief�Executive/Director�of�Finance

36 Trust’s�Strategic�Plan�Document�2014/19Owner:�Chief�Executive/Director�of�Finance

37 Trust’s�Business�Planning�CycleOwner:�Director�of�Finance

38 FOR�INFORMATION/SCRUTINY

39 Quarter�1�Submission�to�MonitorOwner:�Chief�Executive

40 PRESENTATION

41 Transformation�ProgrammeOwner:�Transformation�Director


Top

42 Close�of�MeetingOwner:�Chairman

Attendees


Top

IndexCoG�July�14�a�Minutes�May�14�Part�1�Draft.doc.......................................................................7

CoG�July�14�B�Actions.docx................................................................................................... 16

CoG�July�14�C�Renumerations�and�Allowances�for�Chairman�and�....................................... 18

CoG�July�14�D1�Proposed�Changes�to�Constitution�cover�sheet�.......................................... 19

CoG�July�14�D2�Proposed�Changes�to�the�Constitution.docx................................................ 20

CoG�July�14�D3�Report�to�Governors�on�detail�changes�to�the�.............................................24

CoG�July�14�F1�cover�sheet�-�Quality�report.doc..................................................................165

CoG�July�14�F2�Quality�Account�Report�-Final.pdf...............................................................166

CoG�July�14�G1�cover�sheet�-�Governor�finanical�statement�re........................................... 191

CoG�July�14�G2�Governor�financial�statement�report�-�Poole�H...........................................192

CoG�July�14�H1�2013-14�Annual�Council�of�Governors�Assessmen....................................209

CoG�July�14�H2�2013-14�Annual�CoG�Assessment�of�Collective�P..................................... 210

CoG�July�14�J1�Updates�to�Governors�Meeting�Schedule�for�Cal........................................228

CoG�July�14�I1�Annual�Audit�and�Governance�Report�cover�shee.......................................229

CoG�July�14�I2�AG�Annual�Report�2013-14.docx................................................................. 230

CoG�July�14�J2�CoG�2014�Meeting�Schedule.docx..............................................................248

CoG�July�14�K�IPR�Jun�2014�MM�checked.doc....................................................................251

Governance�Cycle�Apr�14.doc..............................................................................................281

Glossary�of�abbreviations�Feb�13.docx.................................................................................284


1

A

COUNCIL OF GOVERNORS

The minutes of the meeting of the Council of Governors of Poole Hospital NHS Foundation Trust held on 1 May 2014 at 4.30 pm in the Board Room, Poole Hospital.

Present: Mrs A Schofield Chairman AVM G Carleton Purbeck, East Dorset & Christchurch

Mrs L Cherrett Clinical Staff Ms C Cherry Bournemouth University Mr A Creamer Poole

Mrs V Duckenfield Poole Mrs R Gould Purbeck, East Dorset and Christchurch

Mrs B Hooper Purbeck, East Dorset and Christchurch Cllr. D Jones Dorset County Council

Miss K Knudsen Clinical Staff Mrs S Lowrey Clinical Staff

Dr C McCall Dorset Clinical Commissioning Group Mrs I McLellan North Dorset, West Dorset, Weymouth

and Portland Mr B Newman Bournemouth Mrs L Nother Poole Mrs E Purcell Poole Mr T Purnell Bournemouth Cllr. A Stribley Borough of Poole

Mr G Whittaker Non Clinical Staff Mrs S Yeoman Poole

In attendance: Mr M Beswick Company Secretary

Mrs D Fleming Chief Executive Mr M Friedman Director of Transformation Mr P Miller Director of Finance Dame Yvonne Moores Trust Vice Chairman Mr M Mould Chief Operating Officer

Ms T Nutter Director of Nursing & Patient Services Mr G Spencer Senior Independent Director

Mr R Talbot Medical Director Mrs SJ Taylor Director of Human Resources Miss J Retigan Minute Taker

CoG 037/14 Apologies for Absence

Apologies for absence were received from Mr J Pride; Poole.

CoG�July�14�a�Minutes�May�14�P

Top

Overall�Page�7�of�287Page�1�of�9


2

CoG 038/14 Declarations of Interest

The Chairman noted her interest in item 9; Reappointment of Chairman and noted Dame Yvonne Moores and Mr Spencer, who were in attendance, had an interest in item 17; Planned Non Executive Review.

No other declarations of interest were noted. CoG 039/14 Minutes of the Meeting held on the 16 January 2014 (Paper A)

The minutes were agreed as an accurate record of the meeting.

CoG 040/14 Matters Arising (Paper B)

050/13 – It was agreed that the presentation from the Ambulance Service would be removed from the actions list and be revisited when appropriate.

ACTION: JR 010/14 – It was noted that the Walkabout Programme was currently under

review and when this was complete the timetable would be issued for inclusion in the Governor Newsletter. ACTION: TN

015/14 – Ms Nutter reported that the invitations for the Mock QCQ Inspection

are yet to be issued, and would be sent to Governors when available.

It was noted that all actions, unless subject to this agenda, had been executed.

CoG 041/14 Chairman’s Comments

The Chairman welcomed the four new Executive Directors to the Trust and all Directors to the meeting. Monitor had issued a letter on 28 March, which released the Trust from investigation and reverted the governance rating to green. It was noted that monthly monitoring to Monitor would continue. The item identified by Governors from the Quality Accounts for auditing, right patient in the right place at the right time, was proving problematic to measure. It had been agreed to substitute implementation of the Friends and Family Test for audit. Ms Nutter noted that right patient in the right place at the right time remained in the Quality Accounts and work to make this measurable in future was underway. Forest Holme had officially reopened on 23 April. This had been an excellent event that showcased the improvements made. The Chairman noted her thanks to everyone involved in the refurbishment. The staff awards had taken place and been a very successful event, the Governors who had attended were thanked for their support. Elections were underway for two public governor seats in the Poole Constituency and the results were expected on 27 May 2014.


Top



3

Bournemouth Council had put forward a nomination for their Appointed Governor. Subsequently the nominated person had declined the role and a further nomination was awaited from Bournemouth Borough Council. To ensure independence on the Board of Directors, a statement was required in the Annual Report if a Non-Executive Director has served on the board of the NHS foundation trust for more than six years from the date of their first appointment. Due to the proposed merger, which had subsequently been prohibited, the tenure of three Non-Executive Directors had been extended beyond this point. The Board had undertaken a review and confirmed the independence of the three Non-Executives and approved a narrative for inclusion in the Annual Report. The refurbishment of the Maternity Department was nearing completion and the opportunity to put a charity/fundraising shop in the entrance at no cost to the Trust had been presented. Mrs Fleming reported that consideration was being given to this proposal and Governors could forward any comments on this subject to her. ACTION: GOVERNORS Monitor had issued a new publication: Your Duties; a Brief Guide for Governors. The electronic link to the report would be issued with the next Governor Newsletter. ACTION: MB The first in a series of clinical presentations to Governors had taken place earlier in the day. The subject had been emergency care and acute medicine from Dr Gary Cumberbatch and Dr Hannah Smith. The presentation had been very informative and well attended by Governors. At the private Council of Governors meeting on 16 January 2014 the Council had approved the reappointment of two Non-Executive Directors: Mr Guy Spencer for 12 months to 24 April 2014, and Mr Ian Marshall for three years to 31 January 2017. The Governors had endorsed the removal of a disqualified Governor and scrutinised several reports, including the Strategic Risk Report, the Chairman/Non-Executive Reappointments or New Appointments and the Monitor Quarter 2 Monitoring Feedback Report. The Council had also received an update on the 2014/16 Annual Plan. The report was NOTED.

CoG 042/14 Outline Proposed Changes to the Constitution (Paper C) Mr Beswick presented the report which had been discussed at the Informal

Council of Governor meeting on 1 May 2014. Mr Beswick noted that the Council were being asked if they supported the proposed changes and would like them to be pursued.

The first change related to the removal of a Governor. Monitor guidance suggested that an independent assessor agreeable to both parties should be requested to consider the evidence and determine whether the proposed removal is reasonable or otherwise. The Trust currently does not comply with that part of the code of governance and as required, a note to that effect would be included in the Annual Report. It was agreed that a small working group, with access to legal advice, would consider if a change to the Constitution should be recommended in the light of Monitor’s guidance

ACTION: MB


Top



4

The second change related to disqualification periods. Mr Beswick detailed the current position, which was not always consistent, and the proposed periods of disqualification. These were discussed and it was agreed that the working group would also consider whether there should be exceptions to disqualification following the resignation of a Governor. ACTION: MB

Four other miscellaneous changes were detailed and discussed. One of these was to remove the requirement to advertise Council of Governor meetings in the local press. It was agreed that these did not provide value for money and it was suggested a poster with meeting dates and information, along with membership leaflets be issued to local libraries. The other three proposed miscellaneous changes were agreed. ACTION: MB

The report was SUPPORTED in principle. CoG 043/14 Governor Meeting Schedule for 2015 (Paper D)

Mr Beswick presented the proposed meeting schedule for 2015, which followed the same pattern as in recent years with the inclusion of clinical presentations. The report was discussed and some amendments agreed. The revised schedule would be presented at the next meeting. ACTION: MB The report was NOTED. The Chairman left the meeting and Mr Spencer took the Chair.

CoG 044/14 Reappointment of Chairman (Paper E)

Mr Spencer reported that Mrs Angela Schofield’s term of office as Chairman of the Trust was due to expire on 15 May 2014 and this report was submitted to provide the Council with information to allow it to make an informed decision on whether to make a reappointment or not. It was noted that Mrs Schofield was willing to extend her tenure. Mr Spencer presented the report, which included guidance from Monitor’s Code of Governance in relation to the reappointment of chairman/non-executive directors, and this was noted. Mr Spencer detailed the research he had undertaken and noted the high regard for the Chairman that had been expressed by Directors and Governors and the huge support for this reappointment. It was noted that the report evidenced that Mrs Schofield continued to be effective and demonstrate commitment to the role of chairman. Mr Beswick reported that the Nominations, Remuneration and Evaluation Committee had considered this item at its meeting and unanimously recommended that the Council of Governors reappoint Mrs Schofield for a further period of three years until 15 May 2017. The Council of Governors unanimously APPROVED the reappointment of Mrs Schofield as Trust Chairman for a further three years.

Mrs Schofield re-joined the meeting.


Top



5

CoG 045/14 Reappointment of Non-Executive Director (Paper F)

The Chairman reported that Mr Nick Ziebland’s term of office as a non-executive director was due to expire on 30 August 2014.

The Chairman presented the report and noted the Monitor guidance provided.

The attributes and skill set that Mr Ziebland brought to the Board were discussed and noted.

It was noted that following consideration of this item, NREC recommended that the Council of Governors approve the reappointment of Mr Ziebland for a further three year term with effect from 1 September 2014.

The reappointment was APPROVED. CoG 046/14 Revised Governors Meeting Schedule for 2014 (Paper G) The Chairman presented the 2014 meeting schedule which had been updated

to include the programme of clinical presentations. Mr Beswick detailed other changes and following discussion it was agreed

that the 2014 Governors meeting schedule would be revised and presented to the next meeting. ACTION: MB

The report was NOTED. CoG 047/14 Disputes Procedure (Paper H) Mr Beswick presented the report and noted that a formal procedure to resolve

disputes between the Council of Governors and Board of Directors had been approved by the Board and was presented to Council for it to receive this report.

The report was discussed and it was agreed that it would be reissued

following typographical amendment. ACTION: MB The report was RECEIVED. CoG 048/14 Report from NREC Meeting 1 May 2014 The Chairman noted that there was nothing additional to report from the

NREC meeting held on 1 May 2014 that was not covered by the agenda. The report was NOTED. CoG 048/14 Annual Report/Statement of the work of NREC (Paper I) The Chairman presented the report which had been considered at NREC.

The report was discussed and one error was noted which would be amended. ACTION: JR

The Chairman thanked Miss Knudsen and Mrs Purcell for their contribution to

the work of NREC during 2013/14. The report was NOTED.


Top



6

CoG 049/14 Planned Non-Executive Review (Paper J) – For Approval The Chairman reported that due to the proposed and subsequently prohibited

merger it had been agreed to extend expiring contracts of Non-Executive Directors, rather than recruit to those positions. Three Non-Executives had completed two, three year tenures and been reappointed for a further twelve months. These were Dame Yvonne Moores, Mrs Jean Lang and Mr Guy Spencer.

Monitor’s Code of Governance B.7.a noted that the Council of Governors should ensure planned and progressive refreshing of the Non-Executive Directors. Due to the significant changes in the executive team a staged approach to provide change over the next 18 months was proposed and detailed. It was noted that NREC had agreed to recommend the proposals for the planned and progressive refreshing on Non-Executive Directors to the Council of Governors for approval.

The Chairman noted that at its meeting NREC had considered the process,

job description and person specification for a non-executive appointment for November 2014, and these had been agreed in outline. It had also agreed to the appointment of external advisors if deemed appropriate. The Chairman noted that a timetable, which planned for the recommendation for first new non-executive appointment to be submitted at the earliest to the July Council Meeting, had been approved.

The process was discussed and it was noted that quick decisions would be

required to meet the preferred timetable and procurement regulations. The potential to recruit to the positions in parallel was discussed as were the challenges to recruit a person with clinical experience who was resident in Dorset.

The Council of Governors APPROVED the report. CoG 050/14 Update on Trust Position re Francis Report Ms Nutter presented her report and detailed the work undertaken at the Trust

following the publication of the Francis Report. Ms Nutter noted that a report, which presented the final response of the Trust

to the Francis Report with recommendations, would be presented to the May meeting of the Board of Directors.

It was noted that Ms Nutter had commenced work on a quality strategy. The report was NOTED. CoG 051/14 Integrated Trust Performance Report Month 12 (Paper K) Mrs Fleming presented the report which detailed the position of the Trust to

the end of March 2014. Mrs Fleming noted the delivery of the financial plan and the strong operational performance which evidenced the credit due the Board and all staff across the hospital.


Top



7

Mr Miller reported that the target of £900k surplus had been achieved after the fixed asset impairment, which was the result of a write-off due to a valuation from the District Valuer. Mr Miller noted that the Continuity of Service Risk Rating had dropped from level 4 to a 3, which was primarily due to the high level of creditors (£1.5m). Mr Mould detailed the position with the Monitor four hour emergency department target and noted the actions, both undertaken and planned. A report to achieve a sustainable position going forward would be presented to the Board of Directors. Mr Mould emphasised that this important standard was the responsibility of the whole hospital with patient flow being a key factor to compliance. The 36 hour target for fractured neck of femur was considered and Mr Talbot detailed the recent peaks in admissions. It was noted that a report on this issue was scheduled to be presented at the May Board meeting. The importance of ensuring the correct nursing establishment was raised and Ms Nutter reported that the Care Quality Commission (CQC) and NHS England had developed clear guidance in response to the Hard Truths Report, which had been considered by the Board in April. Ms Nutter stated that a report on how this applied to Poole Hospital NHS Foundation Trust would be submitted to the private meeting of the Board in May and the public Board meeting in June. It was noted that there had been an increase in the number of Serious Untoward Incidents and Mr Talbot reported that the Clinical Commissioning Group (CCG) now required recorded moderate events in this data set. Following discussion it was agreed that Mr Mould would amend the presentation of this information to clearly demonstrate the change. ACTION: MM Dr McCall asked about the position with Cancer Target breaches and how the Trust managed its reliance on other organisations. Mr Mould reported that of 12 breaches, 8 involved other Trusts with four of those not referred to Poole Hospital until the target had already been breached. It was noted that documents to formalise responsibilities were being drafted and discussions with the Royal Bournemouth & Christchurch Hospitals (RBCH) and Dorchester County Hospital (DCH) were underway. Ms Nutter reported that there had been ten cases of Clostridium Difficile in 2013/14 and noted that new arrangements with the CCG allowed the Trust to make an application where cases were not avoidable.

The report was NOTED. CoG 052/14 Monitor Quarter 3 Feedback (Paper L) Mrs Fleming presented the report, which included Monitor’s feedback letter

following their assessment of the Trust’s performance during quarter three of 2013/14.

Mrs Fleming noted that while the Monitor investigation had been closed, the

financial challenges remained. The report was discussed and NOTED.


Top



8

CoG 053/14 Disclosure and Debarring Service (DBS) Checks (ex CRB) Mr Beswick reported that Disclosure and Debarring Service (DBS) checks

would replace CRB checks. It was noted that Governors would be subject to the new arrangements and further detail would be provided in the Governor Weekly E-mail.

The report was NOTED. CoG 054/14 Reports from Reference Groups Membership Engagement and Recruitment (MERG) Mrs Yeoman noted that membership of the Trust remained a high priority and

a number of suggestions had been considered and taken forward byMERG. These included leaflets at Chestnut Nursery, engagement with Bournemouth & Poole College and focusing on young people, initially through Poole and Parkstone Grammar Schools.

Mrs Yeoman requested any Governor who could volunteer to attend the Bournemouth University (BU) Festival of Learning, to assist in the recruitment of members, should contact Ms Cherry. ACTION: Governors Mrs Yeoman reported that the Trust was short by 800 members to meet the target of 6250. Options to support Governors in this work were being considered and this included the employment of a marketing agency. Ms Cherry suggested that membership recruitment could potentially be a project for BU students and it was agreed this would be taken forward outside this meeting. ACTION: SY/MERG

Mrs Yeoman noted her thanks to those Governors that supported the work of

MERG and the report was NOTED.

Future Plans & Priorities (FPP)

Mr Purnell reported on a meeting that had taken place on 30 January with Governors, Non-Executive and Executive Directors. It was noted that Mr Friedman had delivered an excellent presentation on the transformation programme. Mr Purnell noted that it had been agreed that FPP would meet twice a year to enable Governors to understand and contribute to plans that would help to sustain the Hospital in the future. Mrs Fleming noted that the views of Governors were critical and Mr Beswick reported that FPP meetings would be built into meeting schedules as discussed earlier in the meeting. The report was NOTED. Governor Training and Development (GTD) Mr Beswick reported that the Governor Training and Development Reference Group met for the first time on 24 April 2014. At this meeting they had approved their Terms of Reference and Mr Pride was made Chairman of the group. Mr Beswick noted that the group would oversee a budget and monitor and support the Governor Development Plan.


Top



9

Mr Beswick reported that the GTD was considering a skills audit for Governors, which would be a self-assessment exercise and, as discussed at their meeting, a skills assessment for members of NREC would also be considered. At their meeting the group had decided that a Governor Awayday, with external support, would take place in the autumn and a guide to being a ‘buddy’ for new Governors would be produced. Governors were asked to note Tuesday 4 November 2014 in their diaries for the Awayday. ACTION: ALL The report was NOTED.

CoG 055/14 Reports from Other Groups SWGEN

It was noted that comprehensive feedback from the SWGEN had been produced by AVM Carleton and had been included in the Governor Weekly E-mail. Staff Governors The Staff Governors noted that they had nothing pressing to report at this time.

CoG 056/14 Future Agenda Items

The Chairman reported that current priorities remained the focus for the Council of Governors agenda.

CoG 057/14 Notices of Motion

No notices of motion were received.

CoG 058/14 Urgent Notices of Motion

No urgent notices of motion were received. CoG 059/14 Date of Next Meeting

31 July 2014 at 4.30 in the Board Room, Poole Hospital.

CoG 060/14 Withdrawal of Press and Public

The Chairman asked any members of the public and representatives of the press to withdraw from the meeting.


Top



B POOLE HOSPITAL NHS FOUNDATION TRUST

COUNCIL OF GOVERNORS ACTION LIST

31 July 2014

Minute No Meeting Date

Agenda Action Deadline Lead

041/14 01/05/2014 Part 1 Any comments on this subject of a charity/fundraising shop in

maternity to be sent to Mrs Fleming

Closed Governors

041/14 01/05/2014 Part 1 A link to Monitor's new publication: Your Duties; a Brief Guide

for Governors to be issued with the next Governor Newsletter

Completed Michael Beswick

042/14 01/05/2014 Part 1 A small working group, with access to legal advice, to consider if

a change to the Constitution should be recommended in the

light of Monitor’s guidance and consider whether there should

be exceptions to disqualification periods following the

resignation of a Governor


042/14 01/05/2014 Part 1 Four other miscellaneous changes to the constitution were

supported


043/14 01/05/2014 Part 1 Revised Governor Meeting Schedule for 2014 to be presented

to the July meeting

On July

agenda

Completed

Michael Beswick

046/14 01/05/2014 Part 1 Revised Governor Meeting Schedule for 2015 to be presented

to the July meeting

On July

agenda

Completed

047/14 01/05/2014 Part 1 Disputes Procedure be reissued following typographical

amendment


CoG�July�14�B�Actions.docx

Top



B POOLE HOSPITAL NHS FOUNDATION TRUST

COUNCIL OF GOVERNORS ACTION LIST

31 July 2014

048/14 01/05/2014 Part 1 Amend Annual Report/Statement of the work of NREC as

agreed

ASAP Jill Retigan

053/13 01/05/2014 Part 1 Following the change in reporting criteria Mr Mould to amend

the presentation of SUI information to clearly demonstrate the

change

July Mark Mould

054/14 01/05/2014 Part 1 Any Governor who could volunteer to attend the Bournemouth

University (BU) Festival of Learning, to assist in the recruitment

of members, to contact Ms Cherry

Closed Governors

054/14 01/05/2014 Part 1 Consider if membership recruitment could potentially be a

project for BU students

As

appropriate

MERG

CoG�July�14�B�Actions.docx

Top




Meeting Date: 31 July 2014

Agenda Item: 7 Paper No: C

Title:

2014/15 Chairman’s and Non-Executive Directors’ Remuneration and Allowances.

Purpose:

To approve the 2014/15 remuneration and allowances for the

Chairman and Non-Executive Directors at the same levels as 2013/14.

Summary:

The Nominations Remuneration and Evaluation Committee (NREC), reflecting the national economic situation, propose to Council of Governors for approval that there are no increases in the remuneration and allowances for the Chairman and Non-Executive Directors for 2014/15. It is noted that this is the fifth year that these remunerations have remained frozen. The current levels of remuneration are;

Chairman £40,000 Vice-Chairman £14,000 Senior Independent Director £14,000 Chairman of Audit & Governance Committee £15,000 Chairman of Finance and Investment Committee £15,000 Chairman of Quality & Safety Committee £15,000 Chairman of Workforce Committee £15,000 Non-Executive Director £12,000

Recommendation:

To approve the remuneration proposal from NREC

Prepared by:

MICHAEL BESWICK Company Secretary

Presented by:

ANGELA SCHOFIELD Chairman

CoG�July�14�C�Renumerations�an

Top





Agenda Item: 8 Paper No: D

Title:

Changes to the Constitution and the Code of Conduct for Governors

Purpose:

The Council is asked to approve amendments, as outlined in the attached papers, to the Trust’s Constitution and Code of Conduct for Governors

Summary:

The changes are presented under the following headings

Removal of a Governor

Disqualification Periods

Miscellaneous

Increasing the public constituency The papers attached include

A summary report of the changes

A referenced detail description of the changes o A revised version of the Constitution (Version 9) o A revised version of the Code of Conduct for Governors

Recommendation:

Council are asked to approve the changes to the Trust’s Constitution and Code of Conduct for Governors with effect from 1 August 2014

Prepared by:


Presented by:


CoG�July�14�D1�Proposed�Change

Top



D

Poole Hospital NHS Foundation Trust

Council of Governors

Meeting Thursday 31 July 2014

AMENDMENTS TO THE CONSTITUTION &

GOVERNORS CODE OF CONDUCT Introduction The Board and the Council confirmed, at the respective April 2014 meetings, that they wished to amend the Trust’s Constitution and Code of Conduct for Governors with regards to;

Removal of a Governor (independent assessor)

Disqualification Periods

Miscellaneous (4 items) At its April 2014 meeting Council agreed a small working group should be set up to consider the particular issues surrounding the commissioning of an independent assessor where there was a proposal to remove a governor and the disqualification periods. The output from that working group is reflected in the changes proposed below. Subsequently it was requested by the Chairman that the changes also consider the increasing of the public constituency These amendments will be considered by the Board at its 30 July meeting Proposed amendments Removal of a Governor The January 2014 Monitor’s Code of Governance provision B.6.6 (slightly amended from previous version D.2.3) says; Where there is any disagreement as to whether the proposal for removal is justified,

an independent assessor agreeable to both parties should be requested to consider

the evidence and determine whether the proposed removal is reasonable or

otherwise.

The Trust does not comply with this part of the code and as required a note of such is made in the 2013/14 Annual Report. Provisions for the requesting of an independent assessor is now included in the amendments for approval.


Top



D

Disqualification Periods The constitution refers to differing disqualification periods the column on the right hand side suggests a more consistent approach. Those on the right hand side are now included in the amendments for approval

Current Disqualification

Period

Reason Proposed Disqualification

Period

3 years Absent from meetings 6 years

Lifetime Refuses to undertake training 6 years

3 years Resigns from office 6 years

Lifetime Expelled as a governor from another NHS foundation Trust

9 years

3 years

Removed as governor of PHFT 9 years

Whilst such a determination is in place

Vexatious complainant/persistent litigant of the Trust

9 years (from lifting of any such determination)

Lifetime Written warning for verbal/physical abuse to staff

Lifetime

Lifetime CRB (DBS) check revelation Lifetime

Miscellaneous The four miscellaneous items supported by the Council in April are set out below and are now included in the amendments for approval

Re; page 64 2.1 xi) the disqualification in relation to verbal/physical abuse of staff; Add ‘patients, relatives or visitors’ (for reasonableness)

Re; Page 10 add to clause 12.1 (re disqualification) new paragraph 12.1.4. ‘A

person who is subject to an unexpired disqualification order made under the

Company Directors’ Disqualification Act 1986’. (Re Monitor’s Fit and Proper

Persons Test)

Re; Page 105 5.3.3 Executive committee structure to be updated to reflect the current arrangements

Re; Page 77 3.1 Notice of public meetings will also be published on the Foundation Trust’s website, in a local newspaper or newspapers circulating in the area served by the Trust and in the Members’ newsletter. The cost of placing adverts results in very few (if any) members of the public attending


Top



D

meetings therefore it is proposed that ’…. in a local newspaper or newspapers circulating in the area served by the Trust…’ be deleted

New Amendment – The increasing of a public constituency The Trust has four public constituencies covering the whole Dorset. There is however established patient flow from without of the county. This patient flow does not warrant the establishment of a new constituency but it should be recognised. It is proposed that the constituency of North Dorset West Dorset and Weymouth & Portland with a current public membership of some 250 be increased to cover the rest of England. Although the growth in the proposed geographic area is considerable the benefits of increasing the North Dorset West Dorset and Weymouth & Portland constituency to cover the rest of England include;

Giving the option of membership to others who use the services of the Hospital

Providing the local student population a chance of membership even if their home address is elsewhere in England.

Giving the opportunity to local members if they move out of the county to remain as members

Giving a greater catchment area for potential non-executive and chairman candidates

The increased patient numbers involved are;

Type Rest of

England

Elective Inpatients

admissions 167

Non-elective Inpatient

Admissions 1645

Daycases 699

Maternity admissions 270

A&E Attendances 4035

1st Outpatient

Attendances 2373

The need to increase the governor representation for this expanded constituency from one to two governors will depend on any concomitant increases in membership. The membership numbers will be kept under review with the option, at a later date, of recommending to Council an increase of governor representation.


Top



D

The election of a governor for the increased constituency will be held by May 2015, this allows time to increase the membership ahead of an election. In the meantime the current governor’s term of office will continue The increasing of the North Dorset West Dorset and Weymouth & Portland to cover the rest of England is now included in the amendments for approval. Supporting documents The attached documents;

Annex 1 sets out the detail of the changes

Annex 2 sets out the proposed revised Constitution

Annex 3 sets out the proposed revised Code of Conduct for Governors Recommendation The Council is asked to approve the amendments to the Trust’s Constitution as set out in annex 1, the revised Constitution as set out in annex 2 and the revised Code of Conduct for Governors as set out in Annex 3.


Top



Appendix 1

Report to Governors on the detail changes to the Foundation Trust's Constitution and Code of Conduct July 2014

Introduction Part 1 of this Report sets out the proposed changes to the Trusts constitution (currently version 8) as a result of a number of issues both general and specific to the Trust which have occurred since the last revision in April 2013. Table 1 below sets out a summary of the proposed changes to the constitution and the reasons for the changes. Appendix 2 contains the proposed version 9 of the constitution incorporating the changes listed below. Part 2 of the Report deals with changes to the Code of Conduct and consequential changes to the constitution to deal with the requirement in Monitor's Code of Governance for the appointment of an independent assessor where there is a disagreement concerning the removal or disqualification of a governor. PART 1: Changes to the Constitution TABLE 1

Constitution Ref

Page number in draft version 9

Basis of Amendment

Rationale for Amendment

New Clause 12.1.4

11

To reflect Monitor's 'fit and proper person' test

To ensure that the FT meets Monitor's licensing criteria i.e. that their directors and governors meet Monitor's fit and proper test, a Governor must not, in addition to the existing requirements at Clause 12.1, be subject to a disqualification order or undertaking.

New Clause 25.5

14

To reflect Monitor's 'fit and proper person' test.

See rationale above.

Annex 3 Table 33

Trust specific amendment to the public constituencies by replacing the current North Dorset, West Dorset, Weymouth and Portland constituency with a rest of England

To reflect the fact that e.g. especially as a tourist destination the Trust increasingly treats patients resident in other parts of the country.

CoG�July�14�D3�Report�to�Gover

Top



constituency (i.e. all England except the Poole, Purbeck, East Dorset & Christchurch and Bournemouth constituencies).

Annex 3 30

Wording to reflect change to public constituencies (as above)

As above.

Annex 5, Paragraph 2.1(xi)

65

Trust specific amendment – extension of disqualification for reasonableness

To make clear that Governors are not eligible to become or continue in office as a Governor where they have received a written warning from the Trust for verbal and/or physical abuse towards Trust patients, relatives or visitors as well as Trust staff (as currently drafted).

Annex 5, Paragraph 2.1(xii), (xv) and (xvi)

65

Trust specific amendment – changes to disqualification periods

Current

Disqualification Period

Reason

Proposed


Whilst such a determination is in place

Vexatious complainant/persistent litigant of the Trust

9 years (from the lifting of any such determination)

Lifetime

Expelled as a Governor from another NHS Foundation Trust

9 years

Lifetime

Refuses to undertake training

6 years

Annex 5, Paragraph 3.1

66

Consequential amendments to Paragraph 3.1 as a result of the changes to the disqualification periods in Paragraphs 2.1 and 3.1

Deletion of Paragraphs 3.1(iv) (b) and (c) – duplication of Paragraph 2.1(xii) and (xvi) but with differing disqualification periods.


Top




67

Trust specific amendment – changes to disqualification periods in Paragraphs 3.1(i), 3.1(ii) and in relation to 3.1(iv)

Current


Reason

Proposed


Lifetime

Resigns from Office

6 years

3 years

Absent from meetings

6 years

3 years

Removed as a Governor of the Trust pursuant to Paragraph 3.1(iv).

9 years

Annex 5 Paragraph 3.5

67

See Table 2 below

See separate note on changes to the Code of Governance and related issues.


77

Cost prohibitive provision

Notice of public meetings currently have to be published on the FT's website, in a local newspaper or newspapers circulating in the area served by the Trust and in the Members' newsletter. The cost of placing adverts results in very few (if any) members of the public attending meetings. In view of this, the words "in a local newspaper or newspapers circulating in the area served by the Trust" have been deleted.

Annex 7, Paragraph 5.3.3.

106

To reflect updated Executive committee structure

Amended to provide greater flexibility for use of sub-committees

Annex 8 Insertion of new paragraphs 6.13, 6.14 and 6.15

125

See Table 2 below.

See separate note on changes to the Code of Governance and related issues.

PART 2: Proposed changes to the Code of Conduct and consequential changes to the constitution. Monitor's Code of Governance (Provision B.6.6) provides that where there is any disagreement as to whether a proposal for removal of a governor is justified, an independent assessor agreeable to both parties should be requested to consider the evidence and determine whether the removal is justified. The Trust is not legally obliged to include this provision (or any provision of the Code) although it must include an explanation in its annual report where it does not do so. The Trust does generally comply with the Code of Governance but there is some uncertainty about the meaning and application of this particular provision. It is however recognised that there may be occasions when an independent assessor could be useful. Monitor has also indicated to the Trust that in its opinion the wording extends not only to proposals to


Top



remove a governor but also (although the Code of Governance does not expressly state this) to situations where a governor may be disqualified or become ineligible to continue in office. In summary, the proposed changes are intended to capture the essence of the Code of Governance but leave the decision, where there is a dispute concerning removal, to the discretion of the chairman to appoint an independent assessor to advise the Council, but with the proviso that such appointment can also be requested by not less than twenty per cent of the governors. There could still be some circumstances in which it might be argued that the Trust has not complied with the Code of Governance where there is a dispute as to the removal or disqualification of a governor and no independent assessor is appointed. The Trust would have to explain this in its annual report, but if such a situation arose the Trust should be able to provide a reasonable explanation for its actions. Note that where an independent assessor advises that removal or disqualification is unreasonable, the Council is not bound to accept that advice but obviously failure to do so without very good reason may cause problems for the Trust. Consequential changes have also been made to Annex 5 and to the disputes provision in Annex 8 of the constitution to reflect the change in circumstances where a governor becomes ineligible or is disqualified. The Table 2 below lists these and other proposed changes and a copy of the revised Code of Conduct showing the changes are set out in Appendix 3. Changes to the constitution are in Appendix 2 to this Report. TABLE 2

Constitution Ref

Page number in draft version 9

Basis of Amendment Rationale for amendment

Annex 5 para 3.5

67

Trust specific amendment to provide for the appointment of an independent assessor (at the instigation of 20% of Governors or by the Chairman) to consider the appropriateness of removal of a Governor.

Addressing requirements of Monitor's Code of Governance - See above.

Annex 8 Insertion of new paragraphs 6.13.

125

This incorporates the new provision in Annex 5 para 3 to enable the Chairman or twenty per cent of governors to request the appointment of an independent assessor where there is a disagreement concerning disqualification



125

Where a governor is disqualified the Trust notifies the governor as soon as it is aware of this (Annex 5 para 2.3). Where an independent assessor is appointed and decides that there is at least reasonable



Top



doubt that the evidence justified disqualification, the matter is to be referred to the Council of Governors to decide whether to uphold the disqualification. This would require at least a 75% vote.


125

This provision covers the position of a governor where the decision to disqualify is being considered by an independent assessor and possibly the Council of Governors and, in effect, means the governor in question is treated as if suspended from office.


Code of Conduct Ref

Page number in CoC version 2

Basis of Amendment Rationale for amendment

Para 3.1(v)

129

The existing wording "Outside Council meetings a Governor has no more rights and privileges than any other member" is moved from sub-para (iv) to a new sub-para (v)

The wording is given a separate sub-clause for clarity

Para 9

131

Advice on liaison with the media is to be sought from the Head of Communications

Change in job title

Para 13.1 (i)

132

Previous wording stated that where misconduct takes place the Chairman may be authorised to take such action as may immediately be required including exclusion of the person from a meeting. The amendment extends the ability of the Chairman, where there is alleged misconduct, after consultation with the Deputy Chairman of Governors and /or the Lead Governor, to take such action as may immediately be required including the exclusion of the governor from Trust premises and meetings

The change provides greater clarity and allows the Chairman a greater ability to deal with issues where it may be appropriate to prevent any possible disruption.

Para 13.1 (ii) 132

This makes the process for the Council to investigate misconduct subject to the potential appointment of an independent assessor


Para 13.1 (iv) 132 As indicated this provides that at any stage in the investigation of

Addressing requirements of Monitor's Code of Governance -


Top



possible misconduct by the Council that either the Chairman or at least twenty per cent of the Governors can require an independent assessor to be appointed pursuant to Annex 5 para 3.5 of the constitution to advise the Council on the appropriateness of removal .

See above.

DAC Beachcroft LLP 26 June 2014


Top



Appendix 2 Revised constitution (v9)

CONSTITUTION OF POOLE HOSPITAL

NHS FOUNDATION TRUST

(A PUBLIC BENEFIT CORPORATION)

Executive Lead: [Draft] Version 9 Chief Executive July 2014


Top




Top



TABLE OF CONTENTS

Page Interpretation and Definitions ....................................................................... 5 1. Name .............................................................................................................. 7 2. Principal Purpose .......................................................................................... 7 3. Powers............................................................................................................ 8 4. Membership and Constituencies .................................................................. 8 5. Application for Membership ......................................................................... 8 6. Public Constituencies ................................................................................... 8 7. Staff Constituency ......................................................................................... 8 8. Restriction on Membership ........................................................................... 9 8A.

Annual Members' Meeting.............................................................................

9

9. Council of Governors – Composition........................................................... 10 10. Council of Governors – Election of Governors………………………………. 10 11. Council of Governors – Tenure .................................................................... 10 12. Council of Governors – Disqualification and Removal ............................... 10 12A

Council of Governors – Duties of Governors ..............................................

11

13. Council of Governors – Meetings of Governors .......................................... 11 14. Council of Governors – Standing Orders .................................................... 11 14A Council of Governors – Referral to the Panel .............................................. 11 15. Council of Governors – Conflicts of Interest of Governors ........................ 12 16. Council of Governors – Travel Expenses .................................................... 12 17. Council of Governors – Further Provisions ................................................. 12 18.

Board of Directors – Composition ................................................................ 12

18A Board of Directors – General Duty ............................................................... 13 19. Board of Directors – Qualification for Appointment as a Non-Executive

Director...........................................................................................................

13 20. Board of Directors – Appointment and Removal of Chairman and other

Non Executive Directors ...............................................................................

13


Top



NOT USED ...................................................................................................... 13 22. Board of Directors – Appointment of Vice Chairman .................................. 13 23. Board of Directors – Appointment and Removal of the Chief Executive

and Other Executive Directors .....................................................................

13 24. NOT USED ...................................................................................................... 13

25. Board of Directors – Disqualification ........................................................... 13 25A Board of Directors – Meetings ...................................................................... 14 26. Board of Directors – Standing Orders .......................................................... 14 27. Board of Directors – Conflicts of Interest of Directors ............................... 14 28. Board of Directors – Remuneration and Terms of Office ........................... 15 29. Registers ........................................................................................................ 15 30. Registers – Inspection and Copies .............................................................. 16 31. Documents Available for Public Inspection ................................................. 16 32. Auditor............................................................................................................ 17 33. Audit and Governance Committee ............................................................... 17 34. Accounts ........................................................................................................ 17 35. Annual Report, Forward Plans and non-NHS Work .................................... 18 36. Presentation of the Annual Accounts and Reports to Governors &

Members .........................................................................................................

18 37. Instruments .................................................................................................... 19 38.

Mergers, acquisitions, separation, dissolution and significant transactions ...................................................................................................

19 ANNEX 1 THE PUBLIC CONSTITUENCIES 21

ANNEX 2 THE STAFF CONSTITUENCY 25

ANNEX 3 COMPOSITION OF COUNCIL OF GOVERNORS 29

ANNEX 4 THE MODEL ELECTION RULES 33

ANNEX 5 ADDITIONAL PROVISIONS – COUNCIL OF GOVERNORS 61

ANNEX 6 STANDING ORDERS – COUNCIL OF GOVERNORS 69

ANNEX 7 STANDING ORDERS – BOARD OF DIRECTORS 87

ANNEX 8 FURTHER PROVISIONS 115


Top



CONSTITUTION

5

INTERPRETATIONS AND DEFINITIONS Unless a contrary intention is evident or the context requires otherwise, words or expressions contained in this Constitution shall bear the same meaning as in the National Health Service Act 2006 as amended by the 2012 Act. Words importing the masculine gender only shall include the feminine gender; words importing the singular shall import the plural and vice-versa.

References in this Constitution to legislation include all amendments, replacements or re-enactments made and references to clause numbers are references to clauses of this Constitution unless the context provides otherwise. References to legislation include all regulations, statutory guidance or directions. Headings are for ease of reference only and are not to affect interpretation. If there is a conflict between the provisions of this Constitution and the provisions of any document referred to herein or the law then the provisions of this Constitution shall prevail unless the law requires otherwise.

All Annexes referred to in this Constitution form part of it. In this Constitution:

“Accounting Officer” means the person who from time to time discharges the functions specified in paragraph 25(5) in Schedule 7 to the 2006 Act;

“2006 Act” means the National Health Service Act 2006;

"2012 Act" means the Health and Social Care Act 2012;

“Annual Members’ Meeting” means the annual meeting of all the Members as described in Clause 8A.1 of this Constitution;

“Appointed Governors” means the CCG Governor, the Local Authority Governors and the Partnership Governors;

“Area of the Trust” means the area consisting of all the areas specified in Annex 1 as an area for a Public Constituency;

“Board of Directors” means the Board of Directors of the Trust as constituted in accordance with this Constitution and referred to in Clause 18 of this Constitution and “Board” shall be construed accordingly;

"CCG" means a Clinical Commissioning Group established in accordance with Chapter A2 of Part 2 of the 2006 Act;

"CCG Governor" means a member of the Council of Governors appointed in accordance with the provisions of this Constitution by the CCG specified in Annex 3;

“Chairman” means the chairman of the Trust appointed in accordance with Clause 20 of this Constitution;

“Chief Executive” means the Chief Executive (and Accounting Officer) of the Trust appointed in accordance with Clause 23 of this


Top



CONSTITUTION

6

Constitution;

“Company Secretary” means the Company Secretary of the Trust or any other person appointed to perform the duties of the secretary of the Trust;

“Constituencies” means the Public Constituencies and the Staff Constituency;

“Constitution” means this Constitution of Poole Hospital NHS Foundation Trust;

“Council of Governors” means the Council of Governors of the Trust as constituted in accordance with this Constitution;

"Director" means a director on the Board of Directors;

“Elected Governors” means the Public Governors and the Staff Governors respectively;

“Election Scheme” means the election scheme and rules set out in Annex 4 and which are to be used in connection with the election of the Elected Governors;

“Executive Director” means an Executive Director of the Trust;

“Finance Director” means the person who from time to time is appointed by the Trust to discharge the usual functions of its chief finance officer;

“Financial Year” means a period of 12 months ending with 31st March in any year;

“Local Authorities” means those Councils specified in Annex 3, all of which are Councils for an area which includes the whole or part of the Area of the Trust, and “Local Authority” shall be construed accordingly;

“Local Authority Governors” means a member of the Council of Governors appointed by a Local Authority in accordance with the provisions of this Constitution and as specified in Annex 3;

"Member" means a Member of the Trust as determined in accordance with Clause 5 and Annex 8 of this Constitution;

“Membership” means membership of the Trust through being a Member of one of its Constituencies;

"Monitor" means the body corporate known as Monitor, as provided by Section 61 of the 2012 Act;

“Governors Meetings” means a meeting of the Governors;

“Governor” means a Governor on the Council of Governors and being either an Elected Governor or an Appointed Governor;

“Model Election Rules” means the model form rules for the conduct of elections published from time to time by the Department of Health and as currently set out in Annex 4;

“NHS Foundation Trust Code of Governance”

means the Code of Governance published by Monitor on the 10 March 2010 or such similar or further guidance as Monitor may publish from time to time;


Top



CONSTITUTION

7

“Nominations Committee” means the Nominations, Remunerations and Evaluation Committee established by the Council of Governors in accordance with Clause 10 of Annex 6;

“Non-Executive Director” means a Non-Executive Director of the Trust;

“Partnership Governor” means a member of the Council of Governors appointed by a Partnership Organisation specified in Annex 3;

“Partnership Organisations” means those organisations designated as partnership organisations for the purposes of this Constitution specified in Annex 3;

“Public Governor” means a Member of the Council of Governors elected by the Members of a Public Constituency;

“Public Constituencies” means that part of the Trust’s membership consisting of Members living in the Area of the Trust;

“Staff Classes” means the classes of the Staff Constituency as specified in Annex 2;

“Staff Constituency” means that part of the Trust’s membership consisting of the staff of the Trust and other persons as more particularly provided for in Clause 7 of this Constitution and which is divided into the staff classes as specified in Annex 2;

“Staff Governor” means a member of the Council of Governors elected by a Staff Class;

“The Trust” means Poole Hospital NHS Foundation Trust;

“Trust’s Hospital” means any premises used by the Trust for the provision of goods and services for the purposes of the health service in England falling within the definition of “hospital” in Section 275 of the 2006 Act;

“Vice Chairman” means the Vice Chairman of the Trust;

“Voluntary Organisation” means a body, other than a public or local authority, the activities of which are not carried on for profit.

1. NAME The name of the foundation trust shall be Poole Hospital NHS Foundation Trust (the “Trust”). 2. PRINCIPAL PURPOSE 2.1 The principal purpose of the Trust is the provision of goods and services for the

purposes of the health service in England. 2.2 The Trust does not fulfil its principal purpose unless, in each Financial Year, its total

income from the provision of goods and services for the purposes of the health service in England is greater than its total income from the provision of goods and services for any other purposes.

2.3 The Trust may provide goods and services for any purposes related to:

2.3.1 the provision of services provided to individuals for or in connection with the prevention, diagnosis or treatment of illness; and


Top



CONSTITUTION

8

2.3.2 the promotion and protection of public health.

2.4 The Trust may also carry on activities other than those mentioned in paragraph 2.3

above for the purpose of making additional income available in order better to carry on its principal purpose.

3. POWERS 3.1 The powers of the Trust are set out in the 2006 Act. 3.2 The powers of the Trust shall be exercised by the Board of Directors on behalf of the

Trust. 3.3 Any of these powers may be delegated to a committee of Directors or to an

Executive Director. 4. MEMBERSHIP AND CONSTITUENCIES The Trust shall have Members, each of whom shall be a member of one of the following constituencies: 4.1 a public constituencies; and 4.2 a staff constituency. 5. APPLICATION FOR MEMBERSHIP 5.1 An individual who is eligible to become a Member of the Trust may do so on

application to the Trust, save as provided for in Clause 7 of this Constitution. 5.2 Applications for Membership shall be dealt with by the Trust in accordance with the

provisions of Annex 8. 6. PUBLIC CONSTITUENCIES 6.1 An individual who lives in an area specified in Annex 1 as an area for a Public

Constituency may become or continue as a Member of the Trust. 6.2 Those individuals who live in an area specified as an area for any Public

Constituency are referred to collectively as the Public Constituency. 6.3 The minimum number of members in each area for a Public Constituency is specified

in Annex 1. 6.4 Further provisions relating to Membership of the Public Constituency are set out in

Annex 8. 7. STAFF CONSTITUENCY 7.1 An individual who is employed by the Trust under a contract of employment with the

Trust may become or continue as a Member of the Trust provided: 7.1.1 he is employed by the Trust under a contract of employment which has no

fixed term or has a fixed term of at least 12 months; or


Top



CONSTITUTION

9

7.1.2 he has been continuously employed by the Trust under a contract of

employment for at least 12 months. 7.2 Individuals who exercise functions for the purposes of the Trust, other than under a

contract of employment with the Trust, may become or continue as Members of the Staff Constituency provided such individuals have exercised these functions continuously for a period of at least 12 months.

7.3 Those individuals who are eligible for Membership of the Trust by reason of the

previous provisions of this Clause 7 of the Constitution are referred to collectively as the Staff Constituency.

7.4 The Staff Constituency shall be divided into two descriptions of individuals who are

eligible for Membership of the Staff Constituency, each description of individuals being specified within Annex 2 and being referred to as a Staff Class within the Staff Constituency.

7.5 The minimum number of members in each Staff Class of the Staff Constituency is

specified in Annex 2. Automatic Membership by Default – Staff

7.6 An individual who is: 7.6.1 eligible to become a Member of the Staff Constituency, and 7.6.2 invited by the Trust to become a Member of the Staff Constituency and a

Member of the appropriate Staff Class within the Staff Constituency,

shall become a Member of the Trust as a Member of the Staff Constituency and appropriate Staff Class within the Staff Constituency without an application being made, unless he informs the Trust that he does not wish to do so.

7.7 The process by which an individual shall be invited to become a Member of the Staff

Constituency shall be in accordance with the provisions of Annex 8. 8. RESTRICTION ON MEMBERSHIP 8.1 An individual who is a Member of a constituency, or of a class within a constituency,

may not while Membership of that constituency or class continues, be a Member of any other constituency or class.

8.2 An individual who satisfies the criteria for Membership of the Staff Constituency may

not become or continue as a Member of any constituency other than the Staff Constituency.

8.3 Further provisions as to the circumstances in which an individual may not become or

continue as a Member of the Trust are set out in Annex 8 – Further Provisions. 8A ANNUAL MEMBERS' MEETING 8A.1 The Trust shall hold an annual meeting of its members ("Annual Members' Meeting").

The Annual Members' Meeting shall be open to members of the public.


Top



CONSTITUTION

10

8A.2 Further provisions about the Annual Members' Meeting are set out in Annex 8, Paragraph 4 (Annual Members' Meeting).

9. COUNCIL OF GOVERNORS – COMPOSITION 9.1 The Trust shall have a Council of Governors which shall comprise both Elected and

Appointed Governors. 9.2 The composition of the Council of Governors shall be as specified in Annex 3. 9.3 The members of the Council of Governors, other than the Appointed Governors, shall

be chosen by election by their constituency or, where there are classes within a constituency, by their class within that constituency.

