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MINUTES OF THE PUBLIC BOARD MEETING 30 January 2020

Seminar Rooms, Leeds Biomedical Research Unit, CAH

Present: Linda Pollard Trust Chair Mark Chamberlain Non-Executive Director Suzanne Clark Non-Executive Director (exited at agenda item 13.2) Lisa Grant Chief Nurse Julian Hartley Chief Executive Tom Keeney Associate Non-Executive Director Jenny Lewis Director of Human Resources & Organisational

Development Moira Livingston Non-Executive Director Jas Narang Non-Executive Director Dr Yvette Oade Chief Medical Officer (exited at agenda item 12.1(i)) Chris Schofield Non-Executive Director (joined at agenda item 4.1(ii)) Bob Simpson Non-Executive Director Clare Smith Chief Operating Officer Professor Paul Stewart Non-Executive Director Craige Richardson Director of Estates and Facilities Tricia Storey-Hart Associate Non-Executive Director Simon Worthington Director of Finance In Attendance: Saj Azeb Deputy Chief Operating Officer (for agenda item 12.1(ii) Jo Bray Company Secretary

Helen Christodoulides Deputy Chief Nurse/ Director of Corporate Nursing (for agenda item 13.2)

Jordan Faithwaite Education, Learning and Organisational Development Managers (for agenda item 4.1(ii))

Vickie Hewitt Trust Board & Membership Administrator Robert Newton Associate Director of Policy and Partnerships Robyn Swain,

Education, Learning and Organisational Development Manager (for agenda item 4.1(ii))

Observing: Lisa Cooke CQC Phil Wood Medical Director, Strategy and Planning Apologies: Gillian Taylor Associate Non-Executive Director

There were six members of staff in the public audience

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Agenda Item

ACTION

1 Welcome and Introductions

The Trust Chair welcomed members of the public audience to the meeting. She welcomed Lisa Cooke, CQC as an observer to the meeting and reflected on the future visit to Leeds Teaching Hospitals NHS Trust (LTHT) from the CQC Board. She congratulated Phil Wood on his successful appointment to the future Chief Medical Officer (CMO) role and commended his performance at interview which was echoed by Moira Livingston.

2 Apologies for Absence

Apologies for absence were received from Gillian Taylor, and it was noted that Dr Yvette Oade would be exiting the meeting from 3.30pm to attend a University of Leeds (UoL) Council meeting.

3 Declarations of Interest

There were no declarations of interest and the meeting was quorate.

4 Patient Story

4(i) Kari’s Story – a Leeds Experience’

Lisa Grant introduced the Patient Story video entitled ‘Kari’s Story - A Leeds Experience’: https://www.youtube.com/watch?v=4UpMCJyr9Eo&feature=youtu.be She explained that the video had been generated by Healthwatch Leeds in response to the CQC Leeds system review and was one of a series of videos being made to capture patient experience in Leeds as people move between system providers. She continued that the aim for these videos was to support better conversation between providers and improved ways of working to benefit patients. She highlighted the specific learning for the Trust of the discharge and medication process and invited Liz Mellor, Governance Lead Pharmacist from the audience to provide an overview of current improvement work within pharmacy to support faster discharge. Liz Mellor reported positively on feedback from patients and improved data results. Moira Livingston reflected on the wider systems understanding of the Do Not Resuscitate (DNR) documentation and Dr Yvette Oade updated on the move away from these to the use of RESPECT forms which based conversations more firmly around patient’s wishes. Julian Hartley informed that the city-wide Partnership Executive Group (PEG) was following Kari’s story through a series of video updates and reflected on the value this provided to understanding services from a patients perspective. The Board received and noted the update.

