THE COUNCIL OF GOVERNORS MEETING...Council of Governors meeting 26 November 2018 Page 2 of 11 been...

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THE COUNCIL OF GOVERNORS MEETING

Friday 1 March 2019 at 10.30 Rooms 13/14, Ashfords Solicitors, Ashford House, Grenadier Road, Exeter

EX1 3LH

PUBLIC AGENDA

Please note the estimated time of the public meeting - 10.30-12.15

Item Title Presented by

Item for approval, information,

noting, action or debate

Est. Time

1. Apologies Catherine Geddes

James Brent, Chairman Information

10.30

1

2. Declaration of Governor Interests

Melanie Holley, Head of Governance

Noting

10.31

1

3. Secretary’s Notes Melanie Holley, Head of Governance

Noting

10.32

5

4. Chairman’s Remarks James Brent, Chairman Information

10.37

2

5.

Minutes of the last meeting held on 26 November 2018

Matters Arising and Actions Summary check

James Brent, Chairman Approval

10.39

5

6. Accountability & Engagement

6.1 Chief Executive’s Public Report

Suzanne Tracey, Chief Executive Information

10.44

10

6.2 Open Question & Answer Suzanne Tracey, Chief Executive Discussion

10.54

15

6.3 Confirmation of the local quality indicator for the Quality Report 2018/19


Approval

11.09

5

7. Performance & Assurance

7.1 Q3 2018/19 Performance Report Suzanne Tracey, Chief Executive Information 11.14 30

8. CoG Business

of 2

8.1 CoG Coordinating Committee and Working Groups progress reports.

Peta Foxall, Lead Governor Tony Ducker, CoG Effectiveness Faye Doris, Patient Safety & Quality Kay Foster, Public & Member Engagement

Information

11.44

10

8.2 Committee and Working Group membership Update


Information

11.54

5

9. Stakeholder Engagement

10. Information

10.1 Update on Tendering for the External Audit Service

Peter Dillon, Vice Chairman and Chairman of Audit Committee

Information 11.59

10

The next meeting of the Council of Governors will be held on Monday 3 June 2019, Meeting Rooms 13/14, Ashfords Solicitors, Ashford House, Grenadier Road, Exeter EX1 3LH

Meeting closes at 12.15

Council of Governors meeting 26 November 2018 Page 1 of 11

MINUTES OF THE MEETING OF THE COUNCIL OF GOVERNORS OF THE ROYAL DEVON & EXETER NHS FOUNDATION TRUST

Held on 26 November 2018 in

the Boardroom, Noy Scott House, RD&E Hospital

Item Minute Action

1. 49.18 APOLOGIES AND QUORUM CHECK

Apologies were listed as noted as above. The meeting was confirmed as quorate. Mr Brent welcomed newly elected Governors Abdul Latif, John Murphy and Dominic Hazell to their first formal CoG meeting.

2. 50.18 ANNUAL REVIEW OF THE REGISTER OF GOVERNOR INTERESTS

Mrs Holley said the annual review of the Register of Governor Interests had

Present James Brent, Chairman Public Governors East Devon, Dorset, Somerset & Rest of England: Richard Bowes Kay Foster Peta Foxall Trish Llewellyn Alan Murdoch Barbara Sweeney Exeter & South Devon: Faye Doris Tony Ducker Abdul Latif John Murphy Rosemary Shepherd Mid, N. W. Devon & Cornwall: James Bradley Cynthia Thornton Christopher Wilde Staff Governors: Susie Costelloe Catherine Geddes Dominic Hazell Hazel Hedicker Appointed Governors: Angela Shore (University of Exeter) Phil Twiss (Devon County Council)

Apologies Douglas Hull (East Devon, Dorset, Somerset & RoE) Did Not Attend: Michele Baxendale-Nichols (Staff) In Attendance: Andrew Barge, Deputy Head of Governance (for item 8.1) Bernadette Coates, Governance Coordinator Jeff Chinnock, Head of Stakeholder Communications & Engagement (from item 8.2) Peter Dillon, Non-Executive Director Melanie Holley, Head of Governance Jenny Jones, Engagement Officer Simon Knowles, Non-Executive Director Phil Luke, Deputy Chief Operating Officer (for items 7.1 & 7.2 only) Alastair Matthews, Non-Executive Director Dave Thomas, Deputy Chief Nurse (for items 7.1 & 7.2 only) Suzanne Tracey, Chief Executive


been undertaken. In addition to the interests declared, she added that Miss Doris was a Member of the Exeter Nursing Academy PPI Advisory Group and that Mr Bradley is also a Lay Member of the NHS England, Specialised Clinical Frailty Programme Board. She reminded Governors to flag any interests should they arise during the course of the meeting.

3. 51.18 SECRETARY’S NOTES

Mrs Holley gave her thanks to all the Governors who attended and supported the Trust’s Annual Members Meeting, held on 26 September 2018.

Mrs Holley provided the Council with a reminder of forthcoming meeting dates. The next meeting was a CoG Development Day on 25 January 2019, with the next formal CoG meeting on 1 March 2019. Mrs Holley said all the dates for 2019 had been emailed to Governors.

Mrs Holley said that Governors would have noted that the Trust was using meeting rooms at Ashford Solicitors, who are based by Junction 29 of the M5, for some of the meetings next year. She said this was due to significant pressures on meetings rooms at the RD&E, particularly ones of a sufficient size to accommodate the Council. She said the Trust would periodically be checking RILD to see if rooms suitable for a CoG meeting become available. Mrs Holley assured Governors that Ashfords were not charging the Trust for meeting room hire and that the Trust had been assured on the accessibility of the building and the rooms. Parking was also available on site, although this would need to be confirmed nearer the time due to other meetings that might be taking place on the same day. The office building was also very close to the Honiton Road Park and Ride site. Governors will be provided with details and directions nearer the time of the meetings.

Mrs Holley said there were currently vacancies on both the Nominations Committee and the Non-Executive Director Remuneration Committee. An election was also required for the Patient Experience Committee, with Miss Foster coming to the end of her first term on the Committee. Elections to fill these vacancies will commence within the next few weeks

The Council of Governors noted the Secretary’s Notes.

4. 52.18 CHAIRMAN’S REMARKS

There were no Chairman’s remarks.

5. 53.18 MINUTES OF LAST MEETING, MATTERS ARISING & ACTION SUMMARY CHECK

The minutes of the meeting held on 20 August 2018 were agreed as a correct record.

Action Summary Check

The actions were all completed as per the action summary with the following addition:

47.18 Dr Ducker and Mr Chinnock to discuss the possibility of a repository for governor documents. Dr Ducker said discussions were on-going and


agreed to provide an update at the March 2019 meeting.

ACCOUNTABILITY AND ENGAGEMENT

6.1 54.18 CHIEF EXECUTIVE’S PUBLIC REPORT

The following was reported to the Council:

1) Mrs Tracey thanked the Council for its contribution to the corporate strategy work at the 9 November 2018 Joint Board and CoG Development Day. Work was continuing on the outcomes from the session and these would be reflected in the strategy. The Board would be further considering the strategy at its meeting on 28 November 2018.

2) Mrs Tracey said work on the My Care Programme was progressing well.

3) The Trust was undertaking a risk assessment on the impact of a ‘no deal’ Brexit and it was taking every opportunity to provide information and assurance to its EU staff.

4) The results from the National Cancer Patient Experience Survey 2017 had been published at the end of October 2018 with the RD&E in the Top 10 of Trusts. The Trust had performed very well, particularly in relation to patient experience. The outcomes from the survey would be reported through the usual governance routes.

