Pack Page 1 of 37 - Mersey Care NHS Foundation …...AGENDA FOR Board of Directors Meeting Date:...

AGENDA FOR

Board of Directors Meeting Date: Wednesday 29 April 2020 Time: 2.30pm to 4.30pm

Venue: Meeting to be held by Skype

PLEASE NOTE – due to the COVID-19 outbreak this meeting will not be a face-to-face meeting in order to permit social distancing - as such the meeting will not be open to the public (please see the Opportunity for Questions from the Public section below). All papers will be published on the website together with the minutes of the meeting when they become available. Members will be expected to have read all the papers prior to the meeting with sufficient time to raise questions (and allow a response): i) those items intended for discussion at the meeting (highlighted in yellow) - these items will have been

identified following discussion between the Chair, Lead Director and Trust Secretary – the key determinant will be whether it is judged to be business critical;

ii) all other items will normally not be discussed (this will include both papers for decision and papers for information / to note). Members are being asked to raise questions by email to the Trust Secretary, who will then liaise to obtain a response. Both the question and the response will be circulated to all members and included in the minutes of the meeting;

iii) in some instances, due to capacity pressures, an item may be supported by an Overarching Committee Paper, rather than a Separate Paper in support of an individual item. This is clarified on the agenda below.

No. Item Lead Details Comment

A A1 Welcome B Fraenkel Verbal to note

B Board of Directors Business

B1 Member’s Apologies: Attendee’s Apologies:

B Fraenkel Verbal to note Comments re the minutes and declarations to be submitted via email

B2 Declarations of Interest Virtual by Email (Information Requested) – members to inform by email the Corporate Governance Team if they have a conflict in respect of any of the items on the agenda

B Fraenkel Verbal to note

B3 Minutes of the Meeting held on 25 March 2020 Virtual by Email (Separate Paper) – to be sent week commencing 20 April

B Fraenkel Paper for decision

B4 Board of Directors Log / Action Plan Virtual by Email (Separate Paper) – to be sent week commencing 20 April

B Fraenkel Paper to note

B5 Matters Arising:

B6 Board Assurance Framework Item for Discussion (Separate Paper) – to be sent week commencing 20 April

N Thomas Paper for decision Item to be discussed

C Our Services

C1 Overarching Committee Report a) Trust Response to COVID-19 – Update b) Patient Safety and Quality Update

T Bennett

N Thomas / T Bennett

Verbal to note

Verbal to note

Items to be discussed

C2 CQC Inspection Report – The Breightmet Centre for Autism Virtual by Email (Separate Paper) – to be sent week commencing 20 April

T Bennett Paper to note Q&A via email

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D Our People

- No items

E Our Resources

- No items

F Our Future

- No Items

G Our Governance

G1 Board Governance Report a) COVID-19 Board Governance Framework b) Policies Update

Virtual by Email (Separate Paper) – to be sent week commencing 13 April

A Meadows

Paper for approval Q&A via email

H End of Meeting Actions

H1 Risk Reflection Virtual by Email (Information Requested) – members to inform by email the Corporate Governance Team if they have a risk they wish to be considered

All

H2 Reflection on the meeting and whether any issues need to be referred to a Board Committee Virtual by Email (Information Requested) – members to inform by email the Corporate Governance Team if they have any matters they wish to be referred

All

H3 Any Other Business Virtual by Email (Information Requested) – members to inform by email the Corporate Governance Team if they have any matters for discussion – this will then be raised with the Chair

Members

Opportunity for Questions from the Public Please note – normally Mersey Care’s Public Meeting of the Board of Directors is a meeting held in public, rather than a public meeting in which the public may participate. However in light of COVID-19 outbreak, the trust has taken a decision to hold this meeting virtually, which will permit the trust to implement social distancing by reducing face-to-face meetings across the trust in favour of meetings by phone / video conferencing. In making this decision, the trust has taken account of the letter from NHS England / Improvement’s Chief Operating Officer of 28 March 2020 entitled Reducing burden and releasing capacity at NHS providers and commissioners to manage the COVID-19 pressures, which states:

“while under normal circumstances the public can attend at least part of provider board meetings, Government social isolation requirements constitute ‘special reasons’ to avoid face to face gatherings as permitted by legislation”

This means that meetings will not be open to the public whilst COVID-19 arrangements are in place. The papers for meetings will continue to be posted on the Trust’s website and minutes of the meetings – including any questions and answers to Board papers raised by members of the Board – will also be published on the website

Should you wish to ask a question about the issues addressed in any of the papers for this meeting, please address your question to the Trust Secretary ([email protected]) and the trust

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mailto:[email protected]

will endeavour to respond to you within 21 days.

We hope your recognise that we are doing this to help protect both our staff and members of the public by reducing the opportunities for transmission through social distancing during the COVID-19 outbreak. The trust will review this decision on a regular basis taking account of national guidance. We will also investigate options for members of the public to join our meetings virtually.

The Board of Directors is invited to adopt the following resolution: ‘That the Board hereby resolves that the remainder of the meeting to be held in private, because publicity would be prejudicial to the public interest, by reason of the confidential nature of the business to be transacted’. [Section (2) of the Public Bodies (Admission to Meetings) Act 1960]

Dates of Future Meetings:

• 20 May 2020

• 29 July 2020

• 30 September 2020

• 25 November 2020

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Agenda Item No: B3

Status of these minutes (check one box):

Draft for Approval: ☒ Report to: Board of Directors

Formally Approved: ☐ Meeting Date: 29 April 2020

MINUTES OF THE MEETING OF THE

Board of Directors – held via Teleconference Date: Wednesday 25 March 2020 Time: 9:30am

Venue: Teleconference

Name Job Title (Division/ Organisation*) *if not Mersey Care

Present: Beatrice Fraenkel Murray Freeman Gaynor Hales Aislinn O’Dwyer Gerry O’Keeffe Pam Williams Nick Williams Joe Rafferty Neil Smith Trish Bennett Arun Chidambaram Noir Thomas Elaine Darbyshire Louise Edwards Amanda Oates

Chairman Non Executive Director Non Executive Director Non Executive Director Non Executive Director Non Executive Director Non Executive Director Chief Executive Executive Director of Finance / Deputy Chief Executive Executive Director of Nursing & Operations Interim Medical Director Operational Medical Director Executive Director of Communications & Corporate Governance Director of Strategy Executive Director of Workforce

In Attendance: Chris Lyons Andy Meadows Sarah Jennings Paula Murphy

Director of Corporate Transformation Trust Secretary Deputy Trust Secretary Corporate Governance Compliance Manager

Apologies Received:

ISSUES CONSIDERED 2020

A1 WELCOME

1. Mrs Fraenkel welcomed all to the teleconference meeting of the Board of Directors, and outlined the etiquette for the meeting.

2. In light of the COVID-19 outbreak, the meeting was being held via teleconference to facilitate social distancing and therefore no members of the public were in attendance, however arrangements would be reviewed going forward to consider how the public could participate.

3. Mrs Fraenkel offered thanks to Mr Meadows and Miss Jennings for their hard work in quickly making arrangements for the virtual meeting and reviewing governance

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Agenda Item No: B3

arrangements, and also to the Executive Directors for their work in maintaining business continuity and supporting each other at this challenging time.

B1 APOLOGIES FOR ABSENCE

4. There were no apologies for absence received for this meeting.

B2 DECLARATIONS OF INTEREST

5. No declarations of interest were made.

B3 Minutes of the Meetings held on:

a) 29 January 2020; b) 26 February 2020;

6. The previous minutes were accepted as an accurate record.

7.

Action Lead Timescale Status

Recommendations approved by the Board, namely: • Approve the minutes of the previous meetings:

a) 29 January 2020; b) 26 February 2020;

Further actions required: • None identified.

B4 BOARD OF DIRECTORS LOG/ACTION PLAN

8. The Board noted the action log.

9.


Recommendations approved by the Board, namely: • Note the action log.


B5 MATTERS ARISING:

a) Coronavirus Update

10. Mrs T Bennett provided a verbal update in relation to the Trust’s response regarding COVID-19 outbreak.

11. Mrs T Bennett stated that the Trust response was as a major incident. As such the Strategic On Call arrangements had been changed from a weekly rota to a daily rota to reflect the nature of the incident and the demands on the On Call Director who chairs the COVID-19 Strategic Coordination Group. The Incident Response Team and Control Room are now working 7 days per week. Mrs T Bennett confirmed that she was the responsible director; however every member of the team had played a significant role in providing support.

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Agenda Item No: B3 12. The daily battle-rhythm included: strategic and tactical on-call staff handover,

directorate/division Sitreps (situation reports) and strategic and tactical daily meetings. There were new arrangements across the local Sustainability & Transformation Partnerships ( STPs), with each STP being expected to establish an Acute Cell and an Out of Hospital Cell. These STP-based cells would coordinate local health systems and requests for mutual aid both within and across local health systems.

