agenda welcome and opening comments

AGENDA

Welcome and opening comments

106/10 Apologies and Declaration of Interests

107/10

Minutes of the meeting held on 14th April 2010

108/10 Matters arising and Action Tracker updates

109/10 ‘This Agenda’ (Reports for Information/Assurance – taken as read) Opportunity for Governors to ask for any element of a report issued for information or assurance to be considered further

110/10 111/10

Thematic reviews

• Annual Plan

• Feedback from CoG informal discussions/questionnaires

112/10 113/10 114/10

Formal Business of the Council

• Re-appointment of Non-Executive Directors; Derek Brown and Teresa Whittaker

• Extension of term of office of a Governor • Quality Reporting (Linked to item 115/10)

115/10

Formal Sub Committee Report

• Standards & Assurance – Quality Account

116/10 Any other business

Close of Meeting

117/10 118/10

Reports issued for information or for assurance purposes

• Annual Report Mapping carer/user engagement

• Chief Executive Quarterly Assurance Report; including quarterly financial update

Council of Governors Meeting

14th April 2010

Wellington Park, Leyland.

Present In Attendance Steve Jones (Chairman) Public Governors Blackburn with Darwen Dan Johnson Alfred Olaiya Blackpool Linda Jones Central Lancashire Barbara Lockett Christine Pownall Frank Smith Lona Smith Moira Mondesire East Lancashire Les Bond Tom Lawman Jennifer Lord Geoff Wharfe Hilary Whitworth North Lancashire John MacLeod Christina McKenzie-Townsend Ian Clift Angela Winter Staff Catherine Dobson Reg Kielty Chris Southworth Liz Taylor Nominated Mark Lunney Valerie Wilson

Derek Brown (NED) Chris Heginbotham (NED) Sam Jones (NED) Heather Tierney-Moore (Chief Executive) Diane Halsey (Company Secretary) Dave Tomlinson (Director of Finance) Patrick Sullivan (Director of Nursing) Sarah Jones (Associate Director of Communications and Corporate Affairs) Hannah Bowie-McLean (Governor & Membership Engagement Officer)

UNCONFIRMED

ITEM 97/10

WELCOME & OPENING COMMENTS The Chair opened the meeting by welcoming everyone and stated his gratitude for the warm welcome he had received from the Council of Governors on starting his tenure with the Trust. He proposed a different style of agenda on a trial basis and asked the Council for feedback as to its suitability.

98/10 APOLOGIES & DECLARATIONS OF INTEREST Apologies were received from Phil Pye, Nigel McMurdo, John Haworth, Nigel Harrison, Gaynor Chisnall, Teresa Whittaker, Shirley Saunders, Joanne Marshall, Max Marshall and Belinda Weir. No declarations of interest were received. It was noted that there being only two Governors from the Nominated category present, the meeting was not quorate.

99/10 MINUTES OF THE MEETING HELD ON 16TH MARCH 2010 The minutes were approved as a true and accurate record.

100/10 MATTERS ARISING & ACTION TRACKER There were no matters arising. In relation to Action Items CoG 32 and 33, the Associate Director of Communications and Corporate Affairs reported that a date of 11th May 2010 had been set to discuss guidance for Governors in relation to public consultation events and that she would report back to the Council of Governors in due course. Actions closed. The Director of Nursing stated that in relation to Action Item CoG 37 the Guidelines on Carers Access to Information about Relatives document had been circulated. Action closed. The Director of Finance stated that in regard to Action Item CoG 39, the Annual Plan would be addressed in the upcoming May 2010 Council of Governors meeting, and that the Annual Report and Accounts would follow in July or August. In relation to Action Item CoG 40, the Company Secretary stated that a Report Guidance and Template document would be circulated to the Council of Governors in June or July. The Director of Finance, in regard to Action Item CoG 41, stated that he would be delivering a presentation in relation to the Bi-Annual Financial Outlook Report, later in the meeting. Action closed. On behalf of the Director of Workforce and Organisational Development, the Chief Executive and Director of Nursing clarified what constitutes mandatory training in regard to the uptake of safeguarding training, Action

Item CoG 42. It was reported that the Trust was looking to make training more accessible, for example by the use of electronic learning facilities. Following a discussion relating to communicating to staff what is mandatory, the Chair stated that he expected training to be evidenced in personal development plans. Action closed.

101/10 THIS AGENDA Governors were invited to raise any queries for further discussion in relation to reports that had been circulated for information or assurance as part of this agenda to be considered further. Following a query relating to the results of the National Staff Survey, the Chief Executive provided clarification around the status of the survey. It was noted that the Trust were required to administer the survey and interpret and take forward the published findings appropriately. She stated that leadership and management training was being processed by the Director of Workforce and Organisational Development, and that she was aware of some issues relating to the effectiveness of the communication between managers and staff which needed addressing such as ‘Team Brief’ being cascaded effectively. A governor queried whether staff integrated into Trust teams, such as Social Workers, were included in the staff survey to which the Chief Executive said she would investigate and report back.

102/10 THEMATIC REVIEWS COUNCIL OF GOVERNORS PRIORITIES The Company Secretary reminded Governors of the developmental journey so far and outlined future plans. She drew attention to the Council of Governors Handbook as an essential reference document and measure of how effective the Council had been in discharging its responsibilities. However a simple ‘Decision Rights’ document was presented and issued as a quick point of reference for Governors. An ‘Annual Rhythm of Council of Governors Standard Business’ document was being developed and was circulated as a draft for comments. The document would be updated to accommodate relevant business and suggestions from Governors as appropriate. The document included many items that were for information and assurance, for example key messages for dissemination to members. The Chair gave an overview of the operating model of the Trust. He challenged the Council of Governors to ensure that all aspects of the work they do in relation to the Trust should ultimately improve the services the Trust offers to the people of Lancashire and ensures that the Trust remained focussed on the key drivers of quality to improve the outcomes for patients and citizens. On behalf of the Director of Workforce and Organisational Development, the Chief Executive, presented a schematic diagram showing the relationships and organisational structures to deliver the strategic plan. She went on to outline the aims of the Trust in the context of the current economically