9.4 The number of Governors to be elected by each constituency, or, where appropriate,

by each class of each constituency, is specified in Annex 3. 10. COUNCIL OF GOVERNORS – ELECTION OF GOVERNORS 10.1 Elections for Elected Governors of the Council of Governors shall be conducted in

accordance with the Model Election Rules, as may be varied from time to time. 10.2 The Model Election Rules, form part of this Constitution. The Model Election Rules

current at the date of the Trust’s Authorisation are attached at Annex 4. 10.3 A subsequent variation of the Model Election Rules by the Department of Health shall

not constitute a variation of the terms of this Constitution. For the avoidance of doubt, the Trust cannot amend the Model Election Rules.

10.4 An election, if contested, shall be by secret ballot. 11. COUNCIL OF GOVERNORS - TENURE 11.1 An Elected Governor shall hold office for a period of 3 years.

11.2 An Elected Governor shall cease to hold office if he ceases to be a Member of the constituency or class by which he was elected.

11.3 An Elected Governor shall be eligible for re-election at the end of his term, subject to the provisions of Clause 1 of Annex 5.

11.4 An Appointed Governor shall hold office for a period of three years, subject to the provisions of Clause 1 of Annex 5.

11.5 Further provision relating to a Governor’s tenure of office are set out in Annex 5. 12. COUNCIL OF GOVERNORS – DISQUALIFICATION AND REMOVAL

12.1 The following may not become or continue as a member of the Council of Governors:

12.1.1 a person who has been adjudged bankrupt or whose estate has been

sequestrated and (in either case) has not been discharged; 12.1.2 a person who has made a composition or arrangement with, or granted a

Trust deed for, his creditors and has not been discharged in respect of it;


Top



CONSTITUTION

11

12.1.3 a person who within the preceding five years has been convicted in the British Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him.

12.1.4 a person who is subject to an unexpired disqualification order made under the

Company Directors' Disqualification Act 1986.

12.2 Governors must be at least 16 years of age at the date they are nominated for election or appointment.

12.3 Further provisions as to the circumstances in which an individual may not become or

may be removed as a member of the Council of Governors are set out in Annex 5. 12A. COUNCIL OF GOVERNORS – DUTIES OF GOVERNORS 12A.1 The general duties of the Council of Governors are: 12A.1.1 to hold the Non-Executive Directors individually and collectively to account

for the performance of the Board of Directors, and 12A.1.2 to represent the interests of the Members as a whole and the interests of

the public. 12A.2 The Trust must take steps to secure that the Governors are equipped with the skills

and knowledge they require in their capacity as such.

13. COUNCIL OF GOVERNORS – MEETINGS OF GOVERNORS 13.1 Subject to paragraph 3.4 of the Standing Orders for the Council of Governors at

Annex 6 of this Constitution the Chairman of the Trust (i.e. the Chairman of the Board of Directors, appointed in accordance with the provisions of Clause 20 of this Constitution) or, in his absence the Vice Chairman appointed in accordance with the provisions of Clause 22 of this Constitution, shall preside at meetings of the Council of Governors.

13.2 Meetings of the Council of Governors shall be open to members of the public save

that members of the public may be excluded from a meeting on the grounds more particularly provided for in Annex 5.

13.3 For the purposes of obtaining information about the Trust's performance of its

functions or the Directors' performance of their duties (and deciding whether to propose a vote on the Trust's or Directors' performance), the Council of Governors may require one or more of the Directors' to attend a meeting.

14. COUNCIL OF GOVERNORS – STANDING ORDERS

The standing orders for the practice and procedure of the Council of Governors, are at Annex 6. 14A. COUNCIL OF GOVERNORS – REFERRAL TO THE PANEL 14A.1 In this Clause, the Panel means a panel of persons appointed by Monitor to which a

governor of an NHS foundation trust may refer a question as to whether the trust has failed or is failing:


Top



CONSTITUTION

12

14A.1.1 to act in accordance with its constitution, or 14A.1.2 to act in accordance with provision made by or under Chapter 5 of the

2006 Act. 14A.2 A Governor may refer a question to the Panel only if more than half of the members

of the Council of Governors voting approve the referral. Governors voting approve the referral.

15. COUNCIL OF GOVERNORS - CONFLICTS OF INTEREST OF GOVERNORS 15.1 If a Governor has a pecuniary, personal or family interest, whether that interest is

actual or potential and whether that interest is direct or indirect, in any proposed contract or other matter which is under consideration or is to be considered by the Council of Governors, the Governor shall disclose that interest to the members of the Council of Governors as soon as he becomes aware of it.

15.2 The Standing Orders for the Council of Governors shall make provision for the disclosure of interests and arrangements for the exclusion of a Governor declaring any interest from any discussion or consideration of the matter in respect of which an interest has been disclosed.

16. COUNCIL OF GOVERNORS – TRAVEL EXPENSES The Trust may pay travelling and other expenses to members of the Council of Governors at rates determined by the Trust. 17. COUNCIL OF GOVERNORS – FURTHER PROVISIONS

17.1 The Council of Governors may appoint a Nominations Committee consisting of all or some of its members to assist in carrying out those functions set out in Clauses 20 and 28.1 of this Constitution but not otherwise

17.2 Further provisions with respect to the Council of Governors are set out in Annex 5.

18. BOARD OF DIRECTORS – COMPOSITION

18.1 The Trust shall have a Board of Directors, which shall comprise both Executive and

Non-Executive Directors. 18.2 The Board of Directors shall subject always to Clause 18.8 of this Constitution

comprise:

18.2.1 a non-executive Chairman; 18.2.2 six other Non-Executive Directors (one of which may be nominated as the

Senior Independent Director, see Annex 7); and 18.2.3 six Executive Directors,

18.3 One of the Executive Directors shall be the Chief Executive. 18.4 The Chief Executive shall be the Accounting Officer. 18.5 One of the Executive Directors shall be the Finance Director.


Top



CONSTITUTION

13

18.6 One of the Executive Directors shall be a registered medical practitioner or a

registered dentist (within the meaning of the Dentists Act 1984). 18.7 One of the Executive Directors is to be a registered nurse or a registered midwife. 18.8 Board of Directors shall at all times be constituted so that the number of Non-

Executive Directors exceeds the number of Executive Directors. 18A BOARD OF DIRECTORS – GENERAL DUTY 18A.1 The general duty of the Board of Directors and of each Director individually, is to act

with a view to promoting the success of the Trust so as to maximise the benefits for the Members as a whole and for the public.

19. BOARD OF DIRECTORS – QUALIFICATION FOR APPOINTMENT AS A NON-

EXECUTIVE DIRECTOR A person may be appointed as a Non-Executive Director only if:

19.1 he is a Member of a Public Constituency, and 19.2 he is not disqualified by virtue of Clause 25 of this Constitution. 20. BOARD OF DIRECTORS – APPOINTMENT AND REMOVAL OF CHAIRMAN

AND OTHER NON-EXECUTIVE DIRECTORS 20.1 The Council of Governors at a general meeting of the Council of Governors shall

appoint or remove the Chairman of the Trust and the other Non-Executive Directors. 20.2 The removal of the Chairman or any other Non-Executive Director shall require the

approval of three-quarters of the members of the Council of Governors. 21. NOT USED

22. BOARD OF DIRECTORS – APPOINTMENT OF VICE CHAIRMAN

22.1 The Council of Governors at a general meeting of the Council of Governors shall

appoint one of the Non-Executive Directors as a Vice Chairman.

23. BOARD OF DIRECTORS - APPOINTMENT AND REMOVAL OF THE CHIEF EXECUTIVE AND OTHER EXECUTIVE DIRECTORS

23.1 The Non-Executive Directors shall appoint or remove the Chief Executive. 23.2 The appointment of the Chief Executive shall require the approval of the Council of

Governors. 23.3 A committee consisting of the Chairman, the Chief Executive and the other Non-

Executive Directors shall appoint or remove the other Executive Directors. 24. NOT USED

25. BOARD OF DIRECTORS – DISQUALIFICATION


Top



CONSTITUTION

14

The following may not become or continue as a member of the Board of Directors: 25.1 A person who has been adjudged bankrupt or whose estate has been sequestrated

and (in either case) has not been discharged. 25.2 A person who has made a composition or arrangement with, or granted a Trust deed

for, his creditors and has not been discharged in respect of it. 25.3 A person who within the preceding five years has been convicted in the British

Islands of any offence if a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on him.

25.4 A person who falls within the further grounds for disqualification set out in Annex 8. 25.5 A person who is subject to an unexpired disqualification order made under the

Company Directors' Disqualification Act 1986. 25A BOARD OF DIRECTORS – MEETINGS 25A.1 Meetings of the Board of Directors shall be open to members of the public. Members

of the public may be excluded from a meeting for special reasons. 25A.2 Before holding a meeting, the Board of Directors must send a copy of the agenda of

the meeting to the Council of Governors. As soon as practicable after holding a meeting, the Board of Directors must send a copy of the minutes of the meeting to the Council of Governors.

26. BOARD OF DIRECTORS – STANDING ORDERS

The standing orders for the practice and procedure of the Board of Directors, are attached at Annex 7. 27. BOARD OF DIRECTORS - CONFLICTS OF INTEREST OF DIRECTORS

27.1 The duties that a Director of the Trust has by virtue of being a Director include in

particular:

27.1.1 A duty to avoid a situation in which the Director has (or can have) a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the Trust.

27.1.2 A duty not to accept a benefit from a third party by reason of being a Director or doing (or not doing) anything in that capacity.

27.2 The duty referred to in sub-clause 27.1.1 is not infringed if:

27.2.1 the situation cannot reasonably be regarded as likely to give rise to a conflict of interest, or

27.2.2 the matter has been authorised in accordance with the Constitution.

27.3 The duty referred to in sub-clause 27.1.2 is not infringed if acceptance of the benefit cannot reasonably be regarded as likely to give rise to a conflict of interest.


Top



CONSTITUTION

15

27.4 In sub-clause 27.1.2, "third party" means a person other than:

27.4.1 the Trust, or

27.4.2 a person acting on its behalf.

27.5 If a Director has in any way a direct or indirect interest in a proposed transaction or arrangement with the Trust, the Director must declare the nature and extent of that interest to the other Directors.

27.6 If a declaration under this clause proves to be, or becomes, inaccurate or incomplete, a further declaration must be made.

27.7 Any declaration required by this clause must be made before the Trust enters into the transaction or arrangement.

27.8 This Clause does not require a declaration of an interest of which the Director is not aware or where the Director is not aware of the transaction or arrangement in question.

27.9 A Director need not declare an interest:

27.9.1 if it cannot reasonably be regarded as likely to give rise to a conflict of interest;

27.9.2 if, or to the extent that, the Directors are already aware of it;

27.9.3 if, or to the extent that, it concerns terms of the Director's appointment that have been or are to be considered:

27.9.3.1 by a meeting of the Board of Directors, or

27.9.3.2 by a committee of the Directors appointed for the purpose under the Constitution.

27.10 The Standing Orders for the Board of Directors shall make provision for the disclosure of interests and arrangements for the exclusion of a Director declaring any interest from any discussion or consideration of the matter in respect of which an interest has been disclosed.

28. BOARD OF DIRECTORS – REMUNERATION AND TERMS OF OFFICE

28.1 The Council of Governors at a general meeting of the Governors shall decide the

remuneration and allowances, and the other terms and conditions of office, of the Chairman and the other Non-Executive Directors.

28.2 The Trust shall establish a committee of Non-Executive Directors to decide the

remuneration and allowances, and the other terms and conditions of office, of the Chief Executive and other Executive Directors.

29 REGISTERS

The Trust shall have: 29.1 A register of members showing, in respect of each Member, the constituency to


Top



CONSTITUTION

16

which he belongs and, where there are classes within it, the class to which he belongs;

29.2 A register of members of the Council of Governors; 29.3 A register of interests of Governors; 29.4 A register of Directors; and 29.5 A register of interests of the Directors. 29.6 The process of admission to and removal from the registers shall be as set out in

Annex 8. 30 REGISTERS – INSPECTION AND COPIES

30.1 The Trust shall make the registers specified in Clause 29 of this Constitution

available for inspection by members of the public, except in the circumstances set out below or as otherwise prescribed by regulations.

30.2 The Trust shall not make any part of its registers available for inspection by members

of the public which shows details of any Member of the Trust, if he so requests. 30.3 So far as the registers are required to be made available:

30.3.1 they are to be available for inspection free of charge at all reasonable times; and

30.3.2 a person who requests a copy of or extract from the registers is to be

provided with a copy or extract. 30.4 If the person requesting a copy or extract is not a Member of the Trust, the Trust may

impose a reasonable charge for doing so. 31 DOCUMENTS AVAILABLE FOR PUBLIC INSPECTION

31.1 The Trust shall make the following documents available for inspection by members of

the public free of charge at all reasonable times:

31.1.1 a copy of the current Constitution;

31.1.2 a copy of the latest annual accounts and of any report of the auditor on them; and

31.1.3 a copy of the latest annual report. 31.2 The Trust shall also make the following documents relating to a special

administration of the Trust available for inspection by members of the public free of charge at all reasonable times:

31.2.1 a copy of any order made under section 65D (appointment of trust special

administrator), 65J (power to extend time), 65KC (action following Secretary of State's rejection of final report), 65L (trusts coming out of administration) or 65LA (trusts to be dissolved) of the 2006 Act;


Top



CONSTITUTION

17

31.2.2 a copy of any report laid under section 65D (appointment of trust special administrator) of the 2006 Act;

31.2.3 a copy of any information published under section 65D (appointment of trust

special administrator) of the 2006 Act; 31.2.4 a copy of any draft report published under Section 65F (administrator's draft

report) of the 2006 Act; 31.2.5 a copy of any statement provided under section 65F (administrator's draft

report) of the 2006 Act; 31.2.6 a copy of any notice published under section 65F (administrator's draft

report), 65G (consultation plan), 65H (consultation requirements), 65J (power to extend time), 65KA (Monitor's decision), 65KB (Secretary of State's response to Monitor's decision), 65KC (action following Secretary of State's rejection of final report) or 65KD (Secretary of State's response to re-submitted final report) of the 2006 Act;

31.2.7 a copy of any statement published or provided under section 65G

(consultation plan) of the 2006 Act; 21.2.8 a copy of any final report published under section 65I (administrator's final

report); 21.2.9 a copy of any statement published under section 65J (power to extend time)

or 65KC (action following Secretary of State's rejection of final report) of the 2006 Act;

21.2.10 a copy of any information published under section 65M (replacement of trust

special administrator) of the 2006 Act. 31.3 Any person who requests a copy of or extract from any of the above documents is to

be provided with a copy. 31.4 If the person requesting a copy or extract is not a Member of the Trust, the Trust may

impose a reasonable charge for doing so. 32 AUDITOR

32.1 The Trust shall have an auditor. 32.2 The Council of Governors shall appoint or remove the auditor at a general meeting of

the Council of Governors. 33 AUDIT AND GOVERNANCE COMMITTEE

The Trust shall establish a committee of Non-Executive Directors as an audit committee to perform such monitoring, reviewing and other functions as are appropriate. 34 ACCOUNTS

34.1 The Trust shall keep proper accounts and proper records in relation to the accounts. 34.2 The Secretary of State may with the approval of the Treasury give directions to the


Top



CONSTITUTION

18

Trust as to the content and form of its accounts. 34.3 The accounts are to be audited by the Trust’s auditor. 34.4 The Trust shall prepare in respect of each Financial Year annual accounts in such

form as the Secretary of State may with the approval of the Treasury direct. 34.5 The functions of the Trust with respect to the preparation of the annual accounts shall

be delegated to the Accounting Officer. 35 ANNUAL REPORT, FORWARD PLANS AND NON-NHS WORK

35.1 The Trust shall prepare an Annual Report and send it to Monitor. 35.2 The Trust shall give information as to its forward planning in respect of each

Financial Year to Monitor. 35.3 The document containing the information with respect to forward planning referred to

at Clause 35.2 of this Constitution shall be prepared by the Directors. 35.4 In preparing the document, the Directors shall have regard to the views of the

Council of Governors. 35.5 Each forward plan must include information about:

35.5.1 the activities other than the provision of goods and services for the purposes of the health service in England that the Trust proposes to carry on; and

35.5.2 the income it expects to receive from doing so.

35.6 Where a forward plan contains a proposal that the Trust carry on an activity of a kind

mentioned in sub-paragraph 35.5.1 the Council of Governors must:

35.6.1 determine whether it is satisfied that the carrying on of the activity will not to any significant extent interfere with the fulfilment by the Trust of its principal purpose or the performance of its other functions; and

35.6.2 notify the Directors of the Trust of its determination.

35.7 The Trust may only implement any proposal to increase by 5% or more the

proportion of its total income in any Financial Year attributable to activities other than the provision of goods and services for the purposes of the health service in England if more than half of the members of the Council of Governors voting approve its implementation.

36 PRESENTATION OF THE ANNUAL ACCOUNTS AND REPORTS TO THE

GOVERNORS AND MEMBERS 36.1 The following documents are to be presented to the Council of Governors at a

general meeting of the Council of Governors:

36.1.1 the annual accounts;

36.1.2 any report of the auditor on them;


Top



CONSTITUTION

19

36.1.3 the annual report. 36.2 The documents shall also be presented to the Members of the Trust at the Annual

Members' Meeting by at least one member of the Board of Directors in attendance. 36.3 The Trust may combine a meeting of the Council of Governors convened for the

purposes of Clause 36.1 with the Annual Members' Meeting. 37 INSTRUMENTS

37.1 The Trust shall have a seal. 37.2 The seal shall not be affixed except under the authority of the Board of Directors. 38. MERGERS, ACQUISITIONS, SEPARATION, DISSOLUTION AND SIGNIFICANT

TRANSACTIONS 38.1 The Trust may only apply for a merger, acquisition, separation or dissolution with the

approval of more than half of the members of the Council of Governors. 38.2 The Trust may enter into a significant transaction only if more than half of the

members of the Council of Governors voting approve entering into the transaction. 38.3 "significant transaction"1 means:

38.3.1 the acquisition of, or an agreement to acquire, whether contingent or not, assets the value of which is more than 25% of the value of the Trust's gross assets before the acquisition; or

38.3.2 the disposition of, or an agreement to dispose of, whether contingent or not,

assets of the Trust the value of which is more than 25% of the value of the Trust's gross assets before the disposition; or

38.3.3 a transaction that has or is likely to have the effect of the Trust acquiring

rights or interests or incurring obligations or liabilities, including contingent liabilities, the value of which is more than 25% of the value of the Trust's gross assets before the transaction.

38.4 For the purpose of this Clause 38: 38.4.1 "gross assets" means the total of fixed assets and current assets;

38.4.2 in assessing the value of any contingent liability for the purposes of sub-clause 38.3.3, the Directors:

38.4.2.1 must have regard to all circumstances that Directors know, or

ought to know, affect or may affect, the value of the contingent liability; and

38.4.2.2 may rely on estimates of the contingent liability that are

reasonable in the circumstances; and 38.4.2.3 may take account of the likelihood of the contingency

occurring.


Top



CONSTITUTION

20


Top



CONSTITUTION

21


Top



ANNEX 1 – PUBLIC CONSTITUENCIES

22

CONSTITUTION

ANNEX 1

THE PUBLIC CONSTITUENCIES


Top




23


Top




24

THE PUBLIC CONSTITUENCY

Table 1

Name of the Public Constituency

Area of the public constituency by Electoral

Wards

Minimum number of Members

Number of Member

Governors to be elected

Poole

The Electoral Area for the Poole Borough Council

50

8

Purbeck, East Dorset and Christchurch

The Electoral Area for the Purbeck District Council, East Dorset District Council and Christchurch Borough Council

50

3

Bournemouth

The Electoral Area for the Bournemouth Borough Council.

50

2

North Dorset, West Dorset and Weymouth and Portland extended to and referred to as the rest of England with effect from 1 August 2014

The Electoral Area for the North Dorset District Council, West Dorset District Council and Weymouth and Portland Borough Council extended to all electoral areas in England not set out above in this Table with effect from 1 August 2014

50

1


Top




25


Top



ANNEX 2 – THE STAFF CONSTITUENCY

26

CONSTITUTION

ANNEX 2

THE STAFF CONSTITUENCY


Top




27


Top




28

THE STAFF CONSTITUENCY

Table 1

Classes within the Staff Constituency

Individuals eligible for Membership of that class

Minimum number of Members

Number of Governors to be

elected

Clinical Staff Class

Those individuals defined in clause 1 below

1,800

3

Non-Clinical Staff Class

Those individuals defined in clause 2 below

600

1

1. CLINICAL STAFF CLASS

1.1 The members of the Clinical Staff Class are those individuals who are Members of

the Staff Constituency who: i) are medical practitioners whose name appears on the List of Registered

Medical Practitioners maintained and administered by the General Medical Council as registered to practice in the United Kingdom or who are pharmacists subject to regulation under the Pharmacy Act 1954 and who are otherwise fully authorised and licensed to practice in England and Wales in those professions; or

ii) are members of a profession regulated by the Nursing and Midwifery Council

and who are otherwise fully authorised and licensed to practice in England and Wales in those professions; or

iii) whose regulatory body falls within the remit of the Council for the Regulation

of Healthcare Professions established by Section 25 of the NHS Reform and Healthcare Professions Act 2002 other than those bodies responsible for the regulation of those individuals referred to at Clauses 1.1 (i) and 1.1 (ii) of this Annex; and

iv) are otherwise designated by the Trust Secretary from time to time as eligible

to be Members of this Staff Class having regard to the usual definitions applicable at that time for persons carrying on such professions; and

v) are employed by the Trust in that capacity at the date of their invitation to

become a Member in accordance with the provisions of Annex 8 and at all times thereafter remain employed by the Trust in that capacity.


Top




29

2. NON-CLINICAL STAFF CLASS

2.1 The members of the Non-Clinical Staff Class are those individuals who are Members

of the Staff Constituency who: i) do not come within those definitions set out in Clauses 1.1 (i) – (iv) of this

Annex and who are designated by the Trust from time to time as eligible to be Members of this Staff Class; and

ii) are employed by the Trust to perform functions designated by the Trust for

the purposes of Clauses 1.1 (i) – (iv) of this Annex and are engaged in that capacity at the date of their invitation to become a Member in accordance with the provisions of Annex 8 and who at all times thereafter remain employed by the Trust in that capacity.

3. MINIMUM NUMBERS AND NUMBERS OF Governors

3.1 The minimum number of Members in each Staff Class shall be as set out in column 3

of Table 1 to this Annex and the number of Governors to be elected by each such Staff Class is given in the corresponding entry in Column 4 of that Table.

4. CONTINUOUS EMPLOYMENT

4.1 For the purposes of Clause 7 of the Constitution, Chapter 1 of Part 14 of the Employment Rights Act 1996 shall apply for the purposes of determining whether an individual has been continuously employed by the Trust or has continuously exercised functions for the purposes of the Trust.


Top



ANNEX 3 – COMPOSITION OF COUNCIL OF GOVERNORS

30

CONSTITUTION

ANNEX 3

COMPOSITION OF COUNCIL OF GOVERNORS


Top




31


Top




32

COMPOSITION OF COUNCIL OF GOVERNORS

1. INTRODUCTION

1.1 The Council of Governors shall comprise of Governors who are:

i) elected by the respective Constituencies in accordance with the provisions of this Constitution; or

ii) appointed in accordance with Clause 2 of this Annex.

1.2 The Council of Governors shall at all times be constituted so that more than half the Council of Governors shall consist of Governors who are elected by Members of the Trust other than those who are Members of the Staff Constituency.

2. BODIES ENTITLED TO APPOINT A MEMBER OF THE COUNCIL OF Governors

2.1 The following bodies in this Clause 2 of this Annex 3 shall be entitled to appoint a

Governor or Governors (as the case may be) to the Council of Governors as provided for in this Clause 2 of Annex 3.

CCG 2.2 NHS Dorset CCG shall be entitled to appoint one Governor in accordance with a

process of appointment agreed by it with the Trust. The absence of any such agreed process of appointment shall not preclude NHS Dorset CCG from appointing its Governor provided the appointment is duly made in accordance with the CCG's own internal processes. Qualifying Local Authorities

2.3 Dorset County Council, Poole Borough Council and Bournemouth Borough Council shall be entitled to appoint one Governor each in accordance with a process of appointment agreed by it with the Trust. The absence of any such agreed process of appointment shall not preclude the said local authority from appointing its Governor.

Partnership Organisations 2.4 The Trust shall nominate the University of Bournemouth to be designated as

Partnership organisations for the purposes of this Constitution. 2.5 The University of Bournemouth shall be entitled to appoint one Governor in

accordance with a process agreed by it with the Trust. 2.6 The absence of any process of appointment agreed with the Trust shall not preclude

Bournemouth University from appointing its Governor provided that appointment is duly made in accordance with the University’s own internal processes.


Top




33

3. COMPOSITION OF THE COUNCIL OF Governors

Electing/Appointing Body

Number of Governors

Total

1.

Public Constituencies 1.1 Poole 1.2 Purbeck, East Dorset & Christchurch 1.3 Bournemouth 1.4 North Dorset, West Dorset and Weymouth &

Portland (extended to the rest of England with effect from 1 August 2014)

8 3 2 1

14

2.

Staff Constituency 2.1 Clinical Staff Class 2.2 Non Clinical Staff Class

3 1

4

3.

Appointed Governors 3.1 NHS Dorset CCG 3.2 Dorset County Council 3.3 Poole Borough Council 3.4 Bournemouth Borough Council 3.5 University of Bournemouth

1 1 1 1 1

5

Total number of Governors

23

23

4. FURTHER PROVISION

4.1 Further provisions relating to the composition of the Council of Governors is at

Annex 5.


Top



ANNEX 4 – THE MODEL ELECTION RULES

34

CONSTITUTION

ANNEX 4

THE MODEL ELECTION RULES


Top




35


Top




36

THE MODEL ELECTION RULES

Part 1 – Interpretation

1. Interpretation

Part 2 – Timetable for election

2. Timetable 3. Computation of time

Part 3 – Returning officer

4. Returning officer 5. Staff 6. Expenditure 7. Duty of co-operation

Part 4 - Stages Common to Contested and Uncontested Elections

8. Notice of election 9. Nomination of candidates 10. Candidate‘s consent and particulars 11. Declaration of interests 12. Declaration of eligibility 13. Signature of candidate 14. Decisions as to validity of nomination papers 15. Publication of statement of nominated candidates 16. Inspection of statement of nominated candidates and nomination papers 17. Withdrawal of candidates 18. Method of election

Part 5 – Contested elections

19. Poll to be taken by ballot 20. The ballot paper 21. The declaration of identity

Action to be taken before the poll 22. List of eligible voters 23. Notice of poll 24. Issue of voting documents 25. Ballot paper envelope and covering envelope

The poll 26. Eligibility to vote 27. Voting by persons who require assistance 28. Spoilt ballot papers 29. Lost ballot papers 30. Issue of replacement ballot paper 31. Declaration of identity for replacement ballot papers

Procedure for receipt of envelopes 32. Receipt of voting documents 33. Validity of ballot paper 34. Declaration of identity but no ballot paper 35. Sealing of packets


Top




37

Part 6 - Counting the votes

36. Interpretation of Part 6 37. Arrangements for counting of the votes 38. The count 39. Rejected ballot papers 40. First stage 41. The quota 42. Transfer of votes 43. Supplementary provisions on transfer 44. Exclusion of candidates 45. Filling of last vacancies 46. Order of election of candidates

Part 7 – Final proceedings in contested and uncontested elections

47. Declaration of result for contested elections 48. Declaration of result for uncontested elections

Part 8 – Disposal of documents

49. Sealing up of documents relating to the poll 50. Delivery of documents 51. Forwarding of documents received after close of the poll 52. Retention and public inspection of documents 53. Application for inspection of certain documents relating to election

Part 9 – Death of a candidate during a contested election

54. Countermand or abandonment of poll on death of candidate

Part 10 – Election expenses and publicity

Expenses 55. Expenses incurred by candidates 56. Expenses incurred by other persons 57. Personal, travelling, and administrative expenses

Publicity 58. Publicity about election by the corporation 59. Information about candidates for inclusion with voting documents

60. Meaning of “for the purposes of an election”

Part 11 – Questioning elections and irregularities

61. Application to question an election

Part 12 – Miscellaneous

62. Secrecy 63. Prohibition of disclosure of vote 64 Disqualification 65 Delay in postal service through industrial action or unforeseen event


Top




38

Part 1 – Interpretation 1. Interpretation – (1) In these rules, unless the context otherwise requires –

“corporation” means the public benefit corporation subject to this constitution; “election” means an election by a constituency, or by a class within a constituency, to fill a vacancy among one or more posts on the Members‘ Council; “the regulator” means the body corporate known as Monitor, as provided by Section 61 of the 2012 Act “the 2006 Act” means the NHS Act 2006 “the 2012 Act” means the Health and Social Care Act 2012 (2) Other expressions used in these rules and in Schedule 7 to the NHS Act 2006

have the same meaning in these rules as in that Schedule.

Part 2 – Timetable for election 2. Timetable - The proceedings at an election shall be conducted in accordance with

the following timetable.

Proceeding

Time

Publication of notice of election Not later than the fortieth day before the day of the close of the poll.

Final day for delivery of nomination papers to returning officer

Not later than the twenty eighth day before the day of the close of the poll.

Publication of statement of nominated candidates

Not later than the twenty seventh day before the day of the close of the poll.

Final day for delivery of notices of withdrawals by candidates from election

Not later than twenty fifth day before the day of the close of the poll.

Notice of the poll Not later than the fifteenth day before the day of the close of the poll.

Close of the poll By 5.00pm on the final day of the election.

3. Computation of time - (1) In computing any period of time for the purposes of the

timetable –

(a) a Saturday or Sunday; (b) Christmas day, Good Friday, or a bank holiday, or (c) a day appointed for public thanksgiving or mourning,

shall be disregarded, and any such day shall not be treated as a day for the purpose of any proceedings up to the completion of the poll, nor shall the returning officer be obliged to proceed with the counting of votes on such a day.


Top




39

(2) In this rule, - “bank holiday” means a day which is a bank holiday under the

Banking and Financial Dealings Act 1971 in England and Wales.

Part 3 – Returning officer

4. Returning officer – (1) Subject to rule 64, the returning officer for an election is to be appointed by the corporation.

(2) Where two or more elections are to be held concurrently, the same returning

officer may be appointed for all those elections. 5. Staff – Subject to rule 64, the returning officer may appoint and pay such staff,

including such technical advisers, as he or she considers necessary for the purposes of the election.

6. Expenditure - The corporation is to pay the returning officer –

(a) any expenses incurred by that officer in the exercise of his or her functions under these rules,

(b) such remuneration and other expenses as the corporation may determine.

7. Duty of co-operation – The corporation is to co-operate with the returning officer in the exercise of his or her functions under these rules.

Part 4 - Stages Common to Contested and Uncontested Elections

8. Notice of election – The returning officer is to publish a notice of the election stating:

(a) the constituency, or class within a constituency, for which the election is being held,

(b) the number of members of the Members‘ Council to be elected from that constituency, or class within that constituency,

(c) the details of any nomination committee that has been established by the corporation,

(d) the address and times at which nomination papers may be obtained;

(e) the address for return of nomination papers and the date and time by which they must be received by the returning officer,

(f) the date and time by which any notice of withdrawal must be received by the returning officer

(g) the contact details of the returning officer, and

(h) the date and time of the close of the poll in the event of a contest.

9. Nomination of candidates – (1) Each candidate must nominate themselves on a single nomination paper.

(2) The returning officer-

(a) is to supply any member of the corporation with a nomination paper, and


Top




40

(b) is to prepare a nomination paper for signature at the request of any member of the corporation, but it is not necessary for a nomination to be on a form supplied by the returning officer.

10. Candidate’s particulars – (1) The nomination paper must state the candidate‘s - (a) full name, (b) contact address in full, and (c) constituency, or class within a constituency, of which the candidate is a

member. 11. Declaration of interests – The nomination paper must state –

(a) any financial interest that the candidate has in the corporation, and

(b) whether the candidate is a member of a political party, and if so, which party,

and if the candidate has no such interests, the paper must include a statement to that effect.

12. Declaration of eligibility – The nomination paper must include a declaration made

by the candidate– (a) that he or she is not prevented from being a member of the Members‘ Council

by paragraph 8 of Schedule 7 of the 2006 Act or by any provision of the constitution; and,

(b) for a member of the public or patient constituency, of the particulars of his or

her qualification to vote as a member of that constituency, or class within that constituency, for which the election is being held.

13. Signature of candidate – The nomination paper must be signed and dated by the

candidate, indicating that – (a) they wish to stand as a candidate, (b) their declaration of interests as required under rule 11, is true and correct, and (c) their declaration of eligibility, as required under rule 12, is true and correct.

14. Decisions as to the validity of nomination – (1) Where a nomination paper is received by the returning officer in accordance with these rules, the candidate is deemed to stand for election unless and until the returning officer- (a) decides that the candidate is not eligible to stand, (b) decides that the nomination paper is invalid, (c) receives satisfactory proof that the candidate has died, or (d) receives a written request by the candidate of their withdrawal from

candidacy. (2) The returning officer is entitled to decide that a nomination paper is invalid


Top




41

only on one of the following grounds – (a) that the paper is not received on or before the final time and date for return of

nomination papers, as specified in the notice of the election, (b) that the paper does not contain the candidate‘s particulars, as required by rule

10; (c) that the paper does not contain a declaration of the interests of the candidate,

as required by rule 11, (d) that the paper does not include a declaration of eligibility as required by rule

12, or (e) that the paper is not signed and dated by the candidate, as required by rule

13. (3) The returning officer is to examine each nomination paper as soon as is

practicable after he or she has received it, and decide whether the candidate has been validly nominated.

(4) Where the returning officer decides that a nomination is invalid, the returning

officer must endorse this on the nomination paper, stating the reasons for their decision.

(5) The returning officer is to send notice of the decision as to whether a

nomination is valid or invalid to the candidate at the contact address given in the candidate‘s nomination paper.

15. Publication of statement of candidates – (1) The returning officer is to prepare and

publish a statement showing the candidates who are standing for election. (2) The statement must show – (a) the name, contact address, and constituency or class within a constituency of

each candidate standing, and (b) the declared interests of each candidate standing, as given in their nomination

paper. (3) The statement must list the candidates standing for election in alphabetical

order by surname. (4) The returning officer must send a copy of the statement of candidates and

copies of the nomination papers to the corporation as soon as is practicable after publishing the statement.

16. Inspection of statement of nominated candidates and nomination papers –

(1) The corporation is to make the statements of the candidates and the

nomination papers supplied by the returning officer under rule 15(4) available for inspection by members of the public free of charge at all reasonable times.

(2) If a person requests a copy or extract of the statements of candidates or their

nomination papers, the corporation is to provide that person with the copy or extract free of charge.


Top




42

17. Withdrawal of candidates - A candidate may withdraw from election on or before

the date and time for withdrawal by candidates, by providing to the returning officer a written notice of withdrawal which is signed by the candidate and attested by a witness.

18. Method of election – (1) If the number of candidates remaining validly nominated for

an election after any withdrawals under these rules is greater than the number of members to be elected to the Members’ Council, a poll is to be taken in accordance with Parts 5 and 6 of these rules.

(2) If the number of candidates remaining validly nominated for an election after

any withdrawals under these rules is equal to the number of members to be elected to the Members‘ Council, those candidates are to be declared elected in accordance with Part 7 of these rules.

(3) If the number of candidates remaining validly nominated for an election after

any withdrawals under these rules is less than the number of members to be elected to be Members‘ Council, then –

(a) the candidates who remain validly nominated are to be declared elected in

accordance with Part 7 of these rules, and (b) the returning officer is to order a new election to fill any vacancy which

remains unfilled, on a day appointed by him or her in consultation with the corporation.

Part 5 – Contested elections

19. Poll to be taken by ballot – (1) The votes at the poll must be given by secret ballot.

(2) The votes are to be counted and the result of the poll determined in accordance with Part 6 of these rules.

20. The ballot paper – (1) The ballot of each voter is to consist of a ballot paper with the

persons remaining validly nominated for an election after any withdrawals under these rules, and no others, inserted in the paper. (2) Every ballot paper must specify – (a) the name of the corporation, (b) the constituency, or class within a constituency, for which the election is being

held, (c) the number of members of the Members‘ Council to be elected from that

constituency, or class within that constituency, (d) the names and other particulars of the candidates standing for election, with

the details and order being the same as in the statement of nominated candidates,

(e) instructions on how to vote, (f) if the ballot paper is to be returned by post, the address for its return and the

date and time of the close of the poll, and


Top




43

(g) the contact details of the returning officer. (3) Each ballot paper must have a unique identifier. (4) Each ballot paper must have features incorporated into it to prevent it from

being reproduced.

21. The declaration of identity (public and patient constituencies) – (1) In respect of an election for a public or patient constituency a declaration of identity must be issued with each ballot paper. (2) The declaration of identity is to include a declaration – (a) that the voter is the person to whom the ballot paper was addressed, (b) that the voter has not marked or returned any other voting paper in the

election, and (c) for a member of the public or patient constituency, of the particulars of that

member‘s qualification to vote as a member of the constituency or class within a constituency for which the election is being held.

(3) The declaration of identity is to include space for – (a) the name of the voter, (b) the address of the voter, (c) the voter‘s signature, and (d) the date that the declaration was made by the voter. (4) The voter must be required to return the declaration of identity together with

the ballot paper. (5) The declaration of identity must caution the voter that, if it is not returned with

the ballot paper, or if it is returned without being correctly completed, the voter‘s ballot paper may be declared invalid.

Action to be taken before the poll 22. List of eligible voters – (1) The corporation is to provide the returning officer with a

list of the members of the constituency or class within a constituency for which the election is being held who are eligible to vote by virtue of rule 26 as soon as is reasonably practicable after the final date for the delivery of notices of withdrawals by candidates from an election.

(2) The list is to include, for each member, a mailing address where his or her

ballot paper is to be sent. 23. Notice of poll - The returning officer is to publish a notice of the poll stating–

(a) the name of the corporation, (b) the constituency, or class within a constituency, for which the election is being


Top




44

held, (c) the number of members of the Members‘ Council to be elected from that

constituency, or class with that constituency, (d) the names, contact addresses, and other particulars of the candidates

standing for election, with the details and order being the same as in the statement of nominated candidates,

(e) that the ballot papers for the election are to be issued and returned, if

appropriate, by post, (f) the address for return of the ballot papers, and the date and time of the close

of the poll, (g) the address and final dates for applications for replacement ballot papers, and (h) the contact details of the returning officer.

24. Issue of voting documents by returning officer – (1) As soon as is reasonably practicable on or after the publication of the notice of the poll, the returning officer is to send the following documents to each member of the corporation named in the list of eligible voters– (a) a ballot paper and ballot paper envelope, (b) a declaration of identity (if required), (c) information about each candidate standing for election, pursuant to rule 59 of

these rules, and (d) a covering envelope. (2) The documents are to be sent to the mailing address for each member, as

specified in the list of eligible voters.

25. Ballot paper envelope and covering envelope – (1) The ballot paper envelope must have clear instructions to the voter printed on it, instructing the voter to seal the ballot paper inside the envelope once the ballot paper has been marked. (2) The covering envelope is to have – (a) the address for return of the ballot paper printed on it, and (b) pre-paid postage for return to that address. (3) There should be clear instructions, either printed on the covering envelope or

elsewhere, instructing the voter to seal the following documents inside the covering envelope and return it to the returning officer –

(a) the completed declaration of identity if required, and (b) the ballot paper envelope, with the ballot paper sealed inside it.

The poll


Top




45

26. Eligibility to vote – An individual who becomes a member of the corporation on or before the closing date for the receipt of nominations by candidates for the election, is eligible to vote in that election.

27. Voting by persons who require assistance – (1) The returning officer is to put in

place arrangements to enable requests for assistance to vote to be made.

(2) Where the returning officer receives a request from a voter who requires assistance to vote, the returning officer is to make such arrangements as he or she considers necessary to enable that voter to vote.

28. Spoilt ballot papers (1) – If a voter has dealt with his or her ballot paper in such a

manner that it cannot be accepted as a ballot paper (referred to a ―”spoilt ballot paper”), that voter may apply to the returning officer for a replacement ballot paper. (2) On receiving an application, the returning officer is to obtain the details of the

unique identifier on the spoilt ballot paper, if he or she can obtain it. (3) The returning officer may not issue a replacement ballot paper for a spoilt

ballot paper unless he or she – (a) is satisfied as to the voter‘s identity, and (b) has ensured that the declaration of identity, if required, has not been returned. (4) After issuing a replacement ballot paper for a spoilt ballot paper, the returning

officer shall enter in a list (“the list of spoilt ballot papers”) – (a) the name of the voter, and (b) the details of the unique identifier of the spoilt ballot paper (if that officer was

able to obtain it), and (c) the details of the unique identifier of the replacement ballot paper.

29. Lost ballot papers – (1) Where a voter has not received his or her ballot paper by the fourth day before the close of the poll, that voter may apply to the returning officer for a replacement ballot paper.

(2) The returning officer may not issue a replacement ballot paper for a lost

ballot paper unless he or she – (a) is satisfied as to the voter‘s identity, (b) has no reason to doubt that the voter did not receive the original ballot

paper, and (c) has ensured that the declaration of identity if required has not been returned. (3) After issuing a replacement ballot paper for a lost ballot paper, the returning

officer shall enter in a list (“the list of lost ballot papers”) – (a) the name of the voter, and (b) the details of the unique identifier of the replacement ballot paper.


Top




46

30. Issue of replacement ballot paper– (1) If a person applies for a replacement ballot paper under rule 28 or 29 and a declaration of identity has already been received by the returning officer in the name of that voter, the returning officer may not issue a replacement ballot paper unless, in addition to the requirements imposed rule 28(3) or 29(2), he or she is also satisfied that that person has not already voted in the election, notwithstanding the fact that a declaration of identity if required has already been received by the returning officer in the name of that voter.

(2) After issuing a replacement ballot paper under this rule, the returning officer

shall enter in a list (“the list of tendered ballot papers”) – (a) the name of the voter, and (b) the details of the unique identifier of the replacement ballot paper issued

under this rule.

31. Declaration of identity for replacement ballot papers (public and patient constituencies) – (1) In respect of an election for a public or patient constituency a declaration of identity must be issued with each replacement ballot paper.

(2) The declaration of identity is to include a declaration – (a) that the voter has not voted in the election with any ballot paper other than the

ballot paper being returned with the declaration, and (b) of the particulars of that member‘s qualification to vote as a member of the

public or patient constituency, or class within a constituency, for which the election is being held.

(3) The declaration of identity is to include space for – (a) the name of the voter, (b) the address of the voter, (c) the voter‘s signature, and (d) the date that the declaration was made by the voter. (4) The voter must be required to return the declaration of identity together with

the ballot paper. (5) The declaration of identity must caution the voter that if it is not returned with

the ballot paper, or if it is returned without being correctly completed, the replacement ballot paper may be declared invalid.

Procedure for receipt of envelopes 32. Receipt of voting documents – (1) Where the returning officer receives a –

(a) covering envelope, or (b) any other envelope containing a declaration of identity if required, a ballot

paper envelope, or a ballot paper, before the close of the poll, that officer is to open it as soon as is practicable; and rules 33 and 34 are to apply.


Top




47

(2) The returning officer may open any ballot paper envelope for the purposes of rules 33 and 34, but must make arrangements to ensure that no person obtains or communicates information as to –

(a) the candidate for whom a voter has voted, or (b) the unique identifier on a ballot paper. (3) The returning officer must make arrangements to ensure the safety and

security of the ballot papers and other documents. 33. Validity of ballot paper – (1) A ballot paper shall not be taken to be duly returned

unless the returning officer is satisfied that it has been received by the returning officer before the close of the poll, with a declaration of identity if required that has been correctly completed, signed, and dated. (2) Where the returning officer is satisfied that paragraph (1) has been fulfilled, he

or she is to – (a) put the declaration of identity if required in a separate packet, and (b) put the ballot paper aside for counting after the close of the poll. (3) Where the returning officer is not satisfied that paragraph (1) has been

fulfilled, he or she is to – (a) mark the ballot paper “disqualified”, (b) if there is a declaration of identity accompanying the ballot paper, mark it as

”disqualified” and attach it the ballot paper, (c) record the unique identifier on the ballot paper in a list (the “list of disqualified

documents”); and (d) place the document or documents in a separate packet.

34. Declaration of identity but no ballot paper (public and patient constituency) –

Where the returning officer receives a declaration of identity if required but no ballot paper, the returning officer is to – (a) mark the declaration of identity “disqualified”, (b) record the name of the voter in the list of disqualified documents, indicating

that a declaration of identity was received from the voter without a ballot paper; and

(c) place the declaration of identity in a separate packet.

35. Sealing of packets – As soon as is possible after the close of the poll and after the completion of the procedure under rules 33 and 34, the returning officer is to seal the packets containing–

(a) the disqualified documents, together with the list of disqualified documents

inside it,

(b) the declarations of identity if required,


Top




48

(c) the list of spoilt ballot papers,

(d) the list of lost ballot papers,

(e) the list of eligible voters, and

(f) the list of tendered ballot papers.

Part 6 - Counting the votes

36. Interpretation of Part 6 – In Part 6 of these rules – “continuing candidate” means any candidate not deemed to be elected, and not excluded, “count” means all the operations involved in counting of the first preferences recorded for candidates, the transfer of the surpluses of elected candidates, and the transfer of the votes of the excluded candidates, “deemed to be elected” means deemed to be elected for the purposes of counting of votes but without prejudice to the declaration of the result of the poll, “mark” means a figure, an identifiable written word, or a mark such as “X”, “non-transferable vote” means a ballot paper – (a) on which no second or subsequent preference is recorded for a continuing

candidate, or (b) which is excluded by the returning officer under rule 44(4) below, “preference” as used in the following contexts has the meaning assigned below– (a) “first preference” means the figure “1” or any mark or word which clearly

indicates a first (or only) preference, (b) “next available preference” means a preference which is the second, or as the

case may be, subsequent preference recorded in consecutive order for a continuing candidate (any candidate who is deemed to be elected or is excluded thereby being ignored); and

(c) in this context, a ”second preference” is shown by the figure “2” or any mark

or word which clearly indicates a second preference, and a third preference by the figure “3” or any mark or word which clearly indicates a third preference, and so on,

“quota” means the number calculated in accordance with rule s41 below, “surplus” means the number of votes by which the total number of votes for any candidate (whether first preference or transferred votes, or a combination of both) exceeds the quota; but references in these rules to the transfer of the surplus means the transfer (at a transfer value) of all transferable papers from the candidate who


Top




49

has the surplus, “stage of the count” means – (a) the determination of the first preference vote of each candidate, (b) the transfer of a surplus of a candidate deemed to be elected, or (c) the exclusion of one or more candidates at any given time, “transferable paper” means a ballot paper on which, following a first preference, a second or subsequent preference is recorded in consecutive numerical order for a continuing candidate,

“transferred vote” means a vote derived from a ballot paper on which a second or subsequent preference is recorded for the candidate to whom that paper has been transferred, and “transfer value” means the value of a transferred vote calculated in accordance with paragraph (4) or (7) of rule 42 below.

37. Arrangements for counting of the votes – The returning officer is to make arrangements for counting the votes as soon as is practicable after the close of the poll.

38. The count – (1) The returning officer is to –

(a) count and record the number of ballot papers that have been returned, and

(b) count the votes according to the provisions in this Part of the rules.

(2) The returning officer, while counting and recording the number of ballot papers and counting the votes, must make arrangements to ensure that no person obtains or communicates information as to the unique identifier on a ballot paper.

(3) The returning officer is to proceed continuously with counting the votes as far

as is practicable. 39. Rejected ballot papers – (1) Any ballot paper –

(a) which does not bear the features that have been incorporated into the other

ballot papers to prevent them from being reproduced, (b) on which the figure ―1‖ standing alone is not placed so as to indicate a first

preference for any candidate, (c) on which anything is written or marked by which the voter can be identified

except the unique identifier, or (d) which is unmarked or rejected because of uncertainty, shall be rejected and

not counted, but the ballot paper shall not be rejected by reason only of carrying the words “one”, “two”, “three” and so on, or any other mark instead of a figure if, in the opinion of the returning officer, the word or mark clearly indicates a preference or preferences.


Top




50

(2) The returning officer is to endorse the word ―rejected‖ on any ballot paper

which under this rule is not to be counted. (3) The returning officer is to draw up a statement showing the number of ballot

papers rejected by him or her under each of the subparagraphs (a) to (d) of paragraph (1).

40. First stage – (1) The returning officer is to sort the ballot papers into parcels

according to the candidates for whom the first preference votes are given.

(2) The returning officer is to then count the number of first preference votes given on ballot papers for each candidate, and is to record those numbers.

(3) The returning officer is to also ascertain and record the number of valid ballot

papers.

41. The quota – (1) The returning officer is to divide the number of valid ballot papers by a number exceeding by one the number of members to be elected. (2) The result, increased by one, of the division under paragraph (1) above (any

fraction being disregarded) shall be the number of votes sufficient to secure the election of a candidate (in these rules referred to as “the quota”).

(3) At any stage of the count a candidate whose total votes equals or exceeds the

quota shall be deemed to be elected, except that any election where there is only one vacancy a candidate shall not be deemed to be elected until the procedure set out in paragraphs (1) to (3) of rule 44 has been complied with.