5) The Trust’s winter plan was now in place. Mrs Tracey said the winter would be a difficult period but the Trust was well-set to meet the challenges.

6) The Channel 5 programme featuring the RD&E, ‘The Secret Life of the Hospital’, had been aired on 31 October 2018. Mrs Tracey said it had highlighted the great work of the hospital’s staff and the Trust had received very good feedback from both staff and the viewing public.

The Council of Governors noted the report.

6.2 55.18 OPEN QUESTION AND ANSWER

Mr Brent referred to the possibility of a ‘No Deal’ Brexit and contingency planning, in particular the issue of stockpiling drugs. Mrs Tracey said this was being taken into account in the risk assessment and that the Department of Health had issued assurances on this issue. Miss Foster asked why stockpiling by Trusts would be an issue and why the Trust would not be able to buy the drugs it needed. Mrs Tracey replied that if all organisations stockpiled drugs, there would be a shortage.

Dr Foxall said there were further questions from Governors but they were more pertinent for the items on the performance report.

No further questions were raised.

PERFORMANCE & ASSURANCE

7.1 56.18 PRESENTATION OF OVERVIEW OF NEW INTEGRATED PERFORMANCE REPORT


Mrs Tracey introduced the presentation by Mr Luke and Mr Thomas by reminding Governors that the Board of Directors was now using its new style integrated performance report. The CoG’s performance report was based upon the Board’s document and it was important to ensure the CoG’s report enabled the Council to undertake its role in holding to account.

Mr Luke outlined the purpose of the presentation to the Council. He highlighted the significant organisations that monitor the Trust’s performance including national, local and auditing bodies. He presented the Trust internal performance management structure and outlined the various reporting lines through to the Board of Directors.

Mr Luke updated the Council on the revised integrated performance report. He said a version of this had been provided to the Council for quarter two 2018/19 and it contained more detail than was usual. He drew the Council’s attention to the Executive Summary section which set out the key headlines and said that data and graphs were now presented alongside the narrative. As to what this meant for the Council, he said it would note the greater detail, a change in the way data was presented and some new performance metrics including community data.

Mr Thomas provided an overview of the Trust’s key safety and quality measures. He outlined the key measures and the challenges to meeting the targets. This included fractured neck of femur, Summary Hospital-level Mortality Indicator (SHMI), harm-free care, venous thromboembolism (VTE) and antimicrobial prescribing.

Mr Luke then outlined the operational measures, namely Emergency Department (ED) four hour wait target, Referral to Treatment (RTT), cancer waiting times and diagnostics. He highlighted the increases in demand across the Trust and the challenges faced in meeting this demand, along with the complexity of the targets. He invited questions.

Mr Twiss asked what work was undertaken to avoid VTE (blood clots). Mr Thomas replied that assessing risk of VTE was undertaken and drug treatment and mobilisation of a patient was used to help prevent blood clots from forming. He said there would always be patients who form a blood clot but the Trust’s performance against the targets was stable.

Mr Twiss asked why some cancer patients were referred late to the Trust. Mr Luke replied that this was often because they had initially been treated at another Trust and tests indicated a need to refer on to the RD&E for specialist treatment, such as robotic surgery.

Mrs Llewellyn expressed concern that there was a 62 day treatment target for cancer patients and asked if having to wait this amount of time for treatment put patients at risk. Mr Luke said it was one of many targets for cancer. Some cancers progressed more quickly than others and all patients were clinically prioritised for treatment. All patients were assessed through the Multi-Disciplinary Team (MDT) process.

There being no further questions, the update was noted.

7.2 57.18 Q2 2018/19 PERFORMANCE REPORT

Mr Luke invited questions regarding the Q2 2018/19 performance report.


Mr Murphy said he was pleased to hear from Mrs Tracey that the Trust was well placed in terms of winter planning. He said the report assured the Council on the sound delivery of care to patients but also flagged the staffing and financial challenges being faced. He asked how the Trust approached winter planning and if there were pinch points during the winter period the Trust was concerned about.

Mr Luke said the approach this year was to target key areas, for example additional staff. Teams were asked for proposals regarding staff and the Trust supported 90% of these, meaning an investment in weekend staffing, therapies and medical outliers. The Trust had also taken a strategic look at long-term issues based around an initiative called ‘Let’s Get You Home’. This involved the ambulatory care unit and home care support, working closely with Devon County Council (DCC) to manage the shortfall in the home care market. Mr Luke said that DCC had recently put better employment contracts in place in order to be more attractive to staff.

Regarding pinch points, Mr Luke said this was likely to be the first two weeks of January 2019 and the Trust was focussed on this period of time. The Trust often sees an increase in medical outliers at this time. He added that if the Trust could manage this period successfully, it would be better placed for the remainder of the winter period.

Mr Murdoch said the Trust was involved in two significant projects, namely the arrangement with Northern Devon Healthcare Trust and the My Care Programme. He said these took up a lot of resources and asked if the Trust was seeing an increase in agency spend as a result. Mrs Tracey assured the Council that the Board was very mindful of this issue. For recruitment to the My Care Programme, there was a clear plan for backfill. In terms of Northern Devon, Mrs Tracey said the arrangement had the biggest impact on the senior team and additional resource had been put in place below the Executive Directors to help manage the day to day work. Mr Brent acknowledged Mr Murdoch’s concern and said it was a valid one; however a consequence of not undertaking the My Care Programme would likely be an increase in agency spend and the Trust was helping to address issues in Northern Devon in part to ensure that the Northern Devon population received high quality care but also in order to prevent them presenting at the RD&E. Mr Brent said both projects were the right thing for the Trust to do for the benefit of the community.

Ms Costelloe referred to the workforce data in the report and said the highest number of vacancies in the Trust was in the Allied Health Professionals (AHP) staff group. She said that unlike with nursing vacancies, it was not possible to recruit from abroad. She asked what action the Board was taking for recruiting to this group of staff. Mr Thomas said the Trust has had a nurse vacancy plan for some years, which did include recruiting overseas, and it now also had a recruitment plan for AHPs. It had established the Nursing, Midwifery and Allied Health Professional (NMAHP) group some time ago, which had the involvement of senior staff at the Trust. It was reviewing how the Trust recruits and trains AHP staff. An AHP school had also been established in January 2018. Mr Thomas assured the Council that vacancies in AHP staffing were monitored, as they were for nursing and other staff groups.

Professor Shore commented on Brexit and the possible impact on the


Trust’s staff. She asked what percentage of the workforce was from the European Union. Mrs Tracey said 11% of the Trust’s staff were from overseas. Large numbers of EU staff worked in nursing and services such as the laundry. Mrs Tracey added that a national EU settlement scheme for all EU nationals wishing to remain in the UK would start on 30 March 2019; however the Trust was part of a pilot that would allow EU staff to apply for settled status during November and December 2018. It was hoped this would provide assurances to staff.

Mrs Sweeney noted the data in the report in regard to the health and wellbeing of Trust staff and said the Council would like to seek assurance that the Board is testing and reviewing the resilience of staff. She commented that the Trust’s sickness absence rate was higher than average and was the Trust learning from other organisations on how to manage this. Mr Brent assured Mrs Sweeney that discussion on the workforce and the wellbeing of staff featured at every Board meeting. He said it was positive to see turnover falling and it compared well to other Trusts. Work continued to improve the number of exit interviews undertaken to understand the reasons for staff leaving the Trust. With regards to sickness absence, the Trust’s rate was above average and it was working to understand why. This work included triangulating the data with the national Staff Survey results and with outcomes from staff engagement. Mr Brent said it was a concern that mental health was the highest reported cause of sickness. Mrs Tracey concurred and added that the Trust had developed an extensive staff health and wellbeing plan and programme. This recognised that staff can experience stress outside of work too. The Trust had put in place mental health first aiders, psychiatric support, a helpline for staff and undertook activities to encourage healthy eating and exercise. She said it was a programme and plan that would continue to be developed.