constrained times. She stated that action would be taken at every level, influencing individuals and teams as well as the wider organisation to ensure effective systems were in place. The Chief Executive drew attention to a document containing the ’12 Priorities List’ and stated that the key action areas would be ‘Lean’ healthcare, quality strategy and service transformation with the aim of providing more efficient inpatient services working to new models and behaviours. She also reported that a ‘Payment by Results’ scheme would be enforced aligning payment for delivering services effectively linked with service line management. The review of the Corporate Function would continue to streamline a function that is fit for purpose. The Vice Chair addressed the Council providing an insight into how he wanted to develop the role of Vice Chair. He explained that his role was to create a robust and open working relationship with the Chair and act as a link to the Council for the development of agendas and surfacing of issues. He said he was there to add value as the Vice Chair and that each Governor should also have the opportunity to do that. He asked the Governors to each fill in a ‘Governor Priorities Questionnaire’ and return to him to help inform the agenda setting process. BI-ANNUAL REPORT ON THE FINANCIAL OUTLOOK The Director of Finance gave a presentation on the current financial situation noting the impact on the public sector financial situation at this point in time. He referenced the public perception of the NHS, the need for the NHS to manage within existing resources and the likelihood of a period of NHS pay restraint. He stated that there was an expectation that the Trust need to do much more with less money, but still maintain standards. He said this would be achieved through working closely with commissioners, PCT provider arms, partners and staff and that radical new approached would have to be adopted to ensure success. A ‘Key Messages’ document would be issued for use by Governors in communicating these complex issues to members.

103/10 FORMAL BUSINESS OF THE COUNCIL QUALITY ACCOUNTS The Director of Nursing updated the Council of Governors in relation to the Quality Account, stating that there was a need to ensure efforts were concentrated on the key drivers of quality to improve outcome for patients. He explained the importance of being held to account and that the results would show the positives the Trust is achieving, and in the worst case scenario will show the areas that need improvement. He explained the process of the Quality Account including the opportunities for Governors and user/carer input, and said that a final copy would be published in the Annual Report and sent to the Secretary of State.

104/10 SUB-COMMITTEE REPORT The Chair explained that a sub-committee report from the Standards and

Assurance Committee would be given at the next meeting which would focus on the evidence base in support of the Quality Account.

105/10 ANY OTHER BUSINESS A Governor stated that she had attended a membership talk about Post Traumatic Stress Disorder, delivered by the Lancashire Traumatic Stress Team, and that they had said the service was oversubscribed and were not taking any referrals at this time. She explained she had since visited the website and it had various references to the fact no referrals were being taken at that time. She raised concerns that individuals seeking help might not find this helpful and that there were no signposts to alternative support. The Associate Director of Communications and Corporate Affairs stated that the team manage their own website, but that she would look into it. The Chief Executive stated she would obtain a written report in relation to the queries. DATE OF NEXT MEETING 18TH May 2010 at 10.00am, Wellington Park.

Meeting Date ACTION OUTPUT BY WHEN EXEC RESPONSIBLE

STATUSCOMMENTS

ACTION ITEM

COG 11 02 10 Annual Plan. Annual Report and Accounts.

Agenda Items

18 05 10 DT OpenAnnual plan being addressed in May CoG. Report & Account to follow in July/August

COG 39

COG 11 02 10 Report Guidance & Template

Agenda Item 14 04 10 DLH Open Document to be circulated in June or July

COG 40

COG 14 04 10 PTSD Service website query

Agenda Item - AOB

18 05 10 HTM Closed Briefing circulated by Chief Executive

COG 43

Agenda Reference: 111/10

Purpose of Paper/Summary: Following the last Council of Governor’s meeting the Chair, Vice Chair and Company Secretary met with members of the Council for an informal discussion to identify issues if concern an discussion topics for consideration for future agendas. Council members had been asked to complete individual questionnaires identifying any such points and return them to the Vice Chair. Similar informal discussions are planned for the end of each Council of Governor meeting. Attached is a monitoring schedule which captures the points raised and provides an update on progress or actions being considered.

FOIA STATUS (delete as applicable)

18th May 2010, 10.00am, Wellington Park, Leyland Council of Governors Agenda Item: Feedback from CoG informal discussions/ questionnaires

Paper Prepared by: Diane Halsey – Company Secretary

Standards for Better Health Link:

Link to Strategic Objective:

Any Background Papers:

Any Financial Implication:

Any Human Resource Implication:

No Exemption

RESPONSES TO THE COUNCIL OF GOVERNORS QUESTIONNAIRE RECEIVED BY THE VICE CHAIR

Questionnaire Responses

Themes/Issues (link to monitoring document)

1 Attendance at Sub-Committees - Governors should attend if they have agreed to be on a Committee

D2 Administration and meeting management

2 Gathering a list of anecdotal information – what to do with it

B2 Communications

3 Reports from project board every 3 months – information on significant project milestones for information

4 Trust website development

B6 Communications

5 Review Foundation News and suggest development

B6 Communications

6 Increase pro-active preventative anti stigma/PR

A8 Possible Discussion Theme

7 Suicide prevention strategy


8 Guest speakers

C4 Meeting management

9 Complaints


10 Accompanied surprise/inspections

E1 Patient Experience

11 Waiting times including equalising across the country


12 Patient Experience – measure 2 yearly

A7 E2

Patient Experience

13 Patient Activity


14 Member Communication – Annual

B7 Communication

15 Complaints monitoring and SUI’s including a breakdown and analysis by district


16 Pro-active Governor activity

D3 Other

17 Support for Charity Day Centres – closing down


18 Staff sickness


19 Service user outcomes and the use of ad hoc questionnaires

E3 Patient Experience

20 Pathways a simple guide to accessing services

B8 Communication

21 Volunteering scheme


LANCASHIRE CARE NHS FOUNDATION TRUST – COUNCIL OF GOVERNORS ISSUES ARISING FROM INFORMAL DISCUSSIONS WITH GOVERNORS – MONITORING DOCUMENT