42. Transfer of votes – (1) Where the number of first preference votes for any candidate

exceeds the quota, the returning officer is to sort all the ballot papers on which first preference votes are given for that candidate into sub-parcels so that they are grouped –

(a) according to next available preference given on those papers for any

continuing candidate, or (b) where no such preference is given, as the sub-parcel of non-transferable

votes.

(2) The returning officer is to count the number of ballot papers in each parcel referred to in paragraph (1) above.

(3) The returning officer is, in accordance with this rule and rule 43 below, to

transfer each sub-parcel of ballot papers referred to in paragraph (1)(a) to the candidate for whom the next available preference is given on those papers.

(4) The vote on each ballot paper transferred under paragraph (3) above shall be

at a value (“the transfer value”) which – (a) reduces the value of each vote transferred so that the total value of all such

votes does not exceed the surplus, and (b) is calculated by dividing the surplus of the candidate from whom the votes are

being transferred by the total number of the ballot papers on which those votes are given, the calculation being made to two decimal places (ignoring


Top




51

the remainder if any). (5) Where at the end of any stage of the count involving the transfer of ballot

papers, the number of votes for any candidate exceeds the quota, the returning officer is to sort the ballot papers in the sub-parcel of transferred votes which was last received by that candidate into separate sub-parcels so that they are grouped –

(a) according to the next available preference given on those papers for any

continuing candidate, or (b) where no such preference is given, as the sub-parcel of non-transferable

votes. (6) The returning officer is, in accordance with this rule and rule 43 below, to

transfer each sub-parcel of ballot papers referred to in paragraph (5)(a) to the candidate for whom the next available preference is given on those papers.

(7) The vote on each ballot paper transferred under paragraph (6) shall be at – (a) a transfer value calculated as set out in paragraph (4) (b) above, or (b) at the value at which that vote was received by the candidate from whom it is

now being transferred, whichever is the less. (8) Each transfer of a surplus constitutes a stage in the count. (9) Subject to paragraph (10), the returning officer shall proceed to transfer

transferable papers until no candidate who is deemed to be elected has a surplus or all the vacancies have been filled.

(10) Transferable papers shall not be liable to be transferred where any surplus or

surpluses which, at a particular stage of the count, have not already been transferred, are –

(a) less than the difference between the total vote then credited to the continuing

candidate with the lowest recorded vote and the vote of the candidate with the next lowest recorded vote, or

(b) less than the difference between the total votes of the two or more continuing

candidates, credited at that stage of the count with the lowest recorded total numbers of votes and the candidate next above such candidates.

(11) This rule does not apply at an election where there is only one vacancy.

43. Supplementary provisions on transfer – (1) If, at any stage of the count, two or more candidates have surpluses, the transferable papers of the candidate with the highest surplus shall be transferred first, and if – (a) The surpluses determined in respect of two or more candidates are equal, the

transferable papers of the candidate who had the highest recorded vote at the earliest preceding stage at which they had unequal votes shall be transferred first, and

(b) the votes credited to two or more candidates were equal at all stages of the

count, the returning officer shall decide between those candidates by lot, and


Top




52

the transferable papers of the candidate on whom the lot falls shall be transferred first.

(2) The returning officer shall, on each transfer of transferable papers under rule

42 above – (a) record the total value of the votes transferred to each candidate, (b) add that value to the previous total of votes recorded for each candidate and

record the new total, (c) record as non-transferable votes the difference between the surplus and the

total transfer value of the transferred votes and add that difference to the previously recorded total of non-transferable votes, and

(d) compare— (i) the total number of votes then recorded for all of the candidates, together with

the total number of non-transferable votes, with (ii) the recorded total of valid first preference votes. (3) All ballot papers transferred under rule 42 or 44 shall be clearly marked, either

individually or as a sub-parcel, so as to indicate the transfer value recorded at that time to each vote on that paper or, as the case may be, all the papers in that subparcel.

(4) Where a ballot paper is so marked that it is unclear to the returning officer at

any stage of the count under rule 42 or 44 for which candidate the next preference is recorded, the returning officer shall treat any vote on that ballot paper as a non-transferable vote; and votes on a ballot paper shall be so treated where, for example, the names of two or more candidates (whether continuing candidates or not) are so marked that, in the opinion of the returning officer, the same order of preference is indicated or the numerical sequence is broken.

44. Exclusion of candidates – (1) If—

(a) all transferable papers which under the provisions of rule 42 above (including that rule as applied by paragraph (11) below) and this rule are required to be transferred, have been transferred, and

(b) subject to rule 45 below, one or more vacancies remain to be filled, the returning officer shall exclude from the election at that stage the candidate with the then lowest vote (or, where paragraph (12) below applies, the candidates with the then lowest votes).

(2) The returning officer shall sort all the ballot papers on which first preference

votes are given for the candidate or candidates excluded under paragraph (1) above into two sub-parcels so that they are grouped as—

(a) ballot papers on which a next available preference is given, and (b) ballot papers on which no such preference is given (thereby including ballot

papers on which preferences are given only for candidates who are deemed to be elected or are excluded).


Top




53

(3) The returning officer shall, in accordance with this rule and rule 43 above, transfer each sub-parcel of ballot papers referred to in paragraph (2)(a) above to the candidate for whom the next available preference is given on those papers.

(4) The exclusion of a candidate, or of two or more candidates together,

constitutes a further stage of the count. (5) If, subject to rule stv45 below, one or more vacancies still remain to be filled,

the returning officer shall then sort the transferable papers, if any, which had been transferred to any candidate excluded under paragraph (1) above into sub-parcels according to their transfer value.

(6) The returning officer shall transfer those papers in the sub-parcel of

transferable papers with the highest transfer value to the continuing candidates in accordance with the next available preferences given on those papers (thereby passing over candidates who are deemed to be elected or are excluded).

(7) The vote on each transferable paper transferred under paragraph (6) above

shall be at the value at which that vote was received by the candidate excluded under paragraph (1) above.

(8) Any papers on which no next available preferences have been expressed

shall be set aside as non-transferable votes. (9) After the returning officer has completed the transfer of the ballot papers in

the sub-parcel of ballot papers with the highest transfer value he or she shall proceed to transfer in the same way the sub-parcel of ballot papers with the next highest value and so on until he has dealt with each sub-parcel of a candidate excluded under paragraph (1) above.

(10) The returning officer shall after each stage of the count completed under this

rule — (a) record – (i) the total value of votes, or

(ii) the total transfer value of votes transferred to each candidate, (b) add that total to the previous total of votes recorded for each candidate and

record the new total, (c) record the value of non-transferable votes and add that value to the previous

non-transferable votes total, and (d) compare—

(i) the total number of votes then recorded for each candidate together with the

total number of non-transferable votes, with (ii) the recorded total of valid first preference votes. (11) If after a transfer of votes under any provision of this rule, a candidate has a

surplus, that surplus shall be dealt with in accordance with paragraphs (5) to


Top




54

(10) of rule 42 and rule 43. (12) Where the total of the votes of the two or more lowest candidates, together

with any surpluses not transferred, is less than the number of votes credited to the next lowest candidate, the returning officer shall in one operation exclude such two or more candidates.

(13) If when a candidate has to be excluded under this rule, two or more

candidates each have the same number of votes and are lowest— (a) regard shall be had to the total number of votes credited to those candidates

at the earliest stage of the count at which they had an unequal number of votes and the candidate with the lowest number of votes at that stage shall be excluded, and

(b) where the number of votes credited to those candidates was equal at all

stages, the returning officer shall decide between the candidates by lot and the candidate on whom the lot falls shall be excluded.

45. Filling of last vacancies – (1) Where the number of continuing candidates is equal

to the number of vacancies remaining unfilled the continuing candidates shall thereupon be deemed to be elected. (2) Where only one vacancy remains unfilled and the votes of any one continuing

candidate are equal to or greater than the total of votes credited to other continuing candidates together with any surplus not transferred, the candidate shall thereupon be deemed to be elected.

(3) Where the last vacancies can be filled under this rule, no further transfer of

votes shall be made. 46. Order of election of candidates – (1) The order in which candidates whose votes

equal or exceed the quota are deemed to be elected shall be the order in which their respective surpluses were transferred, or would have been transferred but for rule 42(10) above.

(2) A candidate credited with a number of votes equal to, and not greater than,

the quota shall, for the purposes of this rule, be regarded as having had the smallest surplus at the stage of the count at which he obtained the quota.

(3) Where the surpluses of two or more candidates are equal and are not

required to be transferred, regard shall be had to the total number of votes credited to such candidates at the earliest stage of the count at which they had an unequal number of votes and the surplus of the candidate who had the greatest number of votes at that stage shall be deemed to be the largest.

(4) Where the number of votes credited to two or more candidates were equal at all stages of the count, the returning officer shall decide between them by lot and the candidate on whom the lot falls shall be deemed to have been elected first.

Part 7 – Final proceedings in contested and uncontested elections

47. Declaration of result for contested elections – (1) In a contested election, when


Top




55

the result of the poll has been ascertained, the returning officer is to— (a) declare the candidates who are deemed to be elected under Part 6 of these

rules as elected, (b) give notice of the name of each candidate who he or she has declared elected (i) where the election is held under a proposed constitution pursuant to powers

conferred on the Great Ormond Street Hospital for Children NHS Trust by section 33(4) of the 2006 Act, to the chairman of the NHS Trust, or

(ii) in any other case, to the chairman of the corporation, and (c) give public notice of the name of each candidate who he or she has declared

elected.

(2) The returning officer is to make – (a) the number of first preference votes for each candidate whether elected or

not, (b) any transfer of votes, (c) the total number of votes for each candidate at each stage of the count at

which such transfer took place, (d) the order in which the successful candidates were elected, and (e) the number of rejected ballot papers under each of the headings in rule 39(1),

available on request.

48. Declaration of result for uncontested elections – In an uncontested election, the returning officer is to as soon as is practicable after final day for the delivery of notices of withdrawals by candidates from the election – (a) declare the candidate or candidates remaining validly nominated to be

elected,

(b) give notice of the name of each candidate who he or she has declared elected to the chairman of the corporation, and

(c) give public notice of the name of each candidate who he or she has declared

elected.

Part 8 – Disposal of documents 49. Sealing up of documents relating to the poll – (1) On completion of the counting

at a contested election, the returning officer is to seal up the following documents in separate packets – (a) the counted ballot papers,


Top




56

(b) the ballot papers endorsed with “rejected in part”,

(c) the rejected ballot papers, and

(d) the statement of rejected ballot papers.

(2) The returning officer must not open the sealed packets of –

(a) the disqualified documents, with the list of disqualified documents inside it,

(b) the declarations of identity,

(c) the list of spoilt ballot papers,

(d) the list of lost ballot papers,

(e) the list of eligible voters, and

(f) the list of tendered ballot papers.

(3) The returning officer must endorse on each packet a description of – (a) its contents, (b) the date of the publication of notice of the election,

(c) the name of the corporation to which the election relates, and

(d) the constituency, or class within a constituency, to which the election relates.

50. Delivery of documents – Once the documents relating to the poll have been sealed up and endorsed pursuant to rule 49, the returning officer is to forward them to the chair of the corporation.

51. Forwarding of documents received after close of the poll – Where –

(a) any voting documents are received by the returning officer after the close of the poll, or

(b) any envelopes addressed to eligible voters are returned as undelivered too

late to be resent, or

(c) any applications for replacement ballot papers are made too late to enable new ballot papers to be issued, the returning officer is to put them in a separate packet, seal it up, and endorse and forward it to the chairman of the corporation.

52. Retention and public inspection of documents – (1) The corporation is to retain

the documents relating to an election that are forwarded to the chair by the returning officer under these rules for one year, and then, unless otherwise directed by the regulator, cause them to be destroyed. (2) With the exception of the documents listed in rule 53(1), the documents

relating to an election that are held by the corporation shall be available for inspection by members of the public at all reasonable times.


Top




57

(3) A person may request a copy or extract from the documents relating to an election that are held by the corporation, and the corporation is to provide it, and may impose a reasonable charge for doing so.

53. Application for inspection of certain documents relating to an election – (1) The corporation may not allow the inspection of, or the opening of any sealed packet containing – (a) any rejected ballot papers, including ballot papers rejected in part, (b) any disqualified documents, or the list of disqualified documents,

(c) any counted ballot papers,

(d) any declarations of identity, or

(e) the list of eligible voters, by any person without the consent of the Regulator. (2) A person may apply to the Regulator to inspect any of the documents listed in

(1), and the Regulator may only consent to such inspection if it is satisfied that it is necessary for the purpose of questioning an election pursuant to Part 11.

(3) The Regulator‘s consent may be on any terms or conditions that it thinks

necessary, including conditions as to –

(a) persons, (b) time,

(c) place and mode of inspection,

(d) production or opening, and the corporation must only make the documents

available for inspection in accordance with those terms and conditions.

(4) On an application to inspect any of the documents listed in paragraph (1), – (a) in giving its consent, the regulator, and (b) and making the documents available for inspection, the corporation, must

ensure that the way in which the vote of any particular member has been given shall not be disclosed, until it has been established –

(i) that his or her vote was given, and

(ii) that the regulator has declared that the vote was invalid.

Part 9 – Death of a candidate during a contested election

54. Countermand or abandonment of poll on death of candidate – (1) If, at a contested election, proof is given to the returning officer‘s satisfaction before the result of the election is declared that one of the persons named or to be named as a candidate has died, then the returning officer is to – (a) publish a notice stating that the candidate has died, and


Top




58

(b) proceed with the counting of the votes as if that candidate had been excluded from the count so that –

(i) ballot papers which only have a first preference recorded for the candidate

that has died, and no preferences for any other candidates, are not to be counted, and

(ii) ballot papers which have preferences recorded for other candidates are to be counted according to the consecutive order of those preferences, passing over preferences marked for the candidate who has died.

(2) The ballot papers which have preferences recorded for the candidate who has died are to be sealed with the other counted ballot papers pursuant to rule 49(1)(a).

Part 10 – Election expenses and publicity

Election expenses 55. Election expenses – Any expenses incurred, or payments made, for the purposes of

an election which contravene this Part are an electoral irregularity, which may only be questioned in an application to the regulator under Part 11 of these rules.

56. Expenses and payments by candidates - A candidate may not incur any expenses

or make a payment (of whatever nature) for the purposes of an election, other than expenses or payments that relate to – (a) personal expenses, (b) travelling expenses, and expenses incurred while living away from home, and

(c) expenses for stationery, postage, telephone, internet (or any similar means of

communication) and other petty expenses, to a limit of £100.

57. Election expenses incurred by other persons – (1) No person may –

(a) incur any expenses or make a payment (of whatever nature) for the purposes of a candidate‘s election, whether on that candidate‘s behalf or otherwise, or

(b) give a candidate or his or her family any money or property (whether as a gift,

donation, loan, or otherwise) to meet or contribute to expenses incurred by or on behalf of the candidate for the purposes of an election.

(2) Nothing in this rule is to prevent the corporation from incurring such expenses, and making such payments, as it considers necessary pursuant to rules 58 and 59.

Publicity 58. Publicity about election by the corporation – (1) The corporation may –

(a) compile and distribute such information about the candidates, and (b) organise and hold such meetings to enable the candidates to speak and

respond to questions, as it considers necessary.


Top




59

(2) Any information provided by the corporation about the candidates, including information compiled by the corporation under rule 59, must be –

(a) objective, balanced and fair,

(b) equivalent in size and content for all candidates,

(c) compiled and distributed in consultation with all of the candidates standing for election, and

(d) must not seek to promote or procure the election of a specific candidate or candidates, at the expense of the electoral prospects of one or more other candidates.

(3) Where the corporation proposes to hold a meeting to enable the candidates

to speak, the corporation must ensure that all of the candidates are invited to attend, and in organising and holding such a meeting, the corporation must not seek to promote or procure the election of a specific candidate or candidates at the expense of the electoral prospects of one or more other candidates.

59. Information about candidates for inclusion with voting documents - (1) The

corporation must compile information about the candidates standing for election, to be distributed by the returning officer pursuant to rule 24 of these rules. (2) The information must consist of – (a) a statement submitted by the candidate of no more than 250 words.

60. Meaning of “for the purposes of an election” - (1) In this Part, the phrase “for the

purposes of an election” means with a view to, or otherwise in connection with, promoting or procuring a candidate‘s election, including the prejudicing of another candidate‘s electoral prospects; and the phrase “for the purposes of a candidate‘s election” is to be construed accordingly. (2) The provision by any individual of his or her own services voluntarily, on his or

her own time, and free of charge is not to be considered an expense for the purposes of this Part.

Part 11 – Questioning elections and the consequence of irregularities

61. Application to question an election – (1) An application alleging a breach of these

rules, including an electoral irregularity under Part 10, may be made to the regulator. (2) An application may only be made once the outcome of the election has been

declared by the returning officer.

(3) An application may only be made to the Regulator by – (a) a person who voted at the election or who claimed to have had the right to

vote, or (b) a candidate, or a person claiming to have had a right to be elected at the

election.

(4) The application must –


Top




60

(a) describe the alleged breach of the rules or electoral irregularity, and

(b) be in such a form as the Regulator may require.

(5) The application must be presented in writing within 21 days of the declaration

of the result of the election. (6) If the Regulator requests further information from the applicant, then that

person must provide it as soon as is reasonably practicable. (a) The Regulator shall delegate the determination of an application to a person

or persons to be nominated for the purpose of the Regulator.

(b) The determination by the person or persons nominated in accordance with Rule 61(7) shall be binding on and shall be given effect by the corporation, the applicant and the members of the constituency (or class within a constituency) including all the candidates for the election to which the application relates.

(c) The Regulator may prescribe rules of procedure for the determination of an

application including costs.

Part 12 – Miscellaneous 62. Secrecy – (1) The following persons –

(a) the returning officer,

(b) the returning officer‘s staff, must maintain and aid in maintaining the secrecy of the voting and the counting of the votes, and must not, except for some purpose authorised by law, communicate to any person any information as to:–

(i) the name of any member of the corporation who has or has not been given a

ballot paper or who has or has not voted, (ii) the unique identifier on any ballot paper,

(iii) the candidate(s) for whom any member has voted.

(2) No person may obtain or attempt to obtain information as to the candidate(s)

for whom a voter is about to vote or has voted, or communicate such information to any person at any time, including the unique identifier on a ballot paper given to a voter.

(3) The returning officer is to make such arrangements as he or she thinks fit to

ensure that the individuals who are affected by this provision are aware of the duties it imposes.

63. Prohibition of disclosure of vote – No person who has voted at an election shall, in any legal or other proceedings to question the election, be required to state for whom he or she has voted.

64. Disqualification – A person may not be appointed as a returning officer, or as staff of the returning officer pursuant to these rules, if that person is –


Top




61

(a) a member of the corporation,

(b) an employee of the corporation,

(c) a director of the corporation, or

(d) employed by or on behalf of a person who has been nominated for election.

65. Delay in postal service through industrial action or unforeseen event – If

industrial action, or some other unforeseen event, results in a delay in – (a) the delivery of the documents in rule 24, or

(b) the return of the ballot papers and declarations of identity, the returning officer

may extend the time between the publication of the notice of the poll and the close of the poll, with the agreement of the Regulator.


Top



ANNEX 5 – ADDITIONAL PROVISIONS: COUNCIL OF GOVERNORS

62

CONSTITUTION

ANNEX 5

ADDITIONAL PROVISIONS: COUNCIL OF GOVERNORS


Top




63


Top




64

1. TERMS OF OFFICE

1.1 A Governor shall be:

i) elected or appointed for a term of three years; ii) shall be eligible for re-election or re-appointment at the end of that term but

may not serve as a Governors for more than a total of nine years;

iii) shall cease to hold office if:

a) he ceases to be a member of a Trust constituency or, in the case of an Appointed Governor, if the body which appointed him withdraws its appointment at any time;

b) his term of office is terminated in accordance with Clause 3 of this

Annex and/or he is disqualified from or is otherwise ineligible to hold office as a Governor; or

c) he resigns by notice in writing to the Trust.

2. REMOVAL AND DISQUALIFICATION

2.1 A Governor shall not be eligible to become or continue in office as a Governor if:

i) he ceases to be eligible to be a Member, save in the case of Appointed Governors;

ii) in the case of an Appointed Governor, the appointing organisation withdraws

its appointment of him; iii) any of the grounds contained in Clause 12 of the Constitution apply to him; iv) he has within the preceding two years been lawfully dismissed otherwise than

by reason of redundancy from any paid employment with a health service body;

v) he is a person whose term of office as the Chairman or as a Member or

Director of a health service body has been terminated on the grounds that his continuance in office is no longer in the best interests of the health service, for non-attendance at meetings or for non-disclosure of a pecuniary interest;

vi) he has had his name removed by a direction under Section 154 of the 2006

Act from any list prepared under Part Two of that Act and has not subsequently had his name included in such a list;

vii) he has failed to make, or has falsely made, any declaration as required to be

made under Section 60 of the 2006 Act; viii) he is subject to a direction made under Section 142 of the Education Act

2002; ix) he is the subject of a sex offender order; x) Monitor has exercised its powers to remove him as a Governor of the Trust or


Top




65

has suspended him from office or has disqualified him from holding office as a Governor of the Trust for a specified period or Monitor has exercised any of those powers in relation to him on any other occasion whether in relation to the Trust or some other NHS Foundation Trust;

xi) he has received a written warning from the Trust for verbal and/or physical

abuse towards Trust staff, patients, relatives or visitors; xii) he is or has been determined by the Trust as a vexatious or persistent litigant

or complainant with regard to the Trust’s affairs and nine years have not passed since the date of lifting of such determination;

xiii) his term of office is terminated pursuant to Clause 3 of this Annex; xiv) he is a member of a Staff Class and any professional registration relevant to

his eligibility to be a member of that Staff Class has been suspended for a continuous period of more than six months;

xv) he has within the preceding nine years been expelled for whatever reason

from another NHS Foundation Trust; xvi) he refuses or has refused within the preceding six years, without reasonable

cause, to undertake training which the Council of Governors requires all Governors to take;

xvii) if he was at any time eligible to be a member of the Staff Constituency during

the period he is or was a member of a Public Constituency; xviii) information revealed by a Criminal Records Bureau check is such that it would

be inappropriate, in the reasonable opinion of the Chief Executive, for him to become or continue as a Governor on the grounds that this would adversely affect public confidence in the Trust or otherwise bring the Trust into disrepute; or

xix) he is a partner or spouse or otherwise related to an existing Director;

xx) he is a Director or Senior Manager of an NHS organisation save of in the case

of an Appointed Governor.

2.2 Where a person has been elected or appointed to be a Governor and he becomes disqualified from that appointment he shall notify the Trust in writing of such disqualification as soon as practicable and in any event within fourteen days of first becoming aware of those matters which rendered him disqualified.

2.3 If it comes to the notice of the Trust that a Governor is disqualified, the Trust shall

immediately declare him disqualified and shall give him notice in writing to that effect as soon as practicable.

2.4 Upon the giving of notice under Clauses 2.2 and 2.3 of this Annex, that person’s

tenure of office as a Governor shall thereupon be terminated and he shall cease to be a Governor and his name shall be removed from the Register of Governors.


Top




66

3. TERMINATION OF TENURE

3.1 A Governor’s term of office shall be terminated:

i) by the Governor giving notice in writing to the Secretary of his resignation from office at any time during that term of office;

ii) by the Trust if any grounds exist under Clause 2 of this Annex;

iii) by the Council of Governors if he has failed to attend two successive

meetings of the Council of Governors unless the Council of Governors is satisfied;

a) the absence was due to reasonable cause; and b) that the Governor will resume attendance at meetings of the Council

of Governors within such period as it considers reasonable.

iv) if the Council of Governors resolves to terminate his term of office for reasonable cause on the grounds that in the reasonable opinion of three quarters of the Governors present and voting at a meeting of the Council of Governors convened for that purpose:

a) find his continuing as a Governor would or would be likely to:

1) prejudice the ability of the Trust to fulfil its principal purpose or of its purposes under this Constitution or otherwise to discharge its duties and functions; or

2) prejudice the Trust’s work with other persons or body with

whom it is engaged or may be engaged in the provision of goods and services; or

3) adversely affect public confidence in the goods and services

provided by the Trust; or 4) otherwise brings the Trust into disrepute or is detrimental to

the interest of the Trust; or 5) not be in the best interests of the Trust for that person to

continue in office as a Governor;

d) he has in his conduct as a Governor failed to comply in a material

way with the values and principles of the National Health Service or the Trust; or

e) he has committed a material breach of any code of conduct

applicable to Governors of the Trust.

3.2 Upon a Governor resigning under Clause 3.1 (i) of this Annex or upon the Council of Governors resolving to terminate a Governor’s tenure of office in accordance with the above provisions, that Governor shall cease to be a Governor and his name shall be


Top




67

forthwith removed from the Register of Governors. 3.3 The Standing Orders adopted by the Council of Governors may contain provisions

governing its procedure for termination under these provisions and for a Governor to appeal against the decision terminating his tenure of office.

3.4 A Governor:

3.4.1 who resigns or whose tenure of office is terminated under Paragraph 3.1(iii) of this Annex” shall not be eligible to stand for re-election for a period of six years from the date of his resignation or removal from office pursuant to Paragraph 3.1(iii); or

3.4.2 whose tenure of office is terminated under Paragraph 3.1(iv) of this Annex

shall not be eligible to stand for re-election for a period of nine years from the date of his removal from office or the date upon which any appeal against his removal from office is disposed of whichever is the later.

3.5 Not less than twenty per cent of the Governors may, where the process leading to the

possible removal of a Governor has been initiated, require the appointment of an Independent Assessor to consider the evidence and advise as to the appropriateness of removal. It will also be available to the Chairman to initiate any such independent assessment at any time.

4. VACANCIES

4.1 Where a Governor’s term of office terminates for whatever reason then:

i) in the case of an Appointed Governor, the Trust shall invite the relevant

appointing body to appoint a new Governor as soon as practicable; and ii) in the case of an Elected Governor, elections for a new Governor shall take

place as soon as practicable subject to the provisions of Clauses 4.2 and 4.3 of this Annex.

4.2 Where an Elected Governor ceases for whatever reason to hold office within twelve

months of his election:

i) the Trust shall offer the candidate who was ranked next highest in the last election for the constituency, class or Staff Class (as the case may be) in which the vacancy has arisen the opportunity to assume the vacant office of Governor for the unexpired balance of the former Governor’s term of office;

ii) if that candidate does not accept that invitation in a timely manner it shall be

offered to that candidate who was next highest ranked in the last said election until the vacancy is filled; but if no other candidate stood for election or there are no remaining candidates who stood for election to that office or no candidate accepts the Trust’s invitation in accordance with the above provisions within such time as the Trust may in its absolute discretion decide, the Trust shall hold an election for the vacancy as soon as reasonably practicable thereafter.

4.3 Subject to the provisions of Clause 4.4 of this Annex, where an Elected Governor

ceases for whatever reason to hold office within the last twelve months of his term of office, the office shall remain vacant until the next scheduled election takes place.


Top




68

4.4 Notwithstanding the above provisions of this Clause 4 of this Annex, where the termination of a Governor’s term of office causes the total number of Public Governors to be equal to or fewer than the other Governors of the Trust then an election for that vacant office shall be held as soon as reasonably practicable.

4.5 No defect in the election or appointment of a Governor nor any deficiency in the

composition of the Council of Governors shall affect the validity of any act or decision of the Council of Governors.

5. ROLE

5.1 The Council of Governors and each Governor shall act in the best interests of the

Trust at all times and with proper regard to the provisions of the NHS Foundation Trust Code of Governance.

5.2 Subject to the requirement specified in Clause 5.1 of this Annex, each Governor shall

exercise his own skill and judgement in his conduct of the Trust’s affairs and shall in his stewardship of the Trust’s affairs bring as appropriate the perspective of the constituency or organisation by which he was elected or appointed, as the case may be.

5.3 Subject to the further provisions of this Constitution and without in any way

derogating from them, the Council of Governors shall;

i) assist the Board of Directors in setting the strategic direction of the Trust and targets for the Trust’s performance and in monitoring the Trust’s performance in terms of achieving those strategic aims and targets which have been set; and

ii) monitor the activities of the Trust with the view to ensuring that they are

being conducted in a manner consistent with the terms of this Constitution.

6. MEETINGS

6.1 The Council of Governors shall hold not less than three general meetings each Financial Year.

6.2 All such meetings shall be open to the public unless the Council of Governors

resolves that the public be excluded from the meeting, whether for the whole or part of the proceedings on the grounds that publicity would be prejudicial to the public interest or the interests of the Trust by reason of the confidential nature of the business to be transacted or for other special reasons stated in the resolution and arising from the nature of the business to be transacted or the proceedings. The Chairman may also exclude any member of the public from a meeting of the Council of Governors if he is interfering with or preventing the proper conduct of the meeting.

6.3 The Council of Governors may appoint committees or sub-committees consisting of

its members to advise and assist it in the discharge of its functions. 6.4 The Council of Governors may request the attendance of some or all of the

members of the Board of Directors at its meetings and the Board of Directors may attend and may give such reports and information to the Council of Governors as the Board of Directors considers appropriate and subject always to the other provisions of this Constitution.

6.5 Further provisions relating to the Council of Governors meetings are set out in the


Top




69

Council of Governors Standing Orders at Annex 6 of this Constitution. 7. DECLARATIONS

7.1 A Member of a Public Constituency standing for election as Governor must make a

declaration for the purposes of Section 60 of the 2006 Act in the form specified below stating the particulars of his qualification to vote as a Member and that he is not prevented from being a Member of the Council of Governors by virtue of any provisions of this Constitution. It is an offence to knowingly or recklessly make a statement or declaration which is false in a material particular.

7.2 The specified form of declaration shall be set out on the Nomination Form referred

to in the Model Election Rules at Annex 4 and shall state as follows:

I, the above named candidate, consent to my nomination and agree to stand for election. I confirm that, to the best of my knowledge, the information provided on (or with) this form is accurate. I also agree to abide by the Poole Hospital NHS Foundation Trust Code of Conduct and the NHS core principles.

I declare that I am resident at the address given and that to the best of my knowledge I am eligible to stand for election to the Council of Governors for the seat named overleaf. I declare that I am not debarred from standing by any of the provisions detailed in Section 1 of the guidance notes and the Exclusion and Disqualification criteria also detailed in the guidance notes supplied with this nominations paper. I understand if any declaration on this form is later found to be false I will, if elected, lose my seat on the Council of Governors and may have my membership withdrawn.

7.3 A Governor elected to the Council of Governors by the Public Constituency or a Staff Class within the Staff Constituency may not vote at a meeting of the Council of Governors unless, within the period since his election, he has made a declaration in the form specified in Clause 7.4 of this Annex stating which Constituency or Class of Constituency he is a Member of and is not prevented from being a member of the Council of Governors by Paragraph 8 of Schedule 7 to the 2006 or by virtue of any provisions of this Constitution.

7.4 The specified form of declaration referred to in Clause 7.3 of this Annex shall states as follows:

I declare that I am a Member of the Public Constituency or Staff Class of the Staff Constituency and am eligible to vote at a meeting of the Council of Governors. I declare that I am not debarred from voting by any of the provisions detailed in paragraph 8 of Schedule 7 to the 2006 Act or by virtue of any provisions of this Constitution.


Top



ANNEX 6 – STANDING ORDERS: COUNCIL OF GOVERNORS

70

CONSTITUTION

ANNEX 6

STANDING ORDERS: COUNCIL OF GOVERNORS


Top




71


Top




72


Standing Orders

Council of Governors


Top




73

FOREWORD This document provides a regulatory and business framework for the conduct of the Council of Governors.


Top




74

CONTENTS PAGE

INTRODUCTION ......................................................................................... 74

1.

INTERPRETATION ..................................................................................... 74

2. THE COUNCIL OF GOVERNORS .............................................................. 75 Roles and Responsibilities ........................................................................... 75 Composition of the Council of Governors ..................................................... 76 Appointment of the Chairman and Non-Executive Directors ......................... 76 Terms of Office of the Chairman and Non-Executive Directors ..................... 76 Appointment of Vice Chairman of the Council of Governors ......................... 76

3. MEETINGS OF THE COUNCIL OF GOVERNORS..................................... 77 Calling Meetings ........................................................................................... 77 Admission of the Public ................................................................................ 77 Chairman of the Meeting .............................................................................. 77 Setting the Agenda ....................................................................................... 77 Agenda ........................................................................................................ 77 Notices of Motion ......................................................................................... 77 Withdrawal of Motion or Amendments .......................................................... 77 Motion to Rescind a Resolution .................................................................... 78 Motions ........................................................................................................ 78 Chairman’s Ruling ........................................................................................ 78 Voting ........................................................................................................... 78 Minutes ........................................................................................................ 79 Suspension of Standing Orders .................................................................... 79 Variation and Amendment of Standing Orders ............................................. 79 Record of Attendance................................................................................... 79 Quorum ........................................................................................................ 79

4. COMMITTEES ............................................................................................ 80

5. DECLARATIONS OF INTEREST AND REGISTER OF INTEREST ........... 80 Declaration of Interests ................................................................................ 80 Register of Interests ..................................................................................... 82

6. STANDARDS OF BUSINESS CONDUCT .................................................. 82 Policy ........................................................................................................... 82

Interest of Governors in Contracts ................................................................ 82

7. REMUNERATION ....................................................................................... 82

8. PAYMENT OF EXPENSES TO GOVERNORS ........................................... 83

9. RESOLUTION OF DISPUTES .................................................................... Dispute Resolution between Board of Directors and Council of Governors...

83 83

10. NOMINATIONS, REMUNERATIONS AND EVALUATION COMMITTEE 83

11. MISCELLANEOUS ..................................................................................... 84 Review of Standing Orders........................................................................... 84 Vice Chairman.............................................................................................. 84 Notice ........................................................................................................... 85 Confidentiality .............................................................................................. 85

INTRODUCTION

Poole Hospital NHS Foundation Trust (the Trust) became a Public Benefit Corporation on 1


Top




75

November 2007 following authorisation by Monitor. The Trust is governed by the 2006 Act, the 2012 Act and its Constitution (the Regulatory Framework). As a Public Benefit Corporation the Trust has specific powers to contract in its own name and to act as a corporate trustee. In the latter role it is accountable to the Charity Commission for those funds deemed to be charitable. Clause 15 of the Constitution, requires the Council of Governors to adopt its own Standing Orders for its practice and procedure.

1. INTERPRETATION 1.1 In these Standing Orders, the provisions relating to Interpretation in the Constitution

shall apply and the words and expressions defined in the Constitution shall have the same meaning and, in addition:

"The 2006 Act" "The 2012 Act"

shall mean the National Health Service Act 2006 as amended by the 2012 Act; shall mean the Health and Social Care Act 2012;

“Board of Directors” shall mean the Board of Directors as constituted in accordance with the Trust’s Constitution;

“Company Secretary” means the Company Secretary of the Trust or any other person appointed to perform the duties of the Company Secretary of the Trust;

“Council of Governors ” shall mean the Council of Governors as constituted in accordance with the Trust’s Constitution;

“Chairman” means the person appointed by the Council of Governors (in accordance with Clause 20 of the Constitution) to be Chairman of the Trust;

“Chief Executive” shall mean the chief officer of the Trust;

“Director” means a member of the Board of Directors;

“Director of Finance” shall mean the chief finance officer of the Trust;

“Governors” shall mean a member of the Council of Governors as defined in interpretations and definitions of the Constitution;

“Motion” means a formal proposal to be discussed and voted on during the course of a meeting;

“Officer” means an employee of the Trust;

“Secretary” means the Board Secretary of the Trust or any other person appointed to perform the duties of the Secretary of the Trust;

“Trust” means the Poole Hospital NHS Foundation Trust;

“Vice Chairman” means the Vice Chairman appointed in accordance with Clause 22 of the Constitution to preside at meetings of the Council of Governors in the Chairman’s absence.


Top




76

2. THE COUNCIL OF GOVERNORS

Roles and Responsibilities 2.1 The roles and responsibilities of Governors are:

i) the appointment and removal of the Chairman and Non-Executive Directors (Constitution Clause 20);

ii) to approve the appointment of the Chief Executive (Constitution Clause 23);

iii) to appoint and remove the Auditor (Constitution Clause 32);

iv) to receive the Annual Report and Accounts (Constitution Clause 36);

v) to oversee and advise the Board of Directors regarding future Trust plans and

priorities;

vi) to respond as appropriate when consulted by the Board of Directors in accordance with the Trust’s Constitution;

vii) to agree and from time to time review the Trust’s membership strategy, its

policy for the composition of the Council of Governors and the Non-Executive Directors;

viii) to be involved in review of a specific issue, or be involved in further

development of a particular strategy as the Board of Directors may from time to time request;

ix) to hold the Non-Executive Directors individually and collectively to account for

the performance of the Board of Directors, and to represent the interests of the Members as a whole and the interests of the public, and monitor the performance of the Trust against the strategic direction and the targets with a view to satisfying itself that the Board of Directors is fulfilling its responsibilities in this regard. This will be achieved by regularly briefings on the performance of the Trust and at its meetings, being able to consider and comment on that performance;

x) to positively contribute to the continued success of the organisation through

overseeing of effective management, partnership working and maintenance of NHS values and principles;

xi) to require one or more Directors to attend a meeting of the Council of

Governors for the purpose of obtaining information about the Trust's performance of its functions or the Directors' performance of their duties (and deciding whether to propose a vote on the Trust's or Directors' performance) (Constitution Clause 12A);

xii) to approve any merger, acquisition, separation or dissolution application in

respect of the Trust before the application is made to Monitor and the entering into of any significant transactions; and


Top




77

xiii) to determine issues in the forward plans regarding the proportion of the Trust's activities and income relation to non-NHS income and implementation of the same.

Composition of the Council of Governors

2.2 The composition of the Council of Governors shall be as set out in Annex 3 of the Constitution.

Appointment of the Chairman and Non Executive Directors

2.3 The Chairman and Non-Executive Directors are appointed by the Council of Governors in accordance with Clause 20 of the Constitution.

Terms of Office of the Chairman and Non Executive Directors 2.4 The provisions governing the period of tenure of office of the Chairman and the Non

Executive Directors are contained in Clause 28 of the Constitution. Appointment of Vice-Chairman of the Board and of the Council of Governors

2.5 The Council of Governors shall appoint a Vice-Chairman in accordance with Clause 22 of the Constitution.

2.6 Any Non-Executive Director so appointed may at any time resign from the office of Vice-Chairman by giving notice in writing to the Chairman (in Chairman’s capacity of Chair of Board and Chair of Council of Governors). The Council of Governors may thereupon appoint another Non-Executive Director as Vice-Chairman in accordance with Clause 22.

2.7 The Vice–Chairman may preside at meetings of the Council of Governors in the following circumstances:

i) when there is a need for someone to have the authority to chair any meeting

of the Council of Governors when the Chairman is not present;

ii) when the remuneration, allowances and other terms and conditions of the Chairman are being considered;

iii) when the appointment of the Chairman is being considered, should the current Chairman be a candidate for reappointment;

iv) on occasions when the Chairman declares a pecuniary interest that prevents him from taking part in the consideration or discussion of a matter before the Council of Governors.

3. MEETINGS OF THE COUNCIL OF Governors

Calling Meetings 3.1 Save in the case of emergencies or the need to conduct urgent business, the


Top




78

Secretary shall give at least fourteen days written notice of the date and place of every meeting of the Council of Governors to all Governors. Notice will also be published on the Foundation Trust’s website and in the Members’ newsletter.

3.2 The Secretary shall ensure that within the meeting cycle of the Council of Governors, general meetings are called at appropriate times to consider matters as required by the 2006 Act and the Constitution.

Admission of the Public 3.3 The provisions for the admission of the public to meetings of the Council of

Governors are detailed at Clause 13 and Annex 5 of the Constitution.

Chairman of Meetings 3.4 The Chairman of the Trust, or in his absence, the Vice Chairman is to preside at

meetings of the Council of Governors. If the Chairman is absent from a meeting or temporarily absent on the grounds of a declared conflict of interest the Vice-Chairman shall preside. If the Chairman and Vice-Chairman are absent, such Non-Executive Director as the Governors present shall choose shall preside.

Setting the Agenda 3.5 The Council of Governors may determine that certain matters shall appear on every

agenda for a meeting of the Council of Governors and shall be addressed prior to any other business being conducted.

Agenda 3.6 A Governor desiring a matter to be included on an agenda shall specify the question

or issue to be included in request in writing to the Chairman or Secretary at least three clear business days before Notice of the meeting is given. Requests made less than three days before the Notice is given may be included on the agenda at the discretion of the Chairman.

Notices of Motion 3.7 A Governor desiring to move or amend a motion shall send a written notice thereof at

least ten clear days before the meeting to the Chairman or Secretary, who shall insert in the agenda for the meeting all notices so received subject to the Notice being permissible under the appropriate regulations. This paragraph shall not prevent any motion being moved during the meeting, without Notice on any business mentioned on the agenda in accordance with Standing Order 3.6 of this Annex, subject to the Chairman’s discretion.

Withdrawal of Motion or Amendments 3.8 A motion or amendment once moved and seconded may be withdrawn by the

proposer with the concurrence of the seconder and the consent of the Chairman.

Motion to Rescind a Resolution 3.9 Notice of motion to amend or rescind any resolution (or the general substance of any

resolution) which has been passed within the preceding six calendar months shall be in writing, be in accordance of Standing Order 3.6 of this Annex and shall bear the


Top




79

signature of the Governor who gives it and also the signature of four other Governors. When any such motion has been disposed of by the Council of Governors, it shall not be competent for any Governor other than the Chairman to propose a motion to the same effect within six months, however the Chairman may do so if he considers it appropriate.

Motions 3.10 The mover of a motion shall have a right of reply at the close of any discussion on the

motion or any amendment thereto. 3.11 When a motion is under discussion or immediately prior to discussion it shall be open

to a Governor to move:

i) an amendment to the motion. ii) the adjournment of the discussion or the meeting. iii) that the meeting proceed to the next business. iv) that the motion be now put.

3.12 No amendment to the motion shall be admitted if, in the opinion of the Chairman of the meeting, the amendment negates the substance of the motion. Chairman’s Ruling

3.13 Statements of Governors made at meetings of the Council of Governors shall be relevant to the matter under discussion at the material time and the decision of the Chairman of the meeting on questions of order, relevancy, regularity and any other matters shall be observed at the meeting.

3.14 Save as permitted by law, at any meeting the person presiding shall be the final authority on the interpretation of Standing Orders (on which he should be advised by the Chief Executive).

Voting 3.15 Save as otherwise provided in the Constitution and/or the 2006 Act, if the Chairman

so determines or if a Governor requests, a question at a meeting shall be determined by a majority of the votes of the Governors present and voting on the question and, in the case of any equality of votes, the person presiding shall have a casting vote.

3.16 All questions put to the vote shall, at the discretion of the person presiding, be

determined by oral expression or by a show of hands. A paper ballot may also be used if a majority of the Governors present so request.

3.17 If at least one-third of the Governors present so request, the voting (other than by

paper ballot) on any question may be recorded to show how each Governor present voted or abstained.

3.18 If a Governor so requests, his/her vote shall be recorded by name upon any vote

(other than by paper ballot). 3.19 If at least one third of the Governors so agree, Governors may participate in a

Council of Governor meeting by telephone, video or computer link. Participating in this manner shall be deemed to constitute presence in person at the meeting.


Top




80

Minutes 3.20 The Minutes of the proceedings of a meeting shall be drawn up and submitted for

agreement at the next ensuing meeting where they will be signed by the person presiding at it.

3.21 No discussion shall take place upon the minutes except upon their accuracy or where

the Chairman considers discussion appropriate. Any amendment to the minutes shall be agreed and recorded at the next meeting.

3.22 Minutes of meetings will be taken and circulated in accordance with Governors’ wishes.

Suspension of Standing Orders 3.23 Except where this would contravene any statutory provision and/or the Regulatory

Framework, any one or more of the Standing Orders may be suspended at any meeting, provided that at least two-thirds of the Council of Governors are present, including one Public Governor and one Staff Governor, and that a majority of those present vote in favour of suspension.

3.24 A decision to suspend Standing Orders shall be recorded in the minutes of the

meeting. 3.25 A separate record of matters discussed during the suspension of Standing Orders

shall be made and shall be available to the Governors. 3.26 No formal business may be transacted while Standing Orders are suspended.

Variation and Amendment of Standing Orders 3.27 These Standing Orders shall be amended only in accordance with Annex 8,

Paragraph 7 (Amendment of Constitution). Record of Attendance

3.28 The names of the Governors present at the meeting shall be recorded in the minutes.

Quorum 3.29 No business shall be transacted at a meeting of the Council of Governors unless at

least ten of the Council of Governors are present and that those present include at least one Staff Governor, seven Public Governors and one Appointed Governor.

3.30 A Governor who has declared a non-pecuniary interest in any matter may participate in the discussion and consideration of the matter but may not vote in respect of it: in these circumstances the Governor will count towards the quorum of the meeting. If a


Top




81

Governor has declared a pecuniary interest in any matter, the Governor must leave the meeting room, and will not count towards the quorum of the meeting, during the consideration, discussion and voting on the matter. If a quorum is then not available for the discussion and/or the passing of a resolution on any matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business.

3.31 Subject to Standing Orders in relation to interests, any Director or their nominated representatives shall have the right to attend meetings of the Council of Governors and, subject to the overall control of the Chairman, to speak to any item under consideration.

4. COMMITTEES

4.1 Except as required by Clause 17.1 of the Constitution, the Council of Governors shall exercise its functions in general meeting and shall not delegate the exercise of any function or any power in relation to any function to a Committee.

5. DECLARATIONS OF INTERESTS AND REGISTER OF INTERESTS

Declaration of Interests

5.1 In accordance with Clause 15 of the Constitution, Governors are required to declare formally any direct or indirect pecuniary interest and any other interest which is relevant and material to the business of the Trust. The responsibility for declaring an interest is solely that of the Governor concerned.

5.2 A Governor must declare to the Secretary:

i) any pecuniary interest, direct or indirect, in any contract, proposed contract or other matter concerning the Trust, and

ii) any interests which are relevant and material to the business of the Trust.

5.3 Such a declaration shall be made by completing and signing a form, as prescribed by the Secretary from time to time, setting out any interests required to be declared in accordance with the Constitution or these Standing Orders and delivering it to the Secretary within twenty eight days of a Governor’s election or appointment or otherwise within seven days of becoming aware of the existence of a relevant or material interest. The Secretary shall amend the Register of Interests upon receipt of notification within three working days.

5.4 If a Governor is present at a meeting of the Council of Governors and has an interest

of any sort in any matter which is the subject of consideration, he shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not vote on any question with respect to the matter and, if he has declared a pecuniary interest, he shall not take part in the consideration or discussion of the matter. The provisions of this Clause are subject to Clause 5.9 of this Annex.

5.5 “relevant and material" interests may include but may not be limited to the following:

i) Directorships, including non-executive directorships held in private companies or PLCs (with the exception of those of dormant companies);


Top




82

i) ownership or part-ownership or directorships of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS;

iii) majority or controlling share holdings in organisations likely or possibly

seeking to do business with the NHS; iv) a position of authority in a charity or voluntary organisation in the field of

health and social care; v) any connection with a voluntary or other organization contracting for or

commissioning NHS services vi) any connection with an organisation, entity or company considering entering

into or having entered into a financial arrangement with the Trust, including but not limited to, lenders or banks.

vii) research funding/grants that may be received by an individual or their

department; viii) interests in pooled funds that are under separate management.

5.6 Any travelling or other expenses or allowances payable to a Governor in accordance with this Constitution shall not be treated as a pecuniary interest.

5.7 Subject to any other provision of this Constitution, a Governor shall be treated as

having indirectly a pecuniary interest in a contract, proposed contract or other matter, if:

i) he, or a nominee of his, is a director of a company or other body, not being a

public body, with which the contract was made or is proposed to be made or which has a direct pecuniary interest in the other matter under consideration; or

ii) he is a partner of, or is in the employment of a person with whom the contract

was made or is proposed to be made or who has a direct pecuniary interest in the other matter under consideration.

5.8 A Governor shall not be treated as having a pecuniary interest in any contract,

proposed contract or other matter by reason only:

i) of his membership of a company or other body, if he has no beneficial interest in any securities of that company or other body;

ii) of an interest in any company, body or person with which he is connected as

mentioned in Clauses 5.3, 5.4 and 5.5 of this Annex which is so remote or insignificant that it cannot reasonably be regarded as likely to influence a Governor in the consideration or discussion of or in voting on, any question with respect to that contract or matter.

5.9 Where a Governor:

i) has an indirect pecuniary interest in a contract, proposed contract or other matter by reason only of a beneficial interest in securities of a company or other body, and


Top




83

ii) the total nominal value of those securities does not exceed £5,000 or one-hundredth of the total nominal value of the issued share capital of the company or body, whichever is the less, and

iii) if the share capital is of more than one class, the total nominal value of

shares of any one class in which he has a beneficial interest does not exceed one-hundredth of the total issued share capital of that class, the Governor shall not be prohibited from taking part in the consideration or discussion of the contract or other matter or from voting on any question with respect to it, without prejudice however to his duty to disclose his interest.

5.10 In the case of persons living together the interest of one partner or spouse shall, if

known to the other, be deemed for the purposes of these Standing Orders to be also an interest of the other.

5.11 If Governors have any doubt about the relevance of an interest, this should be

discussed with the Secretary. Register of Interests 5.12 The Secretary shall record any declarations of interest made in a Register of

Interests kept by him in accordance with Clause 29 of the Constitution. Any interest declared at a meeting shall also be recorded in the minutes of the meeting.