Mr Bowes asked about the Referral to Treatment (RTT) performance for trauma and orthopaedics and cardiology and asked if the issues were related to a lack of capacity, a lack of funding, new NICE directions or even a different focus from the NEW Devon CCG. Mr Luke said that, in relation to orthopaedics, demand was stable; however capacity in the independent sector had changed and therefore the Trust was not sending as many patients there as it had been. In cardiology, there had been a 21% increase in referrals compared to the previous year and it was continuing to grow. There was also an increase in emergency cardiology activity. In addition there had been turnover in the workforce. The Trust had invested £2m in cardiology in terms of clinical staffing and an additional cardio catheter lab and a mobile unit. There had also been a strong focus on cardiology outpatients. Miss Foster asked what service was likely to be challenged next. Mr Luke said this was a good question that was difficult to answer; however the Trust was planning for steady recovery in the areas outlined in the report as being challenged and it was doing what it could to control what it could. He said it was not possible for the Trust to control demand. Mr Brent added that the Board had a session planned in December 2018 where it would look across all services and have a discussion on prioritisation.

Dr Foxall commented that the Council hoped it could work with the Non-Executive Directors on reviewing the cancer targets and focussing on the best questions to ask. She asked if the metrics for cancer included those patients who were considered as ‘watchful waiting’. Mr Luke said the targets


were purely for treatment of patients and therefore did not include any ‘watchful waiting’ patients. He added that NICE guidelines constantly moved towards GPs referring more patients.

Dr Foxall noted the performance for MUST (Malnutrition Universal Screening Tool) and said the narrative did not mention hydration. This had previously been a quality priority for the Council and it was hoped the focus on this had not been dropped. Mr Thomas assured the meeting that this was not the case and that hydration was an important element of MUST. He said it was also important in the Trust’s AKI (Acute Kidney Injury) work.

Mrs Tracey thanked Mr Luke and Mr Thomas for attending the meeting and reiterated that the performance report to the Council of Governors would continue to be developed so that it helped the Council in its role.

There being no further comments or questions, the Council noted the report.

Mr Luke and Mr Thomas left the meeting.

7.3 58.18 AUDIT COMMITTEE UPDATE

Mr Dillon provided the Council with an overview of the Audit Committee, its membership and its role and responsibilities. He said the Committee was the only statutory committee of the Trust Board and it was a key part of the system of governance. It met five times a year and comprised four Non-Executive Director members. In addition, meetings were attended by Mrs Holley, as Head of Governance, the Chief Operating Officer, the Director of Operational Finance and were observed by Mrs Thornton on behalf of the Governors. Meetings were also attended by Audit South West (Internal Audit and Counter Fraud) and KPMG (the Trust’s external auditors). Mr Dillon showed the Council the Trust’s Governance and Performance System and where the Audit Committee sat in that and how information was reported up through the system to the Board. He said there was an expectation of performance and the Trust had in place policies and guidance that define processes which, if followed, would ensure the Trust performs to expectation. He said the Audit Committee looked at non-clinical operational performance principally and, by no means exclusively, financial performance.

Mr Dillon said the Committee’s principal responsibility was to recommend the Board sign its Annual Governance Statement in the Annual Report. It can do that as Audit South West check that the Trust is following the policies and guidance within the internal control system. Through an audit plan of 650 days (plus 110 days dedicated to counter fraud), approximately 35 audits were undertaken each year with Audit South West reporting on good performance and where the Trust must tighten its controls. The Trust directs Audit South West on what to audit by focusing on areas of greatest risk (according to the Board Assurance Framework and the Corporate Risk Register). A significant amount of time was also allocated to reviews chosen by management in order to shine a light on areas of potential future risk. Mr Dillon said that the Head of Internal Audit provided a Head of Internal Audit Opinion each year and the most recent provided significant assurance (the highest rating possible) on the Trust’s system of internal controls.

Mr Dillon outlined the role of the External Auditors, KPMG, and said it provided another level of assurance in regard to the Trust’s financial


statements and internal controls. He said that KPMG were very complimentary of the Trust’s finance team.

Mr Dillon invited questions.

Mr Twiss asked if the Trust benchmarked its Committee against other Trust’s Committees to ensure it was performing effectively. Mr Dillon said that Audit South West provided auditing services to several Trusts in the South West and it produced benchmarking reports and provided information to the Trust on best practice.

Mrs Sweeney asked if Mr Dillon could provide assurance that risk management was embedded throughout the organisation and if he was confident that there were information flows both up and down the Trust. Mr Dillon replied that he was confident and could provide assurance. He said part of the Head of Internal Audit Opinion involved a review of the Trust’s risk management process, with the Head of Internal Audit providing a ‘satisfactory’ rating. He said there was work to do in improving the recording of risk surgeries and further embedding community services.

Mr Murphy asked what training staff received in relation to issues such as spotting scams. Mr Dillon said that the Local Counter Fraud Service (LCFS) had a programme of training and had been working to increase staff awareness of fraud, including attending corporate induction for new staff. Mr Dillon said fraud was a growing issue but he assured the Council that the Trust had no material loss from any individual scam. The NHS Counter Fraud Authority had recently undertaken a quality assessment of the LCFS and the LCFS was currently working through the findings and recommendations.

Mr Twiss asked about work undertaken by audit in relation to GDPR (General Data Protection Regulation). Mr Dillon replied that compliance with the Regulations was always included in the internal audit annual plan and compliance was also confirmed in the Head of Internal Audit Opinion each year.

There being no further questions or comments, the Council noted the report.

CoG BUSINESS

8.1 59.18 COUNCIL OF GOVERNORS ELECTION RESULTS 2018

Mr Barge joined the meeting.

Mr Brent welcomed Mr Barge to the meeting and invited comments or questions on the election report. There being no comments or questions, the report was noted.

Mr Barge left the meeting.

8.2 60.18 CoG COORDINATING COMMITTEE AND WORKING GROUPS PROGRESS REPORTS

Mr Chinnock joined the meeting.

Dr Foxall presented the CoG Coordinating Committee report, highlighting the ongoing review of its and the working groups’ work, ensuring there was no


duplication.

Miss Foster presented the Public and Member Engagement Group report, highlighting the change in name in order to reflect the group’s focus. She added that membership forms were being circulated in the community in order to help increase membership numbers.

Mrs Tracey asked how young people were being encouraged to become members. Miss Foster replied that forms were also being circulated via maternity services with the hope of increasing numbers amongst younger parents. Mrs Sweeney added that she had recently attended a national workshop on membership and attracting younger members was a well-recognised issue. She had picked up several ideas which would feed back into the working group, including existing links in the community such as Exeter College and the University of Exeter. Mr Murdoch said that there had been a Trust stall at recent career fairs at Exmouth College and new members had been recruited. Ms Costelloe said her work at the Trust involved visiting Bramble Ward and the Neo-Natal Unit and she could potentially help the Group with spreading the message of membership to young people and parents. Mrs Hedicker suggested a promotion encouraging staff members to recruit new public members from amongst their family and friends. Miss Foster noted the ideas.