Last updated: 20th April 2010

Issue Current Status A 1 Possible discussion themes (these will be subject to the return of the

questionnaires and our consideration of them)

2 Waiting times for referrals from the standpoint of users and carers

3 Process standards (as opposed to clinical standards) e.g. waiting times, appointment cancellations, accessibility, etc

4 Patient activities (how they are able to spend their time)

5 Possibly volunteering and adding value

6 Frances report – LCFT response

7 SUI’s and complaints including analysis by area

8 Quality measures/ Patient Experience Measures

9 Proactive/ preventative anti stigma activity/ PR

10 Suicide prevention strategy

11 Support for day care centres that are closing down

12 Staff sickness

Issue Current Status B Communications 1 Having a key messages sheet on topics which COG receives/discusses

First key messages document produced following the Financial Outlook Presentation (March) and will be issued this week. Future key messages documents will be produced as part of the presentation and issued at the meeting.

2 Simple guide to which other bodies do what (PIPE, Standards and Assurance, etc) and how these feed in to COG/ mechanisms for Governors to feed into these groups anecdotal evidence re quality standards.

Detail of how the Sub-Committees operate and fit together are contained in the Framework for the Discharge of Responsibilities – Simple one page flow diagram to be



produced for the May CoG meeting 3 A customer interface line that Governors can use or refer citizens to when the

latter are asking questions that Governors themselves cannot answer

Credit card style ‘Signpost’ reference guide giving essential points of contact and phone numbers to be produced for May CoG meeting. Practicalities of Customer Interface Line to be considered

4 Starburst text to remind Governors of meetings and venues

Comms team to include on Governor Briefing and in notification of meetings

5 PowerPoint presentations – need to speak to the slides and not merely read out

6 Need to review Foundation News and website as a tool for communication to members/users/carers a suggest areas for development

7 Member communication discuss annually

8 Pathways – a simple guide to accessing services

Issue Current Status C 1 Administration & Meeting Management 2 Expenses – procedure and process/prompt payment of claims

Expenses claims come in very ad hoc – new procedure for monthly submission including dates to ensure that prompt payment is received to be issued prior to next meeting. Internal process to chase outstanding claims instituted. Following up outstanding claims issues with payroll and will have a resolution prior to the next meeting.

3 If Governors are to discuss fewer issues in greater depth they will need to go with the spirit of reports for information and not raise points on every one

Chairman to manage

We asked that if Governors have matters that they might previously raise as any other business, that they raise them in advance and the answer (for everyone) can then be included in the information reports.

Reminder to be sent out to Governors with the papers to ensure that any questions are raised through the Governor Helpline prior to the meeting and that any items of other business are also notified prior to the meeting.

4 Invite guest speakers to meetings



Issue Current Status D Other 1 Ongoing training needs of Governors

Governor development scheme produced and handed over to training department who are to follow up on the delivery of Induction and other modules. Finance Module planned for June 2010. Elective module option was intended to address the specific committee and personal based learning needs. Meeting with JM planned to establish progress before reporting back to the CoG’s

2 Governors should prioritise attendance at meetings as far as is practical when they have agreed to sit on a committee

3 Reviewing pro-activity of input from Governors

of 2


Purpose of Paper/Summary: Attached is the Nominations Committee report following their last meeting, 7 April 2010.

The Council of Governors is asked to: a) Approve the recommendation of the Nominations Committee that Teresa Whittaker

and Derek Brown are re-appointed as Non-Executive Directors for a further Term of Office of 3 years with effect from 1st October 2010.

FOIA STATUS (delete as applicable

18 MAY 2010, 10.00am, WELLINGTON PARK, LEYLAND COUNCIL OF GOVERNORS Agenda Item: Re-Appointment of Non-Executive Directors; Derek Brown and

Teresa Whittaker.

Paper Prepared by: Steve Jones, Chairman


C7a – Clinical and corporate governance


Maintain the highest standards of financial, corporate and clinical governance




No Exemption

of 2

Nominations Committee Report

The Committee met on the 7 April 2010 to review the procedure for the re-appointment of Non-Executive Directors and for a report from the Chairman on the performance of two Non-Executive Directors, Teresa Whittaker and Derek Brown, who were seeking re-appointment for a further term of office. The outgoing Chairman (Jo Darbyshire) had recommended on the basis of performance that both Non-Executive Directors should be re-appointed. The skills and contribution brought to the Trust Board and the Council of Governors by both Teresa and Derek were discussed in full. The Nominations Committee agreed to recommend to the Council of Governors that Teresa Whittaker and Derek Brown are re-appointed as Non-Executive Directors for a further Term of Office of 3 years with effect from 1st October 2010. It was also agreed that at the next meeting the Nominations Committee would review the skills mix of the Board recognising that in 2011 Belinda Weir and Chris Heginbotham will be eligible for reappointment.


Purpose of Paper/Summary: The cost of running elections to full vacancies on the Council of Governors is relatively high. The Trust constitution requires an election to be called within 3 months of a vacancy arising. To minimise cost and to get a planned and effective process for the development of awareness and promotion of the role of Governors to members eligible to stand for election, it makes sense to aim for an annual planned election process. There are some historical inconsistencies in the terms of office for Governors. One such inconsistency is an end term for Christina Mackenzie-Townsend of April 2010. It is within the authority of the Governors to extend this term to December 2010 which is the usual renewal date for a term of office. The Council of Governors is asked to: - Consider the proposal and if thought fit approve the extension of the term of office of

Christina Mackenzie-Townsend to 1st December 2010.