13. The Trust is adhering to social distancing for staff and patients, for example with wards ensuring a 2.5 meter distance between beds. Staff who can work at home would, and IT had provided significant support to enable this to take place.

14. To date the Trust had not received any formal requests for mutual aid from other organisations, however general enquiries regarding staff availability had been undertaken as part of their planning arrangements and the Trust have been discussing each organisation’s requirements, although given the Trust’s own absence levels, these would need to be carefully considered going forward. The establishment of the STP cells referred to previously would be a welcome addition to ‘regulating’ formal requests for mutual aid within and across local health systems.

15. In relation to clinical services, the Trust were making dynamic decisions on its business continuity arrangements in respect of maintaining clinical services, either due to internal pressures, decisions to minimise risk to patients and staff or in response to national guidance.

16. Walk in Centres – no national guidance had been provided currently, therefore the Trust were influencing and shaping this guidance. The Trust were working with Primary Care and Clinical Commissioning Groups on a model and remote clinical triage was being undertaken where possible. For those who needed to be seen by a clinician, this could be arranged by appointment. Full implementation of the Walk in Centre model was anticipated to be completed by Friday 27 March/Mon 30 March 2020 at the latest.

17. Mersey Care had stopped all visiting into the Trust services in order to protect patients and staff as well as visitors and telephone support for family members was available wherever possible.

18. Dr Freeman queried how front line staff (e.g., District Nurses) were prioritising their visits. Mrs T Bennett stated that every service had a business continuity plan outlining essentials within that service. District Nursing was an essential service, and where telephone call checks could be made, they would be. Visits, e.g., for end of life care, would continue. Mrs T Bennett confirmed that every service was reviewing each task and making decisions regarding what to continue and what can be done differently/temporarily suspended.

19. Miss O’Dwyer thanked Mrs T Bennett for the fantastic job managing this situation. Miss O’Dwyer stated that she would be joining the clinical cell call later today and highlighted a paper in the New England Journal of Medicine, which gave a suggestion of an ethical framework which may be a helpful starting point.

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Agenda Item No: B3 20. Miss O’Dwyer sought clarity regarding pressures on the 111 service and

communications. Mrs T Bennett stated that in relation to the 111 service, this was coordinated nationally, adding that they had requested support and a call with the North West Incident Lead had been held to discuss options.

21. Mr Rafferty referred to communications, stating that the Trust had a communications lead identified and we would be establishing a more strategic communication profile over the coming weeks to ensure messages were distributed appropriately for staff and to keep the level of communication consistent.

22. Mr O’Keeffe congratulated the Trust on the excellent progress, particularly in relation to local services.

23. Mrs Williams welcomed the briefing, adding that it had been reported in the media that people were volunteering to help the NHS at this time and asked if this was something the Trust were considering taking up. Mrs Oates confirmed Mersey Care were setting up that process within our organisation and work was currently on-going in relation to this. It was clear that people wanted to volunteer to help. The HR team were progressing applications as quickly as possible.

24. Mrs Williams queried whether some of the people who had signed up nationally would come to Mersey Care. Mrs Oates confirmed that predominantly it was expected there would be prioritisation in the acute sector and respiratory care at this time.

25. Mrs T Bennett confirmed that the Board had previously approved the Succession Plan document and stated that arrangements were in place should any key members of the Board fall ill.

26. Mrs Darbyshire referred to communication at this time, stating that it had been a challenge to ensure a balance of information for teams, however a daily briefing was being circulated to ensure staff were informed and provided with concise information. All digital media was being updated and the intranet pages were live with national guidance resources. The website was the main message of communication to the broader community providing contact details and advice. Mrs Darbyshire stated that a special edition of the magazine was being produced in relation to managing mental health during isolation. The Life Rooms had been closed and this was a necessary decision. As much information as possible was being provided online and the YouTube channel for the Life Rooms provided pathways advice and 24/7 psychological support.

27. The response to a social media request for people trained in facilities/catering had been good and HR were working around the clock to process applicants. A specialist supply of cleaners from the North East were available to deep clean any areas necessary over and above the normal cleaning process.

28. In response to Dr Freeman, Mrs Darbyshire confirmed that should there be a major outbreak in any Trust sites; the Board would be informed directly and immediately.

29. Mr O’Keeffe welcomed the outstanding leadership across the Executive Team and asked if the team had any concerns or whether the Non Executive Directors were able

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Agenda Item No: B3

to provide any assistance at this time. Mrs Fraenkel agreed to discuss this offline with Mr Rafferty and report back to Non Executive Directors.

30. Mr Williams referred to staff members still using public transport to get to work and asked if there was any support that could be offered. Mrs Oates confirmed that this was currently under consideration at tactical meetings.

31. Mrs T Bennett thanked the Board for their assistance throughout the situation, stating that this was a team effort and it was clear that if required, any member of the Board was happy to be contacted for further support and in particular, Mrs T Bennett thanked Miss O’Dwyer, Mrs Hales and Dr Freeman for their support.

32. Mrs Fraenkel stated that Non Executive Directors were meeting virtually on a weekly basis and reiterated that Non Executive’s want the Executive Team to ask for help wherever support is required and wished to thank the Executive Team for their hard work and the huge progress achieved.

33.


Recommendations approved by the Board, namely: • Note the verbal update.


B6 CHAIRMAN’S REPORT

34. The Chairman’s report highlighted meetings and events attended in the reporting period along with Non-Executive Director’s visits to services and the Positive Achievement Award winners.

35.


Recommendations approved by the Board, namely: • Note the Chairman’s Report.


B7 CHIEF EXECUTIVE’S REPORT

36. Mr Rafferty provided an update on key issues of interest/information arising since the last Board of Directors that were not already covered in other papers to this meeting.

37. Mr Rafferty referred to a letter from Bill McCarthy, NHS England/NHS Improvement North West Region, regarding the need to establish a hospital cell and an out of hospital cell to better manage the situation across the region. These cells were with regard to direct planning and the objective of the cells was to bring together a consistency of approach in relation to the COVID-19 outbreak. The cells largely consisted of people from Cheshire and Merseyside Partnership and people from other organisations would be drawn across also. Mr Rafferty stated that he has been asked to lead the out of hospital cell, however assured the Board that he would remain the CEO of Mersey Care while undertaking this role. It was anticipated that the cells

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Agenda Item No: B3

would be up and running by early week commencing 30 March 2020, adding that this role was to aid the organisations to feel and move more like a single team, confirming that the role would cease once the COVID-19 outbreak ceases.

38.


Recommendations approved by the Board, namely: • Note the Chief Executive’s Report.


B8 BOARD ASSURANCE FRAMEWORK

39. Dr Chidambaram provided an update on the Board Assurance Framework, assuring the Board that the strategically significant risks were being actively managed. It was however recognised that the Board Assurance Framework required updating in respect of the COVID-19 risks facing the Trust.

40.


Recommendations approved by the Board, namely: • Confirm that the risks are being identified and

managed appropriately; • Identify any risks that need to be escalated as part of

the Board Assurance Framework; • Review and approve if agreed the standing BAF risks

for the financial year 2020/21 outlined in Appendix B;

Further actions required: • Risks in respect of the COVID-19 outbreak need to

be considered and added to the Board Assurance Framework as appropriate

A Chidambarum / N Thomas / F Westhead

Apr-2020

Ongoing

C1 EXECUTIVE PERFORMANCE REPORT

41. Mr Smith provided a summary of Trust performance to 29 February 2020 against Regulatory and Operational Plan key performance metrics.

42.


Recommendations approved by the Board, namely: • Note the assessment of performance against

Regulatory and Operational Plan targets; • Note that performance Improvement Plans have been

presented at the quarterly review meetings to provide assurance that improvement plans are in place for areas of underperformance;


C2 SAFETY REPORT

43. Dr Chidambaram provided an overview of assurance on a range of safety, quality and perfect care issues, outlining issues of concern/good practice, together with progress against action plans to address these issues. The report provided details of key

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learning across the organisation in relation to safety issues relating to service delivery and ensured robust quality improvement plans were in place to increase assurance and reduce risk.

44.


Recommendations approved by the Board, namely: • Discuss the report; • Identify any new risks • Identify an further assurances it requires;


C3 WINTER PLAN DELIVERY UPDATE

45. Mrs T Bennett provided an update on the Mersey Care 2019-20 winter plan which was still being mobilised across teams, noting the plan was making progress and having the expected impact.

46.


Recommendations approved by the Board, namely: • Note the mobilisation of the operational teams to

deliver the plan; • Accept and appreciate the delivery challenges that

have been overcome to achieve the impact to date; • Note the approach for winter 2020-21;


D1 STAFF SURVEY RESULTS AND ANALYSIS

47. Mrs Oates provided the Board with a review of the results of the NHS Staff Survey 2019 and asked the Board to note areas of improvement/areas of concern.