Miss Doris presented the Patient Safety and Quality report, encouraging more Governors to join the Group or to attend meetings to observe.

Dr Ducker presented the CoG Effectiveness Report. He said two documents were attached. The Governor Expenses Policy was for information and would soon be presented to the Remuneration Committee for approval. The Working Group Terms of Reference had been reviewed and required CoG approval. The Council of Governors approved the Working Group Terms of Reference.

Dr Foxall informed the Group that she had been invited by NHS Providers to attend a meeting on 14 December 2018 with CQC (Care Quality Commission), the aim of which was to improve Governor interaction with CQC and share best practice.

There being no other comments or questions, the report was noted.

8.3 61.18 REVIEW OF THE CONSTITUTION

Mrs Holley presented the Constitution and its annexes. She said the Constitution had been approved at a previous meeting and it was agreed to present it to the Council in its entirety with its annexes. The documents were noted by the Council.

STAKEHOLDER ENGAGEMENT

INFORMATION

10.1 62.18 TENDER PROCESS OF EXTERNAL AUDITORS

Mr Dillon updated the Council on the tender process for the Trust’s External Auditors. He reminded the Council that a Project Team had been established, with Mrs Thornton a member, alongside colleagues from


Finance and Procurement. The Project Panel (the interview panel) would comprise a majority of Governors and the members would be drawn from a pool of volunteer Governors along with two Non-Executive Directors.

Mr Dillon said the Project Team held its first meeting in September 2018 and had agreed the procurement requirements and the tender specification. The Crown Community Services Framework had been chosen as the Framework for the tender process and all the companies signed up to the Framework would soon be contacted and invited to submit expressions of interest. The next meeting would take place in February 2019 and a further update would be provided to the 1 March 2019 Council of Governors meeting.

Mr Dillon outlined the timetable for the process, with the tender deadline being set for May 2019, presentations to the Project Panel in July 2019 and CoG approval of the recommended company in September 2019 in readiness for the 2019 Annual Members Meeting. The contract would commence on 1 November 2019.

There being no comments or questions, the update was noted.

63.18 ANY OTHER BUSINESS

On behalf of the Council of Governors, Dr Foxall expressed sadness at the news of the death of Mr Cooper, the Trust’s previous Medical Director. The Council requested its condolences be passed to Mr Cooper’s family. This was noted.

64.18 DATE OF NEXT MEETING

Friday 1 March 2019, Meeting Rooms 13 & 14, Ashfords, Grenadier Road, Exeter EX1 3LH.

COG Minutes Actions Summary Page 11 of 11

MEETING OF THE COUNCIL OF GOVERNORS

26 November 2018

ACTIONS SUMMARY This checklist provides a summary of actions agreed at the CoG meeting, and will be updated and attached to the minutes each quarter.

PUBLIC AGENDA

Minute No.

Month raised Description By Target date Remarks

47.18 August 2018 Dr Ducker and Mr Chinnock to discuss the possibility of a repository for governors’ documents.

TD/JC Nov 18

March 2019

An update will be provided at the November 2018 meeting.

November 2018: Dr Ducker informed the meeting that discussions were on-going and he would provide an update to the March 2019 meeting.

March 2019: An email was circulated to all Governors on 28/01/19 about Governors can access core documents. Action completed.

Signed: Name: James Brent Position: Chairman

Performance Report

Council of Governors meeting

1 March 2019

1

Agenda item: 7.1, Public Council of Governors

meeting

Date: 1 March 2019

Title:

Q3 2018/19 Performance Report

Presented by:

Suzanne Tracey, Chief Executive

Purpose:

To provide the Council of Governors with an overview of performance in Quarter 3, 2018/19.

The format of the Board’s Integrated Performance Report, which is the source of information for

this report, has recently been amended, and this is the second report to CoG in the revised

format.

The Council is requested to consider the content and format of this report, ahead of discussion at

the Governor Development Day on 15 March 2019.

Performance Report


1 March 2019

Performance Report – Quarter 3 2018/19

Contents

Section Page

Overview 3 - 4

Executive Summary 5 - 8

Patient Experience – Demonstrating Difference 9-10

Board Focus 11 - 12

2

3

Overview of Q3 2018/19

The Trust experienced good patient flow and generally lower levels of operational pressure during October and November,

however, demand for elective care was high, with GP referrals significantly exceeding planed levels, which continued to place

pressure upon the delivery of key access targets for elective care, as well as the Trust’s financial position. The capacity of the

local domiciliary care market reduced during and after the October half term holiday, which in turn increased the delayed transfers

of care and impacted upon patient flow within acute services. December saw good standards of care maintained for our patients,

a challenging start operationally, leading to a sustained period of good patient flow,, and good performance against the ED 4-hour

target. Performance against other access standards continued to be a challenge, although good work to implement longer term

solutions progressed throughout the quarter.

During the early part of December the Trust experienced a 10-day period of significant operational pressure, with the Trust

declaring OPEL 3 and Emergency Department performance being extremely challenged. A number of initiatives commenced as

part of the Trust’s Winter Plan during the month, most notably the implementation of the “flying squads,” (multidisciplinary teams

scheduled in advance to support the care of medical outliers), which helped improve flow. The week leading up to Christmas saw

a high level of discharges and reducing delayed transfers of care, leading to there being 178 empty beds across the hospital on

Christmas day, which put the Trust in a good position going into the holiday period. Operational flow was somewhat hampered by

episodes of Nor virus and flu, however these were limited and well contained by ward teams, which prevented spread to other

areas. Good progress is being made in implementing domiciliary care contractual changes across Devon, which aims to

guarantee income for local care businesses and their staff in order to help plan service cover and minimise downturns of capacity

over holiday periods.

By the end of December, the Trust had almost achieved the target for flu vaccinations with 74.6% for acute staff and 74.9% for

community staff vaccinated against the 75% target. Quality and safety metrics show on-going high levels of care, with indicators

for harm free care, slips, trips and falls, nutritional screening, antimicrobial prescribing, rates of hospital acquired infection and

stroke care all being maintained at high levels. Due to an extremely high number of patients attending ED following falls at home,

the proportion of patients undergoing surgery following a hip fracture within 36 hours was low in October, however the proportion

receiving surgery within 48 hours was high at almost 90%. The proportion of people undergoing surgery for fractured femur

increased in December, with 74% being treated within 36 hours and 96% within 48 hours. An increase in the level of grade 1 and

2 pressure ulcers is being investigated to ascertain any common themes and further action which might be required. As indicated

in previous months, both the mortality indices of SHMI and HSMR are now demonstrating a sustained reduction over 2018 and

are within expected levels.

Performance Report


1 March 2019

Author: Phil Luke

4

Overview

Within the clinical divisions there were good examples of improvements to care evidenced by the ”demonstrating difference”

process. These included the positive impact that CLiP (Collaborative Learning in Practice) students have had on patients, ward

staff and the students themselves, the development of an excellent information package for patients undergoing investigation and

treatment for breast cancer, and improvements to the ward environment in Tiverton hospital.

Performance against key access standards followed a similar pattern to that seen so far this year, with good performance against

the 4-hour standard but challenges in RTT, diagnostics and cancer services as a result of sustained high levels of demand,. The

high level of GP referrals continues also to impact upon the Trust’s financial position as the additional outpatient, surgical and

diagnostics activity has been a driver of significant extra cost throughout 2018/19. Including all local Minor Injury Units (MIUs) and

Walk in Centres (WICs), performance against the 4-hour target was 92.2% for December, meaning that the Provider Sustainability

Fund (PSF) trajectory of 90.0% was met. Performance against the 4-hour target was 90.87% for Q3, meaning that the PSF

trajectory of 90.8% and the associated income of £1.1m were also achieved.