Staff Experience

4(ii) Apprenticeships

In attendance: Jordan Faithwaite & Robyn Swain, Education, Learning and

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Organisational Development Managers Jenny Lewis provided a brief overview of the LTHT apprenticeship programme and reflected on the benefits it had provided to the overall workforce. She referenced the LTHT People Plan and the support provided through apprentices to ‘hard to recruit’ to areas. Referencing the IQPR at agenda item 12.1(i) she confirmed that the Seven People Priorities (7PP) had been cascaded to CSU’s with associated metrics to report assurance against progress. She reflected on the bottom up approach to the 7PP and the development of entry-level roles to challenge historic staffing structures. Robyn Swain updated on the positive engagement from CSU’s who were taking ownership of these opportunities. Chris Schofield joined the meeting She introduced James Morley, Apprentice Clinical Support Worker (ACSW) and Debbie Moffatt, Business Administrator Apprentice (BAA) to share their experience of the programme. Both James Morley and Debbie Moffatt were positive of their experience to date and shared their future ambitions which the Board explored in more detail. Jordan Faithwaith and Robyn Swain presented an update to the Board on the Apprenticeship Programme to date with the key highlights summarised below:

Apprenticeship Levy introduced 2017 and applied across a wide range of apprenticeships.

40 apprenticeship programmes available within the Trust built upon entry level foundations.

Wide range of Apprenticeships available including: CSW, BAA, Nursing, HR consultant, Data Analyst and Engineering.

589 current apprentices across the Trust.

Average monthly spend (through the Levy) had increased year on year.

Strong link to pre-employment programmes.

Expansion of Degree and Master level apprenticeships.

Alignment to people priorities and wider workforce strategy. The presentation concluded with an overview of the Lincoln Green and Hidden Talents projects. The Trust Chair enquired further about the Lincoln Green Project and Jordan Faithwaite provided further explanation noting the need for individuals to have refugee status before applying. She updated on the Charities supporting the programme and shared positive feedback received. She continued that there was an engagement session scheduled the following week for 40 applicants shortlisted from a pool of 300. Robyn Swain reflected positively on engagement with the local community as part of the programme.

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Craige Richardson commended the programme and updated the Board on the benefits of the Lincoln Green Project within Estates and Facilities (E&F) team. Jas Narang enquired on the retention levels of apprentices who had successfully completed their training and Robyn Swain committed to reporting back on this. Post-Meeting Note: The retention rate for the ACSW programme was confirmed as 67.6% for 2018. Later programmes are still in training therefore accurate retention data is not yet available. The Board thanked James Morley and Debbie Moffatt for sharing their experiences.

Robyn Swain

5 Draft Minutes of the Last Meeting

The draft minutes of the last meeting held 28 November were agreed to be a correct record subject to the following amendments:

Craige Richardson to be included as present on the attendance page.

Vickie Hewitt

6 Matters Arising

There were no matter arising listed on the agenda and none were raised during the meeting.

7 Review of the Action Tracker

The action tracker was reviewed and progress noted.

8 Chair’s Report

The report provided an update on the actions and activity of the Chair since the last Board meeting. The Trust Chair drew attention to the NHS Leadership meeting in December hosted by NHS England/ Improvement (NHSE/I) which had provided an opportunity to explore and reflect on the priorities for the NHS as a result of the re-election of Government. She highlighted the recent visit of delegates from Malta and the formal launch of the Lord Moynihan Surgical Fellowship. She thanked David Berridge, Medical Director for Operational and Roy Charlton, Head of Commercial for co-ordinating the visit which supported further development of the Memorandum of Understanding between LTHT and the Maltese Ministry of Health. The Board received and noted the report.