48. Going forward; this update would be provided to the new People Committee.

49.


Recommendations approved by the Board, namely: • Note the findings of the NHS Staff Survey 2019; • Agree that the delivery of the Trust’s People Plan will

be the vehicle for improvement in response to the enclosed findings.


D2 FREEDOM TO SPEAK UP (FTSU)

a) Update Report/Review Outcomes b) Revised Strategy and Policy

50. Mrs Darbyshire provided the Board with an update in relation to the FTSU

review/outcomes along with the revised Strategy and Policy for approval.

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Agenda Item No: B3 51. Dr Freeman referred to paragraph 22 (page 7) of the report, specifically in respect of

concerns raised by Walk In Centre staff, and queried if any further information was available at this time and whether any further action was planned. Mrs Darbyshire stated that due to operational constraints relating to the COVID-19 response, she was unable to obtain a response on this matter today. Information would be sought and a response will be provided to Board members as soon as possible.

52.


Recommendations approved by the Board, namely: • Approve the FTSU Strategy and vision; • Discuss the progress of the FTSU Guardian

introduction to the Trust and clarify if sufficient assurance had been provided in the way Whistleblowing./FTSU concerns are being managed;

• approve the revised and updated FTSU Policy and procedure;

Further actions required: • Provide a response to the issues raise by Dr

Freeman in paragraph 51 above.

E Darbyshire

Apr-2020

Ongoing

D3 NHS WORKFORCE RACE EQUALITY STANDARD (WRES)

DATA ANALYSIS REPORT

53. Mrs Oates provided an update to the Board in relation to the business critical need to address racial inequality and to provide assurance that the NHS standard contract requirement regarding Workforce Race Equality Standard (WRES) was being met.

54.


Recommendations approved by the Board, namely: • Note the progress made to date; • Continue to give senior support to actions taken to

address racial inequality;


E2 CAPITAL PLAN

55. Mr Smith outlined the process followed in the development of the capital programme for 2020/21, confirming that the Trust would adopt the International Financial Reporting Standard 16 (IFRS16) on 1 April 2020. The report included:

a) the proposed additional expenditure on backlog maintenance; b) the proposed operational capital programme for 2020/21; c) the proposed strategic capital programme for 2020/21; d) the funding of the capital programme for 2020/21 and the importance of Asset

Disposals;

56.


Recommendations approved by the Board, namely: • Approve the inclusion of future leases as part of the

annual capital programme;

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Agenda Item No: B3

• Approve the proposed funding for the electrical infrastructure on the Maghull Health Park site;

• Approve the proposed Capital Programme for 2020/21;


F1 STRATEGIC OPERATIONAL PLAN 2020/21

57. Mrs Edwards provided the Board with the Trust Strategy and Operational Plan 2020/21.

58. Dr Freeman sought clarity in relation to how the role of the Centre for Perfect Care fitted into the Trust’s Strategy, asking:

a) What where the governance arrangements for the Centre; b) Which sub-committee oversees its work; c) How was innovation and transformation coordinated across the Trust;

59. In response, Mrs Edwards confirmed that subject to the Trust’s COVID-19 efforts,

detail on the role of the Centre for Perfect Care will follow soon. a) Ray Walker was currently undertaking a review of its role and function, and this

would include proposing new governance arrangements with some Non-Executive Director involvement, likely to be reporting directly into the Quality Committee. We envisage the Centre for Perfect Care having an important role in supporting the delivery of our BEHAGs (zero suicide, zero restrictive practice etc.) and in supporting the Trust-wide quality priorities identified in the operational plan for 2020/21.

b) Innovation and Transformation are not co-ordinated by any single group or committee because we do not categorise our change programmes in this way but in a sense the Operational Plan is our innovation/transformation agenda, and delivery of the Operational Plan is reported against in a number of different forums, e.g. in the Executive Performance Report, relevant metrics from the plan and reviewed by the Quality committee and PIFC; and the integration work is currently overseen by the Integration Group.

60.


Recommendations approved by the Board, namely: • Note the Strategy and Operational Plan 2020/21;


G1 BOARD GOVERNANCE REPORT

61. Mr Meadows provided the Board with an update and sought approval in relation to a range of issues, including changes and updates to the Board’s governance arrangements:

a) Action Plan following Well-led Review – including renaming Board Committees b) Establishing a People Committee – initial terms of reference

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Agenda Item No: B3

c) Fit and Proper Persons Policy Update d) Risk Management Strategy Update e) EPRR Strategy f) Update on Trust’s Policies & Procedures g) Changes to the Scheme of Reservation and Delegation of Powers

62.


Recommendations approved by the Board, namely: • Note the proposed oversight arrangements for the

well-led review via the Audit Committee; • Approve the changes proposed to the Trust’s

governance arrangements outlined in paragraph 9; • Consider and approve the Fit & Proper Persons

Policy (Appendix A) and the Risk management Strategy (Appendix B);

• Note the EPRR strategy and assurance information on Trust policies;


H1 BOARD COMMITTEE MINUTES (INCLUDING CHAIRS’ REPORTS)

(for information)

63. The Committee noted the report.

64.


Recommendations approved by the Board, namely: • Note the report/Chair’s reports.


J1 RISK REFLECTION

65. No items were raised.

J2 REFLECTION ON THE MEETING AND WHETHER ANY ISSUES NEED TO BE REFERRED TO A BOARD COMMITTEE

66. No items were raised.

J3 ANY OTHER BUSINESS

67. There were no further items of business.

68. The meeting closed.

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1

Date of Meeting Agenda Item Action Executive Lead Operational

Lead

Proposed Date of

Completion

Item Status Comments

28 November 2018 - Public Board Meeting

D2-Side by Side WorkingDevelop a means of evaluation of side by side working to provide the necessary assurance to the Board

E Darbyshire M CrillyMar 2019 (Revised to May-20)

Not due

Update received by email from MC 4th July 19 - All relevant paperwork changes have been implemented. The side by side project has stalled due to the inability of clinical teams to commit time and OE&L have been unable to allocate resource. Scaled down pilot and sense check how to proceed. Exec Director lead agreed extension to May -20 as part of Life Rooms Strategy and Plan. Deferred due to COVID-19 outbreak.

31 July 2019 - Public Board Meeting

F1-Life Rooms Update Life Rooms update report to Board of Directors in November

Exec Lead: E Darbyshire Operational Lead: M Crilly

01/11/2019 (deferred to May 2020)

not due

Update to be provided to Board in March 2020 in addition to Life Rooms Strategy. Deferred to May to allow external input. Further deferred due to COVID-19 outbreak.

25 Sept 2019 - Public Board Meeting

B4 - Board of Directors Log / Action Plan

Future arrangements for patient experience and engagement to be fed back to Board meeting with executive leads to decide direction

Exec Lead: A Chidambaram

01/11/2019 (deferred to May 2020)

Not due

Item deferred due to this being part of Good Governance Review, the report of which is being considered by the Board in january 2020. The implications of this on patient experience and engagement arrangements will be reported back to the Board in May 2020. Deferred due to COVID-19 outbreak.

29 Jan 2020 Public Board Meeting

E1-Estates Update Revise Estates Update Report to include timescales and financial information. E Darbyshire

Exec Lead: E Darbyshire Operational Lead: J Worswick

Apr-20 not due On PIFC agenda Apr-20& on Board agenda May-20

Mar 2020 Public Board Meeting

B8-Board Assurance Framework

Risks in respect of the COVID-19 outbreak need to be considered and added to the Board Assurance Framework as appropriate

A Chidambaram / N Thomas F Westhead Apr-20 completed

Mar 2020 Public Board Meeting

D2-FTSU

Provide a response to the issues raised by Dr Freeman, specifically paragraph 22 (page 7) of the report, specifically in respect of concerns raised by Walk In Centre staff, and queried if any further information was available at this time and whether any further action was planned.

E Darbyshire Apr-20

KEYTO ACTIONONGOINGCOMPLETED

28 November 2018 - Public Board Meeting

31 July 2019 - Public Board Meeting

25 September 2019 - Public Board Meeting

29 January 2020 - Public Board Meeting

25 March 2020 - Public Board Meeting

Public - Board of Directors - Action Log

Agenda Item: B4 Pack of 37

Agenda Item No: B6

Report to: Board of Directors Meeting Date: 29 April 2020 This Report is provided: ☐ for a decision ☒ to note / for information ☐ as a consent item

Board Assurance Framework Report V1 (April 2020)

Accountable Director(s): Noir Thomas, Medical Director Report Author(s): Frank Westhead, Trust Risk Manager

Alignment to Strategic Objectives:

Our Services ☒ Integrate Services ☒ Improve population health ☒

Continuous improvement (STEEP)

Our People ☒ Become and employer of choice ☒

Progress our Just and learning Culture goals

☒ Work side by side with service users and carers

Our Resources ☒ Achieve financial

sustainability ☒ Invest in digital technology ☒ Improve our estate ☒ Transform

Corporate Services

Our Future ☒ Develop Provider Alliances ☒

Accelerate research and development

☒ Commercialise our knowledge

Alignment to the Quality Domains:

STEEEP ☒ Safe ☒ Timely ☒ Effective ☒ Efficient ☒ Equitable ☒ Person-centred

CQC ☒ Safe ☒ Responsive ☒ Effective ☒ Caring ☒ Well-led

Purpose of Report: • To present the Board Assurance Framework for the Board’s consideration.