Following a successful application to NHS Improvement, work to refurbish the Medical Triage Unit (MTU) commenced in

October. Whilst there is inevitably a degree of disruption caused by a significant development such as this, the operational service

delivery has been managed well by the AMU team and the work was completed by 21st December in line with the funding

requirement.

Overall turnover rates improved during October to 9.95%, the lowest rate for more than 4 years, with the rate for registered nurses

also continuing to improve, with a rate of 9.5%. Turnover increased slightly to 10.5% in December. Further international

recruitment for nursing staff took place in December, which resulted in 20 Spanish and Italian nursing appointments. The

sickness rate increased to 4.5%, however, this is not unexpected over the winter months and significant activities to support the

health and wellbeing of staff continue. This year’s NHS Staff Survey was launched from 5th October with the majority of

employees being able to complete the survey online via an email invitation.

The sustained increase in workload continues to place the Trust under financial pressure. After use of all available reserves and

mitigations, the finance position remains broadly on plan, with a deficit position of £5.7m being projected for the year end without

PSF income and a surplus of £6.5m after the PSF income has been applied. As a result of financial performance and the delivery

of the ED performance so far this year the full available PSF income year to date of £7.9m has been achieved. Good performance

against the current year Cost Improvement Plan (CIP) target has been made, with £18.9 out of £23.3m being delivered, however

the recurrent position is less favourable, with £10.3m out of £21.0m being achieved by the end of December. The higher level of

spend linked to the increased demand seen in 2018/19 will require a recurrent funding stream from commissioners in 2019/20 in

order to ensure financial sustainability. Author: Phil Luke

5

Executive Summary

Performance Report


1 March 2019

OPEL Status 1 1 2 3 3 3 3 3 3 3 3 3 3 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1

Unplanned Escalation Beds 0 0 14 20 27 13 23 10 5 21 22 15 17 7 0 0 0 14 18 5 4 0 0 7 0 0 9 12 0 0 10

Delayed Transfer of Care

(DTOC) 63 63 59 59 51 40 38 37 39 39 38 39 36 39 48 46 41 43 38 32 34 41 48 53 46 53 48 51 51 47 55

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20

18

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ove

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20

18

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8

OPEL Status 3 3 3 3 3 3 3 3 2 2 2 1 2 1 1 2 2 2 2 2 2 2 1 1 1 1 1 3 1 1

Unplanned Escalation Beds 11 11 10 8 17 26 23 13 6 4 5 10 9 14 9 10 1 0 10 11 10 6 8 0 0 6 8 12 11 13


(DTOC) 65 72 74 81 84 70 64 49 57 54 54 55 58 58 52 54 54 56 60 57 53 56 59 62 69 72 63 68 59 58

OPEL Status 1 1 1 1 1 1 1 1 2 2 1 2 2 2 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 3

Unplanned Escalation Beds 7 7 6 7 10 4 0 6 11 10 6 0 0 0 13 10 6 11 7 0 0 0 0 7 13 9 0 0 3 13 23


(DTOC) 39 39 40 35 29 39 45 47 47 48 39 45 48 58 61 56 52 40 45 45 49 55 54 47 43 47 53 61 70 66 66

Activity and Flow :

• October was generally a good month for patient flow, with only one day at OPEL 3, 10 at OPEL 2 and 20 at OPEL1.

• Delayed transfers of care increased significantly as a result of reduced domiciliary care capacity around the half-term holiday period, which

was particularly pronounced in the Exeter area. This led to increased pressure on acute bed flow, which is reflected in the period of OPEL 2

and 3 at the end of the month.

• Elective activity was 6.2% below planned levels in October, which continues to be predominantly related to workforce shortfalls with the

exception of Cardiology, where continued high levels of emergency demand has impacted upon elective activity. • November was a variable month in relation to patient flow, with a difficult start and a period of 8 consecutive days of OPEL 3 at the start of the

month, with pressure gradually easing off as the month progressed.

• December saw a challenging period in relation to hospital flow and bed capacity, with 10 days at OPEL 3, 7 days of OPEL 2 and 14 days of OPEL

1. This is reflected in ED performance throughout the month

• A number of initiatives commenced as part of the Trust’s winter plan over December. The week leading up to Christmas saw a high level of

discharges with there being 178 empty beds across the hospital on Christmas day, which put the Trust in a good position going into the holiday

period.

• The Acute Delayed Transfers of Care (DTOC) position has improved, decreasing from an average of 61 delays in November to 45 in December.

• Elective activity was at targeted levels in December and GP referrals were consistent with 2018/19 so far at 7.2% above planned levels.

6

Executive Summary

Operational Performance:

• ED waiting times performance closely reflected the operational pressures throughout the quarter. Including all local MIUs and

WICs, performance against the 4 hour target was 93.1% for October, 92.2% for November, and 92.2% for December, meaning

that the PSF trajectory of 90.0% was met. Performance against the 4-hour target was 90.87% for Q3, meaning that the PSF

trajectory of 90.8% and the associated income of £1.1m were also achieved.

• Ambulance handover delays continued to be low, with only 27 handovers of longer than 30 minutes out of 3017 ambulance

arrivals in December. Overall, the total time of all delays over 15 minutes fell by 36% compared to December 2017, which is good

evidence that the changes made to the process are having a positive impact.

• Performance against the diagnostic standards has been challenging, with 2.2% improvement in October (to 89.1%), 3.2%

deterioration in November (to 85.7%) driven largely by increasing demand in MRI and CT, and deterioration in the December

position of 84.07% due to continued increases in demand and despite the service having undertaken over 1000 additional scans

so far in 2018/19.

• Performance against the 62-day standard was 78.3% in October, 77.0% in November, and 80.8% in December (at the time of

writing), against the national standard of 85%. Although performance was below the targeted levels, there were some

encouraging signs with regards to demand, capacity and a reduction in backlogs in some key areas

• Three of the remaining seven cancer waiting times standards were being achieved. There are challenges with the Radiotherapy

and Oncology services, and increased demand for Urology services. The Trust has made good progress in clearing the backlog

of endoscopy and lower GI clinic appointments, which will lead to improvements in cancer performance during Q4.

• The number of incomplete pathways increased slightly during the first two months of the quarter, with 33923 at the end of

October, 33937 at the end of November, and a reduction to 33533 by the end of December. The key driver of this was the high

levels of referrals. By the end of Q3, RTT performance was 82.6%.

• The Trust had 154 patients over 52 weeks at the end of December, with the largest volume being in Cardiology. Plans are in place

to reduce this by the end of Q4.

• Good progress in filling vacancies within the rapid response team has supported discharges, however, overall domiciliary care

market provision remained challenging throughout the quarter.

Performance Report


1 March 2019

7

Executive Summary

Performance Report


1 March 2019

Patient Experience, Safety & Quality :

• The position for ‘harm free care’ has consistently remained above the 95% threshold since April 2018, given the current nursing workforce

challenges this is very positive and demonstrates the commitment of the ward teams.

• Pressure ulcer assessment rates remain above the 95% threshold. Detailed analysis of pressure ulcers is being reported through the Patient,

Safety & Mortality Review Group to ensure we understand the slight increase in pressure ulcers

• The total number of falls remains within normal variation.