5.13 The Register will be available for inspection by members of the public free of charge

at all reasonable times. A person who requests it is to be provided with a copy or extract from the register. If the person requesting a copy or extract is not a member of the Trust then a charge may be made for doing so.

6. STANDARDS OF BUSINESS CONDUCT

Policy 6.1 In relation to their conduct as a Governor of the Trust, each Governor must comply

with the principles outlined in HSG(93)5, `Standards of Business Conduct for NHS staff'. In particular, the Trust must be impartial and honest in the conduct of its business and its office holders and staff must remain beyond suspicion. Governors are expected to be impartial and honest in the conduct of official business.

Interest of Governors in Contracts 6.2 If it comes to the knowledge of a Governor that a contract in which he/she has any

pecuniary interest not being a contract to which he is himself a party, has been, or is proposed to be, entered into by the Trust he/she shall, at once, give notice in writing to the Secretary of the fact that he/she is interested therein. In the case of married persons or persons living together as partners, the interest of one partner shall, if known to the other, be deemed to be also the interest of that partner.

6.3 A Governor shall not solicit for any person any appointment in the Trust.

7. REMUNERATION

7.1 Governors are not to receive remuneration.

8. PAYMENT OF EXPENSES TO Governors


Top




84

8.1 The Trust will pay travelling expenses to Governors for attendance at General

Meetings of the Governors, or any other business authorised by the Secretary as being under the auspices of the Council of Governors.

8.2 Mileage claims will be reimburse at the prevalent Inland Revenue Allowable Mileage

Rate. Car parking and public transport fares will be reimbursed at the cost incurred subject to Trust policies.

8.3 Any other expenses relating to business will require the prior authorisation of the Company Secretary.

8.4 Expenses will be authorised and reimbursed through the Secretary’s office on receipt of a completed and signed expenses form provided by the Secretary.

8.5 A summary of expenses paid to Governors will be published in the Annual Report.

9. RESOLUTION OF DISPUTES

Dispute Resolution between Board of Directors and Council of Governors 9.1 Within twenty eight days of resolving that a dispute exists with the other, the

Secretary shall call a joint meeting to be held as soon as reasonably practicable within three months of the resolution. The joint meeting shall be held under the Trust’s Board of Directors’ Standing Orders, but the provisions of these Standing Orders in relation to interests shall apply to Governors attending the joint meeting as they apply to a Council of Governor meeting.

9.2 The joint meeting shall be chaired by the Chairman and the agenda shall be agreed

by him with the Chief Executive. The joint meeting shall either recommend to each of the constituents a formula for resolving the dispute which each shall receive and consider formally as soon as practicable, or, if possible, shall agree the relevant issues and the possible ways forward.

9.3 If either constituent resolves to refer the issue to mediation, the Chairman and a

nominated Governor on behalf of the Council of Governors and the Chief Executive and the Vice Chairman of the Board of Directors shall meet within twenty eight days of such resolution to agree a mediator. In default of agreement, either constituent may resolve to refer the dispute to arbitration.

9.4 If either constituent resolves to refer a dispute to arbitration, the same four referred to

in the preceding sub-clause may agree an arbitrator. If this is not done within twenty eight days of such resolution, the Secretary of the Trust on the instructions of either constituent shall refer the dispute to the Chartered Institute for Arbitrators to be finally resolved by arbitration.

9.5 The existence of the dispute shall not prejudice the duty of the Board of Directors in

the exercise of the Trust’s powers on its behalf.

10. NOMINATIONS, REMUNERATIONS AND EVALUATION COMMITTEE

10.1 The Council of Governors shall establish a committee consisting of some or all of its members to be called the Nominations Committee in accordance with Clause 17.1 of the Constitution to discharge those functions in relation to the appointment of the Chairman and Non-Executive Directors described in Clause10.2 below and such other functions as are provided for in Clause 10.4 of this Annex.

10.2 The functions of the Nomination Committee shall be as follows:-


Top




85

10.2.1 to determine the criteria of process for the selection of candidates for office

as Chairman or other Non-Executive Director of the Trust having first consulted with the Board of Directors as to these matters and having regard to such views as may be expressed by the Board of Directors;

10.2.2 to seek by way of open advertisements and other means candidates for

office and to assess, shortlist and select for interview such candidates as are considered appropriate and in doing so the Nomination Committee shall be at liberty to seek advice and assistance from persons other than members of the Nomination Committee or of the Council of Governors such as external organisations recognised as experts at appointment to identify the skills and experience required of Chairman and Non-Executive Directors;

10.2.3 to make recommendations to the Council of Governors as to potential

candidates for appointment as Chairman or other Non-Executive Director, as the case may be;

10.2.4 as further stipulated in Clause 10.4 of this Annex.

10.3 The Council of Governors shall resolve in a general meeting to appoint such

candidate or candidates (as the case may be) as it considers appropriate and on reaching its decision it shall have regard to the Board of Directors and of the Nomination Committee as to the suitability of the available candidates.

10.4 The Nomination Committee shall:-

10.4.1 on a regular and systematic basis monitor the performance of the Chairman and other Non-Executive Directors and make reports thereon to the Council of Governors from time to time when requested to do so or when in the opinion of the Nomination Committee the results of such monitoring ought properly to be brought to the attention of the Council of Governors; and

10.4.2 consider and make recommendations to the Council of Governors as to the

remuneration and allowances and other terms and conditions of office of the Chairman and Non-Executive Directors;

10.4.3 review the structure, size and composition of the Board of Directors from

time to time and to make any recommendation to the Council of Governors.

11. MISCELLANEOUS

Review of Standing Orders 11.1 These Standing Orders shall be reviewed periodically by the Council of Governors.

The requirement for review extends to all documents having the effect as if incorporated in Standing Orders.

Vice Chairman 11.2 In relation to any matter touching or concerning the Council of Governors or a

Governor outside a meeting of the Council of Governors, which arises during the Chairman’s absence or unavailability, the Vice-Chairman may exercise such power as the Chairman would have in those circumstances.

Notice


Top




86

11.3 Any written notice required by these Standing Orders shall be deemed to have been

given on the day the notice was sent to the recipient. Confidentiality 11.4 A Governor shall not disclose any matter reported to the Council of Governors

notwithstanding that the matter has been reported or action has been concluded, if the Council of Governors shall resolve that it is confidential.


Top




87


Top



ANNEX 7 – STANDING ORDERS: BOARD OF DIRECTORS

88

CONSTITUTION

ANNEX 7

STANDING ORDERS: BOARD OF DIRECTORS

(Extract from Standing Orders, Reservation and Delegation of Powers and Standing Financial Instructions)


Top



89


Top




90


Standing Orders

Board of Directors


Top




91

FOREWORD

This document, together with the Standing Financial Instructions provides a regulatory framework for the business conduct of the Trust. They fulfil the dual role of protecting the Trust’s interests and protecting staff from any possible accusation that they have acted less properly. All Executive and Non-Executive Directors should be aware of the existence of this document and, where necessary, be familiar with the detailed provisions.


Top




92

SECTION A: INTERPRETATION AND DEFINITIONS FOR STANDING ORDERS Save as otherwise permitted by law, at any meeting the Chairman of the Trust shall be the final authority on the interpretation of Standing Orders (on which they should be advised by the Chief Executive or Secretary to the Board). Any expression to which a meaning is given in the National Health Service Act 2006 as amended by the 2012 Act, and other Acts relating to the National Health Service or in the Financial Regulations made under the Acts shall have the same meaning in these Standing Orders and in addition:

the 2006 Act

the 2012 Act

means the National Health Service Act 2006.

means the Health and Social Care Act 2012.

Accounting Officer means the Officer who discharges the functions specified in paragraph 25(5) of Schedule 7 to the 2006 Act and who is responsible for ensuring the proper stewardship of public funds and assets, which shall be the Chief Executive.

Associate Member means a person appointed to perform specific statutory and non-statutory duties which have been delegated by the Trust Board for them to perform and these duties have been recorded in an appropriate Trust Board minute or other suitable record.

Board means the Chairman, Executive, and Non-Executive Directors, as constituted in accordance with the Constitution.

Budget means a resource, expressed in financial terms, proposed by the Board for the purpose of carrying out, for a specific period, any or all of the functions of the Trust.

Budget Holder means the Director or employee with delegated authority to manage finances (Income and Expenditure) for a specific area of the organisation.

Chairman means the Chairman of the Trust. The expression “the Chairman” or “the Chairman of the Trust” shall be deemed to include the Vice-Chairman of the Trust if the Chairman is absent from the meeting or is otherwise unavailable.

Chief Executive means the chief officer of the Trust.

Clinical Governance Committee

means a committee whose functions are concerned with the arrangements for the purpose of monitoring and improving the quality of health care for which the Trust has responsibility.

Commissioning means the process for determining the need for and for obtaining the supply of healthcare and related services by the Trust within available resources.

Committee means a committee or sub-committee created and appointed by the Trust.

Committee Members means persons formally appointed by the Board to sit on or to chair specific committees.

Company Secretary means the Company Secretary of the Trust (if one is appointed).


Top




93

Constitution means this Constitution and all annexes to it which describes the operation of the Trust.

Contracting and procuring

means the systems for obtaining the supply of goods, materials, manufactured items, services, building and engineering services, works of construction and maintenance and for disposal of surplus and obsolete assets.

Council of Governors means the body of elected and appointed Governors authorised to be members of the Council of Governors to act in accordance with the Constitution.

Director means a Non-Executive or Executive Director on the Board as the context permits. Director in relation to the Board does not include its Chairman.

Director of Finance means the chief financial officer of the Trust.

Executive Director means a member of the Board who holds an executive office of the Trust.

Funds held on trust shall mean those funds which the Trust holds on date of incorporation, receives on distribution by statutory instrument or chooses subsequently to accept under powers derived under Schedule 6, paragraph 8 of the 2006 Act as amended. Such funds may or may not be charitable.

Governor

Monitor

means a person who is a member of the Council of Governors.

means the body corporate known as Monitor, as provided by Section 61 of the 2012 Act.

NHS Foundation Trust Code

means the Code of Governance published by Monitor on 10 March 2010, or such similar or further guidance as Monitor may publish from time to time.

Nominated Officer means an Officer charged with the responsibility for discharging specific tasks within Standing Orders and Standing Financial Instructions.

Non-Executive Director means a member of the Board who is not an Officer of the Trust.

Officer means employee of the Trust or any other person holding a paid appointment or office with the Trust.

Senior Independent Director

means a Non-Executive Director nominated to the role of Senior Independent Director.

SFIs means Standing Financial Instructions.

SOs means Standing Orders.

Trust means the Poole Hospital NHS Foundation Trust.

Vice-Chairman means the Non-Executive Director member appointed by the Council of Governors to take on the Chairman’s duties if the


Top




94

Chairman is absent for any reason.

SECTION B: STANDING ORDERS

1. INTRODUCTION

1.1 Statutory Framework

1.1.1 The Trust is a public benefit corporation which was established under the 2006 Act on 1 November 2007.

1.1.2 The principal place of business of the Trust is Poole Hospital, Longfleet Road, Poole, BH15 2JB.

1.1.3 NHS Foundation Trusts are governed by a regulatory framework that confers the functions of the Trust and comprises the 2006 Act (as amended by the 2012 Act) and the Constitution ("Regulatory Framework"). The powers of the Trust are set out in the Regulatory Framework. .

1.1.4 As a statutory body, the Trust has specified powers to contract in its own name and to act as a corporate trustee. In the latter role it is accountable to the Charity Commission for those funds deemed to be charitable, as well as the Secretary of State for Health.

1.1.5 The Trust also has statutory powers under Section 256 of the 2006 Act to fund projects jointly planned with local authorities, voluntary organisations and other bodies.

1.1.6 The Constitution requires the Trust to adopt Standing Orders for the regulation of its proceedings and business. This document, together with Standing Financial Instructions (SFIs) and Scheme of Delegation set out the responsibilities of individuals.

1.1.7 The Trust will also be bound by such other statutes and legal provisions which govern the conduct of its affairs.

1.2 NHS Framework

1.2.1 The Code of Accountability requires that, inter alia, the Board will draw up a schedule of decisions reserved to the Board, and ensures that management arrangements are in place to enable responsibility to be clearly delegated to senior executives (a scheme of delegation).

1.2.2 The Freedom of Information Act 2000 sets out the requirements for public access to information.

1.3 Delegation of Powers

1.3.1 The Trust has powers to delegate and make arrangements for delegation. The Standing Orders set out the detail of these arrangements. Under the Standing Order relating to the Arrangements for the Exercise of Functions (Standing Order 5) the Trust is given powers to "make arrangements for the exercise, on behalf of the Trust of any of their functions by a committee, sub-committee or joint committee appointed by virtue of Standing Order 4 or by an officer of the Trust, in each case subject to such restrictions and conditions as the Trust thinks. Delegated Powers are covered in a separate document (Reservation of Powers to the Board and Delegation of Powers). This document has effect as if incorporated into the Standing Orders.

1.4 Integrated Governance


Top




95

1.4.1 Trust Boards are now encouraged to move away from silo governance and develop integrated governance that will lead to good governance and to ensure that decision-making is informed by intelligent information covering the full range of corporate, financial, clinical, information and research governance. Guidance from the Department of Health on the move toward and implementation of integrated governance has been issued and will be incorporated in the Trust’s Governance Strategy (see Integrated Governance Handbook 2006). Integrated governance will better enable the Board to take a holistic view of the organisation and its capacity to meet its legal and statutory requirements and clinical, quality and financial objectives. The Board will also consider guidance from the NHS Foundation Trust Code of Governance, issued by Monitor from time to time.

2. THE BOARD: COMPOSITION OF MEMBERSHIP, TENURE AND ROLE OF

DIRECTORS 2.1 Composition of the Membership of the Board 2.1.1 In accordance with the Constitution the composition of the Board shall be:

i) a non-executive Chairman;

ii) six other Non-Executive Directors (one of which may be nominated as the Senior Independent Director);

iii) six Executive Directors including: - the Chief Executive (Accounting Officer); - the Director of Finance - a medical or dental practitioner.

- a registered nurse or midwife 2.1.2 The Board of Directors shall at all times be constituted so that the number of Non-

Executive Directors exceeds the number of Executive Directors.

2.2 Appointment of Chairman and Directors 2.2.1 The Chairman and Non-Executive Directors are appointed (and removed) by the

Council of Governors.

2.2.2 The Chief Executive is appointed (and removed) by the Non-Executive Directors. The appointment (but not the removal) of the Chief Executive requires approval by the Council of Governors.

2.2.3 The Executive Directors are appointed (and removed) by a Committee whose members shall be the Chairman, the Non-Executive Directors and the Chief Executive.

2.3 Terms of Office of the Directors

2.3.1 The provisions governing the remuneration, allowances, term of office and other terms and conditions of office for the Chairman and Non Executive Directors is set out in Clause 28.1 of the Constitution.

2.3.1 The provisions governing the remuneration, allowances, term of office and other terms and conditions of office for the Chief Executive and other Executive Directors is set out in Clause 28.2 of the Constitution.


Top




96

2.4 Appointment and Powers of Vice-Chairman

2.4.1 Subject to Standing Order 2.4.2 the Council of Governors may appoint a Non-Executive Director to be Vice-Chairman, for such period, not exceeding the remainder of his term as a director of the Trust, as they may specify on appointing him.

2.4.2 Any Non-Executive Director so appointed may at any time resign from the office of Vice-Chairman by giving notice in writing to the Chairman (in the Chairman’s capacity as Chair of the Board and the Council of Governors). The Council of Governors may thereupon appoint another Non-Executive Director as Vice-Chairman in accordance with the provisions of Standing Order 2.4.1.

2.4.3 Where the Chairman of the Trust has died or has ceased to hold office, or where they have been unable to perform their duties as Chairman owing to illness or any other cause, the Vice-Chairman shall act as Chairman until a new Chairman is appointed or the existing Chairman resumes their duties, as the case may be; and references to the Chairman in these Standing Orders shall, so long as there is no Chairman able to perform those duties, be taken to include references to the Vice-Chairman.

2.5 Joint Directors

2.5.1 Where more than one person is appointed jointly to a post of Director those persons shall count for the purpose of Standing Order 2.1 as one person.

2.5.2 Where the office of a Director of the Board is shared jointly by more than one person:

i) either or both of those persons may attend or take part in meetings of the Board;

ii) if both are present at a meeting they should cast one vote if they agree;

iii) in the case of disagreements no vote should be cast;

iv) the presence of either or both of those persons should count as the presence of one person for the purposes of Standing Order 3.11 Quorum.

2.6 Role of Directors

2.6.1 The Board will function as a corporate decision-making body and Non-Executive and Executive Directors, will be full and equal Board members. The general duty of the Board of Directors and each Director individually is to act with a view to promoting the success of the Trust so as to maximise the benefits for the members of the Trust as a whole and for the public. Their role as members of the Board will be to consider the key strategic and managerial issues facing the Trust in carrying out its statutory and other functions. In exercising these functions the Board will consider guidance from the NHS Foundation Trust Code of Governance as amended or replaced from time to time.

2.6.2 Executive Directors Executive Directors shall exercise their authority within the terms of the Constitution

these Standing Orders, the Standing Financial Instructions and the Scheme of Delegation.


Top




97

2.6.3 Chief Executive

The Chief Executive shall be responsible for the overall performance of the Trust.

He/she is the Accounting Officer and shall be responsible for ensuring the discharge of obligations under any financial directions and in line with the requirements of the NHS Foundation Trust Accounting Officer Memorandum.

2.6.4 Director of Finance The Director of Finance shall be responsible for the provision of financial advice to

the Trust and to its Directors and for the supervision of financial control and accounting systems. He/she shall be responsible along with the Chief Executive for ensuring the discharge of obligations under any relevant financial directions.

2.6.5 Non-Executive Directors The Non-Executive Directors shall not be granted nor shall they seek to exercise any

individual executive powers on behalf of the Trust. They may however, exercise collective authority when acting as Directors of or when chairing a Committee of the Trust which has delegated powers.

2.6.6 Chairman

i) The Chairman shall be responsible for the operation of the Board and chair all Board meetings when present. The Chairman has certain delegated executive powers. The Chairman must comply with the terms of appointment, the Constitution and with these Standing Orders.

ii) The Chairman shall take responsibility either directly or indirectly for the Non-

Executive Director’s induction, their portfolios of interests and assignments, and their performance.

iii) The Chairman shall work in close harmony with the Chief Executive and shall

ensure that key and appropriate issues are discussed by the Board in a timely manner with all the necessary information and advice being made available to the Board to inform the debate and ultimate resolutions.

2.7 Corporate Role of the Board 2.7.1 All business shall be conducted in the name of the Trust. 2.7.2 All funds received in trust shall be held in the name of the Trust as corporate trustee. 2.7.3 The powers of the Trust shall be exercised by the Board meeting in public or private

session as provided for in Standing Orders 3.17. 2.8 Schedule of Matters Reserved to the Board and Scheme of Delegation 2.8.1 The Board has resolved that certain powers and decisions may only be exercised by

the Board in formal session. These powers and decisions are set out in the ‘Scheme of Reservation and Delegation of Powers’. Those powers which it has delegated to Officers and other bodies are also contained in the Scheme of Reservation and Delegation of Powers.


Top




98

2.9 Lead Roles for Directors 2.9.1 The Chairman will ensure that the designation of lead roles or appointments of Board

Directors to such lead roles as required by the Department of Health or as set out in any statutory or other guidance will be made in accordance with that guidance or statutory requirement (e.g. appointing a Lead Board Member with responsibilities for Infection Control or Child Protection Services etc.).

3. MEETINGS OF THE TRUST

3.1 Calling Meetings 3.1.1 Ordinary meetings of the Board shall be held at regular intervals at such times and

places as the Board may determine. 3.1.2 The Chairman of the Trust may call a meeting of the Board at any time. 3.1.3 One third or more Directors of the Board may requisition a meeting in writing. If the

Chairman refuses, or fails, to call a meeting within seven days of a requisition being presented, the Directors signing the requisition may forthwith call a meeting.

3.2 Notice of Meetings and the Business to be Transacted 3.2.1 Before each meeting of the Board a written notice specifying the business proposed

to be transacted shall be delivered to every Director, or sent by post to the usual place of residence of each Director, so as to be available to Directors at least three clear days before the meeting. The notice shall be signed by the Chairman or by an officer authorised by the Chairman to sign on their behalf. Want of service of such a notice on any Director shall not affect the validity of a meeting.

3.2.2 In the case of a meeting called by Directors in default of the Chairman calling the

meeting, the notice shall be signed by those Directors. 3.2.3 No business shall be transacted at the meeting other than that specified on the

agenda, or emergency motions allowed under Standing Order 3.6. 3.2.4 A Director desiring a matter to be included on an agenda shall make his/her request

in writing to the Chairman at least 10 clear days before the meeting. The request should state whether the item of business is proposed to be transacted in the presence of the public and should include appropriate supporting information. Requests made less than 10 days before a meeting may be included on the agenda at the discretion of the Chairman.

3.2.5 In the event that a meeting of the Board is to be held in public pursuant to standing

order 3.17 a public notice of the time and place of the meeting, and the public part of the agenda, shall be displayed at the Trust’s principal offices at least three clear days before the meeting.

3.3 Agenda and Supporting Papers 3.3.1 The Agenda will be sent to Directors 6 days before the meeting and supporting

papers, whenever possible, shall accompany the agenda, but will certainly be dispatched no later than three clear days before the meeting, save in emergency.

3.3.2 Before holding a meeting, the Board of Directors will send a copy of the agenda (but


Top




99

not supporting papers) to the Council of Governors. 3.4 Petitions 3.4.1 Where a petition has been received by the Trust the Chairman shall include the

petition as an item for the agenda of the next Board meeting. 3.5 Notice of Motion 3.5.1 Subject to the provision of Standing Orders 3.7 ‘Motions: Procedure at and during a

meeting’ and 3.8 ‘Motions to rescind a resolution’, a Director of the Board wishing to move a motion shall send a written notice to the Chief Executive who will ensure that it is brought to the immediate attention of the Chairman.

3.5.2 The notice shall be delivered at least 10 clear days before the meeting. The Chief

Executive shall include in the agenda for the meeting all notices so received that are in order and permissible under governing regulations. This Standing Order shall not prevent any motion being withdrawn or moved without notice on any business mentioned on the agenda for the meeting.

3.6 Emergency Motions 3.6.1 Subject to the agreement of the Chairman, and subject also to the provision of

Standing Order 3.7 ‘Motions: Procedure at and during a meeting’, a Director of the Board may give written notice of an emergency motion after the issue of the notice of meeting and agenda, up to one hour before the time fixed for the meeting. The notice shall state the grounds of urgency. If in order, it shall be declared to the Board at the commencement of the business of the meeting as an additional item included in the agenda. The Chairman's decision to include the item shall be final.

3.7 Motions: Procedure at and During a Meeting 3.7.1 Who may propose

A motion may be proposed by the Chairman of the meeting or any Director present. It must also be seconded by another Director.

3.7.2 Contents of motions

The Chairman may exclude from the debate at their discretion any such motion of which notice was not given on the notice summoning the meeting other than a motion relating to:

the reception of a report;

consideration of any item of business before the Board;

the accuracy of minutes;

that the Board proceed to next business;

that the Board adjourn;

that the question be now put. 3.7.3 Amendments to motions


Top




100

i) A motion for amendment shall not be discussed unless it has been proposed and seconded.

ii) Amendments to motions shall be moved relevant to the motion, and shall not

have the effect of negating the motion before the Board. iii) If there are a number of amendments, they shall be considered one at a time.

When a motion has been amended, the amended motion shall become the substantive motion before the meeting, upon which any further amendment may be moved.

3.7.4 Rights of reply to motions

i) Amendments The mover of an amendment may reply to the debate on their amendment

immediately prior to the mover of the original motion, who shall have the right of reply at the close of debate on the amendment, but may not otherwise speak on it.

ii) Substantive/original motion The Director who proposed the substantive motion shall have a right of reply

at the close of any debate on the motion. 3.7.5 Withdrawing a motion A motion, or an amendment to a motion, may be withdrawn. 3.7.6 Motions once under debate When a motion is under debate, no motion may be moved other than:

an amendment to the motion;

the adjournment of the discussion, or the meeting;

that the meeting proceed to the next business;

that the question should be now put;

the appointment of an 'ad hoc' committee to deal with a specific item of business;

that a Director be not further heard;

a motion to exclude the public, including the press (see Standing Order 3.17).

3.7.7 In those cases where the motion is either that the meeting proceeds to the ‘next business’ or ‘that the question be now put’ in the interests of objectivity these should only be put forward by a Director of the Board who has not taken part in the debate and who is eligible to vote.

3.7.8 If a motion to proceed to the next business or that the question be now put, is carried,

the Chairman should give the mover of the substantive motion under debate a right of reply, if not already exercised. The matter should then be put to the vote.


Top




101

3.8 Motion to Rescind a Resolution 3.8.1 Notice of motion to rescind any resolution (or the general substance of any

resolution) which has been passed within the preceding six calendar months shall bear the signature of the Director who gives it and also the signature of three other Directors, and before considering any such motion of which notice shall have been given, the Board may refer the matter to any appropriate Committee or the Chief Executive for recommendation.

3.8.2 When any such motion has been dealt with by the Trust Board it shall not be competent for any member other than the Chairman to propose a motion to the same effect within six months. This Standing Order shall not apply to motions moved in pursuance of a report or recommendations of a Committee or the Chief Executive for recommendation.

3.9 Chairman of Meeting 3.9.1 At any meeting of the Board the Chairman, if present, shall preside. If the Chairman

is absent from the meeting, the Vice-Chairman (if one is appointed), if present, shall preside.

3.9.2 If the Chairman and Vice-Chairman are absent, such Non-Executive Director as the

Directors present shall choose shall preside. 3.10 Chairman's Ruling 3.10.1 The decision of the Chairman of the meeting on questions of order, relevancy and

regularity (including procedure on handling motions) and their interpretation of the Standing Orders and Standing Financial Instructions, at the meeting, shall be final.

3.11 Quorum 3.11.1 No business shall be transacted at a meeting unless at least one-third of the whole

number of the Chairman and Directors (including at least one Non-Executive Director and one Executive Director) is present.

3.11.2 An Officer in attendance for an Executive Director but without formal acting up status may not count towards the quorum 3.11.3. If the Chairman or Director has been disqualified from participating in the discussion on any matter and/or from voting on any resolution by reason of a declaration of a conflict of interest (see Standing Order 6) that person shall no longer count towards the quorum. If a quorum is then not available for the discussion and/or the passing of a resolution on any matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business.

3.12 Voting

3.12.1 Save as provided in Standing Orders 3.13 (Suspension of Standing Orders) and 3.14 (Variation and Amendment of Standing Orders), every question put to a vote at a meeting shall be determined by a majority of the votes of Directors present and voting on the question. In the case of an equal vote, the person presiding (i.e.: the Chairman of the meeting) shall have a second, and casting vote.

3.12.2 At the discretion of the Chairman all questions put to the vote shall be determined by


Top




102

oral expression or by a show of hands, unless the Chairman directs otherwise, or it is proposed, seconded and carried that a vote be taken by paper ballot.

3.12.3 If at least one third of the Directors present so request, the voting on any question may be recorded so as to show how each Director present voted or did not vote (except when conducted by paper ballot).

3.12.4 If a Director so requests, their vote shall be recorded by name.

3.12.5 In no circumstances may an absent Director vote by proxy. Absence is defined as being absent at the time of the vote.

3.12.6 An Officer who has been formally appointed to act up for an Executive Director during a period of incapacity or temporarily to fill an Executive Director vacancy shall be entitled to exercise the voting rights of the Executive Director.

3.12.7 An Officer attending the Board meeting to represent an Executive Director during a period of incapacity or temporary absence without formal acting up status may not exercise the voting rights of the Executive Director. An Officer’s status when attending a meeting shall be recorded in the minutes.

3.12.8 For the voting rules relating to joint members see Standing Order 2.5.

3.13 Suspension of Standing Orders

3.13.1 Except where this would contravene any provision in the Regulatory Framework, or the rules relating to the Quorum (Standing Order 3.11), any one or more of the Standing Orders may be suspended at any meeting, provided that at least two-thirds of the whole number of the Directors of the Board are present (including at least one Executive Director and one Non-Executive Director) and that at least two-thirds of those Directors present signify their agreement to such suspension. The reason for the suspension shall be recorded in the Board minutes.

3.13.2 A separate record of matters discussed during the suspension of Standing Orders

shall be made and shall be available to the Chairman and Directors of the Trust. 3.13.3 No formal business may be transacted while Standing Orders are suspended. 3.13.4 The Audit and Governance Committee shall review every decision to suspend

Standing Orders. 3.14 Variation and Amendment of Standing Orders 3.14.1 These Standing Orders shall not be varied except in accordance with Annex 8,

Paragraph 7 (Amendment of Constitution). 3.15 Record of Attendance 3.15.1 The names of the Chairman and Directors present at the meeting shall be recorded. 3.16 Minutes 3.16.1 The minutes of the proceedings of a meeting shall be drawn up and submitted for

agreement at the next ensuing meeting where they shall be signed by the person presiding at it.

3.16.2 No discussion shall take place upon the minutes except upon their accuracy or where


Top




103

the Chairman considers discussion appropriate. 3.16.2 As soon as practicable after holding a meeting, the Board of Directors shall send a

copy of the minutes of the meeting to the Council of Governors. 3.17 Admission of Public and the Press 3.17.1 Meetings of the Board of Directors shall be open to members of the public unless and

to the extent that the Board of Directors has resolved that any members of the public shall be excluded on the grounds that:

3.17.1.1 any publicity would be prejudicial to the public interest by reason of

the confidential nature of the business to be transacted; or 3.17.2 for the reasons stated in the resolution and arising from the nature of

the business and proceedings that the Board considers are special reasons for excluding the public from the meeting in accordance with this Constitution.

3.17.2 General disturbances In the event that the public and press are admitted to all or part of a Board meeting

pursuant to Standing Order 3.17.1 above, the Chairman (or Vice-Chairman if one has been appointed) or the person presiding over the meeting shall give such directions as he thinks fit with regard to the arrangements for meetings and accommodation of the public and representatives of the press such as to ensure that the Trust’s business shall be conducted without interruption and disruption, and the public will be required to withdraw upon the Trust Board resolving that in the interests of public order the meeting adjourn for (the period to be specified) to enable the Board to complete its business without the presence of the public.

3.17.3 Business proposed to be transacted when the press and public have been excluded from a meeting

i) Matters to be dealt with by the Board following the exclusion of

representatives of the press, and other members of the public, as provided in (1) and (2) above, shall be confidential to the Directors of the Board.

ii) Directors and Officers or any employee of the Trust in attendance shall not

reveal or disclose the contents of papers marked 'In Confidence' or minutes headed 'Items Taken in Private' outside of the Trust, without the express permission of the Trust. This prohibition shall apply equally to the content of any discussion during the Board meeting which may take place on such reports or papers.

3.17.4 Use of mechanical or electrical equipment for recording or transmission of meetings Nothing in these Standing Orders shall be construed as permitting the introduction by

the public, or press representatives, of recording, transmitting, video or similar apparatus into meetings of the Board or Committee thereof. Such permission shall be granted only upon resolution of the Trust.

3.18 Observers at Trust Meetings 3.18.1 The Trust will decide what arrangements and terms and conditions it feels are

appropriate to offer in extending an invitation to observers to attend and address any of the Board meetings and may change, alter or vary these terms and conditions as it


Top




104

deems fit. 4. APPOINTMENT OF COMMITTEES AND SUB COMMITTEES

4.1 Appointment of Committees 4.1.1 Subject to the Regulatory Framework, the Board may appoint committees of the Trust subject to such restriction and conditions as the Board thinks fit.

4.1.2 The Trust shall determine the membership and terms of reference of Committees

and sub-committees and shall if it requires to, receive and consider reports of such Committees.

4.2 Joint Committees

4.2.1 Joint Committees may be appointed by the Trust by joining together with one or more

other trusts consisting of, wholly or partly of the Chairman and Directors of the Trust or other health service bodies, or wholly of persons who are not Directors of the Trust or other health bodies in question.

4.2.2 Any Committee or joint Committee appointed under this Standing Order may, subject

to the Constitution, the Trust or other health bodies in question, appoint sub-committees consisting wholly or partly of Directors of the Committees or joint Committee (whether or not they are Directors of the Trust or health bodies in question) or wholly of persons who are not Directors of the Trust or health bodies in question or the Committee of the Trust or health bodies in question.

4.3 Applicability of Standing Orders and Standing Financial Instructions to Committees

4.3.1 The Standing Orders and Standing Financial Instructions of the Trust, as far as they

are applicable, shall as appropriate apply to meetings and any Committees established by the Trust. In which case the term “Chairman” is to be read as a reference to the Chairman of other committee as the context permits, and the term “member” is to be read as a reference to a member of other Committee also as the context permits. (There is no requirement to hold meetings of Committees established by the Trust in public).

4.4 Terms of Reference 4.4.1 Each such Committee shall have such terms of reference and powers and be subject

to such conditions (as to reporting back to the Board), as the Board shall decide and shall be in accordance with any legislation and regulation, or any guidance issued by Monitor .

4.5 Delegation of Powers by Committees to Sub-Committees 4.5.1 Where Committees are authorised to establish sub-committees they may not

delegate executive powers to the sub-committee unless expressly authorised by the Board.


Top




105

4.6 Approval of Appointments to Committees 4.6.1 The Board shall approve the appointments to each of the Committees which it has

formally constituted. Where the Board determines, and regulations permit, that persons, who are neither Directors nor Officers, shall be appointed to a Committee the terms of such appointment shall be within the powers of the Board. The Board shall define the powers of such appointees and shall agree allowances, including reimbursement for loss of earnings, and/or expenses in accordance where appropriate with national guidance.

4.7 Appointments for Statutory Functions 4.7.1 Where the Board is required to appoint persons to a Committee and/or to undertake

statutory functions and where such appointments are to operate independently of the Board such appointment shall be made in accordance with any applicable regulations and directions.

4.8 Committees Established by the Board 4.8.1 The Committees, sub-committees, and joint-committees established by the Board

are:

i) Audit and Governance Committee As laid down in the Constitution and the 2006 Act, a committee of Non-Executive Directors will be established and constituted to provide the Board with an independent and objective review on its financial systems, financial information and compliance with laws, guidance, and regulations governing the NHS. The Audit and Governance Terms of Reference will be approved by the Board and reviewed on a periodic basis.

ii) Finance and Investment Committee

The Committee is responsible for scrutinising the detailed financial reports and making recommendations to ensure the robust use of financial resources. The Committee will review the substance of the Annual Plan and revenue and capital budgets.

iii) Remuneration Committee

As laid down in the Constitution and the 2006 Act, a committee of Non-Executive Directors will be established to decide the remuneration and allowances of, and other terms and conditions of the Executive Directors. The Remuneration Committee Terms of Reference will be approved by the Board and reviewed on a periodic basis.

iv) Appointment Committee

As laid down in the Constitution and the 2006 Act, it is for a committee consisting of the Chairman, the Chief Executive and the Non-Executive Directors to appoint or remove the other Executive Directors. The Terms of Reference of the Appointment Committee will be approved and reviewed by the Board on a periodic basis.


Top




106

v) Other Committees

The Board may also establish such other Committees as required to discharge the Trust's responsibilities

4.8.2 The Board of Directors may elect to change the Committees, sub-Committees and

joint Committees of the Board of Directors, as necessary, without requirement to amend their Standing Orders.

5. ARRANGEMENTS FOR THE EXERCISE OF TRUST FUNCTIONS BY DELEGATION

5.1 Delegation of Functions to Committees, Officers or Other Bodies 5.1.1 Subject to the Regulatory Framework and such guidance as may be given by

Monitor, the Board may make arrangements for the exercise, on behalf of the Board, of any of its functions by a committee, sub-committee appointed by virtue of Standing Order 4, or by an officer of the Trust, or by another body as defined in Standing Order 5.1.2 below, in each case subject to such restrictions and conditions as the Trust thinks fit.

5.1.2 Where a function is delegated to another Trust, then that Trust or health service body

exercises the function in its own right; the receiving Trust has responsibility to ensure that the proper delegation of the function is in place. In other situations, i.e. delegation to committees, sub-committees or officers, the Trust delegating the function retains full responsibility.

5.2 Emergency Powers and Urgent Decisions 5.2.1 The powers which the Board has reserved to itself within these Standing Orders (see

Standing Order 2.8) may in emergency or for an urgent decision be exercised by the Chief Executive and the Chairman after having consulted at least two Non-Executive Directors. The exercise of such powers by the Chief Executive and Chairman shall be reported to the next formal meeting of the Board for formal ratification.

5.3 Delegation to Committees 5.3.1 The Board shall agree from time to time to the delegation of executive powers to be

exercised by other committees, or sub-committees, or joint-committees, which it has formally constituted. The Constitution and terms of reference of these committees, or sub-committees, or joint committees, and their specific executive powers shall be approved by the Board in respect of its sub-committees.

5.3.2 When the Board is not meeting as the Trust in public session it shall operate as a

committee and may only exercise such powers as may have been delegated to it by the Trust in public session.

5.3.3 The Trust shall have a Hospital Executive Group (with supporting sub-groups as

deemed necessary by the Chief Executive) with delegated responsibility of the Chief Executive who may choose to review the structure at any stage.

5.4 Delegation to Officers


Top




107

5.4.1 Those functions of the Trust which have not been retained as reserved by the Board or delegated to other committee or sub-committee or joint-committee shall be exercised on behalf of the Trust by the Chief Executive. The Chief Executive shall determine which functions he/she will perform personally and shall nominate officers to undertake the remaining functions for which he/she will still retain accountability to the Trust.

5.4.2 The Chief Executive shall prepare a Scheme of Delegation identifying his/her proposals which shall be considered and approved by the Board. The Chief Executive may periodically propose amendment to the Scheme of Delegation which shall be considered and approved by the Board.

5.4.3 Nothing in the Scheme of Delegation shall impair the discharge of the direct accountability to the Board of the Director of Finance to provide information and advise the Board in accordance with the Regulatory Framework and any statutory or Department of Health requirements or provisions required by Monitor. Outside these requirements the roles of the Director of Finance shall be accountable to the Chief Executive for operational matters.

5.5 Schedule of Matters Reserved to the Trust and Scheme of Delegation of Powers

5.5.1 The Board shall comply with the arrangements set out in the “Schedule of Matters

Reserved to the Board” and “Scheme of Delegation”. 5.6 Duty to Report Non-Compliance with Standing Orders and Standing Financial

Instructions 5.6.1 If for any reason these Standing Orders are not complied with, full details of the non-

compliance and any justification for non-compliance and the circumstances around the non-compliance, shall be reported to the next formal meeting of the Board for action or ratification. All Directors of the Trust Board, Officers and staff have a duty to disclose any non-compliance with these Standing Orders to the Chief Executive as soon as possible.

6. OVERLAP WITH OTHER TRUST POLICY STATEMENTS/PROCEDURES,

REGULATIONS AND THE STANDING FINANCIAL INSTRUCTIONS

6.1 Policy Statements: General Principles

6.1.1 The Board will from time to time agree and approve Policy statements/ procedures which will apply to all or specific groups of staff employed by Poole Hospital NHS Foundation Trust. The decisions to approve such policies and procedures will be recorded in an appropriate Board minute and will be deemed where appropriate to be an integral part of the Trust's Standing Orders and Standing Financial Instructions.

6.2 Specific Policy Statements

6.2.1 Notwithstanding the application of Standing Order 6.1 above, these Standing Orders and Standing Financial Instructions must be read in conjunction with the following Policy statements:

i) the Standards of Business Conduct and Conflicts of Interest Policy for Poole Hospital NHS Foundation Trust staff;


Top




108

ii) the staff Disciplinary and Appeals Procedures adopted by the Trust.

6.3 Standing Financial Instructions

6.3.1 Standing Financial Instructions will be adopted by the Board in accordance with the financial regulations.

6.4 Specific Guidance

6.4.1 Notwithstanding the application of Standing Order 6.1 above, these Standing Orders and Standing Financial Instructions must be read in conjunction with the following guidance and any other guidance issued by Monitor:

- Caldicott Guardian 1997; - Human Rights Act 1998; - Freedom of Information Act 2000.

7. DUTIES AND OBLIGATIONS OF BOARD MEMBERS/DIRECTORS AND SENIOR MANAGERS UNDER THESE STANDING ORDERS

7.1 Declaration of Interests

7.1.1 Requirements for Declaring Interests and applicability to Board Members

The Constitution and the 2006 Act requires Board Members to declare any direct or indirect interests in a proposed transaction or arrangement with the Trust. All existing Directors should declare such interests. Any Directors appointed subsequently should do so on appointment.

7.1.2 Interests which are relevant and material

(i) Interests which should be regarded as "relevant and material" are:

a) Directorships, including Non-Executive Directorships held in private

companies or PLCs (with the exception of those of dormant companies);

b) ownership or part-ownership of private companies, businesses or consultancies likely or possibly seeking to do business with the NHS;

c) majority or controlling share holdings in organisations likely or possibly seeking to do business with the NHS;

d) a position of Authority in a charity or voluntary organisation in the field of health and social care;

e) any connection with a voluntary or other organisation contracting for NHS services;

f) research funding/grants that may be received by an individual or their department;

g) interests in pooled funds that are under separate management.

(ii) Any Director of the Trust Board who comes to know that the Trust has entered into or proposes to enter into a contract in which he/she or any person connected with him/her (as defined in Standing Order 7.3 below and elsewhere) has any pecuniary interest, direct or indirect, the Board Director


Top




109

shall declare his/her interest by giving notice in writing of such fact to the Trust as soon as practicable.

7.1.3 Advice on interests

i) If Directors have any doubt about the relevance of an interest, this should be discussed with the Chairman or with the Trust’s Company Secretary.

ii) Financial Reporting Standard No 8 (issued by the Accounting Standards

Board) specifies that influence rather than the immediacy of the relationship is more important in assessing the relevance of an interest. The interests of partners in professional partnerships including general practitioners should also be considered.

7.1.4 Recording of interests in Board minutes

i) At the time Board Directors' interests are declared, they should be recorded in the Board minutes.

ii) Any changes in interests should be declared at the next Board meeting

following the change occurring and recorded in the minutes of that meeting. 7.1.5 Publication of declared interests in Annual Report Directors' directorships of companies likely or possibly seeking to do business with

the NHS should be published in the Trust's annual report. The information should be kept up to date for inclusion in succeeding annual reports.

7.1.6 Conflicts of interest which arise during the course of a meeting During the course of a Board meeting, if a conflict of interest is established, the

Director concerned should withdraw from the meeting and play no part in the relevant discussion or decision. (See overlap with Standing Order 7.3)

7.2 Register of Interests

7.2.1 The Chief Executive will ensure that a Register of Interests is established to record formally declarations of interests of Board or Committee members. In particular the Register will include details of all directorships and other relevant and material interests (as defined in Standing Order 7.1.2) which have been declared by both Executive and Non-Executive Directors.

7.2.2 These details will be kept up to date by means of an annual review of the Register in which any changes to interests declared during the preceding twelve months will be incorporated.

7.2.3 The Register will be available to the public and the Chief Executive will take

reasonable steps to bring the existence of the Register to the attention of local residents and to publicise arrangements for viewing it.

7.3 Exclusion of Chairman and Directors in Proceedings on Account of Pecuniary

Interest 7.3.1 Definition of terms used in interpreting ‘Pecuniary’ interest For the sake of clarity, the following definition of terms is to be used in interpreting

this Standing Order:


Top




110

(i) "spouse" shall include any person who lives with another person in the same

household (and any pecuniary interest of one spouse shall, if known to the other spouse, be deemed to be an interest of that other spouse);

(ii) "contract" shall include any proposed contract or other course of dealing; (iii) “Pecuniary interest” Subject to the exceptions set out in this Standing Order, a person shall be

treated as having an indirect pecuniary interest in a contract if:- a) he/she, or a nominee of his/her, is a member of a company or other

body (not being a public body), with which the contract is made, or to be made or which has a direct pecuniary interest in the same, or

b) he/she is a partner, associate or employee of any person with whom

the contract is made or to be made or who has a direct pecuniary interest in the same.

iv) Exception to Pecuniary interests A person shall not be regarded as having a pecuniary interest in any contract

if:- a) neither he/she or any person connected with him/her has any

beneficial interest in the securities of a company of which he/she or such person appears as a member, or

b) any interest that he/she or any person connected with him/her may

have in the contract is so remote or insignificant that it cannot reasonably be regarded as likely to influence him/her in relation to considering or voting on that contract, or

c) those securities of any company in which he/she (or any person

connected with him/her) has a beneficial interest do not exceed £5,000 in nominal value or one per cent of the total issued share capital of the company or of the relevant class of such capital, whichever is the less.

Provided however, that where standing order (c) above applies the person

shall nevertheless be obliged to disclose/declare their interest in accordance with Standing Order 7.1.2 (ii).

7.3.2 Exclusion in proceedings of the Board

i) Subject to the following provisions of this Standing Order, if the Chairman or a Director of the Board has any pecuniary interest, direct or indirect, in any contract, proposed contract or other matter and is present at a meeting of the Board at which the contract or other matter is the subject of consideration, they shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not take part in the consideration or discussion of the contract or other matter or vote on any question with respect to it.

ii) The Board may exclude the Chairman or a member of the Board from a


Top




111

meeting of the Board while any contract, proposed contract or other matter in which he/she has a pecuniary interest is under consideration.

iii) Any remuneration, compensation or allowance payable to the Chairman or a

Director shall not be treated as a pecuniary interest for the purpose of this Standing Order.

iv) This Standing Order applies to a committee or sub-committee and to a joint

committee or sub-committee as it applies to the Trust and applies to a member of any such committee or sub-committee (whether or not he/she is also a member of the Trust) as it applies to a member of the Trust.

7.3.3 NOT USED

7.4 Standards of Business Conduct

7.4.1 Trust policy and national guidance All Trust staff and Director of must comply with the Trust’s Standards of Business

Conduct and Conflicts of Interest Policy and the national guidance contained in HSG(93)5 on ‘Standards of Business Conduct for NHS staff’ (see Standing Order 6.2).

7.4.2 Interest of officers in contracts

i) Any officer or employee of the Trust who comes to know that the Trust has entered into or proposes to enter into a contract in which he/she or any person connected with him/her (as defined in Standing Order 7.3) has any pecuniary interest, direct or indirect, the Officer shall declare their interest by giving notice in writing of such fact to the Chief Executive or Trust’s Secretary as soon as practicable.

ii) An Officer should also declare to the Chief Executive any other employment or business or other relationship of his/her, or of a cohabiting spouse, that conflicts, or might reasonably be predicted could conflict with the interests of the Trust.

iii) The Trust will require interests, employment or relationships so declared to be entered in a register of interests of staff.

7.4.3 Canvassing of and recommendations by directors in relation to appointments

i) Canvassing of Directors of the Trust or of any Committee of the Trust directly or indirectly for any appointment under the Trust shall disqualify the candidate for such appointment. The contents of this paragraph of the Standing Order shall be included in application forms or otherwise brought to the attention of candidates.

ii) Directors of the Trust shall not solicit for any person any appointment under the Trust or recommend any person for such appointment; but this paragraph of this Standing Order shall not preclude a Director from giving written


Top




112

testimonial of a candidate’s ability, experience or character for submission to the Trust.

7.4.4 Relatives of members or officers

i) Candidates for any staff appointment under the Trust shall, when making an application, disclose in writing to the Trust whether they are related to any member or the holder of any office under the Trust. Failure to disclose such a relationship shall disqualify a candidate and, if appointed, render him liable to instant dismissal.

ii) The Chairman and every Director and Officer of the Trust shall disclose to the Trust Board any relationship between himself and a candidate of whose candidature that Director or officer is aware. It shall be the duty of the Chief Executive to report to the Board any such disclosure made.

iii) On appointment, Director (and prior to acceptance of an appointment in the

case of Executive Directors) should disclose to the Trust whether they are related to any other member or holder of any office under the Trust.

iv) Where the relationship to a member of the Trust is disclosed, the Standing

Order headed ‘Disability of Chairman and members in proceedings on account of pecuniary interest’ (Standing Order 7) shall apply.

8. CUSTODY OF SEAL, SEALING OF DOCUMENTS AND SIGNATURE OF

DOCUMENTS

8.1 Custody of Seal

8.1.1 The common seal of the Trust shall be kept by the Chief Executive or a nominated

Manager by him/her in a secure place.

8.2 Sealing of Documents

8.2.1 Where it is necessary that a document shall be sealed, the seal shall be affixed in the

presence of two senior managers duly authorised by the Chief Executive, and not also from the originating department, and shall be attested by them.

8.3 Register of Sealing

8.3.1 The Chief Executive shall keep a register in which he/she, or another manager of the

Authority authorised by him/her, shall enter a record of the sealing of every document.

8.4 Signature of Documents 8.4.1 Where any document will be a necessary step in legal proceedings on behalf of the

Trust, it shall, unless any enactment otherwise requires or authorises, be signed by the Chief Executive or any Executive Director.

8.4.2 In land transactions, the signing of certain supporting documents will be delegated to

Managers and set out clearly in the Scheme of Delegation but will not include the main or principal documents effecting the transfer (e.g. sale/purchase agreement, lease, contracts for construction works and main warranty agreements or any document which is required to be executed as a deed).


