Agenda - swast.nhs.uk · booked for 2016 and was available for Governors to take with him and volunteer to attend. 6. Report of the Chairman and Chief Executive 6.1 The Chairman informed

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Agenda Public Meeting of the Council of Governors 21 April 2016 Double Tree by Hilton, Bristol City Centre Hotel, Redcliffe Way, Bristol, BS1 6NJ Chairman: Heather Strawbridge

Chairman of the NHS Foundation Trust & Council of Governors

PUBLIC SESSION OPENS

1 Welcome, Introductions and Apologies for Absence Verbal Heather Strawbridge

2 Declarations of Interest Verbal Heather Strawbridge

3 A Patient’s Experience Verbal Heather Strawbridge

4 Minutes of the Public Meeting of the Council of Governors held on 10 December 2015 Paper 1 Heather Strawbridge

5 Action Point Register Paper 2 Heather Strawbridge

HOLDING THE NON EXECUTIVE DIRECTORS TO ACCOUNT

6 Report of the Chairman and Chief Executive Paper 3 Heather Strawbridge & Ken Wenman

7

Board Agendas and Minutes including feedback from Governors • 28 January 2016 – Agenda and Minute • 31 March 2016 - Agenda

Paper 4 Heather Strawbridge

8 Non-Executive Director Update Reports Verbal Heather Strawbridge & NEDs

9 Q&A with the Chairman and Non-Executive Directors Verbal Heather Strawbridge & NEDs

MEMBERSHIP AND ENGAGEMENT

10 Membership & Governor Updates Paper 5 Marty McAuley

GOVERNOR DUTIES

11 Policy of Engagement Paper 6 Marty McAuley

12 Council of Governors - Succession Planning Paper 7 Marty McAuley

13 Register of Interests Paper 8 Marty McAuley

14 Composition of the Non-Executive Directors Paper 9 Marty McAuley

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APRIL THEME - QUALITY

15

The Quality Agenda: • Trust Approach • CQC • Quality Account and Report

Presentation Jenny Winslade

16 The Work of the Quality Committee Presentation Venessa James

17

Data Quality: • Trust Approach • Data Protection • Disclosures • Governor Responsibilities

Presentation Francis Gillen

SUB GROUP REPORTING

18 Progress from Remuneration & Recommendations Panel Verbal Heather Strawbridge &

Adrian Rutter

19 Progress from the Planning Sub Group Verbal Craig Holmes

20 Progress from Membership and Engagement Sub Group Verbal William Thomas

ALL OTHER BUSINESS

21 Any Other Business – Items to be notified to the Trust Secretary three clear working days before the meeting.

Verbal Heather Strawbridge

PUBLIC SESSION CLOSES

Chairman: Mrs H Strawbridge HS Chairman of the NHS Foundation Trust Members of the Council of Governors: Mr J Christensen JC Appointed Governor Air Ambulance Charities Mr P Walker PW Appointed Governor Fire and Rescue Mr D Hellier Laing DHL Appointed Governor Local Authorities Prof S Waite SW Appointed Governor Mental Health Partnerships Mr R Care RC Public Governor Bristol B&NES Mrs S Hammond SH Public Governor Cornwall Mr W Thomas WT Public Governor Cornwall Cllr B Deed BD Public Governor Devon Mr P Ford PF Public Governor Devon Mr A Rutter AR Public Governor Devon Mr P Young PY Public Governor Devon Mr R Day RD Public Governor Dorset

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Mr J Duffie JD Public Governor Dorset Cllr A Gravells AG Public Governor Gloucestershire Mr C Holmes CH Public Governor Gloucestershire Mr J Pallister JP Public Governor Gloucestershire Dr C Mills CM Public Governor Isles of Scilly Mr T Beale TB Public Governor Somerset Dr A Leak AL Public Governor Somerset Mr J Liddiatt JL Public Governor Somerset Mr T MacInnes TM Public Governor Wiltshire & Swindon Mrs D Nix DM Public Governor Wiltshire & Swindon Mr N Hunt NH Staff Governor Admin & Support Mr D Shephard DS Staff Governor A&E East Mr A Peak AP Staff Governor A&E North Mr S Gough SG Staff Governor A&E West Mr S Frost SF Staff Governor UCS Mr M Norbury MN Staff Governor Volunteers Non-Executive Directors: Professor M Watkins MW Non-Executive Director and Vice Chairman of the NHS Foundation Trust Ms V James VJ Non-Executive Director and Chairman of the Quality Committee Mr T Fox TF Non-Executive Director and Senior Independent Director Mr P Love PL Non-Executive Director and Chairman of the Audit & Assurance Committee Dr I Reynolds IR Non-Executive Director Officers: Mr K Wenman KW Chief Executive Mrs J Winslade JW Executive Director of Nursing and Governance Mr F Gillen FG Executive Director of IM&T Mr M McAuley MM Trust Secretary Ms H Braid HB Governance and Assurance Manager Mr P Dixon PD Governance Support Manager Miss E Mitchell EM Events and Committee Coordinator