• As indicated in previous months, both the Mortality indices of SHMI and HSMR are now demonstrating a significant, progressive and

sustained reduction over 2018.

• Antimicrobial prescribing has seen an improvement against three of the four key metrics, with a significant improvement seen in the Surgical

Division.

• A new model of learning for nursing student CLiP ( Collaborative Learning in Practice) has demonstrated a positive impact on patients, ward

staff and the students themselves.

• There have been 2 new cases received from the PHSO which are being reviewed. 5 final reports were received during Q2, with 4 not being

upheld. 1 case has been upheld by the PHSO.

• The nursing workforce spend has decreased for the 2nd month, with a notable decrease in agency nursing spend during October, reflecting

an improving recruitment picture.

• Fractured next of femur performance has been challenging with a significantly higher volume of admissions experienced

• Performance against the 90% stay on the stroke unit indicator has achieved the highest position in recent times achieving 97% in October.

Our People:

• The SafeCare module of HealthRoster is being implemented in 7 inpatient areas during January.

• Trustwide turnover rate improved to 9.95% in October, but subsequently increased to10.5% at the end of December – the same as the rate

reported 12 months ago. The rates for registered nurses continue to improve, decreasing to 10.4% compared with 11.3% 12 months ago.

• The number of registered nurse vacancies (184.6) is at the lowest level for four months.

• In December sickness increased to 4.87% from 4.5% recorded in October and 4.74% recorded in November. The 12 month rolling rate

remained stable at 4.50%.

• Anxiety/stress/depression/other mental illnesses continue to be the highest reported cause of sickness but decreased from 26.9% in

November 2018 to 25.6% in December. Analysis shows that workload accounts for 28% of work related stress.

• The number of completed exit interviews improved in October to 26%, however by the end of December the compliance rate reached 20.3%

- the lowest since April 2017. The HR Business Partners continue to work with their areas to increase completion.

• At 54.5% the December rate for completed consultant job plans is the highest since April 2018.

• The Trust is extremely close to reaching the 75% CQUIN target for frontline staff receiving the flu vaccination this year.

• The Trust will spend all apprenticeship levy payments within the 24 month window, and are therefore not looking to transfer or forfeit funds.

• Heath and wellbeing sessions focussed on prevention continue to be promoted and are being very well attended.

• This year’s NHS Staff Survey was launched from 5th October with the majority of employees being able to complete the survey online via an

email invitation. At the middle of November the overall response rate was just under 40% against a target of 55%.

Finance:

• A deficit of £6.7m has been incurred as at the end of December, which is £3.3m adverse to budget, albeit

broadly on plan.

• The adverse 'run rate' position is due mainly to additional activity performed above the block contract for

NEW Devon CCG coupled with higher agency costs, driving year to date overspends on pay (£2.8m) and

non pay (£2.7m), offset by PDC and interest receivable (£0.5m) and reserves (£1.7m)

• After using all available mitigations and reserves, the Trust is still able to forecast a deficit of £5.7m, in

line with budget and annual plan. After receipt of PSF, the Trust is forecasting a surplus of £6.5m in line

with budget.

• It should be noted that the Trust is managing these pressures through a range of non recurrent

measures, which will not be available in 2019/20, so a recurrent funding stream will be required.

• The Board will recall it agreed £6.0m mitigation plan to cover shortfalls in the in year CIP programme,

leaving a £3.0m overspend risk to be addressed to ensure the plan is achieved. In order to mitigate the

£3.0m shortfall there will be a focus on 3 areas - agency reduction, divisional improvement and additional

income.

• The Trust has achieved £18.9m of the £23.3m current year Cost Improvement Programme (CIP) target

but only £10.3m of the £21.0m full year target. Divisions continue to expedite existing schemes and

attempt to identify new ones in order to reduce the unidentified gap of £3.0m, however in the context of

increased demand, this is proving to be challenging

• The Finance and A&E target have been achieved for the first 9 months of the year and therefore the Trust

is guaranteed to receive Provider Sustainability Funding (PSF) of £7.9m.

• A score of 2 in the NHS Improvement Finance and Use of Resources has been achieved year to date,

but is expected to return to a score of 1 at year end.

8

Performance Report


1 March 2019

Executive Summary

Executive Lead: Professor Em Wilkinson-Brice

Demonstrating Difference - examples of service improvements or change arising from patient feedback

9

Ashburn Ward, Medical Services

The Division would like to share the positive impact that CLiP ( Collaborative Learning in Practice) students have had on patients, ward

staff and the students themselves. The CLiP students have been introduced in the Hospital as part of a pilot study monitored by the Clinical

Practice Facilitator (CPF ) team.

The students have been very proactive on the ward and importantly are keen to give caring and compassionate care to the patients. They

have been allocated their own patients (with supervision) and have spent time getting to know their patients individually.

Feedback from students shows they feel that CLiP has enhanced their chance as students to interact and find out further information about

our patients. There is more time with patients to communicate and also to support the relatives and explain any discharge details and

answer any questions they may have.

Student comments included:

“Taking the time to know the person behind the patient makes a difference in the life of that person. Supporting the patient and their family

impacts upon their lives in a positive way and it defines how they see the health care system. As a student I want to make a difference to the

people who I come in contact with, I want them to feel that I care and their thoughts and feeling are being listened to and understood. I have

had many a ‘thank yous’ from patients/relatives and each time I am thanked I think: “I made a difference today”.”

Breast Care, Surgical Services

A patient has given feedback on the resource pack given to breast cancer patients. They stated:

“You are in charge of communication, but whoever put this file together deserves a medal.....it is fantastic...there is everything in it

that one could possibly need or want to know, and I am so grateful.

The centre is phenomenal, luxurious, like a private health facility, and the staff incredible, not an easy job for them. So to conclude, once

more, congratulations on this fabulous Resource Pack, it is a real credit to the hospital, truly thank you.”

Tiverton – Doris Heard ward, Community Services

Feedback was received from patients and staff that there was no area on the ward for private conversations or a place to undertake

assessments, which made it difficult to maintain privacy and dignity.

A store room adjacent to the ward was cleared and comfortable seating and a table provided to enable a better area for use by any

professional to facilitate meaningful conversations or for families to sit quietly together away from the ward activity.

Performance Report


1 March 2019

Executive Lead: Professor Em Wilkinson-Brice

Demonstrating Difference continued

10

Medical Services

Feedback was received by patients that the car park did not make it clear where disabled parking bays are located. The Diabetic Nurse

Team & Clinical Research Facility, Research & Development department have made amendments to the patient and volunteers’ map to

illustrate disabled parking bays. This has been positively received by both staff and visitors. Patients are now able to clearly locate disabled

parking bays, thus improving their experience attending the hospital.

When this example reached the Directorate, it was suggested that this change be shared on HUB and with the Communications team for

other members of staff to use and learn from across the campus.

Specialist Services

Speech & Language Therapy Volunteers

People with disorders of communication are likely to experience high levels of frustration, anger and distress. This can lead to social isolation

and significant mental health problems in the long term. It can take these patients a very long time to convey their thoughts and feelings

and, with the demands of a busy caseload, it can be very difficult for speech and language therapists (SLTs) to invest the time required. In

order to meet these needs the service has taken the initiative to work alongside volunteers. They recruit and train volunteers to communicate

effectively with this client group and they then support the team in two ways:

1) Conversation Partner Scheme

This scheme enables people to practice and generalise skills learnt during speech and language therapy sessions with the aim of

becoming more confident to use them to communicate with others in their social circles. Volunteers are matched with a client whom

they visit once a week for six months. Clients are referred in to the scheme by their speech and language therapist, who closely

supervises and supports the volunteer. In order to reduce potential dependency on volunteers, we encourage partners to jointly link

in with other activities and social support groups. For example, one of our clients found the confidence to join a craft group as a

result of the partnership and we encourage at least one joint visit to the charity Living with Aphasia, which aims to provide ongoing

support with the emotional impact of communication disability and reintegration into society.