18th May 2010, 10.00am, Wellington Park, Leyland Council of Governors Agenda Item: Extension of term of office of a Governor

Paper Prepared by: Diane Halsey – Company Secretary






No Exemption

LANCASHIRE CARE NHS FOUNDATION TRUST COUNCIL OF GOVERNORS

Terms of Office

INTRODUCTION Under the constitution Public Governors are appointed for a usual term of 3 years. On authorisation as a Foundation Trust our Governors were appointed for either one, two or three years to facilitate a staggered succession plan in future years. Most of these terms have now worked their way out of the system either by natural wastage or through re-election. COMMON PLANNED RENEWAL DATE The cost of running a public election to full vacancy is quite high and the Trust would like to minimise the need to run multiple elections during the course of the year and move to a single annual renewal date for terms of office of Governors of 1st December. This would require the adjustment of some current terms of office to align them to this objective and on the whole this can only be achieved as part of future election processes. Apart from the cost, there are other benefits to the single renewal date. The one point of entry will minimise disruption to the activity and work of the Council. It will also enable a planned and efficient approach to Governor induction to fit in with the timetable for governor development. The main benefit is that it will facilitate the Trust mounting an effective approach and programme to raising awareness of the opportunities and benefits of governorship amongst constituent members and hopefully increase the pool of potential governors and participation in the election process. CONSTITUTIONAL ISSUES Under the constitution as it is currently written we are potentially prevented from moving to a single annual election date as we are required to call an election within 3 months of a vacancy arising. If a governor leaves mid term then the renewal date is effectively set under the provisions of the Constitution. With a governing body numbering 34 people, running with a vacancy or two for a period of months would not represent a significant risk to the Governors of the Foundation Trust and indeed recent history by necessity has bourne this out. This is one area where the Trust is likely to recommend an amendment to the Constitution when it is reviewed later in the year. We can however in the meantime plan to minimise the disruption by arising wherever possible to implement a planned common renewal date of 1st December for new appointments. EXTENSION OF A GOVERNOR TERM OF OFFICE One current governor Christine Mackenzie-Townsend remains on the 2 year appointment transitional arrangements and her term of office is due to expire on 22nd April 2010. Whilst the Constitution sits out the usual term of office of three years, it is within the authority of the Governing Body to set a term of office for a governor. Christina Mackenzie-Townsend was appointed for two years and on election no public statement was made, or expectation set about the duration of her term of office. It is proposed that the Governing Body extend the current term of office to 1st December 2010 which would remain within the usual 3 year term parameter and bring it in line with the renewal of five other members of the Council. Attached is a schedule of Term of Office for information. The Council is asked to:

- Consider, and if thought fit, extend the Term of Office of Christina Mackenzie-Townsend from 22nd April 2010 to 1st December 2010.

Lancashire Care NHS Foundation Trust Terms of Office

17/05/20101/1

NAME AREA TERM (years)

START DATE

END DATE

REVIEW DATE

CURRENT YEAR ELECTIONS

ELECTION /APPT METHOD

NON EXECUTIVE DIRECTORSSteve Jones 3 01 04 10 31 03 13 01 06 13 NOMSTeresa Whittaker 4 01 10 06 30 09 10 01 07 10 NOMSSam Jones (Deputy Chair)

3 NOMS

Chris Heginbotham 3 01 09 08 31 08 11 01 06 11 NOMSDerek Brown 4 01 10 06 30 09 10 01 07 10 NOMSBelinda Weir 4 01 10 07 30 09 11 01 07 11 NOMSPeter Ballard 3 01 06 09 31 05 12 01 03 12 NOMSCOUNCIL OF GOVERNORSSTAFFReg Kielty 3 01 12 08 01 12 11 01 09 11 ERSCatherine Dobson 3 01 07 09 30 06 12 01 03 12 ERSJanet Ercan Other 3 31 12 09 30 12 12 01 10 12 ERSVACANCY - OT ERSChris Southworth 3 01 12 07 01 12 10 01 09 10 ERSElizabeth Margaret Taylor

3 01 12 07 31 11 10 01 09 10 ERS

ERSPUBLICMoira Mondesire C Lancs 3 31 12 09 30 12 12 01 10 12 ERSLes Bond E Lancs 3 31 12 09 30 12 12 01 10 12 ERSDan Johnson B w D 3 01 07 09 30 06 12 01 03 12 ERSTom Lawman E Lancs 3 01 07 09 30 06 12 01 03 12Barbara Lockett C Lancs 3 01 12 08 01 12 11 01 09 11 ERSJennifer Lord E Lancs 3 01 12 07 01 12 10 01 09 10 ERSChristine McKenzie-Townsend

N Lancs 2 23 04 08 22 04 10 21 01 10 ERS

John MacLeod N Lancs 3 01 12 08 01 12 11 01 09 11 ERSIan Clift N Lancs 3 31 12 09 30 12 12 01 10 12 ERSAlfred Olaiya B w D 3 01 07 09 30 06 12 01 03 12 ERSGeoff Wharfe E Lancs 3 31 12 09 30 12 12 01 10 12 ERSChristine Pownall C Lancs 3 01 07 09 30 06 12 01 03 12 ERSNigel McMurdo Blackpool 3 31 12 09 30 12 12 01 10 12 ERSPhilip Pye Out of Area 3 01 12 07 01 12 10 01 09 10 ERSFrank Smith C Lancs 3 01 12 08 01 12 11 01 09 11 ERSLona Smith C Lancs 3 01 12 08 01 12 11 01 09 11 ERSHilary Whitworth E Lancs 3 01 12 07 01 12 10 01 09 10 ERSLinda Jones Blackpool 3 31 12 09 30 12 12 01 10 12 ERSAngela Winter N Lancs 3 01 12 08 01 12 11 01 09 11 ERS

PARTNER ORGANISATIONSHazel Bayley Alzheimers

Society3 NOMINATED

Jacqueline Slater B with D 3 NOMINATEDMark Lunney MIND 3 NOMINATEDGaynor Chisnall Making

Space3 NOMINATED

Clive Tattum Lancs Constabulary

3 NOMINATED

Nigel Harrison Higher Education

3 NOMINATED

Susan Ridyard Blackpool BC 3 NOMINATED

Valerie Wilson Lancs CC 3 NOMINATEDDr John Haworth E Lancs PCT 3 NOMINATED


Purpose of Paper/Summary: The paper provides a brief summary of the Standards and Assurance Committee’s review of Standards for Better Health standard C1a. The committee was assured that the evidence presented met the standard. A verbal update will be given on the Quality Account following the Standards and Assurance Committee meeting on 12th May.