• To provide assurance that the strategically significant risks are being actively managed.

The Board of Directors / Committee is asked to:

The Board are asked to: 1) Confirm that the risks are being identified and managed

appropriately.

2) Identify any risks that need to be escalated as part of the Board Assurance Framework.

Previously Presented to: Committee Name Date (Ref) Title of Report Outcome / Action

Do the action(s) outlined in this paper impact on any of the following issues? Area Yes If ‘Yes’, outline the consequence(s) (providing further detail in the report)

Operational Performance ☒ The Board will have significant assurance for operational performances. Good governance standards require that the trust has robust risk management and assurance process which provide significant assurance to the Trust Board, and through them to our regulators.

Provider Licence Compliance ☐ Legal Requirements ☒ Resource Implications ☐

Equality & Human Rights Analysis Yes No N/A Do the issue(s) identified in this report affect one of the protected group(s) less or more favourably than any other? ☐ ☒ ☐

Are there any valid legal / regulatory reasons for discriminatory practice? ☐ ☒ ☐ If answered ‘YES’ to either question, please include a section in this report explaining why

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Agenda Item No: B6

Return to Executive Summary

EXECUTIVE SUMMARY

1. This report contains the Standing Strategic BAF risks identified by the Trust Board aligned to the Operational Plan and the high scoring fifteen and above risks from across Mersey Care NHS Foundation Trust and the four divisions, including Corporate, Local, Secure and Specialist Learning Disabilities and Liverpool and South Sefton Community Care Divisions and escalated project and programme risks.

2. Currently, there are 28 risks identified in the Board Assurance Framework.

The current BAF consists of: a) 14 current strategic risks identified by the Board. b) 13 Strategically significant divisional risks with a score of 15 or above.

• 3 Liverpool and South Sefton Community Division Risks • 7 Local Division Risks • 3 Corporate Risks

c) 1 Strategically significant programme risk with a score of 15 or above.

3. Of the current fourteen strategic risks identified by the Board (Table 1 - Appendix A), the two highest scoring risks for 2020/21 are Corporate CIP targets and Medical Staffing. a) Failure to achieve the cost savings required in corporate services leads to financial

pressures which limit our ability to make good use of our resources. Risk Score 15

b) Continued overspend in our medical staffing costs limits our ability to make more effective use of our resources. Risk Score 15

4. The three highest scoring risks identified by the Liverpool and South Sefton Community Division (Table 2 - Appendix A) are NWAS delays, the identification of un serviced medical equipment in the community and delays in results by Liverpool Clinical Laboratories. a) If performance issues within Liverpool Clinical Laboratories (LCL) cause delays in

results being received by patients, leading to an increased risk of undiagnosed and untreated sexually transmitted Infections being transmitted to the wider population. Risk Score 15

b) If NWAS are delayed in responding to an incident within the walk in centre causing the patient's condition to deteriorate and increase stress on staff. Risk Score 16

c) If the historic CEDAS data quality and PPM arrangements with contractor Ross

Care lead to patients using un-serviced equipment, breaching HSE regulations and putting patient safety at risk. Risk Score 16

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Agenda Item No: B6


5. The Seven highest scoring risks identified by the Local Division (Table 2 - Appendix A) are adhering to the smoking policy, delays to services in both the ADHD and Talk Liverpool, increased demand for inpatient beds, unfilled consultant vacancies, delays in obtaining accommodation and changes to prescriptions for the Addiction Services . The last two risks are COVID19 related. The accommodation risk as been raised into the BAF due to the impacted of nursing homes closing during the outbreak. The second risk notes the changes to a the frequency of scripts issues to methadone patients to reduce potential exposure to the virus, but potentially increasing the risk of overdose. a) If service users gain access to ignition source then there is an increased risk of

arson incident, accidental fire occurring, damage to property and disruption to services. Risk Score 20

b) If there are unfilled Consultant Psychiatrist vacancies within the Local Division then there is a risk that the quality and safety of care is being compromised. Risk Score 16.

c) If increased demand in inpatient treatment outstrips capacity and flow then this may lead to delays in treatment, pressures on community, acute services and a risk to patient safety. Risk Score 16

d) If the ADHD Service is not appropriately funded then service users' clinical needs may not be met due to insufficient resources and delays in assessment. Risk Score 16

e) If Talk Liverpool are unable to recruit to vacancies then service users may

encounter delays in obtaining therapy and the service could fail to meet the agreed access target of 19%. Risk Score 16

f) (Raised Risk): If service users are delayed in obtaining accommodation and

identified support packages that meet their social needs then their independence, life choices and further recovery may be compromised. Risk Score 15 raised from a 9.

g) (New Risk): If weekly prescribing and reduced supervised taking of medications,

leads to an increased risk of patients overdosing, increased harm and potential death. Risk Score 15

6. There are no strategically significant high scoring fifteen and above risks raised by the Secure and Specialist LD Division.

7. There are three high scoring risks identified by the Corporate Division (Table 2 - Appendix A) for competency and standardisation of clinical risk assessments, ability of the Trust to cope with the outbreak, which was lowered as plans are being enacted and a new risk to monitor the supply of PPE to the Trust, which was reduced slightly as stock levels improved.

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a) (Reduced): If the Trust doesn’t have effective and sufficient resources during the Covid19 outbreak to provide priority mental and physical health services, leading to an increased risk of harm to service users and staff. Risk Score 15 reduced from a 20

b) If a lack of training and standardisation means clinical staff do not have sufficient competency to carry out a risk assessment, leading to serious incidents that result in harm to patients including service users taking their own lives. Risk Score 15

c) (New Risk): If PPE equipment is not available causing an unacceptable risk to

staff and patients, an increased risk of infection, anxiety and a potential reduction in clinical services due to staff refusing to work, or removed from higher risk areas. Risk Score 15 reduced from a 20.

8. One strategically significant programme risks have been escalated by the Risk Management Group for the Specialist LD Contraction Programme. The LSU isolation risk as been reviewed by the programme group and reduced, removing it from the BAF. a) Risk that key programme dates for the clinical model implementation will be

delayed due to commissioners / NHS England not being able to meet critical deadlines. Risk Score 15

Frank Westhead Trust Risk Manager April 2020

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Agenda Item No: B6


Table 1 – Standing BAF Risk Identified by the Board Appendix A BAF

Our Service

Reference Risk Type Title Controls Executive

Owner Impact Likelih

ood Date

Identified

Initial Risk

Rating

Current Risk

Rating Target Score

Target Date

Initial Target Date

Next Review

Date

S.1 Quality Failure to make quality care more consistent will result in quality issues for the people we serve and sustainability issues for the organisation

Pursuit of Clinical Excellence and implementation of Quality and Safety. Accreditation Framework across the Trust. Focus on delivery of CQC ‘good’ as a minimum across all services

Trish Bennett / Noir Thomas 4 3 06-Mar-

2020 12 12 8 31-Mar-2021

31-Mar-2021

29-May-2021

S.2 Quality Failure to implement more preventative and integrated models of care means that we are unable to manage rising levels of demand, workforce and financial pressures.

Clinical strategy priorities implementation of more preventative and integrated care models, reducing the risk of people going into crisis and enabling them to take greater control of their own health and wellbeing.

Trish Bennett 4 3 06-Mar-2020 12 12 8 31-Mar-

2021 31-Mar-

2021 29-May-

2021

S.3 Quality

Failure to understand the needs in our population means that we are unable to design services to effectively meet those needs.

Working with partners through Provider Alliances and the Lead Provider Collaborative will support us to have a richer shared picture of the needs of the population upon which we can act. Focus on service user experience as a priority for the Board.

Louise Edwards 4 3 06-Mar-

2020 12 12 8 31-Mar-2021

31-Mar-2021

29-May-2021

S.4 Quality Failure to deliver transformational change in our community services results in less efficient and effective out of hospital care.

Community integration priorities include further deployment of integrated care teams aligned to Primary Care Networks and the transformation of community mental health services with a focus on highly effective out of hospital care.

Trish Bennett 4 3 06-Mar-2020 12 12 8 31-Mar-

2021 31-Mar-

2021 29-May-

2021

Our People


Owner Impact Likelihoo

d

Date Identifie

d

Initial Risk

Rating

Current Risk

Rating Target Score

Target Date

Initial Target Date

Next Review

Date

P.3 Finance Continued overspend in our medical staffing costs limits our ability to make more effective use of our resources.