Top




113

9. MISCELLANEOUS (see overlap with SFI No.10.3)

9.1 Joint Finance Arrangements

9.1.1 The Board may confirm contracts to purchase from a voluntary organisation or a local authority using its powers under Section 256 of the 2006 Act. The Board may confirm contracts to transfer money from the NHS to the voluntary sector or the health related functions of local authorities where such a transfer is to fund services to improve the health of the local population more effectively than equivalent expenditure on NHS services, using its powers under Section 256 of the 2006 Act.

10. COMPANY SECRETARY

10.1 The Chairman and the Chief Executive may jointly appoint or remove (if they so choose) a Company Secretary who is to be employed by the Trust.

10.2 The Company Secretary shall ensure the availability of a secretariat which will: 10.2.1 provide a secretary to the Council of Governors and the Board of Directors, and any

relevant sub-Committees; 10.2.2 attend all meetings of the Council of Governors and the Board of Directors, and keep

the minutes of those meetings and the attendance records; 10.2.3 keep the register of members and other registers as are required by the Constitution to

be kept; and 10.2.4 any other functions as may be set out in the Company Secretary’s terms of reference

from time to time.

11. SENIOR INDEPENDENT DIRECTOR

11.1 The Board of Directors may appoint one of the independent Non-Executive Directors to be the Senior Independent Director following consultation with the Council of Governors.

11.2 The Board of Directors will use reasonable endeavours to ensure that the role and

identity of the Senior Independent Director is made known to the Members and the Council of Governors.

11.3. The role of the Senior Independent Director is attached at Appendix A to this Annex 7.


Top




114

APPENDIX A

ROLE OF THE SENIOR INDEPENDENT DIRECTOR

The Senior Independent Director will be an independent Non-Executive Director of the Board of Directors and maybe the Vice-Chairman. The Senior Independent Director’s role will be: i) to be available to Governors and Members if they have concerns about the

performance of the Board of Directors, compliance with the Regulatory Framework or welfare of the Trust which contact through the normal channels of Chairman or Chief Executive has failed to resolve or for which such contact is inappropriate;

ii) to maintain sufficient contact with Governors to understand their issues and concerns; iii) In accordance with a process to be agreed between the Chair and Council of

Governors, to be involved in the process for evaluating the performance of the Chair; iv) to lead a meeting of the Non-Executive Directors at least annually without the Chair to

evaluate the Chair’s performance, as part of the process agreed with the Council of Governors for appraising the Chair;

v) to liaise with the Chair, and Trust Secretary in relation to setting the agenda of the

Council of Governors.


Top




115


Top



116

CONSTITUTION

ANNEX 8

FURTHER PROVISIONS


Top



117


Top



118

FURTHER PROVISIONS

1. ELIGIBILITY FOR MEMBERSHIP 1.1 An individual shall be eligible for Membership of the Trust provided:

i) he is at least twelve years of age at the date of his application or invitation to become a Member (as the case may be); and

ii) he is otherwise eligible for Membership pursuant of the terms of this

Constitution. 1.2 For the purposes of determining whether an individual lives in an area specified as an

area for Public Constituency, an individual shall be deemed to do so if;

i) his name appears on the electoral roll at an address within the said area and the Trust has no reasonable cause to conclude that the individual is not living at that address; or

ii) the Trust is otherwise satisfied that the individual lives in the said area.

1.3 An individual who is a Member of the Public Constituency shall cease to be eligible to

continue as a Member if he ceases to live in the area of the Public Constituency of which he is a Member save as may otherwise be provided in Clause 1 of this Annex.

1.4 Where a Member of a Public Constituency ceases to live permanently in the area of

the Public Constituency of which he is a Member he shall forthwith advise the Trust that he is no longer eligible to continue as a Member and the Trust shall forthwith remove his name from the Register of Members unless the Trust is satisfied that the individual concerned lives in some other area of a Public Constituency of the Trust. Where the Trust is satisfied that such an individual continues to live in the area of a Public Constituency of the Trust it shall, if the individual so requests, thereafter treat that individual as a Member of that other Public Constituency and amend the Register of Members accordingly provided the Trust has given that individual not less than fourteen days notice of its intention to do so.

1.5 Where a Member ceases to live temporarily in the area of the Public Constituency of

which he is a Member, the Trust may permit that individual nonetheless to remain on the Register of Members for that Public Constituency if it is for good cause satisfied that the absence is of a temporary duration only and that the Member will either return to live in the area of that Public Constituency of which he is a Member or will live in some other part of the Area of the Trust in which case the provisions of Clause 1.4 of this Annex shall apply as appropriate.

1.6 A Member of a Staff Class will cease to be eligible to be a Member of that Staff Class

if they no longer meet the eligibility requirements of Clause 7 of the Constitution and of Annex 2.

1.7 Where an individual is a Member by virtue of their eligibility to be a Member of a Staff Class and they cease to be eligible for membership of that Staff Class but are eligible for membership of some other Staff Class then the Trust may give notice to that Member of its intention to transfer him to that other Staff Class on the expiration of a period of time or upon a date specified in the said notice and shall after the expiration of that notice or date amend the Register of Members accordingly.


Top



119

2. APPLICATION FOR MEMBERSHIP

2.1 An individual may become a Member by application to the Trust in accordance with

this Constitution or, where so provided for in this Constitution, by being invited by the Trust to become a member of a Staff Class of the Staff Constituency in accordance with Clause 7 of the Constitution.

2.2 Where an individual wishes to apply to become a Member of the Trust, the following

procedure shall apply:

i) the Trust shall upon request supply the individual with a form of application for Membership in a form determined by the Trust;

ii) upon receipt of the said form of application duly completed and signed by the

applicant (or in the Trust’s discretion signed on behalf of the applicant) the Trust shall as soon as is reasonable practicable and in any event within ten working days of receipt of the duly completed form consider the same;

iii) unless the applicant is ineligible for Membership or is disqualified from

Membership, the Trust shall cause his name to be entered forthwith on the Trust’s Register of Members and shall give notice in writing to the applicant of that fact;

iv) upon the applicant’s name being entered on the Trust’s Register of Members

the individual shall thereupon become a Member; v) the information to be included in the Trust’s Register of Members shall

include the following details relating to that Member:

a) his full name and title; b) his date of birth; c) his full postal address; d) his home telephone number (if any); e) his email address (if any); f) the constituency of which he is a Member; g) the date upon which he became a Member; h) his gender and ethnicity.

2.3 Where an individual is to be invited by the Trust to become a Member, the following

procedure shall apply:

i) the Trust shall take all reasonable steps to satisfy itself that the individual is eligible to become a Member of the Staff Class of the Staff Constituency relevant to him before inviting him to become a Member of the Trust and that it has all the information needed to complete the Register of Members in accordance with Clause 2.2 (v) of this Annex;


Top



120

ii) the Trust having so satisfied itself, it shall thereupon invite that individual to

become a Member pursuant to Clause 5 of the Constitution and if necessary shall request the individual to provide such further information, if any, as it may need to complete the necessary entry in the Register of Members;

iii) unless the individual has within fourteen days of the date upon which the Trust

dispatches its invitation to him to become a Member advised the Trust that he does not wish to become a Member, the Trust shall thereupon enter that individual’s name on the Register of Members and he shall thereupon become a Member provided that the Trust has been provided with the information, if any, requested pursuant to Clause 2.2 (v) of this Annex to enable it to complete the relevant entry in the Register of Members;

iv) if the individual has failed to provide the information requested by the Trust

within fourteen days of being invited by the Trust to provide it in accordance with Clause 2.2 (v) of this Annex, the Trust shall give notice in writing to the applicant that the information has not been provided and that unless and until the information is provided that individual’s name shall not be entered on the Register of Members.

2.4 No individual who is ineligible or disqualified from Membership shall be entered or

remain on the Register of Members. 2.5 For the avoidance of doubt, an individual shall become a Member on the date upon

which his name is entered on the Trust’s Register of Members and shall cease to be a Member upon the date on which his name is removed from the Register of Members as provided for in this Constitution.

2.6 The Trust shall procure that the Register of Members and all other Registers to be

maintained in accordance with this Constitution or in accordance with the 2006 Act are regularly reviewed and updated and that the Register of Members in particular is reviewed and updated as appropriate and no less often than every twenty eight days.

3. TERMINATION OF MEMBERSHIP

3.1 A Member shall cease to be a Member if:

i) he resigns by notice to the Secretary; ii) he dies; iii) he is expelled from Membership under this Constitution; iv) if it appears to the Secretary that he no longer wishes to be a Member of the

Trust, and after enquiries made in accordance with a process approved by the Council of Governors, he fails to establish that he wishes to continue to be a Member of the Trust.

3.2 A Member may be expelled by a resolution approved by not less than two-thirds of

the Council of Governors present and voting at a General Meeting. The following procedure is to be adopted:

i) any Member may complain to the Secretary that another Member has acted in

a way detrimental to the interests of the Trust.


Top



121

ii) if a complaint is made, the Council of Governors may itself consider the

complaint having taken such steps as it considers appropriate to ensure that each Member's point of view is heard and may either:

a) dismiss the complaint and take no further action; or

b) arrange for a resolution to expel the Member complained of to be

considered at the next General Meeting of the Council of Governors.

iii) if a resolution to expel a Member is to be considered at a General Meeting of the Council of Governor, details of the complaint must be sent to the Member complained of not less than one calendar month before the meeting with an invitation to answer the complaint and attend the meeting.

iv) at the meeting the Council of Governors will consider evidence in support of

the complaint and such evidence as the Member complained of may wish to place before them.

v) if the Member complained of fails to attend the meeting without reasonable

cause the meeting may proceed in his absence. 3.3 A person expelled from Membership will cease to be a Member upon the declaration

by the Chairman of the meeting that the resolution to expel them is carried. 3.4 No person who has been expelled from Membership is to be re-admitted except by a

resolution carried by the votes of two-thirds of the Members of the Council of Governors present and voting at a General Meeting.

4. MEMBERS MEETINGS

4.1 The Trust shall hold an Annual Members’ Meeting within eight months of the end of

each Financial Year of the Trust.

4.2 Any Members’ meetings other than the Annual Members’ Meeting shall be called “Special Members’ Meetings”. Annual Members' Meeting and Special Members' Meetings are referred to in this Paragraph 4 as "Members' Meetings".

4.3 Members’ Meetings shall be open to all Members of the Trust, members of the Council of Governors and the Board of Directors, representatives of the Trust’s financial auditors and to members of the public. The Trust may invite representatives of the media, and any experts or advisors, whose attendance they consider to be in the best interests of the Trust to attend a Members’ Meeting.

4.4 All Members’ Meetings are to be convened by the Secretary by order of the Board of Directors.

4.5 The Trust shall make provision for the Members’ Meeting to be held at Poole Hospital

or a venue close to Poole Hospital.

4.6 The Board of Directors shall present at the Annual Members’ Meeting to the Members: i) a report on steps taken to secure that (taken as a whole) the actual

membership is representative of those eligible for such Membership;


Top



122

ii) the progress of the Membership strategy; iii) any proposed changes to the policy for the composition of the Council of

Governors and of the Non-Executive Directors; iv) the results of the election and appointment of Governors any other reports or

documentation it considers necessary or otherwise required by Monitor or the 2006 Act (to be commenced by the Trust Secretary).

4.7 The Trust shall give notice of all Members’ Meetings:

i) by notice in writing to all Members; ii) by notice prominently displayed at the Trust’s main address and at all of the

Trust’s principal places of business; iii) by notice on the Trust’s website at least fourteen clear days before the date

of the meeting; iv) to the Council of Governors and the Board of Directors, and to the Trust’s

auditors stating whether the meeting is an Annual or Special Members’ Meeting giving the time, date and place of the meeting and indicating the business to be dealt with at the meeting.

4.8 The Chairman or in his absence the Vice Chairman shall preside at all Members’

Meetings of the Trust. If neither the Chairman nor the Vice Chairman is present, the Governor present shall elect one of their number to be Chairman and if there is only one Governor present and willing to act that person shall be Chairman. If no Governor is willing to act as Chairman or if no Governor is present within fifteen minutes after the time appointed for holding the meeting, the Members present and entitled to vote shall choose one of their number to be Chairman.

5. BOARD OF DIRECTORS: DISQUALIFICATION

5.1 In addition to the grounds of disqualification set out in Clause 25 of the Constitution, a

person may also not be or continue as a Director of the Trust if:

i) in the case of a Non-Executive Director, he no longer satisfies relevant appointment requirements;

ii) he is a person whose tenure of office as a Chairman or as a Member or

Director of a health service body has been terminated on the grounds that his appointment is not in the interests of public service, or for non-disclosure of a pecuniary interest;

iii) he has within the preceding two years been dismissed, otherwise than by

reason of redundancy, by the coming to an end of fixed term contract or through ill health, from any paid employment with a health service body;

iv) information revealed by a Criminal Records Bureau check is such that it

would be inappropriate for him to become or continue as a Director on the grounds that this would adversely affect public confidence in the Trust or otherwise bring the Trust into disrepute;


Top



123

v) in the case of an Executive Director, he is no longer employed by the Trust.

6. Governors AND DIRECTORS: COMMUNICATION AND CONFLICT

Summary

6.1 This Clause 6 of this Annex describes the processes intended to ensure a successful and constructive relationship between the Council of Governors and the Board of Directors. It emphasises the importance of informal and formal communication, and confirms the formal arrangements for communication within the Trust. It suggests an approach to informal and formal communications between the Council of Governors and the Board of Directors.

Informal Communications

6.2 Informal and frequent communication between the Governor and the Directors is an essential feature of a positive and constructive relationship designed to benefit the Trust and the services it provides.

6.3 The Chairman shall use his reasonable endeavours to encourage effective informal

methods of communication including:

i) participation of the Board of Directors in the induction, orientation and training of Governors;

ii) development of special interest relationships between Non-Executive

Directors and Governors; iii) discussions between Governors and the Chairman and/or the Chief Executive

and/or Directors through the office of the Chief Executive or his nominated officer;

iv) involvement in membership recruitment and briefings at public events

organised by the Trust. Formal Communication

6.4 Some aspects of formal communication are defined by the constitutional roles and responsibilities of the Council of Governors and the Board of Directors respectively.

6.5 Formal communications initiated by the Council of Governors and intended for the

Board of Directors will be conducted as follows:

i) specific requests by the Council of Governors will be made through the Chairman to the Board of Directors;

ii) any Governor has the right to raise specific issues to be put to the Board of Directors at a duly constituted meeting of the Council of Governors through the Chairman but if the Chairman declines to raise any such issue the said Governor may nonetheless still raise it provided two thirds of the Governors present approve his request to do so. The Chairman shall then raise the matter with the Board of Directors and provide the response to the Council of


Top



124

Governors; iii) joint meetings will take place between the Council of Governors and the Board

of Directors as and when appropriate as determined by the Chairman (in his capacity as the Chairman of both the Board of Directors and the Council of Governors.

6.6 The Board of Directors may request the Chairman to seek the views of the Council of

Governors on such matters as the Board of Directors may from time to time determine.

6.7 Communications between the Council of Governors and the Board of Directors may

occur with regard to, but shall not be limited to:

i) the Board of Directors proposals for the Strategic Direction and the Annual Business Plan;

ii) the Board of Directors’ proposals for developments; iii) Trust performance; iv) involvement in service reviews and evaluation relating to the Trust’s services;

and v) proposed changes, plans and developments for the Trust other than may be

covered by Clause 6.6 of this Annex.

6.8 The Board of Directors shall also present to the Council of Governors the Annual Accounts, Annual Report and Auditors Report in accordance with the terms of this Constitution and of the 2006 Act.

6.9 The following formal methods of communication may also be used as appropriate

with the consent of both the Council of Governors and the Board of Directors:

i) attendance by the Board of Directors at a meeting of the Council of Governors;

ii) provision of formal reports or presentations by Executive Directors to a

meeting of the Council of Governors; ii) inclusion of appropriate minutes for information on the agenda of a meeting of

the Council of Governors; iv) reporting the views of the Council of Governors to the Board of Directors

though the Chairman or Vice Chairman. Disputes

6.10 Where an individual is held by the Trust to be ineligible and/or disqualified from Membership of the Trust and disputes the Trust’s decision in this respect, the matter shall be referred to the Chief Executive (or such other officer of the Trust as the Chief Executive may nominate) as soon as reasonably practicable thereafter.

6.11 The Chief Executive (or his nominated representative) shall:


Top



125

i) review the original decision having regard to any representations made by the individual concerned and such other material, if any, as the Chief Executive considers appropriate;

ii) then either confirm the original decision or make some other decision as

appropriate based on the evidence which he has considered; and iii) communicate his decision and the reasons for it in writing to the individual

concerned as soon as reasonably practicable.

6.12 Where a Governor is declared ineligible or disqualified from office or his term of office as a Governor has been terminated (otherwise than as a consequence of his own resignation) and that person disputes the decision, he shall as reasonably practicable be entitled to attend a meeting with the Chairman and Chief Executive of the Trust, who shall use their best endeavours to facilitate such a meeting, to discuss the decision with a view to resolving any dispute which may have arisen but the Chairman and Chief Executive shall not be entitled to rescind or vary the decision which has already been taken.

6.13 Notwithstanding paragraph 6.12 and the provisions of Annex 5 paragraph 3, an independent assessor may be appointed (as if it had been a possible removal pursuant to and using the process set out in Annex 5 paragraph 3) to consider the evidence and advise on whether this justified disqualification under the terms of the Constitution.

6.14 In the event that the independent assessor appointed pursuant to paragraph 6.13 advises that the evidence justifies the disqualification, the original decision to disqualify shall stand. If however the independent assessor advises that there is at least reasonable doubt that the evidence justified disqualification, the matter shall be put to the Council of Governors to decide whether to uphold the disqualification or not (such decision requiring support of not less than three quarters of the Governors present and voting at a meeting of the Council of Governors convened for that purpose). If the Council of Governors does not uphold the disqualification, then such disqualification shall not stand and the Governor subject to the proposed disqualification shall remain in office.

6.15 Pending a decision of the independent assessor or the Council of Governors as referred to in paragraph 6.13, the Governor shall (without prejudice to the outcome of such review process) not be able to exercise any right or powers of a Governor and shall follow any instruction from the Chairman e.g. as to access to Trust premises or contact with Trust officers or staff or other Governors as the Chairman shall deem appropriate in the interests of the health and safety of any persons or the security or reputation of the Trust.

7. AMENDMENT OF CONSTITUTION

7.1 The Trust may make amendments to this Constitution only if:

7.1.1 more than half of the members of the Council of Governors voting approve the amendments, and

7.1.2 more than half of the members of the Board of Directors voting approve the

amendments.


Top



126

7.2 Amendments made under paragraph 7.1 take effect as soon as the conditions in that paragraph are satisfied, but the amendment has no effect in so far as the Constitution would, as a result of the amendment, not accord with Schedule 7 of the 2006 Act.

7.3 Where an amendment is made to the Constitution in relation to the powers or duties of the Council of Governors (or otherwise in respect to the role that the Council of Governors has as part of the Trust):

7.3.1 at least one member of the Council of Governors must attend the next Annual

Members' Meeting and present the amendment, and 7.3.2 the Trust must give the Members an opportunity to vote on whether they

approve the amendment. 7.4 If more than half of the Members voting approve the amendment, the amendment

continues to have effect; otherwise, it ceases to have effect and the Trust must take such steps as are necessary as a result.

7.5 Amendments by the Trust of its Constitution are to be notified to Monitor. For the

avoidance of doubt, Monitor's functions do not include a power or duty to determine whether or not he Constitution, as a result of the amendments, accords with Schedule 7 of the 2006 Act.

8. INDEMNITY

8.1 Members of the Council of Governors and Board of Directors who act honestly and in good faith will not have to meet out of their personal resources any personal civil liability which is incurred in the execution or purported execution of their Council or Board functions, save where they have acted recklessly. Any costs arising in this way will be met by the Trust and the Trust shall have the power to purchase suitable insurance or make appropriate arrangements with the National Health Service Litigation Special Health Authority to cover such costs.

9. VALIDITY OF ACTIONS

9.1 No defect or deficiency in the appointment or composition of the Council of Governors or the Board of Directors shall affect the validity of any action taken by them.


Top



127

Appendix 3 Code of Conduct (v2)


Top



128

CODE OF CONDUCT FOR COUNCIL OF GOVERNORS

1. INTRODUCTION 1.1 This Code seeks to outline appropriate conduct for Governors and addresses both

the requirements of office and their personal behaviour. Ideally any penalties for non-compliance would never need to be applied; however a code is considered an essential guide for Governors, particularly to provide a source of guidance and advice to those who are newly elected.

1.2 Poole Hospital NHS Foundation Trust prides itself on being open in providing friendly,

professional patient care with dignity and respect. As a Governor, sometimes dealing with difficult and confidential issues, Governors are required to act with discretion and care in the performance of their role without compromising patient and/or staff confidentiality.

1.3 Governors are required to maintain confidentiality with regard to information gained

via their involvement with the Trust this may cover patients, staff or commercial confidentiality. If in any doubt seek guidance from the Company Secretary.

1.4 The Code seeks to expand on and complement our Constitution. 1.5 All Governors are expected to sign the declaration at paragraph 14 to confirm that

they will comply with the Code in all respects and that, in particular, they support the Trust’s objectives.

2. QUALIFICATIONS FOR OFFICE 2.1 Governors must continue to comply with the qualifications required to hold public

office throughout their period of tenure. The Company Secretary must be advised of any changes in circumstance which may disqualify a Governor from continuing in office. For example, a Governor moving out of the constituency they were elected by or (other than the elected staff members) becoming an employee of the Trust.

2.2 One of the key objectives of the Council of Governors is to promote social inclusion

throughout its work. As such, the development and delivery of initiatives should not prejudice any part of the community on the grounds of age, race, disability, marital status sexual orientation or religious belief.

2.3 Elected Governors (ie not Appointed Governors) who are members of any trade’s

union, political party or other organisation should recognise that they will not be representing those organisations (or the views of those organisations) but will be representing the constituency (public or staff) that elected them.

2.4 Governors are expected to uphold the seven principles of public life as detailed by

the Nolan Committee (please see Paragraph 13).


Top



129

3. ROLE AND FUNCTION OF THE COUNCIL OF GOVERNORS 3.1 Governors must:

i) adhere to the Trusts rules and policies, including the Constitution, Standing Orders and Standing Financial Instructions, and support its objectives, in particular those relating to NHS Foundation Trust status and developing a successful Trust;

ii) act in the best interests of the Trust at all times;

iii) contribute to the working of the Council of Governors in order for it to fulfil its role and functions as defined in the Constitution;

iv) recognise that their role is a collective one. Collective decision making is exercised at Council of Governors meetings and Governors support decisions made by the Council of Governors even if against their own wishes. The outcome of collective decision making is recorded in the minutes.

v) Outside Council meetings a Governor has no more rights and privileges than any other member.

4. CONFIDENTIALITY 4.1 All Governors are required to respect the confidentiality of the information they are

made privy to as a result of their membership of the Council of Governors relating to individual patients, members of staff or commercial confidentiality.

5. CONFLICTS OF INTEREST 5.1 Governors should be honest and act with the utmost integrity, probity and objectivity

and in the best interests of the Trust in performing their duties. They should not use their position for personal advantage or seek to gain preferential treatment. They should declare any conflicts of interest which may arise and should not vote on any such matters. If in any doubt they should seek advice from the Company Secretary. It is important that conflicts of interest, actual or potential, are addressed and are seen to be actioned in the interests of the Trust and all the individuals concerned.

5.2 Governors must declare any involvement they may have in any organisation with

which the Trust may be considering entering a contract. 5.3 There will be a register of Interests in which Governors must enter any pecuniary and

non-pecuniary interests. Failure to do so may result in dismissal from the Council of Governors. The Register of Council of Governors Interests is a public document that will be available on the Trust’s website and by request to the Company Secretary.

6. MEETINGS OF THE COUNCIL OF GOVERNORS 6.1 Governors have a responsibility to attend meetings of the Council of Governors.

When this is not possible they should submit an apology to the Company Secretary in advance of the meeting.


Top



130

6.2 Absence from the Council of Governors meetings without good reason established to

the satisfaction of the Council of Governors is grounds for dismissal. Absence from two consecutive meetings will result in the Governor being deemed to have resigned their position unless the grounds for absence are deemed to be satisfactory by the Council of Governors.

6.3 Governors are expected to attend for the duration of each meeting. 7. PERSONAL CONDUCT 7.1 Governors are required to adhere to the highest standards of conduct in the

performance of their duties and abide by the philosophy and values set out in the Poole Approach (Annex One). In respect of their interaction with others they are required to:

i) ensure that fellow Council Members are valued as colleagues and that

judgements about colleagues are consistent, fair and unbiased and are properly founded;

ii) adhere to good practice in respect of conduct of meetings and respect the views of their fellow Governors;

iii) be mindful of conduct which could be deemed to be unfair or discriminatory;

iv) treat the Trust’s Directors, other employees and fellow Governors with respect and in accordance with the Trust policies and the Poole Approach;

v) recognise that the Council of Governors and management have a common purpose, ie the success of the Trust, and so demonstrate their commitment to working as a team member by working with all their colleagues in the NHS and the wider community;

vi) conduct themselves in a manner which reflects positively on the Trust. When attending external meetings or any other events it is important for Governors to be ambassadors for the Trust;

vii) seek to ensure that the membership of the constituency, or partner organisation, they represent are properly informed and that their views are fed back to the Trust.

8 FIT AND PROPER PERSON TEST

8.1 Governors must comply with the Fit and Proper person test contained in the NHS

Provider Licence issued by Monitor. According to the Licence an unfit person is:

a. an individual;

i. who has been adjudged bankrupt or whose estate has been sequestrated

and (in either case) has not been discharged; or

ii. who has made a composition or arrangement with, or granted a trust deed

for, his creditors and has not been discharged in respect of it; or

iii. who within the preceding five years has been convicted in the British

Islands of any offence and a sentence of imprisonment (whether


Top



131

suspended or not) for a period of not less than three months (without the

option of a fine) was imposed on him; or

iv. who is subject to an unexpired disqualification order made under the

Company Directors’ Disqualification Act 1986.

b. a body corporate, or a body corporate with a parent body corporate:

i. where one or more of the Directors of the body corporate or of its parent

body corporate is an unfit person under the provisions of sub-paragraph (a)

of this paragraph, or

ii. in relation to which a voluntary arrangement is proposed under section 1 of

the Insolvency Act 1986, or

iii. which has a receiver (including an administrative receiver within the

meaning of section 29(2) of the 1986 Act) appointed for the whole or any

material part of its assets or undertaking, or

iv. which has an administrator appointed to manage its affairs, business and

property in accordance with Schedule B1 to the 1986 Act, or

v. which passes any resolution for winding up, or

vi. which becomes subject to an order of a Court for winding up.

9 COMMUNICATION 9.1 With regard to liaison with the media, Governors should seek the advice of the Head

of Communications before making comment to or responding to the media. 9.2 Issues of a key or strategic nature should be submitted to the Chairman or Company

Secretary in writing. 10. ACCOUNTABILITY 10.1 Governors are accountable to the membership and should demonstrate this. They

should attend events and provide opportunities to interface with the members or partner organisations they represent in order to best understand their views.

11. TRAINING AND DEVELOPMENT 11.1 Training and development are essential for Governors, as for all staff, in ensuring

effective performance of their role. Governors will be expected to participate in training and development as provided by the Trust, including induction events.

12. VISITS TO TRUST PREMISES 12.1 Governors may wish, as part of their role, to visit Trust premises. However,

Governors will recognise that, as the Trust buildings are busy facilities it is important for visits to be planned to coincide with operational requirements and may need to be conducted in groups to maximise staff availability.

12.2 When the Governors wish to visit the premises of the trust in a formal capacity as

opposed to individuals in a personal capacity, they should liaise with the Company Secretary to make the necessary arrangements.


Top



132

13. NON-COMPLIANCE WITH THE CODE OF CONDUCT 13.1 Non-compliance with this Code of Conduct may result in action being taken as

follows:

i) where alleged misconduct takes place the Chairman following consultation with the Deputy Chairman of Governors and/or the Lead Governor is authorised to take, without prejudice to any decision by the Council of Governors to initiate a process pursuant to paragraph 13.1(ii), such action as may be immediately required, including the exclusion of the person concerned from Trust premises and meetings;

ii) where such misconduct is alleged, it shall be open to the Council of Governors to decide, by simple majority of those in attendance, to initiate formal processes. In such instances it will be the responsibility of the Council of Governors (subject to paragraph 13.1(iv) ) to:

notify the Governor in writing of the allegations, detailing the specific behaviour which is considered to be detrimental to the Trust, and inviting and considering their response within a defined timescale;

inviting the Governor to address the Council of Governors in person if the matter cannot be resolved satisfactorily through correspondence;

deciding, by simple majority of those present and voting, whether to uphold the allegation of conduct detrimental to the Trust;

impose such sanctions as shall be deemed appropriate sanctions will range from the issuing of a verbal or written warning to the removal of the Governor from office;

iii) in order to aid participation of all parties, it is imperative that all Governors observe the points of view of others and conduct likely to give offence will not be permitted. The Chairman will reserve the right to ask any member of the Council of Governors who (in his / her opinion), fails to observe the code to leave the meeting.

iv) Where misconduct is alleged as set out in paragraph 13.1 (ii) an independent assessor may be appointed pursuant to the provision of Annex 5 paragraph 3.5 of the Constitution at any stage in the process and no decision of the Council of Governors shall be made until such time as the Council of Governors has had an opportunity to consider the advice of the independent assessor.

13.2 This Code of Conduct does not limit or invalidate the right of the Governor or the Trust to act under the Constitution.

14. THE SEVEN PRINCIPLES OF PUBLIC LIFE (NOLAN PRINCIPLES)

Selflessness Holders of public office should take decisions solely in terms of the public interest. They should not do so in order to gain financial or other material benefits for themselves, their family, or their friends.


Top



133

Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might influence them in the performance of their official duties. Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. Openness Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. Leadership Holders of public office should promote and support these principles by leadership and example.

15. DECLARATION: I ……………………………………………………………. (print name) agree to abide by the Code of Conduct of the Council of Governors of The Poole Hospital NHS Foundation Trust. Signature …………………………….…………..…………. Date …………………………………….……………………..


Top



134

Updated: January 2009 to reflect title changes April 2014 to include fit and proper person test June 14 miscellaneous & independent review S:\Company-Secretary\FT Governance\Register\E CoG Requirements\E2 CoG Code of Conduct and Declaration\E2 CoG Code of Conduct and Declaration.doc


Top



135

Annex One

THE POOLE APPROACH

“Friendly professional, patient-centred care with dignity and respect for all”

THIS MEANS THAT: Our patients receive excellent care and treatment in a safe and clean environment and we:

listen to our staff, patients and the public;

give information that is relevant and accessible;

safeguard patient privacy, confidentiality and choice;

welcome and involve families, carers and friends to participate in care;

treat each other with respect and consideration;

value and benefit from diversity in beliefs, cultures and abilities;

continually improve the quality of our services by learning from what we do;

take responsibility and are accountable for our own actions;

expect staff and patients to take their share of responsibility for their own health;

work and support all organisations who are committed to promoting the health of local people.


Top





Agenda Item: 10.03 Paper No: F

Title:

Findings and Recommendations from the 2013/14 NHS Quality Report – External Assurance Review

Purpose:

To communicate the external audit findings to the members of the Council of Governors.

Summary:

Deloitte have prepared a final report which covers the 2013/14 NHS Quality Report assurance review. The report is the same report as issued to the Audit and Governance Committee updated only for the final version of the Audit report.

Recommendation:

Prepared by:

Deloitte LLP Presented by:

SUE BARRATT Deloitte LLP

CoG�July�14�F1�cover�sheet�-�Q

Top



Issued on 22 May 2014 for the meeting on 28 May 2014


Findings and Recommendations from the 2013/14 NHS

Quality Report External Assurance Review

CoG�July�14�F2�Quality�Account

Top



Contents

The big picture 2

Content and consistency review findings 6

28 day emergency re-admissions 8

62 day cancer waiting times 11

Friends and Family (Local Indicator) 14

Recommendations for improvement 17

Update on prior year recommendations 18

Data Quality Framework 20

Purpose of our report and responsibility statement 22

We would like to take this

opportunity to thank the

management team for their

assistance and co-operation

during the course of our review

Delivering informed challenge

Providing intelligent insight

Growing investor confidence

Building trust in the profession


Top



The big picture


Top



Findings and Recommendations from the 2013/14 NHS Quality Report External Assurance Review 2

The big picture We have completed our Quality Report testing and are in a

position to issue our limited assurance opinion.

Status of our work

We have completed our review, including

validation of the selected indicators. Upon receipt

of the final signed quality report and letter of

Representation, we will issue our final report to

the Governors.

The scope of our work is to support a “limited

assurance” opinion, which is based upon

procedures specified by Monitor in their “Detailed

Guidance for External Assurance on Quality

Reports 2013/14”.

In response to the growth of performance

indicators across the NHS, we have developed a

framework of considerations for evaluating data

quality. We have used this framework in

evaluating our findings and the recommendations

we have raised.

We anticipate signing an unmodified opinion for

inclusion in your 2013/14 Annual Report.

Context

Q4 Governance Risk Rating: Green

The Care Quality Commission inspected Poole Hospital during the year and did not find any significant issues

2013/14 2012/13

Length of

Quality Report 56 pages 66 pages

Quality

Priorities 5 5

Future year

Quality

Priorities 5 5

Scope of work

We are required to:

Review the content of the Quality Report for compliance with the requirements set out in Monitor’s Annual

Reporting Manual (“ARM”).

Review the content of the Quality Report for consistency with various information sources specified in

Monitor’s detailed guidance, such as Board papers, the Trust’s complaints report, staff and patients surveys

and Care Quality Commission reports.

Perform sample testing of three indicators.

The Trust has selected 28 day emergency readmission and 62 day cancer wait time as its publically

reported indicators – the alternative was C difficile infection rates.

For 2013/14, all Trusts are required to have testing performed on a local indicator selected by the

Council of Governors. The Trust initially selected “Right patient, right beds, right time”, as noted later in

our report, this indicator was deemed unauditable and as such as alternative local indicator was

selected; “Friends and Family”.

The scope of testing includes an evaluation of the key processes and controls for managing and

reporting the indicators; and sample testing of the data used to calculate the indicator back to supporting

documentation.

Provide a signed limited assurance report, covering whether:

Anything has come to our attention that leads us to believe that the Quality Report has not been

prepared in line with the requirements set out in the ARM; or is not consistent with the specified

information sources; or

There is evidence to suggest that the 28 day emergency readmission and 62 day cancer wait time

indicators have not been reasonably stated in all material respects in accordance with the ARM

requirements.

Provide this report to the Council of Governors, setting out our findings and recommendations for

improvements for the indicators tested: 28 day emergency readmission, 62 day cancer wait time and Friends

and Family.


Top




The big picture (continued) We have not identified any significant issues from our work.

Content and consistency review

We have completed our content and consistency review. From our work, nothing has come to our attention that

causes us to believe that, for the year ended 31 March 2014 the Quality Report is not prepared in all material

respects in line with the criteria set out in the ARM).

Overall conclusion

Content

Are the Quality Report contents in line with the requirements of the Annual Reporting

Manual?

Consistency

Are the contents of the Quality Report consistent with the other information sources we

have reviewed (such as Internal Audit Reports and reports of regulators)?

No issues noted

Satisfactory – minor issues only

Requires improvement

Significant improvement required

Other Findings

Right patients, right beds, right time

- Indicator definition: Increasing the number of patients placed in the specialist area they require and

reducing the number of patients outlying in other wards.

- As discussed above, this was the initial indicator selected by the governors for review was part of our

planned audit procedures.

- We met with the local indicator lead who then walked us through how the indicator worked, the

procedures undertaken to collect the indictor data and then how the data was used to calculate the

performance indicator.

- On holding these discussions with management, it became evident that there were some obstacles to

performing testing on the indicator data. These obstacles are outlined below;

1. The Clinical management team do not record details of patients who were outlying on any given

day, merely the overall number of outliers per ward. As such, we could not trace back to patient

records to assess the accuracy of the assessment of these patient as outliers (or indeed,

whether inliers were accurately classified as such);

2. Ecamis (IT data system) cannot show retrospective data, so we cannot rectify the issue outlined

above; and

3. Adjustments are made to the data, but the number of adjustments made and the justification for

these adjustments are not recorded. Therefore, on review, it would be impossible for us to

assess whether these adjustments were accurately made or if an adjustment was made at all.

- As a result, the scope of our testing was limited to understanding the process of compiling the indicator

due to the real time recording of data and lack of audit trail. A recommendation has been reported in the

body of our report - Recommendation 1.


Top




The big picture (continued) Performance indicator testing

Monitor requires Auditors to undertake detailed data testing on a sample basis of three mandated indicators. We

perform our testing against the six dimensions of data quality that Monitor specifies in its guidance.

From our work, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2014,

the indicators in the Quality Report subject to limited assurance have not been reasonably stated in all material

respects in accordance with the ARM and the six dimensions of data quality set out in the “Detailed Guidance for

External Assurance on Quality Reports 2013/14”.

Readmission

Cancer

Wait

Friends

& Family

Accuracy

Is data recorded correctly and is it in line with the methodology.

Validity

Has the data been produced in compliance with relevant requirements.

Reliability

Has data been collected using a stable process in a consistent manner over a period

of time.

Timeliness

Is data captured as close to the associated event as possible and available for use

within a reasonable time period.

Relevance

Does all data used generate the indicator meet eligibility requirements as defined by

guidance.

Completeness

Is all relevant information, as specific in the methodology, included in the calculation.

Recommendations identified? [] [] []

Overall Conclusion

Unmodified Opinion

Unmodified

Opinion

No opinion required

No issues noted




Overall Conclusion:

Despite the finding above in respect to the 28 day readmission calculation, we have issued an unmodified opinion

as the values are being amended in the Quality Report to align with the Monitor guidance.


Top




Content and consistency

findings


Top




Content and consistency review findings Compliant with the Monitor guidelines

The Quality Report is intended to be a key part of how the Trust communicates with its stakeholders.

Our work is based around reviewing content against specified criteria and considering consistency against

other documentation. Although outside the formal scope of our work, we have also made

recommendations to management to assist in preparing a high quality document. We have summarised

below our overall assessment of the Quality Report, based upon the points identified in our NHS Briefing

on Quality Accounts from our wide experience.

Key questions Assessment Statistics

Is the length and balance of the content of the report appropriate?

Length: 51 pages

Is there an introduction to the Quality Report that provides context?

Is there a glossary to the Quality Report?

Is the number of priorities appropriate across all three domains of

quality (Patient Safety, Clinical Effectiveness and Patient

Experience)?

Patient Safety: 3

Clinical Effectivess: 3

Patient Experience: 3

Has the Trust set itself SMART objectives which can be clearly

assessed?

Does the Quality Report clearly present whether there has been

improvement on selected priorities?

Is there appropriate use of graphics to clarify messages?

Does there appear to have been appropriate engagement with

stakeholders (in both choosing priorities as well as getting feedback

on the draft Quality Report)?

Is the language used in the Quality Report at an appropriate

readability level?

No issues noted




Deloitte view

Overall, the Quality Account is in line with the requirements as out lined in the Monitor guidance. Management are

responsive to our audit reviews and have reflected our comments and recommendations into the final draft of the

report.

Particular areas of good practice are as follows

The quality report presentation is compliant with the mandatory requirements for reporting as set out in the

Annual Reporting Manual.

The indicators selected are presented in a clear manner evidencing the issue, aim, current status and plans

for improvement.

Possible areas for improvement next year include:

Enhanced clarity and concise reporting of improvements ensuring all targets are in line with SMART

objectives.

Make use of graphics and tables to demonstrate benchmarking from period to period and against other Trusts

to give greater clarity of the Trusts progression and improvement.


Top




Performance indicator testing


Top




28 day emergency re-admissions The Trust’s process is satisfactory

Trust reported performance Overall evaluation of our work

2013/14 (28 days) 0-14 years

15+ years

11.1%

10.1%

2012/13 (30 days) 0-14 years

15+ years

4.3%

4.4% Not selected

NB. Prior year is currently under review to be recalculated under the same guidelines as 2013/14.

Indicator definition and process

Definition: “Percentage of emergency admissions to a hospital that forms part of the trust occurring within 28

days of the last, previous discharge from a hospital that forms part of the trust.”

The readmission rate can indicate early complications after discharge and how appropriate the original decision

made to discharge was. Some readmissions are to be expected from planned care pathways. There is a

challenge for many trusts in preparing this data due to historic differing demands for 28 day and 30 day reporting

by different organisations.


Top




28 day emergency re-admissions The Trust’s performance has historically been improving on

this indicator

National context

The chart below shows how the Trust compares to other organisations nationally for 2011/12, the latest national

data available.

Approach

We met with the Trust’s lead for emergency readmissions to understand the process from a patient being

readmitted to the result being included in the Quality Report. This was the first year that we have performed

testing on this indicator therefore no follow up procedures were required.

We evaluated the design and implementation of controls through the process.

We selected a sample of 24 from 1 April 2013 to 31 March 2014 including those re-admitted both within and

outside 28 days.

We agreed our sample of 24 to supporting documentation.

-

5

10

15

20

Sta

ndard

ised p

erc

enta

ge o

f cases patie

nts

aged 1

6 o

r old

er

28 day emergency readmissions - 2011/12 data

POOLE HOSPITAL NHS FOUNDATION TRUST Local region

Other English providers England average

Source: Deloitte analysis of Health and Social Care Information Centre data



Top




28 day emergency re-admissions

(continued)

Findings

Findings 1 – The Trust has not correctly calculated the indicator in the current and prior year. On

discussion with those involved in formulating the indicator, the Monitor guidance had not been

communicated and therefore they believed they had been providing management with the information they

needed to report to Monitor - Recommendation 2.

Findings 2 – There is no national target for this indicator, but nor is there an evident target that the Trust

would like to achieve. As such it is difficult to conclude if the hospital is performing well unless they are

compared to other Trusts.

Deloitte View:

We did not identify any errors from our testing of individual cases however we did identify that the indicator rate had

been incorrectly calculated. Despite this finding, we have issued an unmodified opinion as the values are being

amended in the Quality Report.

The Trust has historically been reporting the indicator as 30 day emergency readmissions and using the

information that is reported out of the HECTOR system. For 2013/14, the Trust has recalculated the indicator

under the requirements set out by Monitor to ensure they are reporting the correct calculation. The differences in

the calculation arise due to the fact the Hectar system parameters have been aligned to the requirement per the

PbR guidance and therefore some of the exclusions when calculating the indicator are not aligned. Therefore the

indicator reported in the 2012/13 quality report is not correct when using the Monitor guidance.

We have recommended to management that a recalculation is made for the 2012/13 indictor in order to report a

comparable figure in the 2013/14 quality report and as such stakeholders can truly understand how the Trust is

performing in this area and if they have made improvements from the prior year. In addition to this we recommend

that Trust contacts Monitor in advance of issuing the report to notify them of the changes being made and why the

occurred.

Having corrected the recalculation error, it would appear that the Trust is performing on par with other Trusts (per

the diagram above).


Top




62 day cancer waiting times The Trust’s process is robust and well managed

Trust reported performance

Target Overall evaluation of our work

2013/14 87% 85%

2012/13 87% 85%


Definition: “Percentage of patients receiving first definitive treatment for cancer within 62 days of an urgent GP

referral for suspected cancer.”

The NHS Cancer Plan set the goal that no patient should wait longer than two months (62 days) from a GP urgent

referral for suspected cancer to the beginning of treatment, except for good clinical reasons.


Top




62 day cancer waiting times (continued)

National context

The chart below shows how the Trust compares to other organisations nationally for Q1-3 2013/14, the latest

national data available at the time of writing this report.

Approach

We met with the Trust’s lead for 62 day cancer waits to understand the process from an urgent referral to the

Trust to the result being included in the Quality Report. This indicator was tested in 2012/13 and one

recommendation was raised. Progress on this recommendation has been reported on page 16.

We evaluated the design and implementation of controls through the process. We discussed with management

and used analytical procedures to focus on pathways which appear to be most at risk of error e.g. patients

with manual adjustments and pathways close to the 62 day breach date.

We selected a sample of 24 from 1 April 2013 to 31 March 2014 including in our sample a mixture of cases in

breach and not in breach of the target.

We agreed our sample of 24 to supporting documentation.

65%

75%

85%

95%

% w

ithin

62 d

ay t

arg

et

National 62 day cancer wait performance - Q1-3 2013-14

Poole Hospital WESSEX providers Other English providers

All English providers Target 2012-13 percentage



Top




62 day cancer waiting times (continued)

Findings

Our procedures were undertaken as outlined above, during the course our work we did not identify any

errors.

Deloitte View:

In 2013/14, the trust received approximately 840 urgent referrals from GP’s in respect of cancer. This is an

increase of approximately 90 cases from the prior year. Regardless of this, the trust has preserved the indictor at

87% which exceeds the national target of 85%.

The table outlines the profile of waiting times, this demonstrates that whilst the whilst patient numbers have

increased the Trust has managed to increase the number of patients that have been seen within 62 days.

The Trust is performing well on this indicator and the data recording has improved since the prior year.


Top




Friends and Family (Local Indicator) The Trust’s process is developing as the indictor is immersed

into the Trust.

Trust reported performance Overall evaluation of our

work

2013/14 76


Definition: “Percentage of patients who would recommend the Trust as a provider of care to their family or

friends”

The Friends and Family Test aims to provide a simple, headline metric which, when combined with follow-up

questions, can be used to drive cultural change and continuous improvements in the quality of the care received

by NHS patients.


Top




Friends and Family (Local Indicator) National context

The Friends and Family indicator was rolled out by the Department of Health in 2013/14. The indicator was initially

trialled in the Midlands and East region in 2012/13 and following the success in this region it has been rolled out

nationally for the current financial period.

Approach

We met with the Trust’s leads to understand the process from the point of discharge of the patient who

receives the survey to the point at in which all the surveys are collected and analysed and the overall

performance being included in the Quality Report.

We selected a sample of 24 from 1 April 2013 to 31 March 2014 selecting from the full population of returned

surveys. We agreed the sample from the report back to the original survey to ensure the survey existed and

the data had been reported correctly.

To test completeness of the data, we selected a further 20 samples from the filed surveys back to the monthly

reports to ensure that surveys are being included in the monthly reports.

We have then obtained the final calculation of the indicator, we have agreed that the appropriate parameters

have been used and we have tested the calculation to the underlying reports.

Findings

Findings 2 – The trust does not record the discharge date on the survey slips and therefore we were

unable to review the timeliness of processing the returned slips - Recommendation 3

Deloitte View:

The quality of the Trust’s processes over reporting of this data has worked effectively in the first year of

implementation of the indicator. We have tested the underlying data that is used to calculate the reported

performance and no issues were identified.

The Trust has calculated the indicator inline with the guidance outlined above with no exceptions noted.


Top




Recommendations


Top




Recommendations for improvement Communication and transparency

Indicator Deloitte Recommendation Management Response Maturity

Right people,

right bed, right

time

Audit trail

Backing documentation should

be retained throughout the

year to support the formation

and calculation of the indicator

for auditability and

transparency.

The data collection process will be reviewed in

order to ensure the relevant data is available for

monitoring and audit.

Responsible Officer: Chief Operating Officer

Timeline: July 2014

Process for updating Council of Governors:

Via the formal Council of Governor meetings

28 day

readmissions

Sharing information

Guidance needs to be

disbursed to the hospital leads

for each indictor to ensure that

their team are reporting

information that meets the

national framework.

It is agreed that the guidance will be disseminated

to key staff to ensure all future recording of the 28

day readmission data meets the national

framework.

Responsible Officer: Chief Operating Officer

Timeline: June 2014


Via the formal Council of Governors meetings

Friends and

Family

Timeliness

The date of discharge should

be included on the survey slip

to ensure timeliness of

processing the findings in line

with the recommended

guidelines.

The trust has attempted in the past (in conjunction

with RBCH) to add in the date of discharge onto

the reply slip, this proved problematic (patients

failed to complete the date). The addition of the

discharge date will not affect the timeliness of the

data as this is recorded monthly.

Responsible Officer: Director of Nursing

Timeline: N/A


Via the formal Council of Governors meetings

Key: Developing Lagging


Top




Update on prior year recommendations Our prior year recommendations have been addressed.

Indicator Priority Rating Deloitte Recommendation Current year status Maturity

Cancer

Wait

times

Medium Cancer wait time breach

incorrectly reported as a pass

Management should introduce

a monthly check to confirm the

dates of referral and date of

treatment are correct.

A monthly review is

performed to ensure that

the upload into the

Somerset Cancer Register

is correct. Ensuring that

appropriate transfer has

been made.

Whilst our specific

recommendation has not

been implemented, our

testing has assured us that

there are adequate controls

around the cancer wait data

and we have found no

cause for concern during

our testing.

Key: Addressed Developing Lagging


Top




Data Quality Framework


Top




Data Quality Framework For evaluating the findings from our testing

Overview

The volume and importance of non-financial performance information across the NHS has grown significantly in

recent years. Performance reporting has emerged as a key tool used both internally and externally. Managers use

information to monitor performance, regulators use it to gauge risk, commissioners use it to ensure their priorities

are met, and governors, patients and the public use it to gain more information about their trust and to hold them to

account.