18th May 2010, 10.00am, Wellington Park, Leyland Council of Governors Agenda Item: Standards and Assurance – Quality Account

Paper Prepared by: Emma Garside, Associate Director of Healthcare

Standards and Assurance


C1a





No Exemption

Standards and Assurance – Quality Account

March 2010

Since the last Council of Governors meeting in February, the Standards Assurance Committee has met once (24th March 2010). The membership of the group had been reviewed and new members attended the meeting. The committee was informed that the trust had submitted its application to the CQC in January 2010, and a decision is expected fairly shortly. The Trust could be granted:

• Full registration • Registered with action plans (where minor concerns have been

identified and action plans put in place)

• Registered with conditions (timescales would be given for conditions to be addressed within)

• No registration

The future purpose of the group was discussed inline with the new types of outcome evidence to be reviewed. It was agreed that a calendar for the year will be produced, outlining the outcomes to be reviewed. This will enable members of the Council of Governors to decide if there is a meeting they would like to attend. Review of core standards

• The standards reviewed at the meeting was: o C1a – incident management

o The group agreed there was strong evidence to support C1a and no

concerns were identified


Purpose of Paper/Summary: This paper provides an overview of the ways in which Governors have engaged with service users and carers between April 2009 and March 2010. The paper also proposes a different way for recording this information going forwards. The Council of Governors is asked to:

a) Note the report and agree the proposed future reporting format


18 May 2010, 10.00am, WELLINGTON PARK, LEYLAND COUNCIL OF GOVERNORS Agenda Item: Annual Report mapping carer/user engagement

Paper Prepared by: Sarah L Jones, Associate Director of Communications and

Corporate Affairs


C17, 16


To deliver high quality, person centred, compassionate services To safeguard the welfare and promote the well being of patients and staff




No Exemption

Annual Report mapping carer/ user engagement This report sets out the ways in which Governors have engaged in Trust organised events with carers and service users between April 2009 and March 2010 in their capacity as a Governor. 1. Membership recruitment activities Governors will be aware that the key focus for membership activity during 2009/10 was on achieving the Monitor recruitment target. A number of membership recruitment activities were arranged, some of which also provided opportunities for engagement and these are listed below:

• Carers week stall with Blackpool Carers - June 09 • Dementia awareness week stall - July 09 • World Alzheimer’s Day stall – September 09 • Annual Members’ Meeting – September 09 • Student Life Fair - October 09 • World Mental Health Day Making Space concert – October 09 • World Mental Health Day older adults network event – October 09 • Membership stand at BME event – October 09 • Blackburn College Talk – March 10 • H Factor event – March 10

2. Service user and carer activities Governors have been engaged in the following Trust organised service user and carer activities: • Governors attended the Public Involvement and Patient Experience Sub

Committee • Two Governors attended the opening of the sensory garden at Frank

Gardham House During the same time period, Governors were involved in the following public engagement activities, which includes engagement with service users and carers: • Two Governors were involved in the public consultation on the future of

inpatient services in Lancaster and Morecambe. • Governors donated items for the homeless shoebox appeal and four

Governors helped to pack them. • Six Governors attended the festive carol event which provided an

opportunity to meet with members informally. • Five Governors attended three events held during December linked to the

Annual Plan development. • Three Governors attended a membership talk on post traumatic stress

disorder to which approximately 25 members attended. • Five Governors supported a Love your Mind event held at Sainsbury’s on

February 12th which resulted in 68 new members being recruited.

• Governors are part of the programme board for the new inpatient units and

one Governor also attended the public drop-in event held in February in advance of planning permission being submitted for Whyndyke Farm.

• One Governor attended an event for staff governors hosted in Bolton. 3. Future reporting Governors will also have attended community groups and events not organised by Lancashire Care but in their capacity as a Governor and going forwards it is important that this activity is captured by the Trust. Therefore the form below has been developed for Governors to complete so that the Trust has an accurate record of all engagement activity: Governor name

Date of meeting or event

Title of meeting or event

Key points from the discussion

Any issues LCFT needs to respond back to the group on?

In addition, it is proposed that future reports clearly identify the involvement of Governors in different events using the table below (the following table has been developed for illustration purposes only): Engagement activity

Governor a Governor b Governor c Governor d

Annual Plan member event – 11th Dec 09 Preston

Membership talk on PTSD – March 23rd

Love your Mind event – February 12th


Purpose of Paper/Summary:

i) To assure the Council of Governors that the Board of Directors is operating within the terms of authorisation

ii) As part of the information required to hold the Board of Directors to account for the performance of the Trust


18 MAY 2010, 10.00am, WELLINGTON PARK, LEYLAND COUNCIL OF GOVERNORS Agenda Item: Chief Executive Quarterly Assurance Report Paper Prepared by: Heather Tierney-Moore, Chief Executive