9 Chief Executive’s Report

The report provided an update on news across the Trust and the actions and activity of the Chief Executive since the last Board meeting. Julian Hartley referenced the headline news story in relation to the LGI in the days prior to the December election. He reported that a full review had taken place in the Board Workshop and noted the agreement by the Executive Team to expand the Childrens Assessment Treatment (CAT)

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Unit prior to the media attention. He highlighted the progress that was taking place against the Building the Leeds Way (BtLW) programme, noting the maternity services consultation had opened on 13 January 2020 led by Commissioners. He highlighted areas of development planned for the 2020 year which included the Nursing and Midwifery Conference, opening of the new Clinical Research Facility and the change in law around organ donation. He reflected on the current operational pressures as a result of the winter period and referenced the global concern over the Coronavirus. He provided assurance of the national preparations across the NHS and Dr Yvette Oade provided additional assurance on local procedures and response protocols. Julian Hartley referenced the national media attention in relation to NHS maternity services. Tricia-Storey-Hart shared the assurance she had received from her recent engagement with the maternity leadership team. She noted the positive feedback received by the service from the CQC maternity survey assessment (published 28 January 2020 - https://www.cqc.org.uk/provider/RR8/survey/5 ) Julian Hartley highlighted the recent consultant appointments set out on page four which the Board endorsed. Moira Livingston queried if these were new posts or replacements and Jo Bray noted the action from the previous meeting to summarise this information in the March Chief Executive Update report with an annual review of the Consultant appointments. Julian Hartley updated on progress towards moving to Smoke-Free Hospital status and noted the policy review that would take place to support this ambition. Prof Paul Smith fed back a recent experience of bereaved relatives smoking outside of the hospital and there was a wider discussion on the sensitive nature of challenging smokers on hospital grounds. The discussion noted the need to review the current infrastructure as part of the policy review and the drive towards the Health & Wellbeing agenda. Julian Hartley highlighted the inclusion of the current draft of the West Yorkshire and Harrogate (WY&H) Health and Care Partnership Five Year Plan in the Blue Box at agenda item 9.1 which had been included for information. He reflected on the partnership work across the region and highlighted this as a positive example of collaborative working. The Board received and noted the report.

10 Minutes of Meetings

Audit Committee

10.1 Chair’s Summary Report

The report provided an overview of significant issues of interest to the Board, highlighted key risks discussed, key decisions taken and key

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actions agreed by the Audit Committee at its meeting on 3 December 2019. Suzanne Clark noted the attendance of Sue Brear, Chair of the Leeds CCG Audit Committee at the previous Audit Committee meeting as an observer, and informed she had also been invited to attend the March meeting. She highlighted the agreement of the Audit Committee’s objectives for the coming financial year. She updated on the Committee’s review of patient property loses noting these were of small monetary value but invaluable to individuals. Assurance had been received of the processes in place and some follow-up had been requested to identify any common themes/ occurrences. She noted External Auditor was developing a summary policy to define and support any activities outside the commissioned year-end work in line with best practice. She updated that the Committee had reviewed the strategic risks and governance associated with workforce on the Board Assurance Framework (BAF) and informed the next review would be on the partnership risks. She explained the changes to the Value for Money (VfM) statement as part of the year-end process reporting that the Committee had requested to see a sample format. She continued that there had been a robust discussion on the use of Single Tender Waivers (STW) with Chris Slater, Associate Director, Commercial and Procurement in attendance and assurance received on the appropriateness of the application of the STW process. She updated on the assurance received of the work of the Counter-Fraud Team with positive engagement reported across the Trust. She reported that the Committee had reviewed the draft accounting policies prior to the year-end reporting period with no significant changes to report. She noted that Chris Schofield had stepped down as a member of the Committee and thanked him for his support. The Board received and noted the report

Workforce Committee

10.2 Chair’s Summary Report

The report provided an overview of significant issues of interest to the Board, highlighted key risks discussed, key decisions taken and key actions agreed at the Workforce Committee meeting held 29 November 2019.