Whilst the availability and use of non-financial performance information has developed quickly, the control

frameworks used to produce and control such information has not been subject to the same level of rigour as that of

financial information. On average a trust will receive information on 61 performance indicators on a monthly basis,

but very few will be subject to independent review. This can result in a potential assurance gap.

In the table below we have prepared a summary of key considerations that each trust should be able to answer

regarding their performance information. It can be used as an assurance tool to gauge the risk around accuracy and

completeness of performance information.

Area Overview Key considerations

System The accuracy of an indicator is

influenced by the level of automated

vs. manual controls. In general, an

automated system requiring minimal

manual adjustment has a lower risk of

error. However, this assumes that the

system controls are operating as they

are intended.

Is the indicator generated from one system or the

interaction of different systems?

How often are system controls reviewed to ensure

they are appropriate and meet indicator definitions?

How quickly is data produced after the event?

Does data require manual adjustment prior to being

reported as a performance indicator?

Governance Accuracy and completeness of

indicators are influenced by the ‘tone

at the top’. Good performance would

mean clarity of responsibility for

performance metrics, clear processes

and procedures in place for each

metric which are regularly updated,

and quick and comprehensive action

where concerns have been raised.

Who is responsible for the quality and completeness

of performance information at Board level?

If different individuals are responsible for different

indicators, is it clear who is responsible for each?

Are there documented procedures and processes for

each indicator and is this regularly updated?

If data quality concerns have been raised have they

been addressed quickly and comprehensively?

Inputs Some performance indicators rely on a

wide variety of sources to produce the

end metric. In general, the greater the

number of separate sources of

information, and the higher the volume

of data, the greater the likelihood of

error.

What is the volume of inputs of each indicator on a

daily / weekly / monthly basis?

How many different sources of data are there, and

how do you know they all apply consistent?

Methodology in collecting and reporting the data?

What checks are in place to ensure the consistency

and completeness of input data?

Complexity

and skill

Some indicators require specific skills

to identify, analyse and report

performance. Some indicators have

complex rules, which requires

specialist consideration. If the

complexity of these rules is not

understood and applied correctly, there

is a risk that indicators contain errors

or are reporting incomplete

information.

If performance indicators have specific rules, is there

regular training to ensure that all individuals involved

understand these rules and apply them correctly?

Does the Trust have its own assurance systems in

place to test compliance with such rules?

Has the Trust got the appropriate skill and level of

resources to identify, analyse and report performance

for complex indicators?

If national guidance is not clear, does the Trust have

local guidance regarding process and procedures and

is this shared with appropriate individuals?


Top




Responsibility statement


Top




Purpose of our report and responsibility

statement Our report is designed to help you meet your governance duties

What we report

Our report is designed to help the Council of

Governors, Audit Committee, and the Board discharge

their governance duties. It also represents one way in

which we fulfil our obligations under Monitor’s Audit

Code to report to the Governors and Board our

findings and recommendations for improvement

concerning the content of the Quality Report and the

mandated indicators. Our report includes:

Results of our work on the content and

consistency of the Quality Report, our testing

of performance indicators, and our

observations on the quality of your Quality

Report.

Our views on the effectiveness of your system

of internal control relevant to risks that may

affect the tested indicators.

Other insights we have identified from our

work.

What we don’t report

As you will be aware, our limited assurance

procedures are not designed to identify all matters

that may be relevant to the Council of Governors

or the Board.

Also, there will be further information you need to

discharge your governance responsibilities, such

as matters reported on by management or by

other specialist advisers.

Finally, the views on internal controls and

business risk assessment in our final report

should not be taken as comprehensive or as an

opinion on effectiveness since they will be based

solely on the procedures performed in performing

testing of the selected performance indicators.

The scope of our work

Our observations are developed in the context of

our limited assurance procedures on the Quality

Report and our related audit of the financial

statements.

This report should be read alongside the

supplementary “Briefing on audit matters”

circulated to you on 5 November 2013.

We welcome the opportunity to discuss our report with

you and receive your feedback.

Deloitte LLP

Chartered Accountants

29 May 2014

This report is confidential and prepared solely for the purpose set out in our engagement letter and for the Board

of Directors, as a body, and Council of Governors, as a body, and we therefore accept responsibility to you alone

for its contents. We accept no duty, responsibility or liability to any other parties, since this report has not been

prepared, and is not intended, for any other purpose. Except where required by law or regulation, it should not be

made available to any other parties without our prior written consent. You should not, without our prior written

consent, refer to or use our name on this report for any other purpose, disclose them or refer to them in any

prospectus or other document, or make them available or communicate them to any other party. We agree that a

copy of our report may be provided to Monitor for their information in connection with this purpose, but as made

clear in our engagement letter dated 7 February 2014, only the basis that we accept no duty, liability or

responsibility to Monitor in relation to our Deliverables.


Top



Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited (“DTTL”), a UK private company limited by guarantee, and its network

of member firms, each of which is a legally separate and independent entity. Please see www.deloitte.co.uk/about for a detailed

description of the legal structure of DTTL and its member firms.

Deloitte LLP is the United Kingdom member firm of DTTL.

© 2014 Deloitte LLP. All rights reserved.

Deloitte LLP is a limited liability partnership registered in England and Wales with registered number OC303675 and its registered office at

2 New Street Square, London EC4A 3BZ, United Kingdom. Tel: +44 (0) 20 7936 3000 Fax: +44 (0) 20 7583 1198.

Member of Deloitte Touche Tohmatsu Limited


Top





Agenda Item: 10.04 Paper No: G

Title:

External audit report to the Governing Body on the audit of the Trust’s 2013/14 financial statements

Purpose:

To communicate the external audit findings to the members of the Council of Governors.

Summary:

Deloitte have prepared a final report which covers the 2013/14 audit and will present the document to the members of the Council of Governors

Recommendation:

Prepared by:

Deloitte LLP Presented by:

SUE BARRATT Deloitte LLR

CoG�July�14�G1�cover�sheet�-�G

Top



Issued on 17 July 2014 for the meeting on 31 July 2014


External audit report to the Governing Body

on the audit of the Trust’s 2013/14 financial

statements

CoG�July�14�G2�Governor�financ

Top



Contents

The Big Picture 1

1. Our approach 2

2. The focus of our work 6

3. Analysis of audit fees 10

4. Responsibility statement 12

“I am delighted to present this

report, for your 2013/14 audit,

which sets out the focus of our

audit and how we addressed the

risks we have identified”

Sue Barratt, FCA Audit Partner

Delivering informed challenge

Providing intelligent insight

Growing stakeholder confidence

Building trust in the profession


Top



External audit report to the Governing body 1

The Big Picture


Top




The Big Picture We have issued a clean audit report for the year.

Context

This is a report to you summarising the findings of our external audit of the Trust’s 2013/14 financial statements.

We have also reported on the Trust’s Quality Report. Our findings from that work are set out in a separate report to

you.

Approach

We have performed our audit in accordance with Monitor’s Audit Code and International Standards on Auditing

(UK and Ireland). Details of our approach are set out in section 1 of this report. The significant audit risks and key

areas of focus in our work, set out in section 2, were:

Recognition of NHS revenue;

Going concern;

Provisions;

Property valuations and the treatment of capital additions; and

Management override of controls.

Findings

We provided detailed reports, on both our audit of the Trust’s financial statements and our work on the Trust’s

Quality report, to the Trust’s Audit Committee and Board on 28 May 2014.

On 29 May 2014, we signed our audit opinion on the Trust’s financial statements:

We issued a clean (unmodified) opinion on the Trust’s 2013/14 financial statements.

We did not report on any items ‘by exception’ in our audit report.

The full opinion can be found on page 179 of the Annual Report.

Looking forward

The format of our audit opinion is expected to change next year due to changes in Monitor’s requirements. This will

not impact the nature of our work, but will impact the discussion of audit scope, risks and materiality in our opinion.

To provide transparent reporting to the Governors we have included the equivalent information in this report.

Group 2013/14 2012/13

Increase/

(decrease)

% Increase/

(decrease)

Revenue £211m £200m £11m 5.5%

Deficit for the year (£0.5m) (£10m) £9.5m 95%

Land and buildings value £109m £103m £6m 5.8%

Net assets £110m £107m £3m 2.8%


Top




1. Our approach


Top




1. Our approach We have outlined below an overview of our audit approach.

An overview of the scope of the audit

Our audit was scoped by obtaining an understanding of the Trust and the environment it operates in, including

internal control, and assessing the risks of material misstatement to the financial statements.

Audit work to respond to the risks of material misstatement was performed directly by the audit engagement team,

led by the audit partner, Sue Barratt. The audit team included integrated Deloitte specialists bringing specific skills

and experience in property valuations and Information Technology systems.

Data analytic techniques were used as part of audit testing, in particular to support profiling of populations to

identify items of audit interest and in journal testing.

The focus of our audit work is primarily upon the financial statements and of our limited assurance work on the

Quality Accounts (discussed in the accompanying report) upon the specific testing required by Monitor. The

assurance that our work provides to the Council of Governors and Board of Directors, as a body, is not intended to

be the only source of assurance for the Council of Governors.

Materiality

Our work is planned and performed to detect material misstatements. We define materiality as the magnitude of

misstatement in the financial statements that makes it probable that the economic decisions of a reasonably

knowledgeable person would be changed or influenced. We use materiality both in planning the scope of our audit

work and in evaluating the results of our work.

We determined materiality for the Trust to be £2m, This compares to a materiality for 2012/13 of £1.99m, and has

increased due to the growth in the Trust’s activity levels.

We agreed with the Audit Committee that we would report to the Committee all audit differences in excess of £100k

as well as differences below that threshold that, in our view, warranted reporting on qualitative grounds. We also

report to the Audit Committee on disclosure matters that we identified when assessing the overall presentation of

the financial statements.

An overview our assessment of material account balances, classes of transactions and disclosures

We perform an assessment of risk which includes considering the size, composition and qualitative factors relating

to account balances, classes of transactions and disclosures. This enables us to determine the scope of further

audit procedures to address the risk of material misstatement.

We performed procedures to review and understand significant movements in all material balances compared to

the prior year. We reviewed breakdowns of current year balances to assess whether they contained any unusual

items and we considered, based on our prior year audit knowledge, whether there was a history of error in the

accounts balance.


Top




1. Our approach (continued)

Approach to audit risks

We focused our work on areas where we considered there to be a higher risk of misstatement. We refer to these

areas as significant audit risks.

We provided a detailed audit plan to the Trust’s Audit Committee on 4 November 2013 setting out what we

considered to be the significant audit risks for the Trust, together with our planned approach to addressing those

risks. We have provided a summary of each of the significant audit risks in section 2.

We have made recommendations for the improvement of the Trust’s procedures and internal controls from our

work. However, we do not consider these recommendations to reflect any material weakness in the Trust’s control

environment and the Trust has been committed to the implementation of our recommendations.

Value for Money

We are required to satisfy ourselves that the Trust has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

In contrast to the requirements that apply to NHS Trusts, we are not required to issue a conclusion on value for money. Instead, we report in our audit certificate only significant matters that come to our attention from performing the procedures required by the Audit Code.

In discharging this responsibility, the Code requires that we take into account our work on the Annual Governance Statement and the work of regulators, in particular Monitor and the Care Quality Commission.

We are required to consider the completeness of the disclosures in the Annual Governance Statement in meeting the relevant requirements and identify any inconsistencies between the disclosures and the information that we are aware of from our work on the financial statements and other work.

We have obtained an understanding of the Trust’s arrangements for securing “value for money”, through a

combination of:

“high level” interviews with the Chair of the Audit Committee, Director of Finance and Director of

Transformation;

review of the Trust’s draft annual governance statement;

consideration of issues identified through our other audit and assurance work;

consideration of the Trust’s results, including benchmarking of actual performance (including on CIP

delivery as summarised below) and the 2014/15 Annual Plan;

review of Monitor’s continuity of service and governance risk ratings; and

benchmarking of the Trust’s performance

Through our work we have not identified any specific risks in respect of Value for Money and we have not identified

any issues which we need to report in our audit opinion in respect of:

• the Trust’s arrangements for securing the economy, efficiency and effectiveness of the use of resources; or

• the Annual Governance Statement.

Procedures for auditing the Trust’s financial statements

In summary, our audit of the Trust’s financial statements included:

developing an understanding of the Trust, including its systems, processes, risks, challenges and

opportunities and then using this understanding to focus audit procedures on areas where we consider

there to be a higher risk of misstatement in the Trust’s financial statements;

interviewing members of the Trust’s management team and reviewing documentation to test the design

and implementation of the Trust’s internal controls in certain key areas relevant to the financial statements;

and

performing sample tests on balances in the Trust’s financial statements to supporting documentary

evidence, as well as other analytical procedures, to test the validity, accuracy and completeness of those

balances.


Top




1. Our approach (continued)

Value for Money (continued)

What we would highlight, however, is that:

in recent years the Trust has had a high proportion of non-recurrent CIP savings;

a significant proportion of planned savings are likely to be realised towards the end of the financial year;

however

the Trust has made substantial progress in embedding their transformation programme including the

implementation of enhanced governance arrangements.

We did not “report by exception” on any issues in our audit opinion.


Top




2. The focus of our work


Top




2. The focus of our work We have summarised below how we have responded to the

significant audit risks we identified.

Recognition of NHS Revenue

Description of risk:

As set out in our Audit Plan, we identified recognition of NHS revenue and associated provisions as a key risk due to the potentially judgemental nature of provisions for disputes with commissioners and the challenges experienced this year with the new commissioning regime.

Income: The Trust’s income for 2013/14 is primarily from fixed contracts with commissioners; however there is an element from Payment by Results (‘PbR’) contracts. The Trust has other material income streams including private patient income, education and training and non-patient care services to other bodies.

Receivables: The Trust has performed their agreement of balances exercise within the period for all significant NHS debtors. Following the changes in the commissioning structure, the Trust has assessed that there is no additional concern around the recoverability of these debtors.

Our response and conclusion:

We evaluated the design and implementation of controls over recognition of Payment by Results income, with IT specialists performing the testing of the systems controls.

We performed detailed substantive testing of the recoverability of overperformance income and adequacy of provision for underperformance through the year, and evaluated the results of the agreement of balances exercise.

We tested the historical accuracy of provisions made for disputes with commissioners, and used to evaluate year-end provisions. We challenged key judgements around specific areas of dispute and actual or potential challenge from commissioners and the rationale for the accounting treatments adopted. In doing so, we considered the historical accuracy of provisions for disputes and reviewed correspondence with commissioners,

From performing the tests above, we are satisfied that there are no material misstatements in respect to NHS

revenue recognition.


Top




2. The focus of our work (continued) Going concern


In June 2013 Monitor launched a formal investigation into the financial sustainability of the Trust as the Trust raised

concerns over its ability to demonstrate financial sustainability without the proposed merger plan.

With the merger plan blocked, there was subsequently an increased level of risk over the Trust’s ability to

demonstrate that it was financially sustainable, and therefore a going concern.

To present the accounts on a going concern basis, the Trust is required to demonstrate that it continues to maintain

a cash surplus for the 12 month period following the signing of the accounts, i.e. up to and including May 2015.

Our response:

We have discussed the formulation of the projections (within the plan and the operational analytics report) with the

Trust and challenged the robustness of each key judgement by comparing it to substantive evidence, empirical

evidence or benchmark data from the other Trusts that we audit. We did not identify any material bias in these

judgements or any exception where there was no rationale.

We have reviewed the extent to which the risks and uncertainties are presented in the annual report, and cross-

referred in the notes to the financial statements and consider there to be adequate and fair disclosure. In addition

we considered the adequacy of the mitigating actions disclosed against the key risks and uncertainties and

consider them to be appropriate in terms of the timing and extent to which they can mitigate the risk.

We are satisfied that the Trust’s forecasts have been prepared with robust assumptions and that they demonstrate

that the Trust is a going concern, maintaining a cash surplus for 12 months following signing of the accounts and

annual report.

Provisions


At 31 March 2013, the Trust’s financial statements contained provisions amounting to £1.2m, including £0.5m

reflecting the impact of the proposed merger. Under IAS 37 Provisions, contingent liabilities and contingent assets

management are required to reassess the valuation of this provision as at 31 March 2014, and whether there are

any further conditions or events that meet the recognition criteria.

There is inherent judgement involved in assessing the valuation of provisions, particularly where the timing and

nature of events are uncertain.

Our response:

We have scrutinised each provision in turn, being the pension, redundancy and other provisions. We have verified

assumptions used to published statistical data and supporting documentation and have examined the validity of the

provisions against the recognition criteria of IAS 37 Provisions, contingent liabilities and contingent assets.

As the merger did not take place, management have correctly reversed the unused redundancy provision from

2012/13. We consider that, as the detailed plans for the 2013/14 redundancy provision were not available

(sufficient to be able to communicate to employees that they had been identified as potential candidates for

redundancy), the Trust has not established a legal or constructive obligation at the date of the statement of

financial position. We have therefore proposed an adjustment to reverse it.


Top




2. The focus of our work (continued) Property valuation and treatment of capital additions


The Trust is required to hold property assets within Property, Plant and Equipment at a modern equivalent use valuation. The valuations are by nature significant estimates which are based on specialist and management assumptions and which can be subject to material changes in value.

The Trust has had an independent valuation performed for the purposes of the 31 March 2014 financial statements.

Our response:

We evaluated the design and implementation of controls over property valuations, and tested the accuracy and completeness of data provided by the Trust to the valuer.

We used internal valuation specialists to review and challenge the appropriateness of the key assumptions used in the valuation of the Trust’s properties, including through benchmarking against revaluations performed by other Trusts at 31 March 2014.

We assessed whether the valuation and the accounting treatment of the impairment were compliant with the relevant accounting standards.

Management override of controls


As auditors we are required to assume on all audits that there is a risk of misstatement through management

override of control procedures and processes.

We specifically consider:

accounting estimates, including those identified as separate significant risks and discussed above;

journals; and

significant or unusual transactions.

Our response:

Accounting Estimates

A number of key accounting estimates have been identified as significant risks, as discussed above.

We considered the overall prudence of accounting estimates, whether they lay within what we would consider to be

an acceptable range, and considered whether there were any indicators of management bias in the preparation of

the estimates.

Journals

We have tested the design and implementation of key controls over approval of journal entries.

We used data analytic tools to identify journals of potential audit interest for testing.

Our work focussed on the testing of journal entries made throughout the year and checking that entries had been

properly authorised and reviewed and that there was an appropriate rationale for the journals.

Significant or unusual transactions

We reviewed the accounting treatment for transactions surrounding our significant risk areas and scrutinised

transaction listings as part of our detailed audit testing.

We did not identify any significant transactions outside the normal course of business or transactions where the

business rationale was not clear.


Top



External Audit report to the Governing body 10

3. Analysis of audit fees


Top




3. Analysis of audit fees

The professional fees earned by Deloitte in the period from 1 April 2013 to 31 March 2014 were as follows:

Current year

£’000

Prior year

£’000

Work carried out under the Monitor Audit Code

Financial statement audit 43 43

Consolidation of the Trust’s Charitable Fund 3 -

Whole of Government Accounts 3 3

Quality Accounts audit 13 13

Total audit services 62 59

Audit related assurance services

Audit of the Trust’s Charitable Fund 4 4

Total audit and assurance services 66 63

Non-audit services

None - -

Total Fees 66 63


Top




4. Responsibility statement


Top




4. Responsibility statement

What we report

Our report is designed to help the Council of

Governors, Audit Committee, and the Board

discharge their governance duties. Our report

includes:

Details of our audit approach; and

The significant audit risks we have identified and

our responses to those risks.

What we don’t report

As you will be aware, our audit was not designed

to identify all matters that may be relevant to the

Board or Governing body.

Also, there will be further information you need to

discharge your governance responsibilities, such

as matters reported on by management or by

other specialist advisers.

Finally, our views on internal controls and

business risk assessment should not be taken as

comprehensive or as an opinion on effectiveness

since they have been based solely on the audit

procedures performed in the audit of the financial

statements and the other procedures performed

in fulfilling our audit plan.

The scope of our work

Our observations are developed in the context of

our audit of the financial statements.

We welcome the opportunity to discuss our report

with you and receive your feedback.

Deloitte LLP

Chartered Accountants

Reading

17 July 2014

This report is confidential and prepared solely for the purpose set out in our engagement letter and for the Board

of Directors, as a body, and Council of Governors, as a body, and we therefore accept responsibility to you alone

for its contents. We accept no duty, responsibility or liability to any other parties, since this report has not been

prepared, and is not intended, for any other purpose. Except where required by law or regulation, it should not be

made available to any other parties without our prior written consent. You should not, without our prior written

consent, refer to or use our name on this report for any other purpose, disclose them or refer to them in any

prospectus or other document, or make them available or communicate them to any other party.


Top



Deloitte refers to one or more of Deloitte Touche Tohmatsu Limited (“DTTL”), a UK private

company limited by guarantee, and its network of member firms, each of which is a legally

separate and independent entity. Please see www.deloitte.co.uk/about for a detailed

description of the legal structure of DTTL and its member firms.

Deloitte LLP is the United Kingdom member firm of DTTL.

© 2014 Deloitte LLP. All rights reserved.

Deloitte LLP is a limited liability partnership registered in England and Wales with

registered number OC303675 and its registered office at 2 New Street Square, London

EC4A 3BZ, United Kingdom. Tel: +44 (0) 20 7936 3000 Fax: +44 (0) 20 7583 1198.

Member of Deloitte Touche Tohmatsu Limited


Top





Agenda Item: 11 Paper No: H

Title:

2013/14 Annual Council of Governors Assessment of Collective Performance

Purpose:

To present the Council with its 2013/14 collective performance assessment report.

Summary:

Each year an assessment of the collective performance of the Council of Governors is to be produced as set out in Monitor’s Code of Governance.

Recommendation:

The Council is asked to note the report.

Prepared by:


Presented by:

ANGELA SCHOFIELD Chairman

CoG�July�14�H1�2013-14�Annual�

Top



H


ASSESSMENT OF COLLECTIVE PERFORMANCE

APRIL 2013 - MARCH 2014

June 2014 (for July CoG)


Top



2

TABLE OF CONTENTS

Page

Chairman’s Introduction…………………………………………….....……… 3

1. Purpose of Report………………………………………………………………. 4

2. Overview of the Council…………………………………………………...…… 4

3. Council Membership and Attendance Record…………………………….… 5

4. Elections ................................................................................................... 7

5. Compliance with the Constitution…………………………………………..… 7

6. Council Meetings………………………………………………………………... 7

7. Roles and Responsibilities of Council………………………………………… 12 8. Expenses Paid to Governors....................................................................... 14

9. Membership……………………………………………………………………… 15

10. Communication with Members………………………………………………… 16 11. Communication with Directors ................................................................... 16 12. Development of Governors…………………………………………………….. 17 13. Conclusion……………………………………………………………………….. 17


Top



3

CHAIRMAN’S INTRODUCTION

This review provides the opportunity for me to thank wholeheartedly the Governors of Poole Hospital NHS Foundation Trust for their commitment to the work of the hospital and their role as governors. They give their time freely and generously to ensure that the Trust fulfils its responsibilities towards our patients. Good relationships between Governors and the Board of Directors are crucial to the effective governance of a foundation trust. The Governors of Poole Hospital NHS Foundation Trust collectively as a Council are probing, enquiring and caring for both patients and staff. We could not have better ambassadors for the hospital or greater enthusiasts for the recruitment of members. They are an essential link with public members, staff and our partner organisations and are a cornerstone of our public accountability.


Top



4

1. PURPOSE OF REPORT

1.1 This report sets out the assessment of the collective performance of the Council of Governors and areas for future development.

1.2 As part of Monitor’s Code of Governance, the Council of Governors led by the

Chairman should periodically assess their collective performance:

“Led by the chairperson, the council of governors should periodically assess their

collective performance and they should regularly communicate to members and the

public details on how they have discharged their responsibilities, including their

impact and effectiveness on:

Holding the non-executive directors individually and collectively to

account for the performance of the board of directors.

Communicating with their member constituencies and the public and

transmitting their views to the board of directors; and

Contributing to the development of forward plans of NHS foundation

trusts.

The council of governors should use this process to review its roles, structure, composition and procedures, taking into account emerging best practice.” (Monitor’s Code of Governance Paragraph B.6.5)

1.3 It was agreed by the Council of Governors that the annual review would be presented in the form of a report which would consider the Council’s terms of reference, registers and constitutional requirements for change or development.

2. OVERVIEW OF THE COUNCIL

2.1 The purpose of the Council:

the Council is responsible for representing the interests of NHS Foundation Trust members and partner organisations in the local health economy in the governance of the NHS Foundation Trust;

the Council should hold the Board of Directors to account for the performance of the Trust including ensuring the Board of Directors acts so that the Foundation Trust does not breach its Terms of Authorisation;

Governors are responsible for regularly feeding back information about the Trust, its vision and its performance to the constituencies and the stakeholder organisations that either elected or appointed them.

2.2 The governance cycle of the Council has developed over the review period. A revised governance cycle for 2013/14 was approved by the Council in January 2014. The Council had the opportunity to make any changes they felt would enhance their working practice.


Top



5

3. COUNCIL MEMBERSHIP AND ATTENDANCE RECORD

Name

Constituency Type of M’ship App’t Date

Appt Expires

25 A

pril 1

3

25 J

uly

13

26 S

ept. 1

3

*19

No

v. 1

3

*18

De

c. 1

3

16 J

an. 1

4

Cllr John Adams Bournemouth Borough Council

Appt’d 3 years 26.11.12 09.01.14 x x x

Air Vice Marshal Geoffrey Carleton4

Purbeck, East Dorset & Christchurch

Elected 3 years 01.05. 09 01.11.12

30.04.12 31.10.15

x

Ms Lynn Cherrett Clinical staff Elected 3 years 01.11.07 31.10.16

Ms Colette Cherry Bournemouth University

Appt’d 3 years 11.07.13 10.07.16 x

Mr Andrew Creamer Poole Elected 3 years 01.11.07 31.10.15 x

Mrs Vivien Duckenfield 2 Poole Elected 3 years 01.11.07 31.10.16 x

Mr Barry Faith Poole Elected 3 years 01.11.12 19.11.13 x

Mrs Rosemary Gould

Purbeck, East Dorset & Christchurch

Elected 3 years 01.11.07 31.10.16 x x

Mr Geof Hermsen Poole Elected 3 years 01.11.12 22.10.13

Mrs Barbara Hooper Purbeck, East Dorset & Christchurch

Elected 3 years 01.05.12 30.04.15

Mr David Jones

Dorset County Council

Appt’d 3 years 01.07.10 09.07.13

19.04.13 08.07.16

x x

Mr Richard King Poole Elected 3 years 01.11.10 31.10.13 x x

Miss Kris Knudsen Clinical staff Elected 3 years 01.11.09 31.10.15 x

Canon Jane Lloyd1

Non-clinical staff

Elected 3 years 01.11.07 31.10.13

Mrs Sylvia Lowrey Clinical staff Elected 3 years 01.11.12 31.10.15 x x


Top



6

Name

Constituency Type of M’ship App’t Date

Appt Expires

25 A

pril 1

3

25 J

uly

13

26 S

ept. 1

3

*19

No

v. 1

3

*18

De

c. 1

3

16 J

an. 1

4

Dr Chris McCall Dorset Clinical Commissioning Group

Appt’d 3 years 01.04.13 31.03.16 x x

Mrs Isabel McLellan N Dorset, W Dorset, Weymouth & Portland

Elected 3 years 01.05.09 30.04.15 x x

Mr Brian Newman Bournemouth Elected 3 years 01.11.09 31.10.15 x

Mrs Linda Nother Poole Elected 3 years 01.11.13 31.10.16 x

Mr James Pride3 Poole Elected 3 years 01.11.07 31.10.16 x

Mrs Elizabeth Purcell Poole Elected 3 years 01.11.07 31.10.16 x

Mr Terence Purnell Bournemouth Elected 3 years 01.11.07 31.10.16

Mrs Ann Stribley Poole Borough Council

Appt’d 3 years

27.06.11 26.06.14

x

Mr Graham Whitaker

Non-Clinical Staff

Elected 3 years 01.11.13 01.11.16

Mrs Sandra Yeoman Poole Elected 3 years 01.11.09 31.10.15

No. public governors attending

14 13 9 9 12 8

No. appointed governors attending

2 5 4 2 2 3

No. staff governors attending

4 2 4 4 4 3

1 Lead Governor to 30.10.13 2 Lead Governor from 19.01.14

3 Deputy Chairman to 18.01.14

4 Deputy Chairman from 19.01.14


Top



7

4. ELECTIONS 4.1 During the period of the report elections were held in October 2013.

Constituency No of Candidates

No of Seats

Turnout %

Purbeck, East Dorset & Christchurch 2 1 27.4

Bournemouth 1 1 n/a

Poole 5 4 28.8

Staff: Clinical 2 1 19.7

Staff: Non Clinical 2 1 30.06

4.2 The elections resulted in six re-elected Governors and two new Governors. 5. COMPLIANCE WITH THE CONSTITUTION 5.1 The following elements of the Constitution relating to the Council have been reviewed

and compliance confirmed:

Constituencies - Confirmed per Constitution Composition - Confirmed per Constitution Elections - Confirmed per Constitution Tenure - Confirmed per Constitution (set out in section 4) Disqualification - Confirmed per Constitution Meetings - Confirmed per Constitution Standing Orders - Confirmed per Constitution Travel expenses Confirmed per Constitution (written policy and set out in Section 8)

6. COUNCIL MEETINGS 6.1 In the period of this assessment the Council met on six occasions. There is a

standing agenda item for items on notice and urgent motions or questions.

25 April 2013 – The key agenda items were:

Approve:

amendments to the Constitution;

Nomination of Appointed Governor to NREC;

the governance cycle for the committee;

Receive:

the Annual Report/Statement on the work of the Nominations, Remuneration and Evaluations Committee;

the register of interests of the Council;

an update on the 2013/14 Annual Plan;

an update on actions following the publication of the Francis Report;

an overview of the Trust’s performance;

the Director, Governor Interaction Best Practice Guide and the 2013/14 Governor development programme;


Top



8

an oral summary report from the reference groups.

25 July 2013 – The key agenda items were:

Approve:

the Chairman’s and Non-Executive Directors’ remuneration and allowances.

Receive:

the 2012/13 Annual Report of the Audit and Governance Committee;

the results of the Chairman’s and Non-Executive Directors’ annual performance evaluation;


an oral update on preparations for a Governor Development/Training Event Autumn 2013;

an update on actions following the publication of the Francis Report;

the 2013/14 Annual Plan;

an update on merger discussions and a report on the current position;

an oral update on the reference groups.

26 September 2013 – The key agenda items were:

Approve:

the re-appointment of Non-Executive Directors;

the proposed 2014 meeting dates.

Receive:


the Trust’s Annual Report, Accounts and Auditor’s opinion;

the annual complaints report;

an update on the proposed the merger;

an invitation to discuss the 2013/14 content of the Quality Accounts;

Monitor’s Risk Assessment Framework (FTN Briefing);

The Trust’s Strategic Risk Report;


an oral update on the reference groups.

19 November 2013 (extraordinary meeting) – the key agenda items were:

Consider:

The conduct of a Governor.


Top



9

Resolve:

Whether to uphold the alleged non-compliance with the Code of Conduct or the Constitution;

and, if upheld by the Council of Governors, what sanctions would be appropriate to impose.

18 December 2013 (extraordinary meeting) – The key agenda items were:

Approve

The appointment of the new Chief Executive.

Receive:

A report on the Chief Executive Recruitment Process.

16 January 2014 – The key agenda items were:

Approve:

The Council of Governors 2014/15 Governance Cycle;

The Chairman’s and Non-Executive Directors Appraisal Process for 2013/14 and onwards;

Transitional Arrangements for the tenure of NREC membership;

Revised Terms of Reference for NREC;

Council of Governors development plan.

the re-appointment of Non-Executive Directors

Receive:

The revised membership strategy;

An oral update on the 2014-16 Forward Plan;


an update on the Trust Position in response to the Francis Report;


The outcome of the Deputy Chairman and Lead Governor ballots;

a presentation on the Dorset Clinical Commission Group’s future plans and priorities;

An oral update on the reference groups.

Governor Development Session

6.3 The development plan for the year was updated following a Council of Governors’ event in December 2013 which was professionally facilitated by an external source.

6.4 The programme is split into the following headings:

developing membership engagement and growth;


Top



10

developing the engagement with directors;

developing the informal reference group;

developing the role of the governor;

developing resources.

6.5 The Council of Governors have been involved in a significant number of briefings and events.

6.6 A joint development session between the Board of Directors and Council of

Governors took place in December 2013. This was facilitated workshop to review the roles and requirements of the Council of Governors and the Board of Directors in light of recent legislative changes and Francis and other key reports.

Nominations, Remuneration and Evaluations Committee 6.7 The Council has one formal sub-committee – the Nominations, Remuneration and

Evaluations Committee (NREC). The Committee has agreed Terms of Reference and has met on four occasions:

Name

Constituency Type of Membership

Meetings

25 A

pri

l 2

01

3

25 J

uly

201

3

26

Se

pte

mb

er

201

3

14 J

an

ua

ry 2

014

Mrs Angela Schofield Chairman

Mr Guy Spencer SID

1

Ms Kris Knudsen Clinical staff Elected 3 years

x

Mr Jamie Pride Poole Elected 3 years

x

Mrs Elizabeth Purcell Poole Elected 3 years

x

Mrs Anne Stribley

Poole Borough Council

Appointed 2 years

x

1 Mr Spencer attended the meeting to lead on the annual appraisal of the Chairman.

6.8 Business for the committee during 2013/14:

On 25 April 2013 the Committee considered:

The future re-appointment or appointment of Non-Executive Directors;

The collective performance of the Council of Governors

The annual report on the work of the committee;


Top



11

The attendance of a Governor.

On 25 July 2013 the Committee considered:

The Chairman’s and Non-Executive Directors’ remuneration and allowances

The outcome of the Chairman’s and Non-Executives performance appraisals for 2012/13.

On 26 September 2013 the Committee considered:

Future re-appointment or appointment of Non-Executive Directors.

On 14 January 2014 the Committee considered:

Absent Governors

The future re-appointment or appointment of Chairman & Non-Executive Directors.

The evaluation of the Chairman/Non-Executive Appraisal Processes For 2013/14

The Terms of Reference of NREC

NREC Transitional Arrangements for Tenure of Membership

NREC Governance Cycle

Reference Groups of the Council of Governors

6.9 The Council had three ‘informal’ Committees called Reference Groups during the period of this assessment with a fourth, focussed on development and training, being instigated from January 2014. Governors are nominated onto a Group. Members can be on more than one group.

The groups were:

Membership Engagement and Recruitment;

Future Plans and Priorities;

Development and Training;

Quality Report (ad hoc).

Reports of these groups are delivered by the chairmen of the reference groups to the Council of Governors.

Annual Members’ Meeting

6.10 The Trust held its Annual Members’ Meeting on 30 September 2014. Members were invited via the membership newsletter, Foundation Talkback and letters to individuals who expressed an interest in attending previously. The event was publicised in the local press, on our website and throughout the Hospital. The event was very well attended and Dr Simon Crowther, Consultant Respiratory Physician, provided a presentation on respiratory services at Poole Hospital, a governor presented on the


Top



12

Council and Membership section of the meeting and Directors provided the other required presentations for the lunch time event.

7. ROLES AND RESPONSIBILITIES OF COUNCIL 7.1 The role and responsibilities of Governors are set out in the Trust’s Constitution This

section describes these roles and responsibilities and how they are delivered.

The roles and responsibilities of Governors are:

i) To appointment and remove Chairman and Non-Executive Directors:

- The Nominations, Remuneration and Evaluation Committee has and will continue to make nominations to the Council of Governors for the appointment of Chairman and Non-Executive Directors.

ii) To approve the appointment of the Chief Executive:

- The Council has and will continue to approve the appointment of any

new Chief Executive at a general meeting.

iii) To appoint/remove the Auditors:

- Following the work of a specially convened group the Council approved the appointment of Deloittes as the Auditors for a three year period in 2012.

iv) To receive the Annual Report and Accounts:

- The Council receives the Annual Report and Accounts at a general

meeting usually ahead of the Annual Members Meeting. Governors are sent the link to the Annual Report and Accounts when they have been laid before parliament.

v) To oversee and advise the Board of Directors regarding future Trust

plans and priorities:

- The Council of Governors is briefed on the future plans and priorities of the Trust, their advice is sought and they are asked for contribution through Council meetings, the Future Plans and Priorities Reference Group and planning workshops which for the past year focussed on merger.

- The governors are engaged in the strategic issue of merger with the establishment of joint workshops, a Joint Governor Reference Group, and formal and informal briefings.

vi) To respond as appropriate when consulted by the Board of Directors in

accordance with the Trust’s Constitution:

- Since authorisation there have been no significant issues requiring the Board to formally consult with the Council. Governors have been kept fully informed on the progress of the potential merger.


Top



13

vii) To agree and from time to time review the Trust’s membership strategy,

its policy for the composition of the Council of Governors and the Non-Executive Directors:

- Since authorisation the Council has undertaken a review of the Trust

membership strategy and public Governors have been informed on progress through the membership engagement and recruitment reference group. The Composition of the Council will be subject to review alongside the constitution and the composition of non-executive directors has been looked at when reappointing or replacing non executive directors.

viii) To be involved in review of a specific issue, or be involved in further

development of a particular strategy as the Board of Directors may from time to time request:

- The Council have been involved in; Strategic Planning workshops and

joint meetings with Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust in regards to potential merger.

ix) To hold the Non-Executive Directors individually and collectively to

account for the performance of the Board of Directors, and to represent the interests of the Members as a whole and the interests of the public, and monitor the performance of the Trust against the strategic direction and the targets with a view to satisfying itself that the Board of Directors is fulfilling its responsibilities in this regard. This will be achieved by regularly briefings on the performance of the Trust and at its meetings, being able to consider and comment on that performance;

- The Council receive a performance report as a standing agenda item at its meetings. The Council are invited to consider, discuss and comment on the Trust’s performance.

- The Council attend briefings with the Chairman and Chief Executive to

discuss Part 2 agenda matters from the Board of Director meetings.

- Two nominated governors receive the full monthly finance performance report for scrutiny on behalf of the Council of Governors from the Director of Finance.

- The Lead Governor and Deputy Chairman of the Council of Governors

meet with the Chairman on a regular basis.

- Nominated governors meet with the Director of Nursing and Patient Services regarding the construction of the Annual Quality Report and attend walkabout sessions.

- The Council of Governors receives assurance or is advised of any

breaches in its licence conditions as part of the Trust’s performance report which is a standing agenda item at each meeting of the Council.

- The Council receive a copy of the quarterly monitoring submissions

sent to Monitor and the related feedback response from Monitor


Top



14

x) To positively contribute to the continued success of the organisation

through overseeing of effective management, partnership working and maintenance of NHS values and principles:

- Through the formal governance structure and other working groups

and events the Council evidence a sustained contribution to the work and management of the Trust. The Council have agreed and signed up to a set of values and principles by which they abide.

xi) To require one or more Directors to attend a meeting of the Council of

Governors for the purpose of obtaining information about the Trust's performance of its functions or the Directors' performance of their duties (and deciding whether to propose a vote on the Trust's or Directors' performance) (Constitution Clause 12A); - Council are aware of this power and have not had cause to revert to it.

It should be noted that by invitation directors regularly attend meetings of the Council of Governors

xii) To approve any merger, acquisition, separation or dissolution

application in respect of the Trust before the application is made to Monitor and the entering into of any significant transactions;

- Council are aware of this power. It should be noted that

governors were fully involved in the proposed merger with RB&CNHSFT and had been prepared for a vote the need for which was negated by the prohibition of the merger.

xiii) To determine its satisfaction on other activities within forward plans and

approve proposals to increase income from other activities

- Each forward plan must include information about the activities other than the provision of goods and services for the purposes of the health service in England that the Trust proposes to carry on; the Council of Governors must determine and notify the Directors of the Trust of its determination, whether it is satisfied that the carrying on of the activity will not to any significant extent interfere with the fulfilment by the Trust of its principal purpose or the performance of its other functions. These elements of the forward plan will be presented to the governors for determination

- The Trust may only implement any proposal to increase by 5% or

more the proportion of its total income in any Financial Year attributable to activities other than the provision of goods and services for the purposes of the health service in England if more than half of the members of the Council of Governors voting approve its implementation. Any such increases will be presented to governors for approval


Top



15

8. EXPENSES PAID TO GOVERNORS

8.1 During the period of 2013/14 8 governors claimed expenses for mileage and related car parking charges to attend meetings or training events both locally and nationally*:

Name Total

Geoffrey Carleton £248.60

Vivien Duckenfield £99.00

Barry Faith £39.70

Geof Hermsen £222.82

Barbara Hooper £182.15

Isabel McLellan £238.50

Brian Newman £105.30

Terence Purnell £178.25

* Wherever possible Governors will car share when attending events in the

region.

9. MEMBERSHIP 9.1 For Members the Foundation Trust has four public constituencies and one staff

constituency. The four public constituencies are based on geographical areas that reflect the general, emergency and specialist service catchment areas, local government boundaries and population numbers. They are:

Poole;

Purbeck, East Dorset and Christchurch;

Bournemouth;

North Dorset, West Dorset, Weymouth and Portland. The staff constituency is divided into two classes:

clinical;

non-clinical.

9.2 The Trust has concentrated on the following activity in accordance with the Membership Development Strategy:

Increasing governor participation in the recruitment and engagement of members;

Organising membership events to increase opportunities for membership engagement and participation;

Working to increase overall public membership number in line with agreed annual targets.


Top



16

9.3 It was agreed membership for the period of this report was to have a total membership of 5,900 as of March 2014.

9.4 Monitor expects to see steady growth in membership but has accepted that the

revised target is a matter for local decision. Membership is broadly representative of the local population and appropriate efforts are being made to recruit from underrepresented groups.

9.5 At 31 March 2014 the Trust had 5,647 public members. Staff and volunteer members

total 3,858. All staff and hospital volunteers are members of the Foundation Trust automatically, unless they choose to opt out.

9.6 The Membership Engagement and Recruitment Reference Group of the Council of

Governors had four meetings during 2013/14. The group is chaired by a governor and is supported by the Membership team. During the year the group reviewed the progress on the Membership Development Strategy and related actions of the Governor Development Plan. The group receive a quarterly membership report, influence the content of the Annual Members’ Meeting and agree future recruitment and engagement events.

9.7 Recruitment and engagement events have been held during the year within the

hospital (dining room, discharge lounge, main reception). Talks have been provided to local groups and the group are working to engage young people.

10. COMMUNICATION WITH MEMBERS 10.1 All members receive the newsletter – Foundation Talkback which includes a column

from a Governor detailing the work of the Council. Staff members also have access to a copy of Foundation Talkback through the website.

10.2 Communication between members and the Council are facilitated by the Membership

Manager. 10.3 The staff governors continue to hold staff surgeries where staff members can

approach them to express views on services and developments within the Hospital. The Staff governors also reviewed and updated their intranet page and leaflet in line with the election results leading to a new appointment.

10.4 Other communications for members include:

being invited to the Annual Members Meeting;

being able to vote in elections;

being given the opportunity (if eligible) to stand for Council;

being able to talk to a governor within their constituency.

11. COMMUNICATION WITH DIRECTORS 11.1 The relationship and communication between the Board and the Council is

important. The Board have extended an invitation to the Council whereby the Council can submit questions to the formal meeting of the Board; the Board has also reserved time at the end of the formal meeting to meet with Governors.


Top



17

11.2 The Council have also been provided with a Part Two Board briefing meeting where the reports and decisions made at the part two board meeting can be given where appropriate.

11.3 The Council are also provided with the weekly staff bulletin, copies of press releases

and a weekly Governor email that is sent on the Chairman’s behalf. 11.4 The elected staff representatives have regular meetings outside the formal Council

meetings with the Chairman and Chief Executive in order to discuss specific issues relating to staff Governors.

11.5 The Chairman meets regularly with the Lead Governor and Deputy Chairman of the

Council of Governors in order for specific issues to be raised. 11.6 The full financial performance report is provided to governors with a particular

interest and meetings to discuss this report are also offered to those Governors. 11.7 A governor sits on the Research and Innovation Committee of the Trust. 11.8 Governors are provided time for informal discussion at the monthly briefing sessions

and prior to the full Council meetings with executive and non-executive presence if required.

12. TRAINING & DEVELOPMENT OF GOVERNORS 12.1 The chairman takes steps to ensure that governors have the skills and knowledge

they require to undertake their role. This includes access to a comprehensive

induction process and development training events.

12.2 All governors are provided with an induction and receive appropriate updates on the

publications; “Your Statutory Duties: A Reference Guide for NHS Foundation Trust

Governors” and the “Guide to Monitor for NHS Foundation Trust Governors”. These

documents are also supported by a trust governor reference manual.

12.3 The Council have sent representatives to the South West Governors Exchange Network enabling Governors from each Foundation Trust to meet up to three times a year to discuss matters of mutual interest and meet colleagues.

12.4 The Council approved a Governor Development Plan in January 2014 which has

assisted them in broadening their knowledge and skills. 12.5 The Trust has continued to support Governors in obtaining an understanding of the

impact of the new Health Bill by providing briefings and reports on the changes. 12.6 The trust has continued to support governors in obtaining an understanding of the

impact of the new Health Bill by providing briefings and reports on the changes.The

council of governors held a development event in December 2013 which was

facilitated by professional external support. This event was immediately followed by a

development session with the board of directors and council of governors. Again, this

event was externally facilitated and took the form of a workshop to review the roles


Top



18

and requirements of the council of governors and the board of directors in light of

recent legislative changes and Francis and other key reports.

12.7 Subsequently in January 2014 the council of governors approved a revised

development plan to reflect the learning from these development events.

The governors’ development plan covers:

developing membership engagement and growth

developing the engagement with directors

developing the informal reference group

developing the role of the governor

developing resources.

12.8 The Council will continue to develop further the membership and its engagement

with members through the overarching membership strategy and the Membership Engagement Reference Group.

13. CONCLUSION 13.1 The Council has again had a busy past 12 months. It has delivered in a whole range

of areas as required by the Constitution and Monitor’s Code of Governance. 13.2 The Council should reflect on its achievements as set out in this review and be

prepared to continue to develop to meet the future challenges. June 2014; Produced by Jill Retigan, Board & Council Administrator, on behalf of the Chairman and Council of Governors


Top





Agenda Item: 14 Paper No: J

Title:

2014 and 2015 Governors Meeting Schedules

Purpose:

Receive Governors Meeting Schedule for Calendar years 2014 and 2015

Summary:

To receive the updates the Governors meeting schedule as attached Please note the October 2015 Council of Governors meeting date which is earlier in the month that usual. Please note these meetings in your diaries

Recommendation:

Council receive the updates to its 2014 and 2015 meeting schedule

Prepared by:


Presented by:

ANGELA SCOFIELD Chairman

CoG�July�14�J1�Updates�to�Gove

Top





Agenda Item: 13 Paper No: I

Title:

Annual Audit and Governance Report 2013/14

Purpose:

To present the 2013/14 Annual Report of the Audit & Governance Committee

Summary:

The Audit and Governance Committee produce an annual report on the committee’s work including attendance and areas of discussion and scrutiny. This document is held on the Trust website for public to access and a précis is included in the Trust’s Annual Report.

Recommendation:

For discussion and noting

Prepared by:

JILL RETIGAN Board Administrator JEAN LANG Chairman, Audit & Governance Committee

Presented by:

JEAN LANG Chairman, Audit & Governance Committee

CoG�July�14�I1�Annual�Audit�an

Top



I

1

POOLE HOSPITAL NHS FOUNDATION TRUST

AUDIT AND GOVERNANCE COMMITTEE

ANNUAL REPORT 2013/14

1 PURPOSE OF THE REPORT 1.1 The Audit and Governance Committee (the “Committee”) has prepared this report for

the Board of Directors. It sets out how the Committee satisfied its terms of reference during 2013/14 and seeks to provide the Board with evidence relevant to its responsibilities for the Annual Governance Statement (previously known as the Statement on Internal Control).

1.2 The Audit and Governance Committee terms of reference, which cover the main

aspects of the Department of Health’s Audit Committee Handbook, are attached as Appendix 1.

2 OVERVIEW 2.1 The existence of an independent audit committee is the central means by which a

Board ensures effective control arrangements are in place. In addition the Audit and Governance Committee provides an independent check upon the executive arm of the Board of Directors together with the Quality, Safety and Performance Committee, Finance and Investment Committee and the Workforce Committee.

2.2 The Committee independently reviews, monitors and reports to the Board of

Directors on the attainment of effective control systems and financial reporting processes. In particular, the Committee's work focuses on the framework of risk, control, and related assurances that underpin the delivery of the Trust's objectives.

2.3 The Committee receives and considers reports from both internal and external

auditors, counter fraud and scrutinises the Trust’s annual accounts, financial statements and the annual report.

2.4 A governance cycle detailing which papers are to be expected at each Audit and

Governance Committee is reviewed annually but is updated as necessary throughout the year. The Committee’s governance cycle was reviewed in March 2014 and is attached as Appendix 2.

2.5 The Committee regularly conducts a self-assessment of their work, this was deferred

during 2013/14 due to the merger work but arrangements are in hand to ensure that a review is carried out in 2014/15.