All


Maintain the highest standards of financial, corporate and clinical governance


None


None Specifically


None Specifically

No Exemption

COUNCIL OF GOVERNORS MEETING: 18th MAY 2010 CHIEF EXECUTIVE QUARTERLY ASSURANCE REPORT

INTRODUCTION This paper gives the Council of Governors a summary overview of key areas for the Trust at the end of the Financial Year 2009 – 2010. STATUTORY DUTIES During the past year, the Trust has made significant progress with regard to its approach to Governance. At a constitutional level, the Council of Governors have concluded a significant piece of work in the development of the ‘Framework for the Discharge of Governors’ Role and Statutory Duties’ and this report follows the headings of that document. The Trust has had a number of changes both at Board level and in the Council of Governors, most obviously with the end of Jo Darbyshire’s tenure as Chair, but also with the appointment of new Boards Members and new Members of the Council of Governors. These processes have been carried out in accordance with the Constitution. The Council of Governors has a duty to ensure that suitably qualified Auditors are appointed. During the year, Deloitte’s have been appointed as internal Auditors and KPMG as external Auditors following the agreed procedures. OVERSIGHT – HOLDING THE BOARD OF DIRECTORS TO ACCOUNT As representatives of the local community, the Council of Governors plays an important role in ensuring that the Trusts assets are safeguarded and applied for the greater good in pursuit of the organisations vision mission and goals. Throughout the year, the Council of Governors has been involved at key points of the annual planning and review cycle to enable itself to be assured in these areas. Annual Plan At the beginning of the financial and operational year 2009 - 2010, Lancashire Care undertook a review of its Planning and Review Cycle. The diagram below outlines the framework agreed and Governors have been involved at key milestones.

The Trust adopted revised Vision, Mission and Aims as follows:

Vision 21st Century mental healthcare with well-being at its heart Mission To improve the lives of the people we serve and ensure that mental health matters across the whole community Strategic Aims

• To deliver high-quality, person-centred, compassionate services for mental health.

• Maintain the highest standards of financial, corporate and clinical governance.

• Safeguard the welfare and promote the well-being of patients and staff.

• Maintain and enhance the reputation of the organisation. These aims were translated into 20 priority areas with 186 specific actions to progress these aims. Progress against the Aims has been reported to the Trust Board monthly and an end of year summary is available to Governors. Year End Achievements Governors will be aware that the Trust operates within the risk-based frameworks of Monitor and the Care Quality Commission.

• Monitor The Trust has declared compliance with the key targets for the Monitor Compliance Framework with the exception of the Core Standard for Medical Devices. Governors are aware that the Trust has an action plan to address the concerns raised re the lack of evidence of assurance re Medical Devices and the Trust continues to implement

this plan. The lack of full compliance with this standard did not result in any service delivery or care issues.

• Care Quality Commission In several instances, performance against Care Quality Commission key targets is relative rather than absolute i.e. until the Commission has received information from all Trusts it will not define the thresholds for achievement. Lancashire Care Trust will not, therefore, be able to confirm its performance against all CQC targets until the Autumn. The Health and Social Care Act 2008 introduced a new, single registration system that applies to both health and adult social care and came into force from April 1st 2010. During the year, considerable work was completed to allow the Trust to formally Register as a provider of regulated activities. The Registration was achieved with ‘No Conditions’.

• Financial Results

The Trust has generated a surplus of £2.9m before exceptional items for the twelve months to March, £0.3m better than plan. A financial risk rating of 4 was achieved for the full year, in line with plan, which would mean a rating of ‘Excellent’ from the Care Quality Commission in the Use of Resources score in the Annual Healthcheck.

A revaluation of the estate, carried out periodically to ensure that the value recorded in the accounts is appropriate, was completed prior to the end of March. This resulted in the value of fixed assets on the balance sheet being reduced by £8.4m to £111.5m, reflecting market conditions. This results in a technical charge to the Income and Expenditure Account, described as ‘exceptional items’, which results in a technical deficit of £5.5m for the year, though this does not impact on the Trust’s risk ratings. Capital charges in future years will reduce as a consequence.

Cash held at the end of March was £18.7m, £8.9m above plan.

All figures are subject to audit.

• Performance Report

The Council of Governors has received the Trust’s Performance Report as part of its assurance processes. The final report for the year 2009/10 is attached as an appendix. The quality section of this months report has been superceeded by the Quality Account as outlined below, which gives a full year overview of developments, including an overview of areas important to Governors regarding: risk, staff satisfaction and health and safety.

• Quality Account The Trust has continued its focus on the delivery of high quality services throughout the year. In particular, the implementation of the

Trust’s Quality Strategy has been refined as Lancashire Care – in parallel with the NHS as a whole - has developed a greater understanding of the requirements of Lord Darzi’s report, “High Quality Care for All”. The Report set out a vision of an NHS which has quality of care at its heart and defined quality as “clinically effective, personal and safe”. Amongst his recommendations, Lord Darzi proposed that, by law, NHS Trusts produce an annual Quality Account, just as they publish Financial Accounts. Quality Accounts aim to help staff, patients and the wider public understand best practice and focus on improvement and Lancashire Care Trust’s 2009 – 2010 Quality Account is being considered later on this agenda.

• Highlights While a report such as this must inevitably focus on the formal changes above, it is also important to recognise other elements of change which have had an impact on the way the Trust works. Two areas of importance are how we have developed and improved clinical services and how we have sought to change the culture of the organisation.

o We have developed a number of service areas, including:

opened the new Low Secure Unit, opened The Platform for 16 – 18 year olds, developed patient pathways, established or developed new services for Acute Recovery, Personality Disorder, Dual diagnosis, Post-Traumatic Stress.

o We are consciously looking to develop the Trust’s culture in a number of ways, including: carrying out Membership talks across the County, involving Service users and Carers in more of the Trust’s processes to develop and review Service provision, adopting new Values, holding Engage events with key leaders and Awards events for staff.