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Mark Chamberlain updated on the Committee’s inaugural meeting confirming the agreement of the Terms of Reference (ToR), Forward Plan and governance structure. He summarised the changes to the remits of the sub-committees to allow for more focussed discussions. He noted the closure of the Research, Education and Training (RET) Committee and confirmed Education and Training (E&T) would be reported through the Workforce Committee moving forward. He confirmed the Committee would measure its progress throughout the year against the measurements set out within the 7PP which would be measured through the CSU Joint Accountability Framework. He highlighted the Deep-dives received by the Committee on Free from Discrimination, Health and Wellbeing, and Workforce Planning and confirmed the assurance received. Following a query from Moira Livingston, Mark Chamberlain confirmed the Committee would raise any escalations to other committees as appropriate and Jo Bray noted the standing item that had been included on all committee agendas to highlight areas for escalation to the Board or other committees. The Board received and noted the report.

10.3 Remuneration Committee

28 November 2019 Summary Notes

The summary notes of the extra-ordinary Remuneration Committee meeting held 28 November 2019 were received and noted.

11 Risk

11.1(i) Corporate Risk Register

The Corporate Risk Register (CRR) was presented to the Board for consideration and challenge to confirm that the correct strategy had been adopted to ensure potentially significant risks were kept under prudent control. Julian Hartley summarised the report noting the CRRS 6 (risk of an influenza

pandemic) would remain on the CRR in light of the emerging risks around Coronavirus. He informed of the addition to the CRR of CRRS 15 (failure to provide

radiology images and reporting due to loss of the PACS system) with a risk score of 16. He updated that the CSU had seen the mitigating actions lead to improvement in the back-log however informed this risk would stay under review until the risks to the system upgrade were fully mitigated. He highlighted the removal of CRRS 7 (risks to the delivery of the aseptic service)

and CRRS 13 (inadequate national supply if Total Parenteral Nutrition for Home) from the CRR and commended the work of the teams involved in taking mitigating action to reduce these risks scores. He reported positively that CRRF 1, which was linked to the delivery of the

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Financial Plan, had seen a reduction in score from 20 to 15 as the year-end approached. Julian Hartley noted that mitigations that were commercially sensitive had been removed from the reporting in the public domain however provided assurance that these were reviewed as part of the Board Workshop meeting. Suzanne Clark reflected on her observations of the robust discussions that took place at Risk Management Committee (RMC) and provided assurance on the scrutiny and oversight provided. The Board received and noted the update.

11.1(ii) UK Exit from European Union

The report provided an update on the Trust’s current status with regards to the preparations for the UK leaving the EU and consideration of residual risks and future actions. Clare Smith reported that the NHS had been directed to pause planning for a no-deal EU Exit following the ratification of the EU Withdrawal Bill meaning the UK will leave on 31 January 2020. The Trust Chair reflected on the quality of the updates received by the Board over the past two years and thanked Adam Bland, Head of Resilience for the assurance he had provided. Jenny Lewis confirmed that the Workforce Committee would oversee any potential workforce risks. The Board received and noted the report.

12 Quality and Performance

12.1(i) Integrated Quality & Performance Report

The Integrated Quality & Performance Report (IQPR) was presented for discussion. The Trust Chair explained the deep-dives of this data that had taken place within the Board Assurance Committee structure. It was noted that from March 2020 the report would also incorporate digital metrics. Clare Smith drew attention to page 6 and updated on the Ambulance Handover performance and reminded of the 100% target to complete all ambulance handovers within 15 minutes. She set out the Trust’s performance for December:

SJUH - 956 handovers greater than 15 minutes (34.6%), average handover time: 13:25 minutes.

LGI - 487 handovers greater than 15 minutes (24.2%), average handover time:11:12 minutes

She expanded on the local improvement work taking place through a designated Leeds Improvement Method (LIM) Workstream and noted the deployment of new IT software in December 2020 which should support further improvements in handover times. The Trust Chair reflected on the