Implementation of our plans to address workforce fundamentals and our Just and Learning Culture increases our reputation as an employer of choice.

Noir Thomas 5 3 06-Mar-

2020 15 15 10 31-Mar-2021

31-Mar-2021

29-May-2021

P.1 Quality Failure to implement our People Plan and create a compelling place to work results in continued staffing pressures and impact of quality of services.

Clear priorities are set out in our People Plan to get the basics right for staff and offer continuous development. Monitoring through new People and Culture Committee.

Amanda Oates 4 3 06-Mar-

2020 12 12 8 31-Mar-2021

31-Mar-2021

29-May-2021

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Agenda Item No: B6


P.2 Quality

Failure to adopt new roles and ways of working leads to a widening gap between the needs of the population and our model of care.

Effective workforce planning and support to teams to embed new integrated ways of working. Development of new roles and assessment of clinical competencies in support of new care models

Amanda Oates 4 3 06-Mar-

2020 12 12 8 31-Mar-2021

31-Mar-2021

29-May-2021

Our Resources


Owner Impact likelihood

Date Identifie

d

Initial Risk

Rating

Current Risk

Rating Target Score

Target Date

Initial Target Date

Next Review

Date

R.3 Finance/Quality

Failure to achieve the cost savings required in corporate services leads to financial pressures which limit our ability to make good use of our resources.

Corporate transformation programme including collaboration to generate economies of scale and strategic investment to automate processes. Neil Smith 5 3 06-Mar-

2020 15 15 10 31-Mar-2021

31-Mar-2021

29-May-2021

R.1 Finance/Quality

Failure to implement our digital strategy will effect our ability to meet future demand, workforce and financial challenges.

Prioritised digital tools developed in partnership with clinical divisions offering a range of solutions which can be drawn down to support model of care. Development of productivity return on investment analysis in year ahead.

Neil Smith 4 3 06-Mar-2020 12 12 8 31-Mar-

2021 31-Mar-

2021 29-May-

2021

R.2 Quality

Failure to ensure that corporate services effectively support the needs of the clinical divisions limits our effectiveness

Implementation of operating principles for corporate services and development of effectiveness measures.

Elaine Darbyshire/ Neil Smith/

Amanda Oates

4 2 06-Mar-2020 8 8 4 31-Mar-

2021 31-Mar-

2021 29-May-

2021

R.5 Quality Failure to ensure we have ‘buildings that work for us’ limits our ability to deliver our new models of care.

Prioritisation within Estates Strategy of actions to support integrated care at 30,000 to 50,000 population level and to remove dormitory wards.

Elaine Darbyshire 4 2 06-Mar-

2020 8 8 4 31-Mar-2021

31-Mar-2021

29-May-2021

R.4 Reputational / Quality

Lack of high quality reliable data limits our ability to take intelligence-led decisions.

Implementation of Digital Strategy including new data warehouse and analytical tools to support insight Neil Smith 3 2 06-Mar-

2020 6 6 3 31-Mar-2021

31-Mar-2021

29-May-2021

Our Future



Date Identifie

d

Initial Risk

Rating

Current Risk

Rating Target Score

Target Date

Initial Target Date

Next Review

Date

F.1 Quality Ineffective working with partner organisations results in failure to improve outcomes and reduce inequalities for the people we serve.

Leadership of Provider Alliances in Liverpool and Sefton and of Lead Provider Collaborative for secure services. Louise

Edwards 3 3 06-Mar-2020 9 9 6 31-Mar-

2021 31-Mar-

2021 29-May-

2021

F.2 Quality / Not being a good partner in integrated care Operational Plan is aligned to expectations set out in NHS Louise 3 3 06-Mar- 9 9 6 31-Mar- 31-Mar- 29-May-

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Agenda Item No: B6


Reputational

systems limits our ability to make sure our service users and our communities needs are addressed.

Long Term Plan. Provider Alliances form foundation for providers to collaborate and develop integrated care systems

Edwards 2020 2021 2021 2021

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Agenda Item No: B6


Table 2: Fifteen Plus Divisional / Programme and Project risks raised up into the BAF Liverpool and South Sefton Community Divisional Strategically Significant Risks with a score of 15+

Reference Risk Type Title Controls Exe Owner Impact likeli

hood Date

Identified Initial Risk

Rating

Current Risk

Rating Target Score

Target Date

Initial Target Date

Next Review

Date

298 Quality/Reputational

If performance issues within Liverpool Clinical Laboratories (LCL) cause delays in results being received by patients, leading to an increased risk of undiagnosed and untreated sexually transmitted infections being transmitted to the wider population.

Strategy meeting held by the Sexual Health Clinical Director, Lead nurse, Operational Manager, Office Coordinator and the Appointments and Results Centre Manager to develop a way forward to tackle the risk. Day to day contact with LCL and is manually monitoring test requests sent against the results. Topic being presented to the Executive Safety Huddle as an emerging risk on the 28th November.

Trish Bennett 5 3 27-Sep-

2019 10 15 6 30-Jun-2020

30-Apr-2020

30-Apr-2020

1373 Quality

If the CEDAS data quality and PPM arrangements with contractor Ross Care lead to patients using un serviced equipment, breaching HSE regulations and putting patient safety at risk.

Action plan in place Data cleansing Bank staff team (3 members / bank staff working plan) deployed to contact all 2300 patients holding 3420 items of serviceable equipment

Trish Bennett 4 4 20-Aug-

2018 16 16 8 29-May-2020

31-May-2019

29-Apr-2020

1305 Quality/Reputational

If the NWAS delay responding to an incident within the Walk -In Centres with limited emergency equipment and medication, causing the patient's condition to deteriorate and increase stress on staff.

Staff are escalating when there is a delay Staff escalate to NWAS if patients condition deteriorates whilst awaiting ambulance Risk assessment undertaken on each patient requiring an ambulance to see if safe to send by taxi

Trish Bennett 4 4 21-Nov-

2017 12

16

8 31-Aug-2020

31-Dec-2018

29-Apr-2020

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Agenda Item No: B6


Local Division Strategically Significant Risks with a score of 15+

Reference Risk Type Title Controls Exe


Date Identified

Initial Risk

Rating

Current Risk

Rating Target Score

Target Date

Initial Target Date

Next Revie

w Date

LOC.124 Quality/Reputational

If service users gain access to an ignition source then there is an increased risk of arson incident, accidental fire occurring, damage to property and disruption to services

Service users are informed prior to admission and on admission that the Trust adopts a Smoke Free Policy Service users are encouraged to stop smoking and offered a range of non-smoking solutions and support. Smoking Assessment in place. Environmental sweeps and observation process in place on the wards. Fire detection devices in place & Fire drills undertaken on a six monthly basis. Fire Wardens/Marshalls in place and on-going training in place. Fire Risk Assessment undertaken on a yearly basis. Smoking bins placed back in court yard E cigarette trial in Broad oak

Trish Bennett 5 4 14-Dec-2017 8 20 4 30-Jun-

2020 30-Jun-2018

13-May-2020

LOC.113 Quality

If there are unfilled Consultant Psychiatrist vacancies within the Local Division then there is a risk that the quality and safety of care is being compromised.

Monthly medical management review meetings regarding budget and recruitment continue to take place. Further work is being undertaken as part of the transformation programme to review caseload numbers. Currently, locum staff are used to cover vacancies Recruited ten Physician Associates to cover traditional roles carried out by junior and career grade Dr’s. Progress in writing the Job Descriptions for the CMHT posts and Vacancy Authorisation Forms (VAF). Medical recruit plan continues to be progressed with some recruitment to new posts, but internal candidates only.

Arun Chidamb

aram 4 4 20-Mar-2020 12 16 8 30-Apr-

2021 31-Dec-2017

13-May-2020

LOC.143 Quality

If increased demand in inpatient treatment outstrips capacity and flow then this may lead to delays in treatment, pressures on community and acute services and a risk to patient safety.

Daily Bed Management Meetings and escalation process of conference calls if pressure on beds is at a peak. Raised through Executive Safety Huddle when increase in admission leads to inability to admit patients. RADAR/Delayed Discharge Meetings weekly Review process in place for medical colleagues to review service users who have had a stay of 30, 60, 90 days. Out of area placements, Stepped Up Care, YMCA beds Red 2 Green

Trish Bennett 4 4 19-Nov-2018 12 16 6 31-Aug-

2020 31-Mar-2019

13-May-2020

LOC.154 Quality/ Finance

If the ADHD Service is not appropriately funded then service users' clinical needs may not be met due to insufficient resources and delays in assessment

Operational Managers/ Meeting Financial Sustainability Meeting Data collection via RiO Contracts Meetings

Trish Bennett 4 4 13-Feb-2019 16 16 8 30-Jun-

2020 13-Feb-2020

13-May-2020

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Agenda Item No: B6


Reference Risk Type Title Controls Exe


Date Identified

Initial Risk

Rating

Current Risk

Rating Target Score

Target Date

Initial Target Date

Next Revie

w Date

LOC.152 Quality/

Reputational

If Talk Liverpool are unable to recruit to vacancies then service users may encounter delays in obtaining therapy and the service could fail to meet the agreed access target of 19%.