DIRECTION AND PARTICIPATION A key target for the Trust during the year has been to achieve a wider and more representative Membership. To this end a Membership Strategy was approved in May 2009 by the Council of Governors and a public membership target of 9,000 was met by the end of the year. Our continuing challenge is to ensure that we make best use of our Governors and Members to better inform our provision of services. At the March meeting, therefore, Governors agreed to take this work forward in three streams, working with: Users and Carers; Staff; and Partner organisations. The Council of Governors has a role in responding when consulted which it has performed as required, for example in commenting on the Annual Plan, the report on Mid-Staffordshire, or in joining visits to Wards as part of the implementation of the Quality Strategy. Professor Heather Tierney-Moore Chief Executive, 18 May 2010

Council of Governors 18 May 2010

Chief Executive Quarterly Assurance Report - Key Messages

• The Council of Governors has carried out its Statutory Duties during 2009

– 2010 with regard to: i) changes in Membership in both Board and Council of Governors ii) appointment of Auditors

• During the year, the Trust has developed and implemented a revised

planning and review cycle. • The Trust has declared itself to be compliant with all key targets in the

Monitor Compliance Framework, with the exception of the Medical Devices Core Standard

• Under the requirements of the Health and Social Care Act, the Trust has

Registered with the Care Quality Commission with no conditions • The Trust is not yet clear how it will perform on the Annual Health Check

criteria, because the criteria are relative, not absolute. • The Trust has placed considerable focus during the year on implementing

its Quality Strategy and developing its Quality Account. • The Trust set itself a large number of initiatives as part of its Annual Plan

and a detailed report on these is available to Governors. • The Trust has achieved its target of recruiting over 9,000 public Members

and is focusing on involving Governors and Members in three streams: Users and Carers; Staff; Partner Organisations.

• The Council of Governors has responded to requests for consultation over

the year on a range of topics.

COUNCIL OF GOVERNORS MEETING 18 MAY 2010

QUALITY AND PERFORMANCE MANAGEMENT REPORT: May 2010

1. Introduction This paper summarises key areas of performance for March 2010 which was considered by the Board at its April 2010 meeting. 2. Performance The attached report includes commentary on performance. The Board’s attention was however, drawn specifically to the following:

• The retirement of the former Chairman, Jo Darbyshire on March 31st and the appointment of a new Chairman, Steve Jones, who commenced his duties on April 1st.

• The Trust has agreed a three year contract with PCT’s. Blackburn with Darwen remains the Lead Commissioner. The Associates are:

o NHS East Lancashire o NHS North Lancashire o NHS Central Lancashire o NHS Blackpool o North West Specialist Commissioning Team o NHS Ashton, Leigh and Wigan o NHS Liverpool

As in previous years a number of areas have been agreed subject to further detail being considered as part of the Schedule, Commissioning Intentions.

• Compliance with Core Standards remains at 43/44 because of insufficient evidence to support a declaration of full compliance for C4b, the Medical Devices Core Standard.

• Financial indicators have been noted as “To follow” because of year end accounts.

• Seven Day follow-up is below the 95% threshold. The trust is currently assessing in detail the full year performance which is close to the threshold.

• The Trust has not only met its overall target for Membership, but has met both constituent parts of the target, having recruited 9001 Public Members

• Delayed Transfers of Care are shown as Green as they are well within the 7.5% target. However, the Older Adult Network in particular is experiencing pressure in this area and is looking to work with Commissioners to develop more consistent systems across all areas

• Sickness absence has fallen to 5.75%, a significant fall. • As forecast, Harvey House occupancy remained low during March. It is

anticipated that the new financial year will lead to an increase in occupancy levels.

• Adult Services occupancy is also highlighted as Red, but because of high occupancy indicating continued pressure in this area.

• More broadly, the Trust is assessing its end of year position to upload data to the Care Quality Commission website for indicators which will form part of the Commission’s annual assessment of performance against key indicators of existing commitments and national priorities. Monitor and the Care Quality Commission are aligning their indicators more closely and a report will be brought to the next board meeting giving an overview of performance in 2009 – 2010 and an assessment of the impact of changes in the Monitor Compliance framework for 2010 -2011.

• The third page of the Report, Annual Plan, summarises the end of year position. A more detailed end of year report on performance against the Plan is to be considered at the May EMT Governance meeting.

3. Quality The Boards received a report on quality indicators for the month of March but these have been incorporated into the Quality Account for the full year. 4. Conclusion The Board received the report and:-

i) noted the performance issues raised and actions/further investigations to be undertaken.

Mike Wistow Associate Director of Performance & Planning

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Council of Governors Meeting

10th February 2010 Wellington Park, Leyland.

PART ONE

Present Jo Darbyshire (Chair) Public Governors BwD Dan Johnson Alfred Olaiya Central Lancashire Barbara Lockett Christine Pownall Frank Smith Lona Smith Moira Mondesire East Lancashire Les Bond Tom Lawman Jennifer Lord Geoff Wharfe Hilary Whitworth North Lancashire John MacLeod Christina McKenzie Townsend Ian Clift Angela Winter Out of Area Phil Pye Staff Governors Catherine Dobson Reg Kielty Elizabeth Taylor Nominated Governor Mark Lunney (Vice Chair)

In attendance Peter Ballard (NED) Derek Brown (NED) Chris Heginbotham (NED) Sam Jones (NED & Deputy Chair) Teresa Whittaker (NED) Heather Tierney-Moore (Chief Executive) Diane Halsey (Company Secretary) Patrick Sullivan (Director of Nursing) Shirley Saunders (Deputy Chief Executive) Dave Tomlinson (Director of Finance) Joanne Marshall (Director of HR) Sarah Jones (Associate Director of Communications and Corporate Affairs) Emma Garside (Associate Director of Healthcare, Standards and Assurance) Hannah Bowie-McLean (Governor & Membership Engagement Officer. Minutes)

CONFIRMED

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ITEM 69/10

WELCOME AND INTRODUCTIONS The Chair opened the meeting by welcoming everyone Apologies Apologies were received from Valerie Wilson, Linda Jones, Chris Southworth, Nigel Harrison, Jacqueline Slater, Belinda Weir and Nigel McMurdo. Quoracy It was noted that the meeting was not quorate; however Linda Jones, Blackpool Constituency, would be joining the meeting via the telephone for item 75/10, External Audit Tender Results. Minutes Deferred for approval to the next meeting on 16th March 2010. Matters Arising/Action Tracker The Director of Nursing and Clinical Quality circulated a ‘Bluelight’ newsletter in relation to the Trust guidelines on Carers’ access to information about relatives.