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feedback received from her 1:1 meetings with the Chair of the Yorkshire Ambulance Service (YAS), who had commended LTHT for not having ambulances backed up at A&E with long handovers. Julian Hartley referenced the challenging position other trust’s were facing and reflected on the recent media attention of this. Clare Smith highlighted the Cancelled Operations performance highlighting the improvements seen in December 2019. Bob Simpson summarised the Deep-dive into this standard received by the Finance and Performance (F&P) Committee the previous day and assurance received on the levels of focus and support. Moving to the Cancer Waiting Times (CWT) performance set out from page 8, Clare Smith reported that both the 2 Week Wait (ww) and 31 Day standards had been achieved during November (noting that Cancer data was validated one month behind other performance indicators). The Trust Chair reflected on the multi-factorial challenges faced by the Breast service in relation to the 2ww pathway and commended this turnaround. Clare Smith reported the 62 Day performance at 70.1% which whilst below target, remained within normal process control limits. She updated on the work taking place to optimise cancer pathways and explained the focus to achieve a decision for treatment by day 38 and driving this across the region. Prof Paul Stewart requested that actual numbers as well as percentages be included in the reporting of this data which was agreed. Drawing attention to page 12 Clare Smith set out performance against the Emergency Care Standard (ECS) which for December was 79.3% (against a trajectory of 88.6%). She noted the significant increase in attendances compared to the previous year which equated to a 4.04% increase in adults and a 10.54% increase in Paediatrics. She updated on the proactive actions been taken to support flow within the hospital which had included ‘bringing forward’ several of the actions set out in the Decision Management Tool (DMT). Moira Livingston reflected on the discussions that had taken place at the Quality Assurance Committee (QAC) and commended the Safety Walkrounds undertaken by the Executive Team to provide visibility and support. Reporting against the Referral to Treatment (RTT) performance Clare Smith highlighted the consecutive improvement that had been seen over the previous three months with December performance at 84.88%. She continued that the Total Waiting List (TWL) size (at December) was 57,302 (5,979 better than the trajectory of 63,281) noting that a Deep-dive had been received the previous day by the F&P Committee. Bob Simpson, as a member of the F&P Committee confirmed the Committees support and assurance of the actions in place to further address this. Julian Hartley reflected on the Spinal Summit held in 2019 with regulators and the acknowledgement to agree a sustainable plan and achievable trajectory noting the national capacity challenges. Prof Paul Stewart referenced the Leadership Walkrounds that had taken place that day and

Clare Smith

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reflected on the support and capacity provided through theatre utilisation at CAH. Clare Smith provided assurance that this was being closely monitored to ensure no unforeseen impact on other services. Referencing the Outpatients Measures on page 15 Clare Smith noted that a Business Case had been approved the previous day by the F&P Committee to introduce Intelligent Automation technology to release staff time to focus on valued added processes whilst routine tasks were performed to a consistent output by the robot. She explained this would initially be rolled out within the Outpatients CSU before wider roll-out across the Trust. Following a query from the Trust Chair, Clare Smith committed to reporting the national DNA data to the Chair in their next 1:1. She noted the increased pressure to the TWL size from the use of the Referral Assessment Service (RAS) booking system which had been ‘switched off’ in four specialities to prevent automatic referral into the Trust where other options were available. She confirmed that the Quality Management Group (QMG) were monitoring this position with assurance and escalation to the F&P Committee as required. Moving to page 42 she summarised the Super Stranded Patients (SSP) position noting the detailed update received at the Board Workshop that morning. She reflected that this remained a challenging position for the Trust however work with system partners continued to strengthen. She highlighted the addition of a ward social work team leader to the SSP weekly review process meetings to further support work regarding external delays. Saj Azeb joined the meeting Dr Yvette Oade updated on the Trust’s mortality indicators summarised on page 20 for the reporting period August 2018 – July 2019. Both the Summary Hospital Mortality Indicator (SHMI) and the Hospital Standard Mortality Rate (HSMR) had seen a slight increase however remained within expected limits. She explained the underlying causes which was predominantly around patient coding when considering the acuity of patients (noting the Trust was both a Tertiary and Major Trauma Centre). She updated on continued work with external reference organisations to fully understand this. Moira Livingston provided additional assurance of the detailed reviews undertaken quarterly by the QAC (who had previously sought additional explanation and assurance from Dr Foster regarding the HSMR) and reported positively of this escalation and information sharing process. Drawing attention to page 23, Dr Yvette Oade summarised the C Diff position noting the changes to the allocations process in April 2019 which saw case definitions 1 and 2 attributed to the Trust if the case was detected after two days of admission. Referencing the MRSA performance, she reported that since April 2019 the Trust had had two cases of MRSA bloodstream infection, and