Social Media and Marketing Event arranged for 2019 Silver Cloud software obtained Agency staff and nursing Bank Linking with Liverpool John Moore's University around training package for Assistant Psychological Wellbeing Practitioners (PWP) •Away-Day Event •CPD •Supervision

Trish Bennett 4 4 13-Feb-2019 16 16 8 31-May-

2020 30-Sep-2019

13-May-2020

LOC.147 (Raised) Quality

If service users are delayed in obtaining accommodation and identified support packages that meets their social needs then their independence, life choices and further recovery may be compromised

Risk score raised due to increased pressure due to the COVID-19 Outbreak. The closures/restrictions of some Care Homes preventing service users discharge from hospital, receiving their agreed care package. (COVID-19 Pandemic information noted in Bold) •Daily Conference Calls with Care Homes. •Information of which Care Homes are shut or have restrictions in place is provided on a daily basis. •Information (as above) is shared with Modern Matrons and used to inform discussion around Bed Allocations. •RADAR / DTOC Meetings. RADAR Meetings with Local Authority (Liverpool and Sefton) in attendance. •Weekly overarching meetings held in which Local Authority and CCG attend. •Weekly EMS monitoring twice daily. •Red 2 Green •Complex Care Meetings held on a monthly basis to discuss service users who are difficult to place.

Trish Bennett 3 5 9 15 6 31-Jul-

2020 30-

Sept-2019

13-May-2020

CV-14 (New)

Quality / Reputationa

l

If weekly prescribing and reduced supervised taking of medications, leads to an increased risk of patients overdosing, increased harm and potential death.

Risk added on due to change in processes in the Addiction Service Due to the COVID-19 outbreak - Addiction Service developed risk grading for patient at greater risk of overdosing. - Providing some daily scripts for high risk patients - Allowing a designated person to pick up the script for a patient

Trish Bennett 5 3 03-Ap-2020 15 15 10 30-May-

2020 30-

May-2020

13-May-2020

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Agenda Item No: B6


Corporate Division Strategically Significant Quality Risks with a score of 15+

Reference Risk Type Title Controls

Executive Owner

Impact

Likelihood Date


Rating

Current Risk

Rating Target Score

Target Date

Initial

Target

Date

Next Revie

w Date

PS 8 Quality/

Reputational

If a lack of training and standardisation means that clinical staff do not have sufficient competency to carry out a risk assessment this could lead to serious incidents that result in harm to patients including service users taking their own lives.

- Level 1 and level 2 core training - Delivered wither face to face or available as an e-learning package - Modules are delivered by Quality Improvement staff member - Over 400 staff members have completed the risk assessment modules within the suicide prevention package. - Trust Policy

Trish Bennett 5 3 11-Mar-

2019 15 15 5 01-Jun-2020

01-Oct-2019

25-Apr-2020

EPRR (Reduced)

Financial/Quality/Regulatory/Reputa

tional

If the Trust doesn’t have effective and sufficient resources during the Covid19 outbreak to provide priority mental and physical health services, leading to an increased risk of harm to service users and staff.

Risk Reduced by Executive Owner due to increased levels of planning and preparation by the Trust to manage the COVID 19 outbreak and maintain primary services. Command and control processes put in Business Continuity and Impact Assessment plans for all divisions Plans to be reviewed as part of confirm and challenge workshops Working from home to reduce footfall. All non essential training to be rescheduled Staffs support line to be set up. Digital solutions such as Skype to Business and extended VPN capacity, being rolled out Pressure testing exercise to be carried out on the 20th March. Clinical staff in the Corporate Division to be identified in case of redeployment.


2020 20 15 10 30-Aug-2020

30-Aug-2020

30-Apr-2020

CV-2 (New)

Quality/ Regulatory/ Reputationa

l

If PPE equipment is not available causing an unacceptable risk to staff and patients, an increased risk of infection, anxiety and a potential reduction in clinical services due to staff refusing to work, or removed from higher risk areas.

Risk placed on to monitor the supply of PPE to the Trust. The risk was lowered slightly after the Trust received a number of key deliveries - Procurement team members imbedded with Infection Control - Senior management escalation to NHS England - Infection Control team on call to deliver PPE to teams out of hours. - Identifying storage that can be accessed 7 days a week for storage of PPE. - Audit of Trust locations to identify existing stock. - Increased training and fit testing for staff. - Development of SOP's and guides for use.


2020 20 15 10 31-May-2020

10-April-2020

24-Apr-2020

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Agenda Item No: B6


Programme Project Strategically Significant Quality Risks with a score of 15+

Programme

Reference

Risk Type Title Controls

Exe Owner Impa

ct

Likelihood Date


Rating

Current Risk

Rating Target Score

Target Date

Initial

Target

Date

Next Revie

w Date

Specialist LD Contraction

SPLD CM 03 Finance

Risk that key programme dates for the clinical model implementation will be delayed due to commissioners / NHS England not being able to meet critical deadlines

Divisional COO in discussion with TCPs regarding interim solution The Operational Delivery Network (ODN) has made recommendation to the TCP for future requirements, type and number of beds. Awaiting feedback from TCP. NHSI have confirmed they will not approve the Outline Business Case (OBC) until the funding is confirmed in November by the STP. Business Case submitted in July for a soft review by NHSI to avoid delays to the process. Following the submission queries from NHSI have been answered. OBC approved by the PIFC in August and the Board in September.

Trish Bennett 3 5 12-Nov-

2015 8 15 4 31-

May-2020

01-Dec-2017

25-Apr-2020

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Agenda Item No: C2

Report to: Public Board of Directors Meeting Date: 29 January 2020 This Report is provided: ☐ for a decision ☒ to note / for information ☐ as a consent item

CQC Inspection Report – The Breightmet Centre for Autism

Accountable Director(s): Trish Bennett, Executive Director of Nursing & Operations

Report Author(s): Fran Cairns, Deputy Director of Therapies & AHPs Andy Meadows, Trust Secretary


Our Services ☐ Integrate Services ☒ Improve population health ☒


Our People ☐ Become an employer of choice ☐


☒ Work side by side with service users and carers

Our Resources ☐ Achieve financial

sustainability ☐ Invest in digital technology ☐ Improve our estate ☐ Transform

Corporate Services

Our Future ☐ Develop Provider Alliances ☐


☒ Commercialise our knowledge


STEEEP ☒ Safe ☒ Timely ☒ Effective ☒ Efficient ☒ Equitable ☒ Person-centred

CQC ☒ Safe ☒ Responsive ☒ Effective ☒ Caring ☒ Well-led

Purpose of Report: To allow members of the Board of Directors to: 1) consider the Care Quality Commission’s (CQC) inspection report

of the Breightmet Centre of Autism when this service was registered with Mersey Care

Recommendation: The Board of Directors is asked to: 1) consider and note the content of both this report and the CQC’s

inspection report


Quality Committee Jan 2020 Breightmet Centre for Autism Report Noted


Operational Performance ☐ For a short period the Breightmet Centre for Autism was registered as a location with the CQC as a service provided by the Trust Provider Licence Compliance ☒

Legal Requirements ☒ Resource Implications ☒

Equality & Human Rights Analysis Yes No N/A Do the issue(s) identified in this report affect one of the protected group(s) less or more favourably than any other? ☐ ☒ ☐

Are there any valid legal / regulatory reasons for discriminatory practice? ☐ ☐ ☒ If answered ‘YES’ to either question, please include a section in this report explaining why

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Agenda Item No: C2

EXECUTIVE SUMMARY

1. As members of the Board will recall, from 18 July 2019 until 1 November 2019 Mersey Care took over the Care Quality Commission (CQC) registration of the Breightmet Centre for Autism from its existing provider, ASC Healthcare Limited.

2. Whilst this service was registered with Mersey Care, the CQC undertook an inspection on 15 October 2019. Attached is the inspection report that was published by the CQC on 6 April 2020.

BACKGROUND

3. The Breightmet Centre for Autism in Bolton is an 18-bed service for men and women owned by ASC Healthcare that offers assessment, care and treatment to people with autism and/or a learning disability informally, or to people who are detained under the Mental Health Act.

4. Following a number of CQC inspections in June and July 2019 the CQC issued a Section 31 Notice under the Health and Social Care Act 2008 to remove the CQC registration from the Breightmet Centre due to serious concerns about the care, treatment and welfare of patients and the risk of harm posed. This should have resulted in the immediate closure of the Centre and the urgent transfer of patients to other units, which could have been detrimental to their care and treatment. Following a request by NHS England/Improvement (with the agreement of the CQC), and so as to ensure the safety of patients and avoid an urgent transfer, Mersey Care offered its assistance which resulted in the trust assuming the registration for the service.