70/10

FEEDBACK FROM THE LAST BOARD TO BOARD The Company Secretary presented a paper which outlined the feedback from the last Board to Board on 16th November 2009. The issues arising from the meeting had been grouped into a number of themes around the provision of information, membership engagement and communication. The paper outlined progress against actions or development plans in each of these areas. It was brought to the governors’ attention that laminated sheets with a timetable of meetings and contact details were available for governors to take away with them as well as membership forms.

71/10 NOMINATED GOVERNORS PROGRESS ON REVIEW PROCESSES The Chair gave a verbal report on progress on the review of the Nominated Governor constituency of the Council of Governors. The Chair had been asked to address issues of poor attendance and the continued relevance of the stakeholder partners. She reported that letters had been sent to the Chief Executives of the appointed bodies, asking if they wished to continue being represented. Copies had also been sent to the respective appointed Governors. The chair stated her disappointment that some of the partner organisations had not been represented at the council meetings for over 12 months. A written report would be brought to the 16th March 2010 meeting.

72/10 QIPP PRESENTATION The Chief Executive gave a detailed presentation on Quality through Innovation, Productivity and Prevention (QIPP) and the Trusts plans to work in partnership with other NHS organisations to make better use of the resources. This was followed by a discussion about the role of the governing body in the initiative. The Chief Executive explained that understanding the larger picture is helpful in understanding our own organisation. In the future,

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there would be opportunities for Governors to get involved through the communication strategy which is currently being developed, and aims to explain the initiative to the wider public. It was stated that in the past the NHS had been about growth and competition between Trusts, but that it is now recognised that partnership working is crucial. Following a number of questions from Governors, the Chief Executive assured the Council that whilst committed to working in partnership to contribute to the QIPP aims, the Trust would be thoughtful about protecting its own interests and in particular the level of resource allocated to this initiative relative to the potential benefit. Some of the initiatives were aligned to our own interests as a pan Lancashire organisation. She acknowledged that change of this scale would be challenging and require real changes in behaviour at all levels but that the economic imperative would now drive that agenda. The Chief Executive would provide regular updates on progress to the Council of Governors. In response to a question about the appetite to address cuts at management level and about who holds the power to make staff cuts, the Chief Executive responded that the cash would be taken out at PCT level and there was a clear target for the PCTs and SHA to reduce management costs by 30%. There was a discussion around the continued viability of a Final Salary Pension Scheme

73/10 DRAFT ANNUAL PLAN PRESENATION The Director of Finance gave a presentation on progress against the development of the 2010/11 Annual Plan. He reminded Governors of their input to date in the planning process. The Council of Governors, and invited Trust Board Directors, divided into groups to consider and comment on the values, benefit, major priorities, how the governors are involved in the process and how to improve future involvement of the membership and stakeholders. The information would be collated and will be reported back to the next meeting. Chris Heginbotham left the meeting. Linda Jones (Public Governor, Blackpool) joined the meeting by telephone link. The meeting was declared quorate.

75/10 EXTERNAL AUDIT TENDER RESULTS The Director of Finance presented the External Audit Tenders report and outlined the process undertaken in the market testing of the services, A governor had been invited to participate in the selection interview and she confirmed to the meeting that the process had been thorough, conducted fairly and transparently, and that the recommendations made were a fair reflection of the outcome of the selection process. The Audit Committee recommend that KPMG are appointed as provider of External Audit services. The Director of Finance stated that there would be a £12,000 reduction in the fees associated with a move to the recommended provider following a

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question about whether the appointment of KPMG would result in an increase or decrease of costs. The Council of Governors unanimously approved the appointment of KPMG as the provider of External Audit Services with effect from the end of the current providers contract in the summer of 2010. Linda Jones (Public Governors – Blackpool) left the meeting. It was noted that the meeting was no longer quorate.

74/10 CQC REGISTRATION PRESENTATION The Associate Director of Healthcare, Standards and Assurance delivered a CQC Registration Presentation in which she outlined the new registration process, provided assurances around the Trusts preparedness for registration outlining the actions taken and the nature of any risks to continued registration and finally gave an overview of the role the Governing Body will play in ongoing monitoring of the process. Following a question about the grouping of services in the declaration, the Associate Director of Healthcare, Standards and Assurance explained how the assessment of services at locations had been carried out, and how evidence would be collected from each location. In response to a question about whether there would be a resource implication in the change of regime, the Associate Director indicated that it was too early to assess the impact at this stage.

76/10 AOB Complaint against the Board The Chair updated the Council of Governors in relation to a complaint against the Board which had previously been circulated to the Governors and which had been referred to the Ombudsman. The Council noted that the Ombudsman had declined to undertake a review. Meeting Format The Chair led a discussion to provide clarity around the changes in meeting format agreed at the November 2009 meeting. The current meeting had inaccurately been published as a Board to Board meeting but under the new arrangements was in fact a meeting of the Council of Governors, to which the Trust Board had an open invitation to attend. The Council agreed that the new arrangements were that there would be a total of eight Council meetings in the year, four of which would extend an open invitation to the Trust Board to attend. The expectation would be that, subject to the provisions of the standing orders, Governors would be expected to attend all of these meetings. It was noted that the length of meeting would be reduced hence the total time commitment would not increase. In addition, there would be a further two scheduled development sessions in the year. Attendance at these sessions is encouraged but would not count as part of the published attendance figures. All the dates had been set for the 2010/11 year and the Company Secretary agreed to write to Governors to clarify the expectation.

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77/10

REVIEW OF PROCEEDINGS As agreed at the last meeting, there would be a review of the proceedings at the end of each meeting. However, given time constraints and in the interest of expediency the Company Secretary asked the Governors to feedback their views to her outside of the meeting including thoughts on the venue. Date of next meeting 16th March 2010 at 10.00am

agenda welcome and opening comments

Documents