3 MEMBERSHIP 3.1 The Committee membership in respect of financial year 2013/14 comprised of:

Mrs Jean Lang, Non-Executive Director and Committee Chairman

Mr Ian Marshall, Non-Executive Director

Dame Yvonne Moores, Non-Executive Director

Mr Guy Spencer, Non-Executive Director.

CoG�July�14�I2�AG�Annual�Repor

Top



I

2

4 COMPLIANCE WITH TERMS OF REFERENCE 4.1 A review of the Committee’s compliance with its own terms of reference and minutes

was undertaken and reported to the Committee in March 2014. The Committee was assessed as being fully compliant.

4.2 The Committee is composed of four Trust non-executive directors. The Trust

Chairman attends meetings at the invitation of the Audit and Governance Committee Chairman.

4.3 All meetings in 2013/14 were quorate.

4.4 There is time set aside prior to each meeting should the auditors wish to discuss any

matters with the Chairman of the Committee and one formal meeting is scheduled in each calendar year with the auditors. Non-executive directors of the Trust proposed items for internal audit to cover in its 2014/15 plan.

5 MEETINGS 5.1 Six formal meetings were held during the year:

Wednesday 15 May 2013

Wednesday 29 May 2013

Wednesday 18 September 2013

Wednesday 13 November 2013

Wednesday 8 January 2014

Wednesday 12 March 2014 One electronic meeting was held during the year:

During the 5 and 6 November 2014 5.2 Meeting attendance is detailed in Appendix 3. 6 AUDIT AND COUNTER FRAUD PROVISION Internal Audit 6.1 Internal audit is provided by TIAA Ltd. South Coast Audit (SCA) transferred to TIAA

Ltd. effective from the 31 December 2013. Internal Audit was represented at all the Committee meetings in 2013/14.

External Audit 6.2 The Trust’s external auditors were Deloitte LLP. 6.3 The Council of Governors approved the appointment for a period of three years

commencing October 2012. Deloitte LLP was represented at all the Committee meetings for 2013/14.


Top



I

3

Counter Fraud 6.4 Counter fraud services are provided by the Local Counter Fraud Service which has

operational responsibility for ensuring all instances of suspected fraud and corruption within the NHS are properly investigated. There are a number of local counter fraud specialists covering all the NHS organisations in Dorset and Somerset, one of whom reports to the majority of the Committee meetings.

7 DUTIES AND FINDINGS 7.1 The Committee’s terms of reference requires the Committee to review the

establishment and maintenance of effective systems of: Integrated Governance 7.2 The Committee received and scrutinised the minutes of the Hospital Executive

Group and Risk Management and Safety Group for assurance on the Trust’s systems of internal control for the mitigation of risk.

7.3 The Trust’s non-executive directors have a standing invitation to attend the Trust’s

executive committees.

7.4 The Committee received for scrutiny a quarterly senior information risk officer (SIRO) report for information governance across the Trust.

7.5 The Committee received working documents of the Board Assessment of the Terms of Licence and compliance with Monitor’s Code of Governance.

7.6 The Committee reviewed the revisions made to the 3 year Review of Scheme of Delegation. Risk Management

7.7 The Committee received a report at every meeting on new red and amber risks added to the Trust’s Risk Register since the previous meeting. The Committee also received an annual report on the Trust’s risk register.

7.8 The Local Counter Fraud Specialist (LCFS) formally reported to all the Committee meetings held in May 2013, November 2013, January 2014 and March 2014 with the Counter Fraud Annual Report for 2012/13 being presented at the May 2013 meeting. The Committee is satisfied that adequate arrangements are in place to counter fraud.

7.9 The Counter Fraud Workplan for 2014/15 was discussed and approved by the Audit and Governance Committee in March 2014. Internal Control

7.10 The Committee scrutinised the Trust’s draft Annual Governance Statement and agreed that the draft report subject to amendments could be presented to the Board of Directors in May 2014 as part of the Annual Plan.

7.11 The Committee reviewed the register of authorisations of tenders in excess of £50k at each meeting.


Top



I

4

7.12 The Committee reviewed the losses incurred and special payments made by the Trust at each meeting.

7.13 The Committee reviewed the Annual Data Assurance and Framework report.

7.14 During 2013/14 the Committee paid particular attention to the following areas:

i) Business Continuity Plans; ii) The Whistle Blowing Policy; iii) Controlled drugs and drug fridge management iv) Standards of Business Conduct v) Non-clinical policies and procedures vi) Income from research; vii) Emergency Preparedness.

Internal Audit 7.15 The Internal Audit workplan for 2013/14 was approved at the March 2013 meeting.

7.16 At each meeting the Committee received details of recent internal audit work together

with a schedule of management’s progress in implementing agreed actions. A schedule of all of the internal audits undertaken in 2013/14 is attached as Appendix 4.

7.17 The Committee received the Internal Audit annual report for 2012/13 in May 2013.

7.18 The Committee has overseen and supported the work of Internal Audit through:

agreeing the Audit Plan including the prioritisation of work;

considering the results of internal audit reviews;

suggesting areas which Internal Audit might review;

reviewing and agreeing the Head of Internal Audit Opinion. 7.19 The Committee is satisfied that the delivery of the Internal Audit plan for 2013/14 has

given it assurance that controls are effective and action plans are developed for improvement.

Board Assurance

7.20 In May 2013, the Committee received the Head of Internal Audit opinion on the

effectiveness of the system of internal control at Poole Hospital NHS Foundation Trust for the period 1 April 2012 to 31 March 2013. This opinion was based on the Trust’s Assurance Framework and Internal Audit’s own work. Significant assurance was given to the Trust in respect of its system of internal control.

Production of the Annual Report and Accounts 7.21 In May 2013, the Committee received the draft Annual Report (including the Quality

Report). The document was scrutinised and minor amendments agreed prior to being submitted to the Board of Directors for approval.

7.22 The Committee reviewed the Board Statements/Certifications and Going Concern

statements.


Top



I

5

8 CONCLUSION 8.1 The Committee has complied with its terms of reference during 2013/14 during

which time it has:

i) reviewed reports prepared by Internal and External Auditors together with the ensuing management actions, where appropriate;

ii) reviewed reports prepared by the Counter Fraud Service together with the ensuring management actions, where appropriate;

iii) reviewed the risk register and received regular updates; iv) reviewed the reports of the Trust’s Committees and asked for specific

reassurance on points arising. JEAN LANG Chairman of Audit and Governance Committee April 2014


Top



I

6

Appendix 1

TERMS OF REFERENCE for the


Audit & Governance Committee


Top



I

7

Author: Michael Beswick

Job Title: Company Secretary

Signed:

Date: January 2011

Version No: (Author Allocated)

3.1

Next Review Date: January 2016

Approving Body/Committee: Board of Directors

Chair: Jean Lang

Signed:

Date Approved: January 2011

Target Audience: Non-Executive Directors and Executive Directors

Document History

Date of Issue

Version No:

Next Review

Date:

Date

Approved:

Director responsible for Change

Nature of Change

November 2007

1 November 2008

December 2008

2 December 2013

17 December 2008

Chairman of A&G

Changed review date to every 5 years

December 2010

3 December 2013

1 December

A formal minute of the meeting will be recorded 2010

Company Secretary

In line with Board development programme

January 2011

3.1 January 2016

Jan 2011

A formal minute of the meeting will be recorded 2010

Chairman of A&G

Change in membership and no. meetings pre year

DOCUMENT DETAILS


Top



I

8

1. CONSTITUTION .................................................................................................. 5

2. MEMBERSHIP ..................................................................................................... 5

3. FREQUENCY OF MEETINGS.............................................................................. 5

4. QUORUM ............................................................................................................. 6

5. ACCOUNTABILITY .............................................................................................. 6

6. AUTHORITY ........................................................................................................ 6

7. RESPONSIBLITIES ............................................................................................. 6

8. RELATIONSHIP WITH OTHER COMMITTEES ................................................... 6

9. REPORTING MECHANISMS ............................................................................... 6

10. PROCESS ............................................................................................................ 7

11. COMMUNICATIONS ............................................................................................ 8

12. MONITORING ...................................................................................................... 8

13. REVIEW ............................................................................................................... 8

INDIVIDUAL APPROVAL

Job Title Date

Print Name Signature

COMMITTEE APPROVAL

If the committee is happy to approve this document, please sign and date it and forward copies for inclusion on the Intranet.

Name of Committee

Board of Directors Date 1 December 2010

Print Name Chairman Signature of Chair

TABLE OF CONTENTS


Top



I

9


AUDIT & GOVERNANCE COMMITTEE

TERMS OF REFERENCE 1. CONSTITUTION 1.1 The Audit and Governance Committee is a Non-Executive Committee of the

Board of Directors. 1.2 The Audit and Governance Committee is responsible for reviewing the

establishment and maintenance of effective systems of:

Integrated Governance;

Risk Management;

Internal Control;

Internal Audit;

Board Assurance;

Production of the Annual Report across the whole of the organisation’s activities (clinical and non-clinical).

1.3 The Committee will seek the views of the Trust’s External Auditor and

consider the Executives’ response to the auditors work. 1.4 The Committee will seek the views of the Trust’s Executive Committees,

looking for assurance on systems. 2. MEMBERSHIP 2.1 Membership of the Audit & Governance Committee comprises of four

nominated non-executive directors including the Chairman of the Committee. At least one member must have significant financial experience.

2.2 The Non-Executive members of the Trust will appoint the Chair of the

Committee from the Non-Executive Directors (not the Chairman of the Trust or the Chairman). A nominated deputy will be identified from the Non-Executive group, if the Chair is unable to attend a meeting.

2.3 The Committee will invite relevant Executive Directors and Internal and External auditors to attend meetings, specifically to discuss areas of risk or operation within their sphere of operation.

3. FREQUENCY OF MEETINGS 3.1 The committee will meet normally four times a year. 3.2 At least one meeting a year will be with the Internal and External Auditors in

private. 3.3 At one meeting a year the Chief Executive should be invited to attend to

discuss the process for Assurance that supports the statement on Internal Control.


Top



I

10

3.4 The Trust’s auditors may request to be present at an audit meeting to raise

any aspect of their work. 4. QUORUM 4.1 The quorum of the Committee is the Chairman or nominated deputy and one

other non-executive director. 4.2 A matrix (see Appendix A) of membership attendees will be used for

monitoring purposes. 5. ACCOUNTABILITY 5.1 The committee is accountable through the Board of Directors for reviewing the

audit and governance aspects of plans and performance of the Trust. 6. AUTHORITY 6.1 The Committee is authorised by the Board of Directors to investigate/review

any activity within its Terms of Reference. 6.2 It is authorised to seek information from any employee and the employee is

directed to co-operate with the Committee. 6.3 The Committee is authorised by the Board of Directors to obtain any external

advice it requires to discharge its duties. 6.4 The Committee will receive minutes of the Trust Executive Committees for

scrutiny 7. RESPONSIBILITIES 7.1 The responsibilities of the Committee are set out in its Constitution (see 1.2)

above and in its Governance Cycle. 8. RELATIONSHIP WITH OTHER COMMITTEES 8.1 The committee will receive the minutes of the Hospital Executive Group and

the sub committees of the Hospital Executive Group. 9. REPORTING MECHANISMS 9.1 A Chairman’s report of each meeting of the Committee will be submitted to the

Board of Directors. The Chairman of the Committee should draw to the attention of the Board any issues that require disclosure or further action.

9.2 9.3

The Agenda and Papers will be circulated to other members of the Board of Directors and those required for regular attendance. A formal minute of the meeting will be recorded.

9.4 The Committee will provide an annual report on its work to the Board of

Directors.


Top



I

11

9.5 The Committee will be supported by the office of the Company Secretary. 10. PROCESS 10.1 The Committee will review, in order to gain the necessary evidence of

assurance: i) The minutes of the Trust’s Executive Committees;

ii) The integrity of financial statements of the Trust and

announcements relating to financial performance, reviewing significant financial judgements made within them;

iii) All risk and control related disclosure statements (in particular, the statement on Internal Control and declarations of compliance with the Standards for Better Health) together with any accompanying head of Internal Audit statement, External Audit opinion or other appropriate independent assurances, prior to endorsement by the Board of Directors;

iv) The underlying Assurance processes that indicate the degree of the achievement of corporate objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements;

v) The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements;

vi) The policies and procedures for all work related to fraud and corruption as set out in the Secretary of State Directions and as required by the Counter Fraud and Security Management Service;

vii) Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and dismissal;

viii) Review and approval of the Internal Audit strategy, operational plan and more detailed programme of work, ensuring that this consistent with the audit needs of the organisation as identified in the Assurance Framework;

ix) Consideration of the major finds of Internal Audit work (and management’s response) and ensure co-ordination between the Internal and External Auditors to optimise audit resources;

x) Ensuring that the Internal Audit function is adequately resourced and has appropriate standing within the organisation;

xi) Annual review of the effectiveness of Internal Audit; xii) Discussion and agreement with the External Auditor, before the

audit commences, of the nature and scope of the audit as set out in the Annual Plan, and ensure co-ordination as appropriate, with other External Auditors in the local health economy;

xiii) Discussion with the External Auditors of their local evaluation of audit risks and assessment of the Trust associated impact of the audit fee;

xiv) Review all External Audit reports, including agreement of the annual audit letter before submission to the Board of Directors and any work carried outside the annual audit plan, together with the appropriateness of management responses;

xv) The wording in the statement on Internal Control and other disclosures relevant to the Terms of Reference of the Committee;


Top



I

12

xvi) Changes in, and compliance with, accounting policies and practices;

xvii) Unadjusted mis-statements in the financial statements; xviii) Major judgmental areas; xix) Significant adjustments resulting from the audit.

11. COMMUNICATION 11.1 A report on each meeting of the committee will be made to the Board of

Directors. 11.2 The Annual Report of the Trust will contain a section regarding the work of the

Audit and Governance Committee. 12. MONITORING 12.1 Attendance will be monitored as part of the agenda at each committee

meeting. 12.2 The Trusts Annual Report will include membership attendance, frequency of

meetings and whether meetings were held in quorum. 13. REVIEW 13.1 These Terms of Reference will be reviewed in December 2013 or as requested

by the Trust Chairman or the Committee Chairman. 13.2 The position of Chairman of the Committee will be reviewed at least every

three years.


Top



I

13

Appendix 2 AUDIT AND GOVERNANCE COMMITTEE

GOVERNANCE CYCLE

MARCH 2014

REGULAR REPORTS

Audit and Governance Committee Minutes Chairman

Hospital Executive Group Minutes CEO/Executive

Risk Management Group Minutes DoNPS

Register of Authorisation of Tenders DoF

Review of Losses and Special Payments DoF

Risk Register: New Red and Amber Risks DoN

SIRO Information Governance Report (Quarterly Mar/May/Sept/Nov) Joint DoIT

Trust Assurance Framework Exception Report Update DoN

External Audit (DELOITTE LLP)

External Auditors Update Report Deloitte LLP

Internal Audit (Internal Audit Consortium)

Internal Audit Progress Report Internal Audit

Counter Fraud

Counter Fraud Report (To attend in Sept, Jan and March 2014/15) LCFS

Payroll Concerns DoF (Oral)

AD HOC REPORTS

Other reports as requested by Chairman TBA

ANNUAL REPORTS

External Audit (Deloitte LLP)

Deloitte LLP Audit Plan November Deloitte LLP

Annual Governance/Quality Report (including recommendations)

May/June Deloitte LLP

Internal Audit (Internal Audit Consortium)

Internal Audit Annual Report May/June Internal Audit

Internal Audit Workplan March Internal Audit

Counter Fraud Service

Counter Fraud Annual Report September (June 15)

LCFS

Counter Fraud Draft Workplan January LCFS

Counter Fraud Final Workplan March LCFS

Chairman

Review of Terms of Reference December 16 Chairman


Top



I

14

Audit and Governance Committee Annual Report May/June Chairman

Self Assessment of AGC (Inc in Annual Report) and future audit plans

May/June Chairman

Company Secretary

Timeline for Annual Report and Accounts January CS

Audit and Governance Committee Governance Cycle March CS

Review of Scheme of Delegation (3 yearly) –See SFIs January 2014 CS

Chief Executive

Monitor’s Terms of Licence –Draft Compliance Report

March CEO

Monitor’s Code of Governance – Draft Compliance Report

March CEO

Draft Annual Governance Statement (AR) March CEO (DoNPS)

Quality Governance Framework May CEO (DoNPS)

Draft Annual Report & Accounts (inc Quality) May CEO (DoF/ DoNPS/HoC)

Annual Letter of Representation (re Financial Statement)

May CEO (DoF)

Process for the production of the Annual Governance Statement (coming year)

May CEO (DoNPS)

Draft Assurance for Board Governance Statement (APR)

May CEO (DoF)

Director of Finance

Review of Auditors’ Performance September DoF

Review of Standing Financial Instructions (yearly) November DoF

Draft Annual Financial Statement (Final Accounts) May/June DoF

Annual Data Assurance and Framework Report May/June DoF

Director of Nursing

Risk Register Review (To inform next year Audit Plan)

January DoNPS

Annual Risk Register Report September DoNPS

Draft Annual Governance Statement March DoNPS

Safety Alert Broadcast (SAB) Assurance Update

(Not required for 2014 – closed May 2013)

May/June DoNPS

Review of Current Year Assurance Framework May DoNPS

Trust Assurance Framework (for Scrutiny) May DoNPS

Annual report on the number of whistle blowers and the process used in reaction to each report (from March 15)

March DoNPS

Chief Operating Officer

Business Continuity Plans March COO


Top



I

15

Joint meeting with Finance and Investment Committee in May to consider Annual Report and Accounts Mar 2014


Top



I

16

Appendix 3


COMMITTEE MEETING ATTENDANCE RECORD

NAME OF COMMITTEE:

AUDIT & GOVERNANCE COMMITTEE

REPORTS TO :

BOARD OF DIRECTORS

Membership (as per Terms of Reference). Please give names and/or full job title below:

MEETING DATES

15 M

ay 2

01

3

* 2

9 M

ay 2

01

3

18 S

epte

mb

er

201

3

5-6

Novem

ber

201

31

8 N

ove

mb

er

201

3

8 J

an

uary

201

4

12 M

arc

h 2

01

4

Jean Lang (Chairman) x

Ian Marshall (NED) from 01.02.11

x x x

Yvonne Moores (NED) x x x

Guy Spencer (NED)

In attendance:

Angela Schofield (Trust Chairman)

x NA x x x

Executive Directors/Deputies 1 3 3 NA 3 2 5

External Audit* 0 3 1 NA 2 1 1

Internal Audit 1 1 1 NA 2 1 1

Counter Fraud 1 0 0 NA 1 1 1

Was the meeting quorate? Y / N Y Y Y Y Y Y Y

* Special meeting with Finance & Investment Committee

1 Electronic Meeting


Top



I

17

Appendix 4 POOLE HOSPITAL NHS FOUNDATION TRUST

RESOURCE CONTROL SCHEDULE 1 APRIL 2013 TO 31 MARCH 2014

Assignment

Status Budgeted Days

Actual Days

Variance

A B A – B

Data Quality Final 10 10 -

Assurance Framework & Risk Management

Final 5 5 -

Policies & Procedures Final 2 2 -

Abnormal Test Results Final 13 13 -

Revalidation Final 10 10

Controlled Drug Administration

Final 12 12

CQC Outcome 12: Requirements relating to Workers

Final 10 10

Francis Report Outcomes Final 12 12

Finance & Payroll Controls Final 24 24 -

Benefits Realisation – CCU Clinical Info System

Final - Report taken to Nov FIC

5 5 -

Benefits Realisation – Private Patient Unit

Final - Report taken to Nov FIC

5 5 -

Benefits Realisation – Oncology Management System

Final - Report taken to Feb FIC

5 5 -

Benefits Realisation – MRI & CT Scanner

Final - Report taken to Feb FIC

5 7 (2)

CD & Drug Fridge Management Follow Up

Draft 6 6 -

Cost Improvement Programme

Final 10 9 1

Compliance Framework Final 8 8 -

IG Toolkit Draft 13 13 -

Digital Dictation Draft 6 6 -

Network Security Days taken to 14/15 Plan

6 - 6

Management & Planning WIP 6 6 -

Audit & Governance Committee Attendance & Reporting

WIP 12 12 -

Annual Report & Head of Internal Audit Opinion

WIP 2 2 -

Audit Needs Assessment WIP 5 5 -

Follow Up’s WIP 8 9 (1)


Top



I

18

Totals

200

196

4

Key: WIP is Work in Progress


Top



c:\programdata\activepdf\dc_ent\tmp\9ffc2c\cog july 14 j2 cog 2014 meeting schedule.docx

COUNCIL OF GOVERNORS MEETING SCHEDULE 2014

NREC Clinical

Presentation Pre Meeting

Briefing CoG

BoD/CoG Development

Session

CoG Development

Day

BoD Governor Briefing

AMM

January 14/01/14 11.00am

--- 16/01/14 3.15pm

16/01/14 4.30pm

--- --- 30/01/14 5.00pm

Chair of A&G ---

February --- --- --- --- --- --- 27/02/14 5.00pm

---

March --- --- --- --- --- --- 27/03/14 5.00pm

Chair of QSPC ---

April --- --- --- --- --- --- 24/04/14 5.00pm

Chair of WF ---

May 01/05/14 1.00pm

01/05/14 2.00pm

01/05/14 3.15pm

01/05/14 4.30pm

--- --- 29/05/14 5.00pm

---

June --- --- --- --- 11/06/14 4.30pm

--- 26/06/14 5.00pm

CE ---

July 31/07/14 1.00pm

31/07/14 2.00pm

Education Centre*

31/07/14 3.15pm

Chair of FIC

31/07/14 4.30pm

--- --- --- ---

August --- --- --- --- --- --- --- ---

September --- --- --- 25/09/14

12.15-1.00 --- --- ---

25/09/14 2.00pm

October 30/10/14 1.00pm

30/10/14 2.00pm

30/10/14 3.15pm Med Dir

30/10/14 4.30pm

--- --- --- ---

November --- --- --- --- --- 04/11/14

TBA

27/11/14 5.00pm

Chair of WFC ---

December --- --- --- --- 17/12/14

10.30 Dev & X lunch

--- --- ---

All meetings in Board Rooms unless stated otherwise *Members to Attend

CoG�July�14�J2�CoG�2014�Meetin

Top




CHAIRMANS MEETING SCHEDULE WITH COUNCIL 2014

Chair/CE meeting Staff Governors

Chair meeting with DC & LG

January --- ---

February --- 27/02/14 4.15pm

Chair's Office

March 11/03/13 11.00am CE Office

---

April --- ---

May --- TBC PM

Chair's Office

June 03/06/13 11.00am CE Office

---

July --- TBC

Chair's Office

August --- ---

September 09/09/13 11.00am CE Office

TBC Chair's Office

October --- ---

November --- TBC

Chair's Office

December 02/12/13 11.00am CE Office

---


Top




COUNCIL OF GOVERNORS REFERENCE GROUP MEETING SCHEDULE WITH COUNCIL 2014

Governor Training &

Development Reference Group

Membership Engagement &

Recruitment Group

Future Plans and Priorities Group Meetings TBA

January --- ---

February --- ---

March --- ---

April 24/04/14 3.45pm

03.04/14 5.15pm

May --- ---

June 26/06/14 3.45pm

---

July --- 03/07/14 5.15pm

August --- ---

September --- ---

October --- 16/10/14 5.15pm

November 27/11/14 3.45pm

---

December --- ---


Top



1

COUNCIL OF GOVERNORS PART 1 – COVER SHEET


Agenda Item: 17 Paper No: K

Title: Integrated Performance Report

Purpose: To report on performance against key indicators for the Trust in June 2014.

Summary:

Financial Performance The Trust reported a deficit of £453k in the month of June compared to a planned deficit of £549k. The favourable variance arises primarily from additional non-contract income and a small underspend on non-pay costs. The year to date deficit is £953k compared to a planned deficit of £1,172k, meaning that the Trust is £219k ahead of the plan submitted to Monitor. Clinical Performance & Quality Treating and caring for people in a safe environment and protecting them from avoidable harm

Stroke performance was achieved in June.

There was one Mixed Sex Accommodation (MSA) breaches in June.

There have been no C-Diff cases in June, bringing the year to date total to two

The MRSA year to date total for 2014-15 remains one, following the identification of a case in April 2014.

The monthly delayed discharges snapshot for June was 2.17%.

Helping people to recover from episodes of ill health following injury

The A&E metric (95% within 4 hours) was achieved for the month of June and overall for Quarter 1, the 13 period 31

st March to 29

th June (95.30%).

The 36 hour target for Fractured Neck of Femur patients to be operated on within 36 hours of admission was not achieved in June, 75% against a target of ≥ 90%.

Preventing people from dying prematurely

The RTT standards for admitted and non-admitted clock stops were met for June at aggregate level.

The Monitor Cancer standards were all achieved in May except for the Breast Symptomatic Two Week Wait standard. The forecast position for cancer Standards that all will be achieved for quarter 1.

All four Breast Screening access targets were achieved in June.

The National DM01 diagnostic target from referral to examination was met; as less than 1% of patients (0.24%) were waiting more than six weeks at month end.

CoG�July�14�K�IPR�Jun�2014�MM�

Top



2

Recommendation:

The Board are asked to note, discuss and assess the performance of the Trust report in July and for the Quarter 1 reporting period. Note: Monitor define Quarter 1 as a 13 week period from 31st March to 29th June 2014

Prepared by: KATE THOMAS Performance Manager

Presented

by:

Mark Mould Chief Operating Officer Director of Finance HR Director

Assurance

Framework:

YES

Risk

Register

I/D No:

Healthcare Standards:

Please specify which

standard/ standards that

apply;

CQC Standard (Please provide details):

Other; i.e /NHSLA/HSE etc

Monitor compliance: YES

Human Resources implications NO Financial implications YES

Legal implications NO

Please ensure all boxes are completed in order to comply with national requirements


Top



3

INDEX

Page No

1. Executive Summary

4

2. Performance Scorecard

7

3. Performance Summary

9

4. Operations Summary

14

5. Workforce Scorecard

20

6. Quality Indicator Dashboard

23

Appendices Appendix 1 ~ Referral To Treatment (RTT) Exception Report

24

Appendix 2 ~ Emergency Department Professional Standards Exception Report

25

Appendix 3 ~ Diagnostic Access Times

26

Appendix 4 ~ Appointment Slot Issue (ASI) Exception Report

28

Appendix 5 ~ Trauma Exception Report

30

Appendix 6 ~ Day Theatre Services Exception Report

32

Appendix 7 ~ Cancer Waiting Times Exception Report

34


Top



4

1. EXECUTIVE SUMMARY ~ JUNE 2014 1.0 FINANCE

1.1 The Trust reported a deficit of £453k in the month of June compared to a planned deficit of

£549k. The favourable variance arises primarily from additional non-contract income and a small underspend on non-pay costs.

1.2 The year to date deficit is £953k compared to a planned deficit of £1,172k, meaning that the Trust is £219k ahead of the plan submitted to Monitor. This is despite the escalation beds continuing to be open in the month and high spend on agency staff, but reflects the number of vacancies which are currently being recruited to.

1.3 Non-pay costs were slightly under-spent in the month, although a number of areas such as drugs and premises costs continue to overspend.

1.4 Non-patient income was ahead of plan as a result of additional funding from Health Education England and other miscellaneous income.

1.5 CIP achieved in the month was £518k, equating to 87% of plan. At the end of June, the Trust is £170k behind plan on CIP delivery.

2.0 WORKFORCE The Trust workforce metrics are rated as follows:

2.1 Avoidable' staff turnover in month 3 was 0.83% (29 leavers) compared with 0.41% in the

same month last year. "Other/Unspecified" was the most commonly recorded reason for leaving in the month. Work/life balance and relocation were also frequently cited. The year-end target is <=11%, which requires an average monthly rate of <=0.92% to be achieved and an early projection based on year to date data indicates a year end out turn of 9.32%

2.2 The HCA turnover rate in M3 was 0.96% (5 leavers), compared with 0.40% in the same month in 2013. The Trust's target is <=13.5% which requires an average monthly rate of <=1.12% to be achieved. The current cumulative rate translates into a projected year end rate of 11.56% which would be an all-time low level if achieved. This is a flexible and at times transient staff group, with high turnover levels across the NHS in general. Much has been done in the Trust to support this staff group in terms of recruitment, training and development, with the support of senior nursing staff and management.

2.3 The staff sickness absence rate for month 3 was 3.48% compared with 3.38% in month 3

2013. This is an average rate for May, using the Electronic Staff Record data for comparison (this was implemented in 2007).

In an inter-organisation comparison of all direct health providers in England and Wales (data from the NHS Information Centre) Poole was just outside the top quartile in the latest 12 month data comparison, with a rate of 3.63%. The average sickness rate for the whole group was 4.13%. A local benchmark for the whole of Dorset shows an average rate of 4.20% which highlights the Trust's continued excellent performance in this area.

2.4 The percentage of staff with up to date annual appraisals recorded on ESR rose again in June. Progress continues to be made in the non-clinical / corporate areas and the significant time and effort expended by both managers and HR to raise the level of compliance is bearing fruit.


Top



5

3.0 OPERATIONAL HIGHLIGHTS (Quality & Access) 3.1 The A&E metric (95% within 4 hours) was achieved for June with performance reported as

96.86%. Monitor Q1 perfromance was achieved at 95.30%. (Monitor define Quarter 1 as a 13 week period from 31st March to 29th June 2014). Achieving the target on a daily or weekly basis remains a challenge including wait to be seen times, bed capacity and acuity of patients driven by an increase in demand.

3.2 The Trust achieved all the Referral to Treatment Standards. The targets for admitted RTT

(95.6% achieved V 90% target) and non-admitted RTT (96.7% V 95% target), at aggregate level in June.

3.3 The Trust achieved all but one of the cancer standards in May of the cancer standards have

been confirmed as achieved in May, and it is anticipated all standards will be achieved for

quarter 1. (One area of under delivery Breast symptomatic two week waits 88.4% v 93%) 3.4 During the three month period ended March 2014, (the latest information available from the Dr

Foster information service) the overall hospital standardised mortality rate (HSMR) for the Trust was 84.9, well within the target of 100. The April update is not yet available from Dr Foster.

3.5 The Bowel Screening Programme offered 100% of patients a diagnostic screening

appointment within 14 days in June. In addition, the programme continued to meet (100%) of the target stating that all patients must be offered a Specialist Screening Nurse Practitioner clinic appointment within 14 days of their positive FOB test result.

3.6 All 4 of the Breast Screening targets were achieved in June an improvement on the previously

reported position 3.7 Stroke performance was achieved in June with 84% of patients spending > 90% of their LOS

on the Stroke Unit (target ≥ 80%).

3.8 The DM01 diagnostic target of no more than 1% of eligible patients waiting more than 6

weeks for examinations was achieved, with 0.24% (9 DM01 patients) waiting > 6 weeks at the

end of June. In total 19 patients were waiting more than 6 weeks from referral to diagnostic

test at the end of June 2014. This is a sustained improvement when compared to the

beginning of the calendar year.

3.9 The percentage of patients formally delayed on the last Thursday of June 2014 (DH reporting methodology) was 2.17 %, which meets the National target of < 3.5%.

3.10 There have been no further cases of hospital acquired MRSA Bacteraemia since April. There

were no cases of C-Difficile identified in June, bringing the quarter total to 2, the annual target is 13.

3.11 Main theatre utilisation was achieved at 84% against a target of 85%. Day Theatre reached

79% utilisation for June 2014 which is an improvement in utilisation compared to May 2014 (77%).

Areas for the Board to Note and consider (Exception reports in Appendices)

RTT targets were met at aggregate level however at speciality level the non-admitted target was not achieved for Trauma & Orthopaedics (92.3%), Urology (90.7%), ENT (92.2%) or Oral Surgery (92.8%).

All but 1 of the cancer standards have been confirmed as achieved in May. The cancer target ‘Two Week Wait for Symptomatic Breast Patients (Cancer Not initially Suspected)’ was not achieved in May, 88.4% (target ≥93%).

The local Appointment Slot Issue (ASI) target (with an associated financial penalty, the Trust risks fines for every week >10%) was not achieved during June at 22%.

Neither the 36 hour targets for Fractured Neck of Femur patients nor 48 hour target for other Trauma patients were achieved in June.

Day Theatre reached 79% utilisation for June 2014 which is an improvement in utilisation compared to May 2014 (77%).

Average bed occupancy in June was 100%, and did not meet the internal target of 95%.

A Mixed Sex Accommodation (MSA) breach occured in June.


Top



6

Year End

Target /

LimitMar-12 Mar-13 Mar-14 Apr-14 May-14 Jun-14

current

or YTD

Actual

YTD

Target /

LimitForecast

Jan-00

PATIENT EXPERIENCE

meeting the C-Diff objective (month on month) 13 24 27 1 0 2 0 ↑ 2

Qtr1

3 cases A 1.0

meeting the MRSA objective (month on month)no longer Monitor target w ith effect from 1st October 2013 =<1 1 4 0 1 0 0

↔1 =<1 G 0.0

MSA occurances 0 0 1 0 0 0 1 ↓ 1 0 G

MSA patients 0 0 5 0 0 0 4 ↓ 4 0 G

Family & Friends test - % response rate 20% 25.2% 23.4% 27.7% 26.5% ↓ 27.7% G

Family and Friends % reported extremely likely to recommend to a

family member 80% 81% 80% 79%↓

81% G

VTE (target 90% to Mar 2013, 95% from Apr 1203) 95% 93.00% 97.30% 97.70% 97.00% tbc ↓ 97.0% 95% G

CLINICAL QUALITY

Dr Foster Mortality relative risk rating (3 month rolling) 100% 78.0 101.0 84.9 ↑ 84.9 100% G

All deaths - actual as % of expected (Dr Foster) 100% 88.8% 102.4% 101.4% ↓ 101.4% 100% G

HSMR deaths - actual as % of expected (Dr Foster) 100% 94.3% 101.3% 100.8% ↓ 100.8% 100% G

Number of SUIs reported within appropriate timeframe (ytd) 12 19 60 9 3 8 ↓ 20 G

Number of Serious Untoward Incidents (SUIs) for the year to date 12 20 61 9 3 8 ↓ 20 R

ACCESS AND TARGETS

Referral to waiting time (weeks) for admitted (95th centile) 23.0 21.3 17.1 18.6 18.0 18.0 17.9 ↑ 17.9 - G

Referral to waiting time (weeks) for non-admitted (95th centile) 18.3 17.0 16.7 17.1 16.6 16.9 17.3 ↓ 17.3 - G

Referral to treatment (18 weeks) for admitted 90% 92.5% 98.0% 94.6% 95.0% 95.3% 95.6% ↑ 95.6% 90% G 1.0

Referral to treatment (18 weeks) for non-admitted 95% 96.6% 97.2% 96.2% 97.2% 96.9% 96.7% ↓ 96.7% 95% G 1.0

Referral to waiting time (18 weeks) for incomplete pathways 92% 93.5% 97.5% 97.0% 97.3% 97.6% 97.5% ↓ 97.5% 92% G 1.0

Maximum 62 day wait from referral to treatment for all cancers 85%

90.1%

qtr 92.2%

87.4%

qtr 89.3%

91.7%

qtr 87.6%88.0% 86.5%

qtr 1 est

89.0 % ↓ 86.5% 85% G

62 day wait for 1st treatment - consultant screening service 90%

100%

qtr 98.2%

100%

qtr 100%

94.8%

qtr 92.9%96.1% 91.4%

qtr 1 est

93.8 % ↓ 91.4% 90% G

62 day wait for 1st treatment following consultant decision to upgrade

the priority of the patient (all cancers) 90% -100.0%

92.9%

qtr 95.0%90.6% 100.0%

qtr 1 est

100 % ↑ 0.0% 90% G -

31 day wait for 2nd or sub treatment : Anti cancer drug treat 98%

100%

qtr 100%

100%

qtr 100%

100%

qtr 100%100.0% 100.0%

qtr 1 est

100 % ↔ 100.0% 98% G

31 day wait for 2nd or sub treatment : Surgery 94%

97.9%

qtr 98.8%

100.0%

qtr 98.9%

100%

qtr 97.5%96.8% 100.0%

qtr 1 est

98.1 % ↑ 100.0% 94% G

31 day wait for 2nd or sub treatment : Radiotherapy 94%

99.3%

qtr 99.6%

100.0%

qtr 98.2%

100%

qtr 99.5%97.9% 100.0%

qtr 1 est

98.9 % ↑ 100.0% 94% G

31 days wait decision to start of 1st treatment: All cancers 96%

100%

qtr 98.8%

99.2%

qtr 99.3%

99.3%

qtr 99.6%97.8% 100.0%

qtr 1 est

98.6 % ↑ 100.0% 96% G1.0

2 week wait from urgent GP referral to 1st appt (susp cancer) 93%

95.8%

qtr 96.3%

97.3%

qtr 99.3%

95.3%

qtr 96%91.7% 96.8%

qtr 1 est

94.4 % ↑ 96.8% 93% G

2 week wait for Symptomatic Breast Patients 93%

100%

qtr 96.1%

88.7%

qtr 93.5%

89.3%

qtr 94.1%91.5% 88.4%

qtr 1 est

93.4 % ↓ 88.4% 93% G

percentage of patients within the 4 hour target 95% 96.11%

93.28%

qtr 94.85%

94.53%

qtr 94.00% 95.23% 95.28%

96.86%

qtr 95.30%↑ 96.86%

qtr 95.30% 95%G 1.0

Total time in A+E (95th centile) =< 4 hours 3hrs 59 4hrs 29 4hrs 37 4hrs 03 4hrs 01 3hrs 59 ↑ 3hrs 59 =< 4 hours G

Time to initial asessement (95th centile) =< 15 mins 12 21 23 18 19 25 ↓ 25 =< 15 mins G

Time to treatment decision (median) =< 60 mins 67 62 71 61 63 66 ↓ 66 =< 60 mins G

Unplanned reattendance rate (unlinked wef 1/4/14) =< 5% 2.83% 2.50% - 6.50% 5.90% 7.00% ↓ 7.00% =< 5% G

Left without being seen =< 5% 3.35% 3.10% 2.30% 2.80% 2.90% 3.80% ↓ 3.80% =< 5% G

RT

T

2012-13 2013-14

cancer

1.0

2. TRUST PERFORMANCE SUMMARY

DQ

AF

ratin

gs

Year To Date

June 2014

Dire

ctio

n #

Monitor

targets &

weightings

2011-12 2014-15

1.0

1.0

A&

E

G

G

G

G


Top



7

Year End

Target /

Limit

Mar-12 Mar-13 Mar-14 Apr-14 May-14 Jun-14

current

or YTD

Actual

YTD

Target /

Limit

Forecast

Diagnostic patients waiting more than 6 weeks

(DM01 investigations only) <= 1% 31 2 32 34 31 9↑

9 0

G

% waits more than 6 weeks for DM01 diagnostic investigations <= 1% 0% 0% 0.86% 0.99% 0.86% 0.24% ↑ 0.24% <= 1% G

Elective Access - rebooking 0 1 1 0 0 0 0 ↔ 0 0 G

Patients who spend at least 90% of their time on a stroke unit 80% 68% 82% 85% 84% 86% 84%↓

84% 80%G

Higher risk TIA cases who are treated within 24 hours 60% 70.6% 43% 65.0% 77.0% 57% 77.0% ↑ 77.0% 60% G

Outpatient Access : ASIs at =< 4% 4% 8% 27% 27% 28% 24% 22% ↑ 22% 4% R

Screening to normal results within 14 days 90% 96.8% 90.0% 96.0% 64.0% 93.0% 99.0% ↑ 99.0% 90% G

Screening to assessment in 21 days - screening to 1st appt offer 90% 94.8% 97.0% 95.0% 93.0% 78.0% 97.0% ↑ 97.0% 90% G

Screening to assessment in 21 days - screening to attended appt 90% 92.2% 92.0% 91.0% 88.0% 79.0% 95.0% ↑ 95.0% 90% G

round length 90% of eligible woman screened within 36 months 90% 99.2% 99.0% 99.3% 99.5% 97.0% 95.0% ↓ 95.0% 90% G

Delayed transfers of care to be maintained at a minimal level 3.5% 6.18% 2.44% 3.33% 3.46% 3.46% 2.17% ↑ 2.17% 3.5% G

Hip fractures who are medically fit for surgery receive treatment within

36 hours95% - 96% 85% 90% 96% 91% ↓ 91% 95% G

Hip fractures within 36 hours of admission (NHFD) 90% - 74% 75% 74% 88% 75% ↓ 75% 90% G

Other trauma inpatients (fit for surgery) receive treatment within 48 hrs95% 96% 98% 95% 98% 95% 94% ↓ 94%

95%G

OPERATIONAL EFFICIENCY

Theatre Utilisation - Main 85% 87.0% 87.0% 86.0% 85.0% 89.0% 88.0% ↓ 88.0% 85% G

Theatre Utilisation - Day (target 85% to Mar 2013, 80% from Apr 2013) 80% 74.0% 74.0% 79.0% 74.0% 77.0% 79.0% ↑ 79.0% 80% G

Day Case Rates (basket of 25) 75% 83.5% 78.7% 82.7% ↑ 82.7% 75% G

Bed Occupancy 95% 96% 98% 98% 100% 100% 100% ↔ 100% 95% G

WORKFORCE INDICATORS

Staff Turnover (Overall) <=11% 0.92% 1.05% 0.81% 0.78% 0.72% 0.83% ↓ 2.33% <=11% 9.32%

Staff Turnover (Auxiliaries and HCAs) <= 13.5% 1.54% 0.62% 1.54% 0.58% 1.35% 0.96% ↑ 2.89% <= 13.5% 11.56%

Absence <=3.5% 3.85% 3.57% 3.77% 3.44% 3.42% 3.48% ↓ 3.53% <=3.5% G

FINANCE & ACTIVITY

Cash balance 15.4 15.0 10.1 8.7 8.5 7.6 7.6 7.1 9.5

Income 195.10 19.00 20.10 17.50 17.50 17.60 52.6 52.4 209.2

Operating Expenditure -182.20 -18.00 -18.57 -16.80 -16.80 -17.10 -50.6 -50.6 -200.9

EBITDA 12.30 0.80 1.35 0.60 0.60 0.40 1.6 1.4 6.9

EBITDA % 6.3% 4.4% 6.8% 3.5% 3.3% 2.2% 3.0% 2.6% 3.3%

Surplus/Deficit 1.00 -0.10 -0.10 -0.20 -0.30 -0.50 -1.0 -1.20 -3.8

SLA over / (under) performance 0.8 0.3

CIP 0.3 0.5 0.5 1.3 1.5 6.6

Financial Risk rating - current 3 3 2 3 3 3 3 3 3

Financial Risk rating - revised 3 4 4

2011-12

Dire

ctio

n #

Year To Date

Monitor

targets &

weightings

2012-13

# : Arrow direction indicates improvement ↑, deterioration ↓, or no change ↔ in performance since the previous month

access

Are

as

of

Co

nc

ern

bre

ast s

cre

en

traum

a a

ccess

2013-14

not c

overe

d b

y D

QA

F

2014-15


Top



8

3.0 PERFORMANCE SUMMARY

Month Three – June 2014

Key Issue Month 3 Summary – June 2014 RAG Sch

Monitor Targets for Q1

RTT

The Trust achieved the targets for admitted clock stops (95.6% against 90% target) and non-admitted (96.7% against 95% target) clock stops, at aggregate level in June. The incomplete pathways target was achieved, (97.5% against 92% target).

Cancer

The cancer target ‘Two Week Wait for Symptomatic Breast Patients (Cancer Not initially Suspected)’ was not achieved in May, 88.4 (target ≥93%).

Ensuring patients are ready willing and able at the time of referral, remains a priority, and continues to be actively pursued with the Commissioner and GPs. In addition the booking process has been strengthened to ensure patients are aware of the importance of attending within 2 weeks.

It is anticipated that all Cancer targets will be met for the quarter, and the best estimate for Quarter 1 based on current data is included in the scorecard.

Emergency Department

The A&E metric (95% within 4 hours) was achieved for the June

quarter with performance reported as 95.30%. Monitor defines

Quarter 1 as a 13 week period from 31st March to 29th June 2014.

Achieving the target on a daily or weekly basis remains a

challenge for a number of reasons including patient flow, bed

capacity and acuity of patients.

C-Diff

There were no C-Diff cases in June, giving 2 for the year to date. This is within the trajectory for Q1 of 3 cases, 25% of the annual target of 13 as defined by Monitor.

Risk Assessment Framework (RAF)

The Risk Assessment Framework has now replaced the Compliance Framework used by Monitor (with effect from 1

st October 2013).

Performance metrics include the following:

o Cancer targets (now all weighted as 1.0 – Quarterly measured) o ED 4 hour target (13 week quarter) o Referral to Treatment (admitted, non admitted, incompletes all at

aggregate level) o Infection control - C-Diff The risk rating calculation is no longer a purely transparent quantitative process in that a variety of reports (e.g. CQC) will also be taken into account in addition to weighting scores.

Mo

nito

r sco

rec

ard

G

G

G

G


Top



9

Patient Experience

The Patient Experience scorecard is comprised of six key indicators; one of these is part of the Monitor scorecard.

C-Diff

See Monitor section

MRSA

There have been no further cases of MRSA since April 2014. This metric is no longer part of the monitor framework (RAF), but would still be subject to Monitor scrutiny in the event of an outbreak or sudden increase in cases. Action: Infection Control issues remain under continued scrutiny DoN/Infection Control.

Mixed Sex Accommodation (MSA)

There was one mixed sex accommodation (MSA) breach in June, this involved 4 patients.

Venous Thromboembolism (VTE)

VTE performance for May (the latest data available) was 97.0%, a sustained improvement on previous months.

Friends and Family Test The response rate to the Friends and Family Test in June was 26.5% (CQUIN target ≥ 20%). The combined FFT score is 73.

Patie

nt E

xp

erie

nc

e S

co

recard

Clinical Quality

The Clinical Quality scorecard is comprised of five key indicators (3 relate to Mortality and 2 to SUIs), none of which are part of the Monitor scorecard.

Mortality

During the three month period ended March 2014, (the latest information available from the Dr Foster information service) the overall hospital standardised mortality rate (HSMR) for the Trust was 84.9, well within the target of 100, and an improvement on the previous month.

Mortality performance for March has been red rated as both the overall and HSMR number of deaths was higher than the expected level calculated by Dr Foster.

The Mortality group will continue to ensure that; o cases with a zero or very low co-morbidity rating are

reviewed; o deaths are reviewed by clinicians; o pneumonia remains under scrutiny.

Serious Untoward Incidents

There were 8 SUIs declared in June, all were reported within the appropriate timescale, and relate to adult safeguarding.

The categorisation of SUIs reportable to the CCG changed from July 2013, and now amber in addition to red category events must be reported.

Clin

ical Q

uality

Sco

rec

ard

A

4/5

G


Top



10

Access and Targets

The Access and Targets scorecard is comprised of 22 key indicators.

RTT

See Monitor section above. An exception report is included in Appendix 1

Cancer

See Monitor section above.

Emergency Department: 4 hour target

See Monitor section above.

Diagnostic Access

The DM01 target of no more than 1% of patients waiting more than 6 weeks for examinations was achieved in June (9 patients were reported in the DM01 return as waiting 6 weeks or more, 0.24%)

The total number of patients waiting for diagnostic examinations at the end of June was 19.

An exception report is included in Appendix 3 Breast Screening

All four of the Breast Screening Service targets for were achieved in June. Delayed Transfers of Care (Operations Summary Section 4)

The percentage of patients formally delayed on the last Thursday of June 2014 (DH reporting methodology) was 2.17 %.

The focus continues on the reduction of informal delays and all other internal delays in order to further improve inpatient pathways.

A joint project with RBH has been commenced with IT to build a new in-house delays database. This will streamline the data processing and reporting as well as improve the depth of detail collected in the current database.

Access standards for #NoF and Trauma

Neither the 36 hour targets for Fractured Neck of Femur patients nor 48

hour target for other Trauma patients were achieved in June.

The 36 hour operating target for Neck of Femur (NoF) target of 90% for all

patients, i.e. regardless of their fitness for surgery, was not met (75%).

For the tranche of patients who were medically fit, the 36 hour target of

95% was not achieved in June (91%).

The 48 hour target for other Trauma patients of 95% was not achieved in June (94%).

An exception report is included in Appendix 5. Stroke

Stroke performance was achieved in June, with more than 80% of patients spending 90% of their stay on a stroke ward.

ASI (Appointment Slot Issues)

ASIs did not achieve the 4% local target (with a potential financial penalty for every week >10%) during June (22%).

Actions continue to reduce the level of ASI, targeted at specialty level in the coming months.

An exception report is included in Appendix 4

Acce

ss a

nd

Targ

ets

Sco

recard

G

G

G

A/R

G

G

A/G

A/R

G


Top



11

Efficiency The Efficiency scorecard is comprised of four key indicators; none of these are part of the Monitor scorecard. For the most recent year to date position (March 2014 / June 2014) there are two red rated indicators which relate to Day Theatre utilisation and bed occupancy:

Theatre Utilisation

Main theatre utilisation (88%) achieved the 85% target in June.

Day theatre utilisation has improved substantially but did not achieve 80% target (79%). An exception report is included in Appendix 6

Day case Rates (Basket of 25 procedures)

The latest day case rate is March, which at 83% achieved the 75% target. Bed Occupancy

Average bed occupancy in June was 100%, and did not meet the internal target of 95%.