5. A memorandum of understanding was agreed between the Trust and ASC Healthcare (who retained the service contracts, continued to own the premises and employ most of the staff) which enabled the Trust to provide a Senior Manager, a Matron and a Specialist Practitioner to work within the service alongside the ASC Healthcare staff team. Therefore from July 2019 Mersey Care became accountable for the delivery of care to patients, with governance and oversight through the Secure and Specialist Learning Disability Division.

6. During the period of being the registered provider, Mersey Care undertook a range of assessments and worked with ASC Healthcare, NHS England/Improvement and a number of Clinical Commissioning Groups (who commissioned this service) to develop and implement an action plan to improve both the service provided and the physical environment. ASC Healthcare sought to appeal the Section 31 notice through the courts during this period and was successful in this appeal at the beginning of November 2019. This resulted in ASC Healthcare assuming registration with the CQC for this service from 1 November and Mersey Care withdrew from the service on 5 November 2019 as part of a managed handover between Mersey Care and ASC Healthcare.

7. On the 15 October 2019, whilst the Centre was still registered with Mersey Care, the CQC undertook an inspection visit, the report from which was published by the CQC on 6 April 2020. As members can see, the CQC found “significant improvements in the quality of care and the care environment, making it safe for the remaining

Page 2 of 3

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Agenda Item No: C2

patients” since its last inspections in June and July 2019 which had led the CQC to issue the Section 31 Notice. Given the circumstances which led to this report, it was unrated by the CQC and it only focussed on 2 of the 5 domains, namely are services safe and are services well-led.

8. Since December 2019, a contract has been in place with Bolton Clinical Commissioning Group (CCG) for Mersey Care to provide additional oversight and scrutiny of the service, with Bolton CCG as the overarching host commissioner responsible for the quality oversight of the service on behalf of all the CCG’s.

9. Mersey Care has continued to provide independent clinical assurance and support to the Centre through (i) weekly attendance at the ward round from a Learning Disability nurse to provide advice and support to the Centre’s staff, and (ii) a monthly review of standards and checking of sustained quality to support delivery of the action plans. Mersey Care have representation on the newly established ASC Quality Board chaired by Bolton CCG, however does not have any responsibility for service delivery at the Breightmet Centre or for ensuring that recommendations are implemented by ASC Healthcare or Bolton CCG. This contracted support is due to finish at the end of May 2020.

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Agenda Item No: G1

Report to: Public Board of Directors Meeting Date: 29 January 2020 This Report is provided: ☐ for a decision ☒ to note / for information ☐ as a consent item

Board Governance

Accountable Director(s): Elaine Darbyshire, Executive Director of Communications & Corporate Governance

Report Author(s): Andy Meadows, Trust Secretary Sarah Jennings, Deputy Trust Secretary


Our Services ☐ Integrate Services ☐ Improve population health ☐


Our People ☐ Become an employer of choice ☐


☐ Work side by side with service users and carers

Our Resources ☐ Achieve financial

sustainability ☐ Invest in digital technology ☐ Improve our estate ☐ Transform

Corporate Services

Our Future ☐ Develop Provider Alliances ☐


☐ Commercialise our knowledge


STEEEP ☐ Safe ☐ Timely ☐ Effective ☐ Efficient ☐ Equitable ☐ Person-centred

CQC ☐ Safe ☐ Responsive ☐ Effective ☐ Caring ☒ Well-led

Purpose of Report: To inform members of the Board of Directors 1) on the processes that will be used to maintain assurance to the

Council of Governors, the Board and its Committees during the COVID-19 outbreak through a COVID-19 Governance Framework (part 1 of this paper);

2) about the temporary changes approved by the Board to trust-wide policies during the COVID-19 outbreak (part 2 of this paper)

Recommendation: The Board of Directors is asked to: 1) consider and comment on this issues highlighted in the paper



Operational Performance ☐ To ensure the trust continues to provide assurance to the Council of Governors, The Board and its regulators on its activities throughout the COVID-19 outbreak Provider Licence Compliance ☒

Legal Requirements ☒ Resource Implications ☐

Equality & Human Rights Analysis Yes No N/A Do the issue(s) identified in this report affect one of the protected group(s) less or more favourably than any other? ☐ ☐ ☐

Are there any valid legal / regulatory reasons for discriminatory practice? ☐ ☐ ☐ If answered ‘YES’ to either question, please include a section in this report explaining why

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Agenda Item No: G1

PART 1 - COVID-19 GOVERNANCE FRAMEWORK

A INTRODUCTION

1. The Government’s advice to stay safe, stay home and social distancing in response to the COVID-19 outbreak has led the Trust to develop it governance framework to meet these requirements. This section of the paper outlines the temporary arrangements being place so that we may continue to operate the Trust’s governance framework and provide assurance, both internally and externally as required

B BOARD OF DIRECTORS MEETINGS

2. Board meetings will be virtual meetings by Skype, similar to the arrangements used for March 2020’s meeting (i.e., discussion on the call limited to a few items, with the rest of the items subject to a question and response by email process). The Trust will continue to have both public and private Board sessions.

3. Although agendas will be developed using the annual cycle of business as a guide (see Section F below), the items for discussion will most likely to be limited to:

a) the COVID-19 response of the trust and local health and social care systems

b) patient safety and quality issues – informed by discussion at the Clinical Cell / the Ethical Advisory Cell;

c) the Board Assurance Framework.

4. Meetings will take place monthly, with the existing Board Development Sessions changed to ‘formal’ Board meetings. Information as to how agendas will be prepared etc is detailed in Section F – Arrangements for Meetings below.

5. In line with national guidance, the public will be excluded from public sessions. The trust will explore the use of technology to allow members of the public to view meetings, but such a solution has not been sourced at the time of writing this paper

6. To facilitate public oversight at this time, members will be aware that for March’s Board the Trust asked members of the public to send in questions re the papers following the meeting. In future the Trust will request questions prior to the meetings as well, i.e., once the papers have been published on the public website as normal.

C BOARD COMMITTEE MEETINGS

7. All Board Committee meetings will be virtual meetings by email. Although national guidance suggests trusts should continue with quality meetings but streamline other committee agendas, the Trust intends to adopt the same approach with all Board Committees. In part this is informed by the capacity pressures on those teams that normally provide the bulk of the papers to the Quality Committee. It is for this reason that the monthly Board meetings will discuss patient safety / quality issues and the Board Assurance Framework. the Trust also intends that the Board Assurance Framework is deferred from being discussed at Board Committees at this time, with it only being prepared for the Board itself (but also please see Section E below).

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Agenda Item No: G1

8. Meetings will ‘take place’ in accordance with the existing meetings timetable.

Information as to how agendas will be prepared etc is detailed in Section F – Arrangements for Meetings below.

9. The terms of reference for the new People Committee are currently being drafted, with the first meeting now intended to take place in May 2020. Once the terms of reference for the People Committee are available, the Corporate Governance Team will then liaise with the Non Executive Chairs and Lead Directors for the Resources Committee and the Quality Committee to review the terms of reference for their committee. It is intended, subject to capacity constraints, to submit the terms of reference and annual cycles of business for all three of these Committees to May’s Board meeting for consideration and approval.

D COUNCIL OF GOVERNORS MEETINGS

10. All Council of Governors meetings will be virtual meetings by teleconference similar to the arrangements used for March 2020’s Board meeting. For the meeting on 23 April 2020, the only item for discussion will be the COVID-19 briefing circulated to Governors on 15 April 2020. Meetings will take place as scheduled. Information as to how agendas will be prepared etc is detailed in Section F – Arrangements for Meetings below.

11. Following discussions with the Lead Governors, the Council of Governor meeting will be held by teleconference. In line with national guidance, the public will be excluded from public sessions. The Trust will explore the use of technology to allow members of the public to view meetings, but such a solution has not been sourced at the time of writing this paper.

12. To facilitate public oversight at this time, members will be aware that for March’s Board the Trust asked members of the public to send in questions re the papers following the meeting. In future the Trust will request questions prior to the meetings as well, i.e., once the papers have been published on the public website as normal.

13. As Governors meet only four times a year, a monthly COVID-19 confidential briefing will be provided.

E WEEKLY BRIEFING FOR THE BOARD

14. Arrangement will also be put in place to provide members of the Board with a confidential weekly briefing on the Trust’s response to the COVID-19 outbreak.