2) Stroke volunteers – ASU and Yealm

Having a stroke can be a traumatic experience and for people with communication disorders this trauma is heightened by being

unable to effectively communicate thoughts, emotions and questions. Volunteers support our speech and language therapists by

giving people the opportunity to have successful and meaningful conversations whilst on the ward, which research has shown

significantly boosts wellbeing. Conversations are client-led and there are no limits to subject matter. Often, volunteers gather

information about client’s families, careers and interests and record this information which can then be later used by SLTs when

delivering therapy to ensure the therapy is meaningful to the person. It can also be used by the wider team for care and discharge

planning.

Performance Report


1 March 2019

11

Board Focus during Q3 2018/19

This section provides an overview of issues discussed by the Board

of Directors during the third quarter of 2018/19. The CoG is

reminded that agendas and minutes from the Board meetings held

in public are available on the Trust’s website.

The Board looked in detail at the Trust’s performance during the

quarter in the discussions around the Performance Reports but also

in relation to other items on the Board’s agenda.

• At its October 2018 meeting, the Board received the Q2 Home,

Community and Hospital Report (previous known as Ward to

Board). It received the Research & Development Annual Report

and was informed that the Trust was compliant with NHS

England Core Standards for Emergency Preparedness,

Response and Resilience.

• It had a detailed presentation on treatment choices in cardiology

and received its annual update on End of Life care.

• In October the Board approved the Trust’s Operational Capacity

and Resilience Plan 2018/19. The Board discussed in detail the

challenges of the winter period, including capacity and demand

and staffing, not just at the Trust but also within domiciliary care.

It also discussed how to communicate the plan to staff and to the

public.

• The Board invited Dame Suzi Leather, Chair of the Devon STP,

to its October 2018 meeting. Topics discussed included the new

electronic patient record, service delivery networks and decision

making within the STP.

• In November, the Board met as the Corporate Trustee of the

Trust’s General Charity. It received an update on the new care

model as well as feedback from the My Care Programme. There

was a detailed presentation on cancer performance in the public

meeting with the Board discussing the challenges around the

cancer pathways, outcomes and the workforce.

Performance Report


1 March 2019

• The Board’s discussions on the integrated performance reports

throughout the quarter focussed on access to treatment times,

workforce challenges and the financial challenge and the links

between such issues. There was also a focus on appointment

slot issues, diagnostic performance and referrals to the Trust.

• Several business cases were discussed during the quarter

including vascular hybrid theatre, Children and Young People

services tender, 4th linear accelerator and pathology services.

• During the quarter the Trust received notice of the Care Quality

Commission routine inspection of core services in January 2019

and the Well Led inspection in February 2019 and discussed

preparations for this.

• As there was business to transact, the Board held a confidential

meeting in December 2019. It held a session with the Senior

Delivery Group (SDG) on the Trust’s strategy. There was an

update on My Care. There was an update on the draft

Operational and Financial Plan 2019/20 as well as discussion on

the Trust’s five year capital plan, including drivers for the plan,

options to fund the plan and what projects would be included in

the plan.

12

Board Focus during Q3 continued

• During the quarter, the Board received routine reports from

the Audit and Governance Committee. It held detailed

discussions on key strategic issues at each of its

confidential meetings, including updates on the My Care

Programme and a quarterly update on all the strategic

projects underway at the Trust.

• There was a joint Board and Council of Governors

Development Day in November 2018. Items for discussion

included the Trust’s corporate strategy, the NHS 10 year

plan, population health in Devon, an update from the Devon

STP and an update on plans for Greater Exeter. The Board

also met that day to discuss the Trust’s 5 year road map

and the arrangement with Northern Devon Healthcare

Trust.

• At the end of each Board meeting, the Board also had a

discussion on the effectiveness of the meeting (What Went

Well, Even Better If) and reflected on whether the Board

had considered and upheld the Trust’s Vision and Values

during its meeting. It also discussed whether there were

any risks that required escalation to the Board Assurance

Framework.

Performance Report


1 March 2019

• There were regular Chief Executive updates to the Board

throughout the quarter:

• the Trust had received positive feedback in relation

to patient experience from the National Cancer

Survey outcome. The Trust had performed very well

again, and was in the top ten nationally. Detailed

analysis of the survey results were presented to the

Patient Experience Committee.

• Mrs Tracey provided regular updates on

preparations for Brexit, including providing

assurances to the Trust’s EU members of staff. It

was agreed at the December 2018 meeting to

escalate Brexit as a risk to the Board Assurance

Framework.

• Mrs Tracey informed the Board of changes in

supplier of domiciliary care in Devon and the

challenges this brought, particularly within Exeter.

• At the December 2018 meeting, Mrs Tracey

informed the Board of a recent Never Event,

involving wrong site surgery.

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COUNCIL OF GOVERNORS PAPER Meeting date: 1 March 2019

Agenda item: 8.1, Public meeting

Title: COG COORDINATING COMMITTEE AND WORKING GROUP PROGRESS REPORT

Purpose: To update the Council of Governors on the work of, and the progress being made, by the three working groups and the CoG Coordinating Committee.

Background: The three working groups are: CoG Effectiveness, Public and Member Engagement and Patient Safety and Quality. Each Group is led by a Governor with membership of each Group open to all Governors. Each Group reports quarterly to the CoG Coordinating Committee, with the Chair of each Group a member of the CoG Coordinating Committee.

CoG Coordinating Committee (update from Peta Foxall, Lead Governor)

This report provides an update on the discussions and actions from the meeting of the CoG Coordinating Committee held on 14 January 2019.

Introduction: All members of the Committee were present. The action notes of the meeting held on 9 October 2018 were confirmed as accurate. Progress against the action tracker was noted.

Key Issues: Discussions focused on the CQC’s visit, its purpose and planned meetings, including that with CoG on 25 January 2019. The draft agenda for that development day was considered and agreed. Similarly, for the agendas for the 1 March (CoG meeting) and 15 March 2019 (development day) based on the annual schedule for reviews and decisions. The impact of recent governor resignations on CoG and working group membership, including the Board observation rota, was discussed and solutions explored. Reassurance was given that working group activities would continue as planned with opportunities to collaborate where tasks overlap. Governor attendance at meetings and apologies in advance were noted. There was a separate confidential item that enabled reflections on processes and outcomes associated with the Code of Conduct and Behaviour Charter for Governors.

Forward View: The following were agreed: (i) an annual planner for CoG meetings and governor commitments to be distributed, (ii) the role description for the Deputy Lead Governor to be updated to ensure minimum period of officer as a governor and (iii) advice for governors on how to access and file core documents will be sent by email (this a post-meeting note).

To note: the proposed date of the next meeting is the 29 April 2019.

Public and Member Engagement working group (update from Kay Foster) Purpose of the working group: To ensure that the Council of Governors is

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meeting its duty to represent the interests of members of the Trust and the interests of the public and contribute a Governor perspective to the development of the Trust’s engagement work. The last meeting was held on 12 February 2019. The key points were as follows: 1. 500 Membership Forms have been issued to the Maternity Wards and

Community; however the uptake to join Trust Membership has been negligible. 2. Partly as a result of 2 Governors being involved with the Deaf Community the

Trust has now employed a full time staff member to work with Out-Reach Groups.