E

fficie

nc

y S

co

reca

rd

Workforce Indicators

The Staff Experience Scorecard (See section 5) comprises of eight key measures of HR performance, of note are:

Staff Turnover (overall) at 0.83% (2.33% ytd),

Staff Turnover (Auxiliaries and HCA) at 0.96% (2.89% ytd),

Staff sickness at 3.48% (3.53% ytd).

Finance & Activity

The Trust reported a deficit of £453k in the month of June compared to a planned deficit of £549k. The favourable variance arises primarily from additional non-contract income and a small underspend on non-pay costs.

The year to date deficit is £953k compared to a planned deficit of £1,172k, meaning that the Trust is £219k ahead of the plan submitted to Monitor.

This is despite the escalation beds continuing to be open in the month and high spend on agency staff, but reflects the number of vacancies which are currently being recruited to.

Non-pay costs were slightly under-spent in the month, although a number of areas such as drugs and premises costs continue to overspend.

Non-patient income was ahead of plan as a result of additional funding from Health Education England and other miscellaneous income.

CIP achieved in the month was £518k, equating to 87% of plan. At the end of June, the Trust is £170k behind plan on CIP delivery.

A-G

A

A

A

G


Top



12

4. OPERATIONS SUMMARY (For the period of 1

st to 30

th June 2014)

4.1 Contract Activity This report summarises various operational aspects year to date and for the month of June. The performance information relates to actual activity rather than a comparison against contract.

Adult non-elective admissions in June (2,182). This is similar to the level of admissions in May and remains at the highest levels of monthly non-elective admissions reported over the past 5 years. Year to date this represents a 9.4% increase when compared with the same period in 2013/14 – an additional 557 admissions which equates to an additional average of 9 admissions per day

Paediatric non-elective admissions in June (671) were similar to levels experienced in both April and May. Year to date, this represents a 9.7% increase when compared with the same period in 2013/14 –an additional 178 admissions which equates to an additional average of 2 admissions per day

Total elective inpatient admissions in June (338) were similar to May. However, year to date there were 87 fewer admissions which represents a 8.4% decrease compared to the same period in 2013/14. - Equivalent to an average of just under 1 less admission per day.

Day case admissions (2,440) increased slightly in June compared to May. Year to date there were 220 more admissions, which represents a 3.1% increase compared to the same period in 2013/14 - equivalent to an average of 2.1 additional admissions per day.

Outpatient new attendances in June (6,336) showed a slight increase of 2.8% compared to the May 2014. However, year to date the number of new attendances is similar in 2014/15 when compared to the same period in 2013/14.

4.1.1 The number of Maternity admissions in June (575) was similar to May. Year to date, this

represented a 38.7% decrease compared to the same period in 2013/14. This reduction is partially due to a reclassification of admitted activity to outpatient within the Antenatal Day Assessment Unit, which occurred in September 2013.

4.1.2 There were 6,011 attendances (including nurse practitioner activity) in the Emergency Department in June. This represents a 3.5% increase in the number of attendances compared to May and is the highest level of attendances seen over the past 5 years. Year to date, this represented a 14.3% increase compared to the same period in 2013/14 and is equivalent to an average of 24 additional attendances per day in Q1 this year compared to last.

Table 1.The variance in Trust activity (YTD) is summarised below

LENGTH OF STAY

Activity Year to Date

Year to date 13/14

Year to date 14/15

Variance

Adult Non Elective Admissions (Spells) (Inc. emergency & transfers excl maternity)

5899 6456 +9.4%

Child Non Elective Admissions (Spells) (Excl maternity and Incl. children under 16)

1841 2019 +9.7%

Elective Inpatient Spells (all ages) 1033 946 --8.4%

Day case admissions 7010 7230 +3.1%

Maternity Admissions (Spells) 2799 1715 -38.7%

Emergency Dept. Attendances 15167 17338 +14.3%

Outpatient New Attendances (Adult and Paediatrics) 18182 18486 +1.7%


Top



13

4.2 Length Of Stay

Adult Non Elective average Length of Stay (LOS) for June 2014 was 5.15 days. This represents a decrease of 0.36 days compared to the previous month. The following graph shows monthly comparisons of the average adult non-elective LOS from April 2012 to date.

Adult Elective average Length of Stay (LOS) for June 2014 was 3.11 which I similar to the May average. The following graph shows monthly comparisons of the average adult inpatient elective LOS from April 2012 to date

The average length of stay for children (elective and non-elective) in June decreased from the reported May position of 1.18 to 1.12 days, similar to the average for 2013/14 of 1.11. The graph below shows the average LOS for children (elective and non-elective) from April 2012 to date

The average length of stay for Maternity in June was 1.73. The graph below shows the average LOS for Maternity. The increase from September 2013 reflects the reclassification of short stay ANDA inpatients as outpatient attendances.


Top



14

4.3 Occupancy Levels

The percentage of time the Trust is in a red bed state is a clear indication of the pressure on the whole hospital. The Hospital was in red bed state throughout most of June – 80% of the month overall. This is significantly higher than in June 2013 – 23% and demonstrates the pressure on the current funded bed capacity. During this period additional bed capacity was maintained to ensure the safe delivery of care for patients.

4.4 Delayed Transfer of Care

2.17% of beds occupied at midnight on the last Thursday in June 2014 (DH reporting methodology)

were occupied by delayed patients. This meets the National target of up to 3.5%. This is also an

improvement in performance since last month (May 2014 we achieved 3.46%). In real terms this

relates to 9 delayed patients, compared to 15 delayed patients on the snapshot day last month.

The total number of bed days lost in the month due to delayed transfer of care (DTOC) is a far more statistically significant measure. In May 2014 we lost 536 bed days to DTOC. In June we lost 471 bed days, an improvement of 65 days.

Delays during June– both the snapshot of patients delayed on the last Thursday of the month and the total number of bed days lost to DTOC during the calendar month:


Top



15

Description of delay Delayed patients on snapshot day

% of snapshot delays

Bed days lost to delays in month

% of total reportable

delays

Continuing Health Care 3 34 137 29

Patient or Family Choice 1 11 66 14

Community Hospitals 2 22 77 16

Housing 0 0 0 0

Intermediate Care 0 0 30 6

NHS Other (NWB patients) 1 11 59 13

Self-Funding 1 11 73 16

Social Services 0 0 24 5

Joint Funding 1 11 5 1

Total 9 100 471 100

Angio waits are not included, as the National target does not count these as DTOC

4.5 Cancellations

All Waiting List Cancellations The number of Elective admissions cancelled as a percentage of all elective admissions in June increased to 17.9% in month - this represents the highest level for the past 2 years. The graph below shows the % of elective admissions cancelled as a % of all elective admissions.

Waiting List cancellations within 1 Day of the TCI (To Come In) Date Elective admissions cancelled within a day of their TCI date (subset of the total in the previous paragraph) increased to 5.8% in June; this is the highest level reported over the past 4 years. The graph below shows the % of elective admissions cancelled within 1 day of TCI.

The graph below shows monthly numbers of cancelled operations on the day of admission or

operation, split by cause.


Top



16

Outpatient Cancelations 22.4% of all outpatient appointments were cancelled by the hospital in June 2014, similar to levels in previous months. The graph below shows the proportion of Outpatient Appointments Cancelled by the Hospital as a % of All Outpatient Attendances

4.6 READMISSIONS

The readmission rate is calculated by dividing the number of discharges that were followed by an emergency readmission within 30 days by total number of discharges (excluding deaths). The table below shows the monthly emergency readmission rates for up to May 2014 (latest available data). The data is based on the month of original discharge and is categorised by the discharging specialty of first admission

Apr-14

ACCIDENT AND EMERGENCY 3.2%

ACUTE INTERNAL MEDICINE 7.2%

ADULT CYSTIC FIBROSIS 0.0%

CARDIOLOGY 7.1%

CLINICAL ONCOLOGY 0.8%

DERMATOLOGY 0.8%

EAR, NOSE AND THROAT 3.4%

GASTROENTEROLOGY 1.5%

GENERAL MEDICINE 10.8%

GENERAL SURGERY 4.4%

GERIATRIC MEDICINE 12.3%

GYNAECOLOGY 5.4%

HAEMATOLOGY (CLINICAL) 2.7%

Max Fax & Oral Surgery 0.5%

MEDICAL ONCOLOGY 4.1%

NEONATOLOGY 0.0%

NEUROLOGY 2.9%

OBSTETRICS 0.0%

OPHTHALMOLOGY

PAEDIATRICS 5.0%

PALLIATIVE MEDICINE 8.3%

REHABILITATION 6.7%

RHEUMATOLOGY 1.5%

TRANSIENT ISCHAEMIC ATTACK

TRAUMA AND ORTHOPAEDICS 4.7%

WELL BABIES 0.0%

Total 4.6% 4.7%

Emergency Readmissions by month of Original discharge

4.1%

0.0%

0.0%

0.0%

12.5%

0.0%

0.0%

5.2%

0.0%

0.0%

3.6%

0.0%

2.0%

1.9%

14.7%

4.2%

9.2%

5.7%

2.4%

4.0%

1.3%

0.4%

0.0%

8.3%

4.8%

10.2%

M ay-14

4.24 The overall readmission rate increased slightly in May 2014 to 4.7%. Readmission rates are

being monitored closely by the Directorate teams to ensure safe discharging is in place


Top



17

5. WORKFORCE SCORECARD Reporting Month: June 2014

Standard Description TargetMonitoring

periodJun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Comment

Staff Turnover

(Overall)

Overall avoidable staff turnover under

11% (average rate of 0.92% per month)

<=11% Monthly

0.41%

(2.05%

cumulative)

8.20%

projected

0.77%

(2.82%

cumulative)

8.46%

projected

1.12%

(3.94%

cumulative)

9.46%

projected

1.28%

(5.22%

cumulative)

10.44%

projected

1.17%

(6.39%

cumulative)

10.95%

projected

0.85%

(7.24%

cumulative)

10.86%

projected

0.72%

(7.96%

cumulative)

10.61%

projected

0.75%

(8.71%

cumulative)

10.45%

projected

1.01%

(9.72%

cumulative)

10.60%

projected

0.81%

(10.53%

cumulative)0.78%

0.72%

(1.50%

cumulative)

8.99%

projected

0.83%

(2.33%

cumulative)

9.32%

projected

'Avoidable' staff turnover in M3 was 0.83%

(29 leavers) compared with 0.41% in the

same month last year.

"Other/Unspecified" was the most

commonly recorded reason for leaving in

the month. Work/life balance and

relocation were also frequently cited. The

year end target is <=11%, which requires

an average monthly rate of <=0.92% to be

achieved and an early projection based on

year to date data indicates a year end out

turn of 9.32%

Staff Turnover

(HCAs)

Overall avoidable staff turnover in

Auxiliaries/ HCAs under 13.5% (average

rate of 1.12% per month).

<=

13.5%Monthly

0.40%

(3.50%

cumulative)

14.00%

projected

0.59%

(4.09%

cumulative)

12.27%

projected

1.95%

(6.04%

cumulative)

14.50%

projected

3.19%

(9.23%

cumulative)

18.46%

projected

2.04%

(11.27%

cumulative)

19.32%

projected

1.35%

(12.62%

cumulative)

18.93%

projected

0.98%

(13.60%

cumulative)

18.13%

projected

0.97%

(14.57%

cumulative)

17.48%

projected

1.36%

(15.93%

cumulative)

17.38%

projected

1.54%

(17.47%

cumulative)0.58%

1.35%

(1.93%

cumulative)

11.58%

projected

0.96%

(2.89%

cumulative)

11.56%

projected

The HCA turnover rate in M3 was 0.96%

(5 leavers), compared with 0.40% in the

same month in 2013. The Trust's target is

<=13.5% which requires an average

monthly rate of <=1.12% to be achieved.

The current cumulative rate translates into

a projected year end rate of 11.56% which

would be an all time low level if achieved.

This is a flexible, and at times transient

staff group, with high turnover levels

across the NHS in general.

Much has been done in the Trust to

support this staff group in terms of

recruitment, training and development,

with the support of senior nursing staff

and management.

Sickness

Absence

Sickness absence rate <= 3.5%. (By

31st March 2013).

First figure is rate for the month,

second is cumulative rate for year to

date.

<=3.5% Monthly

3.38%

(3.47%

cumulative

ytd)

3.28%

(3.43%

cumulative

ytd)

3.16%

(3.37%

cumulative

ytd)

3.53%

(3.40%

cumulative

ytd)

3.53%

(3.42%

cumulative

ytd)

3.88%

(3.48%

cumulative

ytd)

3.82%

(3.51%

cumulative

ytd)

4.08%

(3.57%

cumulative

ytd)

4.04%

(3.61%

cumulative

ytd)

3.77%

(3.63%

cumulative

ytd)

3.66%

3.47%

(3.57%

cumulative

ytd)

3.48%

(3.53%

cumulative

ytd)

The first run sickness absence rate for M3

was 3.48% compared with 3.38% in M3

2013. This is an average rate for May in

the period since Electronic Staff Record

was implemented in 2007.

In an inter-organisation comparison of all

direct health providers in England and

Wales (data from the NHS Information

Centre) Poole was just outside the top

quartile in the latest 12 month data

comparison, with a rate of 3.63%. The

average sickness rate for the whole group

was 4.13%, A local benchmark for the

whole of Dorset shows an average rate of

4.20% which highlights the Trust's

continued excellent performance in this

area.

Appraisal Appraisal Records On ESR

43% % 62% 64% 70% 71% 71% 71% 72% 69% 73% 76% 77%

The percentage of staff with up to date

annual appraisals recorded on ESR rose

again in June. Progress continues to be

made in the non-clinical / corporate areas

and the significant time and effort

expended by both managers and HR to

raise the level of compliance is bearing

fruit..


Top



18

Establishment

compared with

Substantive Staff

in Post

WTE establisment and staff in post on

the final day of the month.

Monthly

3224 estab

3049 in post

Variance =

-175 wte

3219 estab

3061 in post

Variance =

-158 wte

3219 estab

3060 in post

Variance =

-159 wte

3211 estab

3075 in post

Variance =

-136 wte

3234 estab

3089 in post

Variance =

-145 wte

3239 estab

3097 in post

Variance =

-142 wte

3235 estab

3113 in post

Variance =

-122 wte

3235 estab

3130 in post

Variance =

-105 wte

3235 estab

3128 in post

Variance =

-107 wte

3235 estab

3123 in post

Variance =

-112 wte

3267 estab

3111 in post

Variance =

-156 wte

3288 estab

3105 in post

Variance =

-183 wte

3272 estab

3107 in post

Variance =

-165 wte

Comparison of the wte staff in post

numbers with the wte budgeted

establishment number gives an indication

of the level of unfilled posts in the Trust.

These are of two main kinds - those going

through the recruitment process, which

are by far the majority, and a much

smaller number which are being held for a

variety of reasons, such as during

workforce reprofiling exercises or for which

a recruitment exercise was unsuccessful

and which need to be readvertised in due

course.

The variance between wte establishment

staffing and wte staff in post on the last

day of the month decreased in M3 to -165 Substantive

Starters

Headcount and WTE (excl junior

medical staff)Monthly

58

(50.57 wte)

41

(34.31 wte)

52

(45.20 wte)

67

(64.10 wte)

57

(53.59 wte)

37

(31.88 wte)

50

(45.94 wte)

48

(43.53 wte)

33

(26.04 wte)

40

(33.47 wte)

59

(52.76 wte)

26

(21.42 wte)

34

(28.42 wte)

Recruitment activity continues across the

Trust. All recruitment activities are vetted

by the Pay Spend Review Group,

comprising Executive Directors, Divisional

Substantive

Leavers

Headcount and WTE (excl junior

medical staff) Monthly 57

(52.98 wte)

35

(29.60 wte)

49

(43.68 wte)

55

(44.38 wte)

45

(39.96 wte)

33

(26.27 wte)

29

(26.68 wte)

28

(26.04 wte)

43

(34.97 wte)

68

(54.67 wte)

31

(27.99 wte)

29

(23.76 wte)

37

(30.06 wte)

The most frequently cited reason for

leaving recorded by managers in June was

"Voluntary -Other/Unknown. Where

specific reasons were noted, work-life Nursing Bank and

Agency Requests

Number of individual requests for

temporary nursing cover.

Monthly

2960 shift

requests

=99 per day

2924 shifts

requested

= 94 per day

3291 shifts

requested

=106 per day

3356 shifts

requested

=112 per day

3086 shifts

requested

=100 per day

2906 shifts

requested

=97 per day

2947 shifts

requested

= 95 per day

2979 shifts

requested

=96 per day

3171 shifts

requested

=113 per day

3455 shifts

requested

=111 per day

3144 shifts

requested

=105 per day

3320 shifts

requested

=107 per day

3235 shifts

requested

=108 per day

Demand for temporary nurse staffing

continues to be high, and recourse to

agency staff is required due to the volume

of requests for temporary staffing and the

continued opening of additional beds in

order to support patient care. On

average, 21 additional beds were

opened each day in June, and the

daily number of requests for bank and

agency nurses was 108. Work

continues to ensure Agency spend is

carefully managed and is only used in

exceptional circumstances.

The table below shows the comparative

year on year numbers of available Bank

worker/staff numbers for both qualified

nurses and HCAs.

Nursing Bank and

Agency fill rate

Percentage of requested shifts filled by

the Temporary Staffing Office (excl

cancelled requests).

Monthly 87.64% 90.46% 87.39% 88.03% 87.81% 90.10% 84.60% 88.12% 87.83% 90.29% 91.31% 89.55% 91.68%

The fill rate for temporary nursing staff

rose in June to 91.68%, the highest rate

since this measure was first recorded in

April 2013. This is in the context of

continuing high demand. On average, 21

additional beds were opened each day in

the month.

2012 2013 2014 2012 2013 2014

Bank & Substantive 763 843 867 380 432 435

Bank Only 94 132 114 159 311 290

Registered HCAs


Top



19

6. QUALITY INDICATOR DASHBOARD June 2014

6.1 All target/thresholds are marked as a dotted black line.


Top



20

APPENDIX 1 ~ REFERRAL TO TREATMENT (RTT) EXCEPTION REPORT

Prepared by: Kate Thomas, Trust Performance Manager Reporting month: June 2014

Summary of Risk: The Monitor Risk Assessment Framework 2014-15 RTT operational standards are: Admitted target: 90% of RTT periods where the patient needs to be admitted (as an inpatient or day case) for their first definitive treatment must be completed within 18 weeks of referral. Non-admitted target: 95% of RTT periods where patients received their first definitive treatment in an outpatient (non-admitted) setting must be completed within 18 weeks of referral. Incomplete target: 92% of patients who have not yet started treatment should have been waiting no more than 18 weeks (patients who have had a clock start but have not had a clock stop). Within the PHFT contract with the CCG, it is expected that each of the main specialties achieves all three targets at specialty level. All remaining ‘sub-specialties’ are grouped together into a category ‘X01’; this category must be achieved at aggregated level.

Current position: The Trust RTT position at the end of June 2014: - Admitted target (90%) 95.6% (better than May - 95.3%) - Non-admitted target (95%) 96.7% (worse than May - 96.9%) - Incomplete target (92%) 97.5% (worse than May - 97.6%) At aggregate and Unify specialty level, all specialties passed the admitted target for June 2014. The non-admitted target of 95% was not achieved for Trauma & Orthopaedics (92.3%), Urology (90.7%), ENT (92.2%) or Oral Surgery (92.8%). At the Trust Weekly Performance meeting, monitoring at patient level continues of all patients waiting over 26 weeks for treatment. Reasons for pathway delays are reviewed in more detail with Specialty Managers in addition to this forum.

Actions: Trauma & Orthopaedics (92.3%) The specialty General Manager has been working to clear the T&O backlog and performance has improved since April but looking ahead, the non-admitted position is likely to remain fragile for some months to come, as demand continues to outstrip capacity. Extra sessions are being undertaken opportunistically whenever possible in order to increase capacity, and extra cover is also being sought through. In addition a current middle grade has been appointed to the Hip Fellow post for development, and cover will be sought with RBH. Urology (90.7%) All incomplete 18 week breaches have been booked in in order to clear the backlog. ENT (92.2%) Backlog clearance continues with a number of breaches booked in July through to September. Extra capacity is being made available wherever possible. Oral Surgery (92.8%) A sizeable number of breaches are booked for appointments in both August and September, leaving very few breaches now not booked.


Top



21

APPENDIX 2 ~ EMERGENCY DEPARTMENT PROFESSIONAL STANDARDS EXCEPTION REPORT

Prepared by: Martin Smith, Matron/General Manager Reporting period: 02 – 29 June 2014

The Position: The 4-hour target for Period 3 was met at 95.30%. The Monitor reportable quarter for Emergency Departments is a 13-week period which is divided into two 4-week and one 5-week sub-periods (rather than calendar months). The final performance for Period 3, previous periods and Quarter 1 complete is outlined below

Performance is mixed across the range of performance standards. The clinician seen-time has increased slightly from the previous period. Continued high attendance has mitigated the use of extra medical staffing put in to remedy this. The nurse seen-time has yet to improve since the implementation of a change in the nurse-handover procedure. New procedures in both Majors Rapid Assessment by a Consultant (MRAC) and a new updated nurse-to-ambulance handover procedure have begun but have not yet had an impact on clinician-seen and nurse-assessment times.

Current Position and Actions:

Extra consultant cover at weekends has begun in line with the two new consultants in the department.

Action:

Majors Rapid Assessment by a Consultant (MRAC) has begun.

A direct handover from Ambulance crews to the nurse who will care for a patient has begun. This should

improve care and nurse assessment times.

A quarterly ED Review Group of clinical directors has begun to address issues of flow and specialty

support to ED.

In progress:

The department is actively recruiting new middle-grade and junior doctors to bolster the rota, including the

use of international recruitment agencies.

Hospital-wide escalation procedure is being drafted to help the department cope with spikes in demand.

Implementation of a primary-care facility in the department, to provide GP cover, is being investigated.


Top



22

APPENDIX 3 ~ DIAGNOSTIC ACCESS TIMES: PATIENTS WAITING IN EXCESS OF SIX WEEKS EXCEPTION REPORT

Prepared by: David Clark & Mandy Tanner

General Managers for Medicine and Radiology Reporting month: June 2014

The Risk: 19 examinations in total were waiting more than 6 weeks from referral to diagnostic examination at the end of June 2014. The mandated national return that provides waiting list and activity data for a selection of diagnostic examinations (the DM01) is produced and published on the 10

th working day of the month. The target of less

than 1% of (DM01) patients waiting more than six weeks was met at the end of May. There were 9 examinations waiting over six weeks which represents 0.2% of the DM01 total. This was comprised of 4 MRI examinations, 1 CT examinations, 2 non-obstetric ultrasound examinations, and 2 echocardiography examinations. This report provides an overview of all breaches of the 6-week target, from referral to all diagnostic tests, not just those tests included in the DM01 statutory return.

Current Position: Radiology There were 14 examinations waiting over six weeks at the end of June. This is comprised of 2 non-obstetric ultrasound, 4 MRI, 4 CT, 1 Fluoroscopy, 1 nuclear medicine and 2 PET examinations. 9 examinations are eligible to be declared in the DM01 return MRI The MR cases were all Cardiac, some referred late from DCH. There is work taking place to ensure that all the Cardiac work is accommodated by both Radiology and Cardiology. Non-Obstetric Ultrasound The 2 Ultrasound waits were 1 patient and the examination was rebooked at the patients request. CT 1 of the CT scans was booked after 6 weeks to suit the patient, the other 3 were due to a scanner breakdown. The patients were all scanned within 48 hours, but were over the 42 days . Nuclear Medicine The 1 examination was due to patient choice Fluoroscopy The 1 Fluoroscopy patient was again awaiting confirmation of Menstrual cycle. PET The 2 PET examinations were due to patient choice, patients often prefer to wait until the mobile is available in their area (Poole) Endoscopy There were 3 patients (all active surveillance, i.e. planned) waiting over 6 weeks at the end of June. There were 302 patients on the waiting list as at 30

th June (378 at the end of May) and over 99% of patients

referred to the department are being seen within six weeks.


Top



23

The department is now working at full capacity and this is reflected in the reduction in the number of month end breaches Actions:

Continue to closely monitor the waiting list and flex service to meet demands. Surveillance notes are now being reviewed at least one month in advance and this has resulted in a reduction in potential breaches for surveillance patients.

Cardiology There were 2 echocardiography examinations waiting over 6 weeks at the end of June. Both were patient choice who had been offered early appointments. Actions: Capacity remains tight as recruitment of Physiologists is challenging, we now have Home Office approval for the certificate of sponsorship application submitted for 1 of the 2 overseas applicants. They should be in post for September, with the other by October.


Top



24

APPENDIX 4 ~ APPOINTMENT SLOT ISSUE (ASI) EXCEPTION REPORT Prepared by: Barry Duell/Yvonne Hunter/Nicola Ashby

General Managers – Medical & Surgical

Reporting Month: June 2014

Appointment Slot Issue (ASI): Trust performance for June was 22%

Summary: Provider to ensure that ‘sufficient appointment slots’ are made available on the Choose and Book system. Standard: <4% slot availability issues. The Trust risks fines for every week >10%.

Current Position: At end of June 2014, the Trust position was 22%. The Specialties with the most ASIs were:

Specialty No. of ASIs Polling Range (Weeks)

Rheumatology 125 12

GI & Liver (Medicine & Surgery) 80 12/7

Neurology 75 11

Children’s & Adolescent* 49 Multiple Specialties

Orthopaedics 48 8

Respiratory Medicine 47 6

Gynaecology 46 5 (general) 5 (uro-gynae)

Ophthalmology 24 8

OMF 23 6

Sleep Medicine 19 6

ENT 18 6

Actions for July/August 2014:

Rheumatology:

ASI concerns continue to be discussed at performance meetings. CCG remain appraised of continuing impact of 24% increased referral rates on departmental capacity.

Advert for substantive Consultant now closed. Interviews scheduled for 29th July..

SpR now left. No cover provided by Deanery reflecting national shortage of middle grades. This is being raised and future planning discussed with potential replacement in autumn 2014.

ESP cover continues to provide cover for SpR clinics, sessions remain on choose and book.

Agreement to return chronic pain management to community now agreed. Handover of patients on a monthly basis commences in June.

New Lead Rheumatology Practitioner now in post and new clinic slots opened.

GI & Liver (Medicine and Surgery):

Impact of annual leave and patients requiring named consultant for specific condition diagnosis and management.

Further work being undertaken to understand demand and management of referrals.

Neurology:

ASI’s due to slots lost as a consequence of GPSI retirement.

Locum Consultant contract extended to March 2015. Clinical templates opened to reflect this which will reduce ASI’s.

A draft proposal to progress to review the possibility of a substantive Consultant position is being reviewed.

*Children’s & Adolescent Services ~ Includes all Children booked into the following Specialties Surgery 21 ASIs Paediatrics 12 ASIs ENT 1 ASI Ophthalmology 9 ASIs Orthopaedics 4 ASIs Rheumatology 1 ASI


Top



25

Orthopaedics - Adult:

46 ASI’s received in the four week period 02/06/14 – 29/06/14. Reduction from previous month.

Issues remain insufficient capacity for number of choose and book referrals due to a combination of lack of routine cover for cancelled clinics during the polling range for this period and the overall number of referrals received.

Additional clinics have been provided to address the backlog and reduce the number of long waiters as the first phase of addressing the capacity issues.

Trauma and MSK demand s=discussed with CCG representatives on 25/06/14 who believe patients may be being incorrectly referred to PHFT. CCG to send details of correct pathway to the interface service/acute trusts. PHFT to provide details to CCG of referrals received and source.

Respiratory including Sleep:

Down by 1 Consultant leaving 33% less capacity, maintaining RTT well currently. No appointment at interviews for replacement Consultant on 23

rd May 2014, post will now go out to

Locum advert to manage the service in the short term.

Gynaecology: General Gynaecology:

There has been a 16% increase in referrals in Gynaecology 2013- 2014. Reduced capacity due to the retirement and re-employment of a senior gynaecology consultant who will only now be undertaking oncology work and consultant long term sickness.

GM has met with Medical HR re- looking at increasing capacity through a proposed Specialty Dr post. GM to draft business case for submission

Ophthalmology:

RBCH currently one Consultant down, therefore it is predicted that ASI’s will continue to be problematic for the time being.

OMF:

OMF reduced clinics due to attendances at conference and locum contract ending.

ENT:

ENT continues with 1 consultant vacancy. Interview process has completed and a candidate appointed who will commence in post October.


Top



26

APPENDIX 5 ~ TRAUMA EXCEPTION REPORT

Prepared by: Yvonne Hunter, General Manager – Trauma & Orthopaedics

Reporting month: June 2014

Standard Compliance

1 90% of Fractured Neck of Femur patients operated on within 36 hours of admission (NHFD)

75%

2 95% of Fractured Neck of Femur patients operated on within 36 hours of being deemed clinically appropriate for surgery (CCG)

91%

3 95% of Trauma patients (excluding NOF’s) operated on within 48 hours of being deemed clinically appropriate for surgery

94%

Standard 1: Fractured Neck of Femur patients operated on within 36 hours of admission

Standard 2: Fractured Neck of Femur patients operated on within 36 hours of being deemed clinically appropriate for surgery

Standard 3: Trauma patients (excluding NOF’s) operated on within 48 hours of being deemed clinically

appropriate for surgery


Top



27

Standard 1: Reasons for #NOF breaches in Jun 2014

Reason

Not fit within 36 Hours High INR Low platelets/Low Hb/wait for blood products out of area CVA MI Bradycardia Pre-op echo ordered by anaesthetist

13 (3) (5) (1) (2) (1) (1)

Lack of Capacity – 8 NOF’s admitted Mon 30 June 4

Patient listed but cancelled due to previous cases/reprioritisation of cases

3

Awaited hip surgeon 1

Total 21

Actions Taken:

Detailed action plan in place to address specific issues. To be included as part of a report to the QSP Committee to be held 28 August 2014

Clinical Director reviewing quality access targets to ensure most clinically appropriate target(s) reported.


Top



28

APPENDIX 6 ~ DAY THEATRE SERVICES EXCEPTION REPORT

Prepared by: Vivian Stevens, Head of Theatres

Reporting month: June 2014

The Risk: Day Theatres is not reaching the 80% target

Current Position: Booked utilisation 85% Expected utilisation 85% Actual utilisation 79% Losses on day of surgery 6% Previous calculations have shown that best achievement for Day Theatres ranges between 80 and 82%. This is based on the number of patients that is reasonable to put on each session which range from 2 patients to 6 patients. Based on these levels of activity it is impossible for every list to achieve 85% as any list with three patients or more is already unable to achieve the target. Working on the potential operating time available for each list based on the number of cases utilisation would be expected: 2 patients excluding team brief and turnaround time – 92% 3 patients - 89% 4 patients – 85% 5 patients – 82% 6 patients – 79% Based on the above matrix utilisation available for June 2014 was 85% Day Theatre reached 79% utilisation for June 2014 which is 2% increase in utilisation compared to May 2014. The table below shows the total utilisation in Day Theatres

Day Theatre utilisation

NOV 13

DEC 13

JAN 14

FEB 14

MAR 14

APR 14

MAY 14

JUN 14

% % % % % % % %

OVERALL 77 74 76 79 79 74 77 79

ENT 72 64 80 79 81 78 75 88

General surgery 85 77 88 90 87 73 83 89

Gynae 79 85 73 79 80 81 88 85

OMF 78 70 65 78 83 75 72 78

Trauma 67 72 73 69 67 61 70 70

80% and above 79% - 76% 75% and below


Top



29

The graph above shows the number of patients that were booked for total sessions and the number of completed patient episodes. The patient cancellations on the day for this month were 1.1% which is within the agreed acceptable level of 2%.

Time lost on day of surgery Previous quarter

(Q4)

April 14

May 14

Jun 14

% % % %

Patient unfit 1 2.1 1.6 0.6

Cancellations/DNA’s 1.3 2.3 1.8 0.8

Procedure – less time 0.5 1.4 0.5

Trauma – no patients waiting 2 7.0 2.2 2.2

Patient declined surgery 0 0.6 0.4 0.2

Operation no longer required 0.5 0.4 0.2 0.8

Session under booked 1.7 1.7 2.5 1.8

Beds not available 0 0 0

Clinical/Staff shortages 0 0 0

Kit availability 0 0 0

RAG rating ≤ 2% >2%

The table above shows the percentage of time lost across total sessions in Day Theatres as indicated by the reasons on the chart and the movements, month on month and quarter on quarter. - Trauma no patieints waiting 1.8% - Despite being in Truama escalation during the later part of the month, there was capacity in Day Theatres but there were not enough suitable patients waiting for surgery that meet the day case criteria/or did not need an inpatient bed. - Sessions under booked – although there is a small improvement in the previous month though increasing patient througput were possible, there was still 6 hours lost due to underbooking. Some of this was due to patients short notice cancellation and some was due to the cases not fitting the time left available.

Actions:

-Head of Theatres and Elective Admissions Coordinator will review every theatre list that has underutilised

daily (review previous 24 hours activity) and clearly identify, record and report to Directorates issues relating to

underutilisation.

- Ward Manager is perusing the use of a voice messaging system to contact all patients 7 days before surgery

and remind them of attendance 48 hours before surgery. This should give an opportunity to book alternative

patients if there are cancellations.


Top



30

APPENDIX 7 ~ CANCER WAITING TIMES - EXCEPTION REPORT

Prepared by: Anne Foulkes

Business & Performance Manager

Reporting month: May 2014

The Risk: the following Cancer Waiting Times target was breached in May 20141

The target ‘Two Week Wait for Symptomatic Breast Patients (Cancer Not initially Suspected)’ was not achieved in May, 88.4% (target ≥93%). Provisional results for Quarter 1, however, indicate that the target was achieved for Q1 14/15 with 93.5% of patients first seen ≤ 14 days from receipt of referral

Current Position:

There were 8 patients who breached the target in May; all breaches were due to patient choice. Similar issues

were experienced in both March and April.

Due to a number of actions taken, the position improved considerably in June. 2 breaches were reported due

to patient choice and the target was achieved in the month - the provisional result indicates that 97.9% of

patients were fist seen ≤ 14 days from receipt of referral in June

Actions:

1. GPs continue to be notified of the details of any patient who breached this target due to patient choice

and the GP Locality Leads have agreed to challenge individual GPs on patient choice breaches

2. Monitoring and booking of appointments for this group of patients has been allocated to senior

administrative staff within the Outpatient Department to support robust management of the target

3. Senior administrative staff within the Department are now contacting patients prior to the appointment

date, with a courtesy call, to support patient attendance

4. During June, daily meetings were held with management staff from Outpatients, Breast Surgery and

Oncology departments to manage achievement of the target through identification of changes in

process. It has been agreed that these meetings will continue twice weekly going forward to support

ongoing achievement of the target and with the aim to rollout some of the good practice identified to the

wider Two Week Wait process for patients referred with suspected cancer.

1 Latest published month


Top



POOLE HOSPITAL NHS FOUNDATION TRUST COUNCIL OF GOVERNORS

GOVERNANCE CYCLE (Apr 14)

Code of Governance Reference

REPORTS Q4 May 14

Q1 July 14

Q2 Oct 14

Q3 Jan 15

LEAD

Committee/Reference Groups

Constitution Receive report/minutes from Nominations, Remuneration and Evaluations Committee

AD HOC

AD HOC

AD HOC

AD HOC

Chair

Reference Groups

Receive updates from any of the three Reference Groups:

Membership Engagement

Future Plans and Priorities

Quality Report (Ad Hoc)

X

X X X

MERG Chair

FPP Chair

DoNPS

Regular Reports

Monthly Report Cycle

Receive Chairman's Comments X X X X Chair

A.5.9. Receive Trust Performance Report (assurance of according with terms of authorisation)

X X X X CEO

Good Practice

Receive Strategic Risk Report (Part 2)

X X X X DoNPS

Good Practice

Receive Quarterly Submissions to Monitor (Part 2)

X X X X DoF

Good Practice

Receive Feedback from Monitor on Quarterly Submissions (Part 2)

X X X X DoF

Annual Report Cycle

B.6. Receive outcome of the Chairman’s and non-executive directors’ annual performance evaluation (Part 2)

X Chair/ SID

D.2.4. Approve recommendations from Nominations, Remuneration and Evaluation Committee on Chairman’s and non-executives’ remuneration/ allowances/terms & conditions

X Chair/ CEO

B.6.5. Receive Council of Governors Assessment of collective Performance

X Chair/ Co Sec

A.5.e. Receive Trust's Annual Plan

X CEO/ DoF

Governance�Cycle�Apr�14.doc

Top




REPORTS Q4 May 14

Q1 July 14

Q2 Oct 14

Q3 Jan 15

LEAD

Constitution & A.5.e.

Receive Trust’s Annual Report & Accounts

X DoS/ DoF

Good Practice

Quality Accounts and Financial Accounts audits from Deloitte to the September meeting.

X Ext. Audit

C.3.2. Receive Annual Audit and Governance Report

X

Chair A&GC

Constitution Agree changes to the Constitution (3 yearly - April 16)

X Co Sec

Good Practice

Receive Annual Report/statement on the work of the Nominations, Remuneration and Evaluations Committee

X Chair/ Co Sec

Good Practice

Discuss Content of current year's Quality Accounts

X DoNPS

Good Practice

Review the Register of Interests X Co Sec/ BM

Good Practice

Agree the Governance Cycle X Co Sec/ BM

Good Practice

Receive the Annual Complaints Report

x MD


Ad Hoc Reports LEAD

Constitution If necessary, review/update the Constitution on ad hoc basis

Co Sec

A.5.6. Receive Statement on Engagement with the Board of Directors (last done Nov 07)

Chair

B.2.13. Agree with Nominations, Remuneration and Evaluation Committee the process for nomination of new Chairman and non-executive directors

Chair/ SID

B.2.6. B.7.4.

Appoint Chairman and non-executive directors

Chair/ SID & DoHR

B.2.12. Approval of appointment of Chief Executive

Chair

B.6. Agree the process of performance evaluation for the Chairman and non executive directors (last time April 2011).

Chair


Top




Ad Hoc Reports LEAD

C.3. Agree with Audit & Governance Committee the criteria for the appointment/reappointment and removal of the Trust’s auditors (appointment Oct 12 for 3 years) Receive the Letter of Engagement from the Auditor Appoint Auditors

Chair A&GC/ DoF Chair/ DoF Chair A&G

Constitution Review policy for Composition of CoG and non- executive directors (CoG (Constitution Review) April 15 & NEDs April 14)

Chair

Constitution Review Membership Strategy (June 14)

Co Sec

NREC ToR Review the Terms of Reference of the Nominations, Remuneration and Evaluation Committee (postponed)

Co Sec

MJB Jan 2014


Top




COMMONLY USED ABBREVIATIONS

ABBREVIATION EXPLANATION

18-week target Delivery of a maximum 18-week wait from GP referral to start of treatment (RTT)

A & E Accident and Emergency

A&GC Audit & Governance Committee

AfC Agenda for Change is the pay system for NHS staff implemented in 2004. A summary of the system is available on the Department of Health website

AHPs Allied Health Professionals – physiotherapists, occupational therapists, speech therapists and orthotists. Previously PAMs (Professions Allied to Medicine)

AIRS Adverse Incident Recording System – the Trust’s no-blame system for reporting all clinical and non-clinical adverse incidents and near misses

AQP Any Qualified Provider – this scheme means that, for some conditions, patients will be able to choose from a range of approved providers, such as hospitals or high street service providers.

ASI Appointment Slot Issue

ASU Acute Stroke Unit

c.difficile Clostridium difficile - the major cause of antibiotic-associated diarrhoea and colitis, an intestinal infection that mostly affects elderly patients with other underlying diseases.

CEA Clinical Excellence Awards - given to recognise and reward the exceptional contribution of NHS consultants, over and above that normally expected in a job, to the values and goals of the NHS and to patient care

CHKS CHKS is a national independent provider of comparative performance and benchmarking healthcare data

CEPOD CEPOD (Confidential Enquiry into Perioperative Death) lists are theatre lists specifically dedicated for the provision of emergency surgery

CHC Continuing Healthcare

CIP Cost Improvement Plan

CMT Clinical Management Team

CoG The Council of Governors comprises:

14 public governors who are elected by members of their own constituency – Poole (8); Purbeck, East Dorset & Christchurch (3); Bournemouth (2); North Dorset, West Dorset , Weymouth & Portland (1);

4 staff governors who are elected by members of Trust staff – clinical (3); non-clinical (1);

6 appointed governors nominated by the Trust’s partner organisations – Bournemouth & Poole PCT (1); Dorset PCT (1); Dorset County Council (1); Poole Borough Council (1) Bournemouth Borough Council (1); Bournemouth University (1).

CQC The Care Quality Commission is the independent regulator of health and social care in England. The CQC regulates health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations, and protects the rights of people detained under the Mental Health Act

CQUIN Commissioning for Quality and Innovation - the CQUIN payment framework makes a proportion of providers' income conditional on quality and innovation. Its aim is to support the vision set out in High Quality Care for All of an NHS where quality is the organising principle. The framework was launched in April 2009 and helps ensure quality is part of the commissioner-provider discussion everywhere.

CRES Cost Releasing Efficiency Saving

CRT Clinical Record Tracking – a bar-code based system for recording the location of patients’ medical records.

Glossary�of�abbreviations�Feb�

Top




DATIX National software programme for Risk Management

DME Department of Medicine for the Elderly

Dr Foster Dr Foster Intelligence, a joint venture between the Department of Health’s Information Centre and a private sector company Dr Foster LLP. Dr Foster provides a range of health information to the public (online and via supplements in the national media) and makes NHS performance data available under licence to health sector organisations

DToC Delayed Transfer of Care

EBITDA Earnings Before Interest, Taxation, Depreciation and Amortisation

EBME Electrical, Biomedical Equipment

ENT Ear, Nose and Throat

ESR Electronic Staff Record - the national, integrated Human Resources (HR) and Payroll system used by all NHS organisations throughout England and Wales. The ESR has a bi-directional interface with NHS Pensions. Personal data for all staff will be transferred to a data warehouse. This will include contact details, salary information, HR records, trainings, qualification, occupational health and other records. It will also include sensitive information such as sickness record absence, disabilities, ethnic origin

EWTD European Working Time Directive - lays down minimum requirements in relation to working hours/rest periods/annual leave for all workers and working arrangements for night workers. The current limit is an average of 48 hours work per week.

FCE Finished Consultant Episode is a measurement which assigns a patient’s episode of care to a consultant

FFCE First Finished Consultant Episode identifies the first consultant episode of care during a patients hospital stay

FIC Finance & Investment Committee

Foundation Trust/FT

NHS foundation trusts are autonomous organisations, free from central Government control. They decide how to improve their services and can retain any surpluses they generate, or borrow money, to support these investments. They establish strong connections with their local communities; local people can become members and governors. These freedoms mean NHS foundation trusts can better shape their healthcare services around local needs and priorities. NHS foundation trusts remain providers of healthcare according to core NHS principles: free care, based on need and not ability to pay. Poole Hospital NHS Foundation Trust was authorised on 1 November 2007

FRP Financial Recovery Plan.

H@N Hospital at Night - the provision of multi disciplinary teams working in hospital Out of Hours who between them have the full range of skills and competencies to meet patients’ immediate needs

HDU High Dependency Unit, for patients requiring close monitoring and high levels of care but not life support

HR Human Resources

HRG Healthcare Resource Group – groupings of treatment episodes which are similar in resource use and in clinical response

HSE Health & Safety Executive

ICU or ITU Intensive Care Unit or Intensive Therapy Unit

I&E Income and Expenditure

IT or IM&T Information Technology or Information Management & Technology

KSF Knowledge & Skills Framework - identifies the knowledge and skills that individuals need to apply in their post. Used to provide a fair and objective framework on which to base review and development for all staff

LNC Local Negotiating Committee – the main management/medical staff forum


Top




LoS Length of Stay

LTFM Long Term Financial Model

MDT Multi-Disciplinary Team

Monitor The independent regulator of NHS Foundation Trusts. Monitor rigorously assesses applicants for NHS foundation trust status and subsequently monitors their activities to ensure that they comply with the requirements of their terms of authorisation. Monitor has powers to intervene in the running of a foundation trust in the event of failings in its healthcare standards or other aspects of its activities, which amount to a significant breach in the terms of its authorisation

Mortality rate The ratio of total deaths to total population in a specified community or area over a specified period of time. The death rate is often expressed as the number of deaths per 1,000 of the population per year.

MRSA Methicillin Resistant Staphylococcus Aureus – an antibiotic resistant infection commonly found on the skin and/or in the noses of healthy people. Although usually harmless at these sites, it may occasionally get into the body (eg through breaks in the skin such as abrasions, cuts, wounds, surgical incisions or indwelling catheters) and cause infections. These infections may be mild (eg pimples or boils) or serious (eg infection of the bloodstream, bones or joints). An infection of the bloodstream is called a bacteraemia

MSC Medical Staff Committee

NCEPOD NCEPOD (National Confidential Enquiry into Perioperative Death) lists are theatre lists specifically dedicated for the provision of emergency surgery

NHSLA National Health Service Litigation Authority – the NHS clinical “insurance” scheme

NICE National Institute for Health & Clinical Excellence

NICU Neonatal Intensive Care Unit

NPfIT National Programme for Information Technology

NPSA National Patient Safety Agency

NSF National Service Framework - sets national standards and identifies key interventions for a defined service or care group. Also sets measurable goals within specified time frames.

NREC Nominations, Remuneration & Evaluations Committee - a sub-committee of the CoG responsible for the making recommendations to the CoG regarding the appointment, remuneration and performance review of the Chairman and non-executive directors

NVQ

National Vocational Qualification

OMF Oral Maxillo Facial

OFT Office of Fair Trading

PA/SPA Programmed Activities and Supporting Professional Activities. PAs identify medical staff clinical sessional commitments. SPAs are defined as “activities that underpin direct clinical care. This may include participation in training, medical education, continuing professional development, formal teaching, audit, job planning, appraisal, research, clinical management and local clinical governance activities.”

PACS Picture Archiving and Communications System – the digital storage of x-rays

PALS Patient Advice and Liaison Service - provide information, advice and support to help patients, families and their carers

PBC Practice Based Commissioning – an initiative which enables clinicians and other front line staff to redesign services that better meet the needs of their patients

PbR Payment by Results - the funding system for the NHS in England. This pays a standard tariff for the treatment of different conditions. Not all hospital activity is funded by PbR and hospitals still have to negotiate “block funding” to cover these areas – eg. diagnostic and screening tests.


Top




PCT Primary Care Trust. The two local PCTs are now known as NHS Bournemouth & Poole and NHS Dorset.

PEAT Patient Environment Action Team - PEAT team Inspections are a national initiative coordinated by the Department of Health

PFI Private Finance Initiative

PEWS Poole Early Warning System – a system to identify and alert staff of the deteriorating patient based on scoring patient observations against a number of criteria. Patients causing ‘alarm’ are reviewed by the nurse in charge of the ward and an emergency call made to switchboard requesting attendance of a member of the patients medical team or on call team

PHFT Poole Hospital NHS Foundation Trust

PMETB Postgraduate Medical Education and Training Board

PMO Programme Management Office

PROM Patient Recorded Outcomes Measures

PTIP Post Transaction Implementation Plan

PYLL Potential Years of Life Lost

QIPP The Quality, Innovation, Productivity and Prevention Programme. This is about ensuring that each pound spent is used to bring maximum benefit and quality of care to patients.

QSP Quality, Safety and Performance Committee

RBH Royal Bournemouth & Christchurch Hospitals NHS Foundation Trust

RCI/Reference costs

Reference Cost Index – reference costs are the average cost to the NHS of providing a defined service within a given financial year. The RCI compares the actual cost of activity with the same activity at national average costs - organisations with costs equal to the national average score 100 whilst an organisations with a score of 80 or 115 has costs 20% below/ or 15% above the national average. The RCI is used for benchmarking and as the basis of PbR

RTT Referral to Treatment. The current RTT Target is 18 weeks.

Self-funding patients

This relates to patients who are not eligible for funding of future long-term care due to personal assets over the agreed threshold of £23,250, therefore they are deemed to be responsible for funding their care themselves.

SHA Strategic Health Authority – NHS South West is one of the ten Strategic Health Authorities in England formed on 1 July 2006

SLA Service Level Agreement - a SLA is an agreement that sets out formally the relationship between service providers and customers for the supply of a service by one or another.

SLM Service Line Management

SLR Service Line Report

SMR Standardised Mortality rate – see Mortality Rate

SpR Specialist Registrar – medical staff grade below consultant

SPF Staff partnership Forum – the main management/ staff forum, previously known as the JCNC (Joint Negotiating & Consultation Committee)

STEIS Strategic Executive Information System

SUI Serious Untoward Incident

TAL

NHS Direct provides The Appointments Line service as part of the Choose & Book system. Choose and Book is the electronic hospital appointments booking system. It allows people to make their first outpatient appointment online, at their GP practice, or by calling the Appointments Line (TAL). Patients can choose the place, date and time of the appointment to suit them.

VTE Venous Thromboembolism

WTE Whole Time Equivalent

Apr 2014


Top



Deloitte proposal document A4 - Poole Hospital July 2014 Part 1 Board... · 2014. 7. 23. · CoG...

Documents

Transcript of Deloitte proposal document A4 - Poole Hospital July 2014 Part 1 Board... · 2014. 7. 23. · CoG...