F ARRANGEMENTS FOR MEETINGS

F1 Agenda Development

15. The starting point for the development of meeting agendas will be the meeting’s annual cycle of business. From that the Corporate Governance Team will then look to streamline the agenda, whether it is a virtual meeting by teleconference, Skype or email – in consultation with the Non-Executive Chair and Lead Director for the meeting - using one of the following categories:

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a) Item for Discussion – when the virtual meeting is by teleconference / Skype, a

limited number of items on the agenda will be marked for discussion at the meeting. We will further indicate whether it will be a separate paper or a committee paper (see below). Members will be encourage also to forward questions by email, so as to get the most benefit from the discussions at the meeting;

b) Virtual by Email (Information Requested) – for all virtual meetings when information is requested from members – this is intended to be used for standard items such as the conflict of interest, risk refection and referral to other Committees / the Board;

c) Virtual by Email (Separate Paper) – for all virtual meetings (including when an item is not to be discussed) members are asked to raise issues / ask questions / make comments on the paper provided. Responses will be provided to all members of the Board / Committee to aid their decision-making / understanding of the item. We will also note if the paper will be different from that usually received if capacity issues means the team who usually provide the report is unable to produce the full report;

d) Virtual by Email (Overarching Committee Paper) – for all virtual meetings (including when an item is not to be discussed), rather than a separate paper to support an item, a short brief will be provided by the relevant author / team in support of an item. The Corporate Governance Team will collate these briefs into a single paper covering a range of items on the Committee’s agenda – the Overarching Committee Paper. The same process will then be used for Separate Papers outlined above. (Please Note – this paper is intended to allow some key information to be shared with members, whilst reducing the burden on the team who normally produce the report);

e) Defer to a Future / Other Meeting – for all virtual meetings, taking account of the pressures on a particular team, an item may be deferred to a future meeting or another Committee / the Board. When deferring an item one of the following actions will be noted: (i) the date of the meeting when this item will be considered; (ii) the item will be reviewed when the next agenda for this meeting is considered; (iii) the item will be deferred from the Committee to the Board itself.

16. The advantage of retaining the items deferred on the agenda is that it allows transparency (and also means the meeting doesn’t forget to pick up items in the future).

F2 Raising Issues / Questions and Responses

17. Members will be asked to raise any issues or questions they have in respect of the Virtual by Email items. Issues / questions raised and responses will then be shared with all members:

a) prior to the meeting for a virtual meeting by Skype / teleconference; or

b) within 5 or 10 days for a virtual meeting by email (as shown against the item on the meeting agenda).

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18. Where a member objects to a paper or agreement cannot be reached / appropriate

assurance cannot be provided – (i) at the virtual meeting by Skype / teleconference (ii) in the time set aside to consider the paper at the virtual meeting by email – then the Trust Secretary or Deputy Trust Secretary will be assumed to have been provided with delegated authority to allow further ‘discussion’ (exchange of emails) in the weeks following the meeting. The Trust Secretary or Deputy Trust Secretary will email all members of the Committee / Board of Director / Council of Governors (as appropriate) to notify them then this delegated authority is being used.

19. If the matter cannot be resolved in a reasonable timescale by consent, then the Trust Secretary or Deputy Trust Secretary will add this as an item for discussion at the next formal Board of Directors / Council of Governors meeting, producing a paper summarising the issues for discussion at that meeting.

F3 Minutes of Meetings and Quorum

20. For all virtual meetings, questions and answers will be included in the minutes of the meeting. For virtual meetings by email attendance will be recorded as the list members of Committee sent the papers. For virtual meetings by Skype / teleconference, attendance will reflect those members who join the call.

21. Existing quorums for meetings will remain in place. Virtual meetings by email will be assumed to be quorate, however should a number of members be indisposed the Corporate Governance Team will liaise with other members to ensure the meeting is quorate. Should sufficient members be indisposed so that any type of virtual meeting is not quorate, the meeting shall still proceed, with any decisions taken using emergency powers as appropriate.

22. Any virtual meeting proceeding without being quorate will technically be in breach of Standing Orders. However, together with the use of emergency powers, such a breach will need to be reported to the Audit Committee and the Board of Directors.

F4 Unscheduled Virtual Meetings by Email

23. Firstly, to be clear, nothing in this paper is intended to stop extraordinary meetings being called in line with Standing Orders. However occasions may arise when the Trust Secretary or Deputy Trust Secretary writes to the Board of Directors / Council of Governors, using the virtual meeting byemail process, in order to obtain approval for a decision. This new unscheduled virtual meeting by email provision is most likely to be used in respect of policies that are subject to approval by the Board of Directors.

24. As members may be aware, the COVID-19 Strategic Coordination Group (SCG) has agreed a set of processes whereby divisional or trust-wide policy documents may be amended - outside of the usual policy review process - to ensure they reflect national instructions or changes due to COVID-19 capacity pressure being faced by the trust. Where approval of a policy is retained by the Board of Directors, then the SCG will make a recommendation to the Board of Directors to approve a change. Where this has occurred it will be reported to the next Board meeting – see Part 2 of this paper.

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F5 Process for Conducting the Board of Directors / Council of Governors Meetings

25. Potentially for Board meetings at least 15 people will be separately joining virtual meetings by Skype and for Council meeting at least 30 people will be joining virtual meetings by teleconference, so the following virtual meeting etiquette must be observed for items being discussed:

a) only the chair and person speaking to a paper will have their mike open – all others will have their mikes set to mute. Presenters should not be interrupted when presenting a paper;

b) following the presentation of an item, the presenter will mute their mike and the chair will ask if members wish to comment. Members wishing to comment will identify themselves to the Chair;

c) the Chair will then list those people to be called and invite them to speak one at a time. The Chair will then identify the person who can respond. Please Note – as is normal during all Trust meeting, time constraints may mean that not everyone can be called to speak;

d) all those joining a teleconference meeting are asked not to use a speakerphone as this causes interference/feedback for other members.

F6 Others Attending

26. For Board meetings held as virtual meetings by Skype it has been decided that only members of the Executive Team will present papers at the virtual meeting rather than non-Board members ‘in attendance’. This is to reduce the number of people ‘on the line’.

G OTHER RELATED ISSUES

G1 Council of Governors Elections

27. At present we have Governor elections scheduled to start on 4 June 2020, with results to be declared on 31 July 2020. In all seven seats will be up for election:

a) three existing vacancies – Public (Ribble Valley), Staff (Nursing) and a Service User / Carer;

b) four seats for Governors whose terms of office are due to end at the end of September 2020: • Garrick Prayogg (Public) • Dr Sayed Ahmed (Staff – Medical) • Tracey Cummins (Staff – Nursing) • Paul Allen (Staff – Other Clinical).

28. The election had been scheduled early to avoid the holiday period. National guidance now allows us to either stop or delay Governor elections. As such, following consultation with the Chair, the Trust currently intends to postpone these elections as we will be unable to hold any governor awareness sessions to encourage applicants. We have two other possible electoral windows (2 July to 28 August 2020 and 30 July

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to 25 September 2020) before those whose terms are due to end at the end of September 2020.

29. The Trust will review the situation at the end of June 2020 in respect of rescheduling the elections or extending electoral terms if the COVID-19 situation means we can’t hold elections as suggested above.

H REVIEWING THESE ARRANGEMENTS

30. As has been stated above, initially it is intended that this COVID-19 Governance Framework remain in place until 30 June 2020. However they will be subject to continual review in light of (i) experience gained; (ii) national guidance and regulatory requirements; (iii) capacity pressures faced by the Trust.

PART 2 – BOARD APPROVED POLICIES

31. As has been outlined in paragraph 24 above, the COVID-19 Strategic Coordination Group (SCG) has agreed a set of processes whereby divisional or trust-wide policy documents may be temporarily amended. If these policies are normally approved by the Board of Directors, then members of the Board are asked to approve these temporary changes using the virtual meeting by email process outline above. Those policies approved using this process will then be reported to the next formal Board meeting

32. To date, temporary changes have been approved by the Board of Directors to the following policies:

a) SA03 – Reporting, Management, Review and Learning from Incidents (available by clicking here);

b) SA06 – Management of Complaints / Concerns (available by clicking here).

33. When making a temporary change to a policy, the policy document itself is not actually physically updated. Instead a COVID-19 Document Change Form is added to the front of the policy, which explains which section(s) have been temporarily changed and the rationale for that / these change(s). Please click on the links above to be taken to the policies temporarily changed by the Board itself on the Trust’s website. Copies of all the trust-wide policies are available at https://www.merseycare.nhs.uk/about-us/policies-and-procedures/.

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https://www.merseycare.nhs.uk/media/7181/sa03-v3-reporting-management-review-and-learning-from-incidents-up-17apr20-rev-jan2023-covid.pdf

https://www.merseycare.nhs.uk/media/7182/sa06-v3-reporting-management-review-of-complaints-conerns-up17apr20-rev-20-nov-2020-covid.pdf

https://www.merseycare.nhs.uk/about-us/policies-and-procedures/

https://www.merseycare.nhs.uk/about-us/policies-and-procedures/

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