Clare Smith

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highlighted the achievement of the longest time between cases at 204 days. In relation to VTE she updated that risk assessment rates had been consistently improving since February 2019, with November 2019 achieving 96%. The year-to-date position was 94.7% just below the 95% target. Moira Livingston updated on the discussion at QAC regarding the variation across CSU’s and collaborations to share and encourage good practice. Lisa Grant highlighted the Complaints performance for December 2019; she reported that December had being a challenging month with only 10% of responses sent within the 40 working day target defined by the Trust. Following a query from Mark Chamberlain she clarified that this standard was for the closure of the complaint and not the initial contact. Lisa Grant updated on the focussed work taking place in reducing waste and other work to improve complaint handling time. She noted that the externally commissioned review of the Trust’s complaint process was due to report to the QAC in April 2020. Dr Yvette Oade exited the meeting Tricia Storey-Hart referenced her recent engagement with the maternity services and updated they had nominated a member of staff to lead on complaints. She confirmed they were making good progress with this and were keen to share learning with other CSU’s. Craige Richardson updated on the Estates sustainability agenda and reported that the Greener NHS Campaign had launched the previous week. He noted the performance metrics set out on page 38 and updated on progress against the Sustainability Development Management Plan (SDMP) noting a full report had been provided to the F&P Committee the previous day. Drawing attention to page 29 he summarised performance against the measures placed on Patient Environment and noted that a PLACE (Patient-led Assessments of the Care Environment) announcement had been published that morning. He provided a verbal update and confirmed the Trust had improved in year and compared well against both regional and national peers. He confirmed a more detailed update would be provided to the Board in March. The October results had seen Cleaning Standards reported as high from both an internal and external perspective and patient and internal catering standards rated 5 (very good) in the food hygiene rating. Patient satisfaction of food had also increased over the last quarter. Tom Keeney reflected on the importance in understanding these softer measures which made a big difference to patient experience. Jenny Lewis updated on the current workforce position and planning noting the new format of reporting. She reflected on the development of the Workforce Committee and the re-design of its sub-committee to provide greater assurance and focus. She reported that Resource

Craige Richardson

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Management Group (RMG) were providing management of the deployment of the 7PP to CSU’s and were providing support to workforce plans to reduce the overall number of workforce risks. She highlighted the performance measures agreed to provide clear performance expectations set out on page 32. There was a wider discussion on the actions taken to improve the quality of appraisals noting the actions agreed by the Executive Team. Drawing attention to page 33 she updated on the Leeds Health and Care Academy which was now open and the need to continue to form strong partnerships to ensure success which the Board explored in more detail. Simon Worthington summarised the current financial position set out from page 46 and reported that the Trust continued to forecast delivery of its control total. He highlighted the increased capital spend throughout the year reminding that a significant portion of the Capital Programme was backlogged to the final quarter. It was noted that the F&P Committee had received assurance of the reminder of the programme for 2019/20. Moira Livingston explored the variance in the Cash Position SPC chart on page 48 and Simon Worthington explained the quarterly allocation of Provider Sustainability Fund (PSF) payments and the phasing of income from the CCG. The Board received and noted the report.