3. The Annual Members Meeting was discussed particularly the poor turn out of Members at the last few years meeting. Consideration will be given to changing to a lunch time meeting, with a letter from the Governors prior to the meeting asking if Members would like Governors to ask questions on their behalf. Also the possibility of the inclusion of a key speaker.

4. John Murphy is to set up a stand in Exeter Library to be available to engage with the public, listen to them, identify potential Governors and encourage membership.

Patient Safety and Quality Working Group (update from Faye Doris) Purpose of the working group: To contribute a lay/governor perspective to the Trust’s Patient Experience Committee (PEC) and to the development of the Trust’s Quality Account submissions and future priorities on quality. Update from the PEC meeting on the 21 February 2019:

Administration staff: wide discussion about staffing, workload, staff shortages. Issues identified throughout the report and seen in themes running through complaints. Strategies to manage this were discussed.

MyCare: There are a number of challenges from the Committee to which MyCare is given as the solution. However we cannot wait 18 months to resolve many issues.

Update on Deaf Awareness Workshop and Learning Disability Strategy: Common themes and solutions in these two presentations e.g. easy read documents, staff awareness training. Important that Inclusion is more than an overarching term and updates should include other hard to reach groups.

Volunteers Strategy: targets challenged as too ambitious and possibly not achievable. Assurance that recruitment in younger age groups may be cohorts rather than individuals. Request for redraft considering inclusivity, potential role of part time non-clinical staff.

Also received were:

The National Maternity Survey Results – largely positive with improvements from previous survey.

Patient Experience Report Q3 2018/2019 – Narrative useful.

Open Visiting: Worked well. Will now be from 08.00 – 20.00.

Patient Stories: Work progressing.

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To Note: The next meeting of the Patient Safety and Quality working group will be on Monday 25 March 2019, 09.30 – 11.00, E218.

CoG Effectiveness working group (EWG) (update from Tony Ducker) Purpose: To enhance the effectiveness of the CoG by ensuring that its knowledge base, processes and operations are fit for the purpose defined in the Health and Social Care Act 2012. The group meet on 13 December 2018 with six members present and again on the 4 February 2019 with three members present following the resignation of a number of Governors. The Group’s membership now has five Members. Following the previous discussion on how Governor’s access relevant documents Bernadette has sent out guidelines on how to download them. The needs of the Governors is being taken into consideration by Website working group. Kay is Governors rep on the group. The CoG performance report was reviewed with regard to the amount of detail included in the November performance report and the possibility of reducing this to focus on exception reporting. The Group felt it did not want to focus on exception reporting, as this meant the good performance was also excluded from the report. It was agreed to keep the same format and detail in the performance report and for CoG to discuss it on 15 March 2019 Development Day. Membership constituencies / number and classes of Governors were discussed, it was noted that members of the PMEG had also discussed this. As this was laid down in the constitution it was felt that it was a EWG remit and the a task and finish group should be set up to include any member of PMEG who wished to contribute. It was planned to catch up and get ahead on the document to be reviewed, however it was not possible to arrange a meeting of the Document Review Group (DRG) as on the only day everyone was available no room could be found. Next meeting Thursday 16 May 2019 09.30-11.00 room E218.

Recommendation: That the Council of Governors notes the report and approves the Working Groups Terms of Reference.

Presented by: Peta Foxall, Lead Governor Kay Foster, Public & Member Engagement Faye Doris, Patient Safety & Quality Tony Ducker, CoG Effectiveness

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COUNCIL OF GOVERNORS PAPER

Meeting date: 1 March 2019 Agenda Item: 8.2, Public

Title: COMMITTEE AND WORKING GROUP MEMBERSHIP

Purpose: To update Council of Governors on the current composition for the CoG committees and working groups.

Background: The Council of Governors has two statutory committees: Nominations Committee and the NED Remuneration Committee (NEDRC). Each committee has its own Terms of Reference which state the membership and terms of office. In addition the CoG has established three working groups which report to CoG via the CoG Coordinating Committee. The CoG Coordinating Committee has a Terms of Reference which outlines the membership as do the working groups.

Key Issues:

Governors are asked to review the information below and highlight any additions or amendments.

CoG Committees

Membership of both Committees is constituency based as defined in the Terms of Reference. Governors are elected to each Committee by the Governors within the constituency area.

Nominations Committee

The membership of the Nominations Committee is as follows:

Governor Elected to Committee Term of office on Committee due to end

Peta Foxall, Lead Governor

n/a n/a

Tony Ducker (Exeter & South Devon)

January 2017 January 2020

Vacancy (Exeter & South Devon)

Vacancy (East Devon, Dorset & Somerset)

Kay Foster (East Devon, Dorset & Somerset)

October 2017 October 2020

Chris Wilde (Mid, North, West Devon & Cornwall)

January 2015 and 2018 January 2021

Cynthia Thornton (Mid, North, West Devon & Cornwall)


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Hazel Hedicker (Staff) January 2014 and 2017 January 2020

Angela Shore (Appointed)


Non-Executive Director Remuneration Committee (NEDRC) The membership of the NEDRC committee is confirmed as follows:

Governor Elected to Committee Term of office on committee due to end

Peta Foxall (Lead Governor)

n/a n/a

Vacancy (Exeter & South Devon)

Vacancy (East Devon, Dorset & Somerset)

Cynthia Thornton (Mid, North, West Devon & Cornwall)

February 2017 February 2020

Hazel Hedicker (Staff)

February 2017 February 2020

Vacancy (Appointed)

There are vacancies on both Committees and elections will be required to fill these. These will be commenced during March 2019. CoG Coordinating Committee and Working Groups CoG Coordinating Committee The Committee comprises the Chairman of the CoG, Lead Governor, Deputy Lead Governor, the Chairs of the three Governor Working Groups and a Staff Governor representative. Staff from the Corporate and Engagement Teams also attend.

Trust Chairman James Brent

Lead Governor Peta Foxall (Chair of the Committee)

Deputy Lead Governor Faye Doris

Chair, CoG Effectiveness Working Group

Tony Ducker

Chair, Patient & Membership Engagement Working Group

Kay Foster

Chair, Patient Safety & Quality Working Group

Faye Doris

Staff Governor representative Hazel Hedicker

Working Groups The membership of the groups is voluntary with Group electing its own Chair and Vice Chair. Governors can be a member of as many Groups as they choose and all Governors are encouraged to join a Group. Governors are welcome to observe meetings before deciding to join. The current membership is laid out below.

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CoG Effectiveness Working Group

Tony Ducker (Chair) Faye Doris

John Murphy Rosemary Shepherd

Barbara Sweeney

Public and Membership Engagement

Kay Foster (Chair) Peta Foxall

John Murphy Barbara Sweeney

Chris Wilde

Patient Safety & Quality Working Group

Faye Doris (Chair) Tony Ducker

Kay Foster Catherine Geddes

Douglas Hull Rosemary Shepherd

Barbara Sweeney Chris Wilde

In addition to the above, there are also three Governor members of the Patient Experience Committee (PEC). The PEC is a sub-committee of the Governance Committee, which in turn reports to the Board of Directors. The current members are: Kay Foster, Faye Doris and Barbara Sweeney. The Governor members are decided by election amongst the Governors.

Recommendation: It is recommended that the Council of Governors note the information and inform of any amendments required.

Presented by: Melanie Holley, Head of Governance

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