12.1(ii) Progress Against Winter Planning

In attendance: Saj Azeb, Deputy Chief Operating Officer Saj Azeb presented a Deep-dive to the Board updating on progress against winter planning. He reminded of the pro-active approach to winter planning through the use of the Winter Gantt Chart, Bed Modelling Analysis, DMT and Operational Response Guidance. He presented several SPC charts detailing the performance over the winter period and highlighting seasonal trends which the Board explored in detail. It was noted that variability had reduced significantly on the SPC charts which evidenced the system was in greater control. He outlined the mechanisms in place for receiving additional assurance on patients safety and quality during the winter including the Nurse Staffing Status Report (NSSR) tool, Safety Checklists and Safety Walks. The Trust Chair commended the progress that had been made and the improvements for patients despite the increased attendances over the winter period and capacity challenges across the City. Julian Hartley reflected on the new models for collating and analysing data to better inform the Trust’s understanding of the operational pressures. There was

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a wider discussion by the Board noting the continued work of the frontline teams and impact on patient experience. The Board received and noted the report Saj Azeb exited the meeting

12.2(i) Nursing & Midwifery Quality & Safety Staffing Report

The report provided the Board with key nursing and midwifery workforce data and described staffing levels in relation to the safety and quality of care provided. Data in the report was provided for October and November 2019. Lisa Grant provided context to the understanding and transparency of the data reported to the Board. She referenced the use of national staffing tools integrated with professional judgement and explained the ability to flex the nursing establishment to respond to patient acuity. She drew attention to section 3 which summarised the results for October 2019; Of the 87 inpatient areas reviewed 23 areas had reported less than an average of 80% fill rate against their planned staffing levels. None of these clinical areas had triggered the safety and quality requirements in the formal escalation process of the Ward Healthcheck however three had however scored as Amber in the ward metrics audit. She drew attention to the quality indicators of these areas at Appendix 1 and confirmed she had met with the ward managers with assurance received on the actions taken. Highlighting section 4 she presented the November 2019 results: Of the 87 inpatient areas reviewed 16 areas had reported less than an average of 80% fill rate against their planned staffing levels. Of these 16 one area had triggered the safety and quality requirements in the formal escalation process of the Ward Healthcheck. She expanded on the first stage of the escalation process and confirmed the area had developed an action plan with appropriate support being provided to ward leaders. She noted further analysis was available at Appendix 2. She reported there had been no significant updates regarding maternity staffing since the previous Board with the midwife: birth ration static at 1:26-27. She reminded of the strengthened escalation processes for reporting safety and quality concerns through the Nurse Staffing Status Report (NSSR) with wards rating the safety of each shift in relation to available staff and patient acuity and dependency. She highlighted the rating of a BLUE shift status which indicated unmitigated safety concerns and triggered an immediate operational response. She reported that during October one shift had reported as Blue and provided assurance over the mitigating actions taken. She reported that from November all CSU’s had commenced reporting RED Flags via the DATIX system to escalate staffing concerns. She

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explained that Nursing Red Flags were events that had an impact on the way care was delivered to patients, therefore requiring a prompt response by the Nurse in Charge or a more senior nurse to mitigate patient safety concerns. She reminded that Nursing Red Flags could be raised at any point during any shift by any member of staff. She continued that 17 Red Flag events were reported in DATIX during November and summarised the responses in line with standard operating procedures which led to a senior nurse review and staff redeployed if deemed necessary. She informed that the Nursing Establishments had been agreed for each area with Roster templates currently being updated on workforce systems ready for implementation in the 2020/21 financial year. She highlighted the commencement of the international recruitment with Health Education England informing the first cohort of nurses was scheduled to arrive in February. Moira Livingston commended the formatting of the report which had allowed for focussed quality discussions at the QAC on the impact of actual staffing against the quality of the services. Prof Paul Stewart reflected on the correlation of the trends to provide assurance and reflected that underpinning this was also skill sets and capability which prompted wider discussion. The Board received and noted the report.

12.2(ii) BLUE BOX ITEM - Supplementary Information Quality & Safety Staffing Report

Supplementary information to support the Quality & Safety Staffing Report at agenda item 12.2(i) was provided in the Blue box for information and was received and noted.

Strategy and Planning

13.1 Building the Leeds Way

The report provided an update on delivery against the Building the Leeds Way (BtLW) programme and outlined the 2020 key activities. Simon Worthington summarised the report and noted that as the programme planning and design stages advanced so would the report. He highlighted progress to date which included:

Finalisation of the Pathology OBC and Outline Planning Application – both documents to be formally submitted in early February 2020.

Secured Outline Planning Consent for the Hospitals of the Future Project (November 2019).

Submission of the Hospitals of the Future Strategic Outline Case.

Finalisation of up-dates to the Hospitals of the Future Outline Business Case ready for submission in February 2020.

Commencement of the formal public consultation on the proposed centralisation of maternity and neonatal services.

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The Board received and noted the report.

13.2 Caring the Leeds Way Annual Update

In attendance: Helen Christodoulides, Director of Corporate Nursing Lisa Grant set context to the update reminding that the previous set of objectives associated with Caring the Leeds Way would conclude in 2020. Helen Christodoulides presented an update to the Board on progress against the Caring the Leeds Way objectives. She provided an overview of the 48 underpinning objectives categorised against each of the Trust’s five corporate goals which had made up the 2018-20 Nursing, Midwifery and Allied Health Partners (AHP) Professional Commitment. She highlighted a selection of improvements throughout the year including:

Increased accessibility to adult and children leaflets;

Increased Matron and AHP forums;

Digital champions across all CSU’s;

Standardised workforce information being implemented via Safe care and NSSR tool (improve deployment);

‘Think Family’ approach to safeguarding embedded into Nursing Specialist Assessment.

Suzanne Clark exited the meeting Lisa Grant updated on the development of the strategy for 2020-22 noting that moving forward AHP’s would have a separate set of unique objectives. She explained the use of the LIM to support alignment of the vision and strategy from Board to Front line staff and confirmed the integration with the 7PP and wider strategic plans. She summarised the initial areas of focus which included increasing recruitment and improving retention, the Leeds Excellence in Practice Programme and alignment of the Perfect Ward with People Link Boards. She informed of the desire to formally launch the new objectives at the 2020 Nursing & Midwifery Conference. The Board received and noted the update.

14 Governance and Regulation

14.1 Amendments to Standing Orders, Standing Financial Instructions & Scheme of Delegation

The Board was asked to approve the following amendments to the Trust’s Standing Orders, Standing Financial Instructions and Scheme of Delegation:

ToR for a new assurance Committee of the Board - Building and Development Committee (BDC);

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Amendments to the ToR for the Digital and Information Technology (DIT) Committee;

Amendments to Committee membership;

Inclusion of the process of amending a variation to a PFI contract with the defined thresholds.

Jo Bray summarised the report, highlighting the changes to the membership of Committees set out on page 2 and noted the ToR for the DIT Committee and BDC were provided as agenda item 14.1 (G) and 14.1(I). The Board received the report and approved the changes as described.

Items for Information

15.1 BLUE BOX ITEM - Forward Planner

The Forward Planner was provided in the Blue Box for information and was received and noted.

15.2 BLUE BOX ITEM – FOI Requests Annual Report

The Freedom of Information (FoI) Requests Annual Report was provided in the Blue Box for information and was received and noted.

Standing Agenda Items

16 Issues from the Meeting for Consideration on the Corporate Risk Register

There were no items arising from the meeting for escalation for consideration to the CRR.

Legal Advice

There were no items arising from the meeting that may warrant the consideration of legal advice.

Issues to be Reported to CQC or NHS England/ Improvement

There were no issues from the meeting to be reported to the CQC or NHSE/I.

17 Review of Meeting and Effectiveness

It was agreed that sufficient time had been allowed for each item to allow effective discussion.

19 Any Other Business

No other business was discussed.

Date of next meeting: Thursday 26 March 2020