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Public Minutes Meeting of the Council of Governors 10 December 2015 at 11.00am Exeter Court Hotel, Kennford, Exeter, EX6 7UX Chairman: Heather Strawbridge (HS)

Chairman of the NHS Foundation Trust & Council of Governors Members of the Council of Governors in attendance: Rae Care (RC) Public Governor – Bristol and Bath & North East Somerset Robert Day (RD) Public Governor - Dorset Bob Deed (BD) Public Governor - Devon Philip Ford (PF) Public Governor – Devon Steve Frost (SF) Staff Governor – Urgent Care Services Craig Holmes (CH) Public Governor – Gloucestershire Neil Hunt (NH) Staff Governor – Admin and Support Services Ann Kesteven (AK) Public Governor – Somerset Anthony Leak (AL) Public Governor - Somerset Torquil MacInnes (TM) Public Governor – Wiltshire & Swindon Dee Nix (DN) Public Governor – Wiltshire & Swindon Mark Norbury (MN) Staff Governor – Volunteers Jerry Pallister (JP) Public Governor – Gloucestershire Alan Peak (AP) Staff Governor – A&E North Adrian Rutter (AR) Public Governor - Devon David Shephard (DS) Staff Governor – A&E East William Thomas (WT) Public Governor – Cornwall Iain Tulley (IT) Appointed Governor - NHS Mental Health Trusts Board of Directors in attendance: Ken Wenman (KW) Chief Executive Mary Watkins (MW) Non-Executive Director Paul Love (PL) Non-Executive Director Ian Reynolds (IR) Non- Executive Director Hugh Hood (HH) Non-Executive Director Officers in attendance: Marty McAuley (MM) Trust Secretary Martyn Callow (MC) External Relations Officer Helen Braid (HB) Interim Compliance Manager Linda Johns (LJ) Council of Governors and Membership Administrator

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1. Welcome, Introductions and Apologies for Absence 1.1 The Chairman opened the meeting and welcomed the Governors, in particular

Steve Frost the new Staff Governor for Urgent Care Services and Lee Wyatt who was standing for election to the post of Staff Governor for A&E West.

1.2 The Chairman congratulated Mary Watkins who was attending this meeting as

Baroness Watkins for the first time. 1.3 The Chairman confirmed that Harriet Lupton, Public Governor for Bristol and Bath &

North East Somerset would not be attending the meeting and would be resigning due to the pressures of her retraining for general practice and thanked Ann Kesteven for her contribution to the Council and who would be leaving due to her relocation to another part of the country.

1.4 It was noted that apologies for absence had been received from; Juliet Cross,

Appointed Governor – Acute Trusts; Andrew Gravells, Public Governor – Gloucestershire; Chris Mills, Public Governor – Isles of Scilly; Jim Duffie, Public Governor – Dorset; Terry Beale, Public Governor – Somerset; John Christensen, Appointed Governor – Air Ambulance Charities; Harriet Lupton, Public Governor – Bristol and Bath & North East Somerset; Paul Young, Public Governor – Devon; Sylvia Hammond, Public Governor – Cornwall; Tony Fox, Non-Executive Director

2. Declarations of Interest 2.1 There were no further declarations of interest made in respect of any item on the

agenda. 3. A Patient’s Experience 3.1 The Chairman informed the meeting that at the most recent meeting of the Board of

Directors, rather than a patient story being read, a patient attended and told their story to the Board. The patient was a man called Mick who had learning difficulties and a fear of healthcare professionals and who at the time of the incident had his young son with him. The patient had been accompanied to the meeting by a member of the Patient Experience Team.

3.2 AR, who had attended the Board meeting, informed Governors that he had found it

very interesting listening to a patient experience directly. The patient’s very real fear of healthcare professionals and the green uniform had been of particular interest.

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3.3 RC, who had also been in attendance, added that when the patient was taken ill his concern was about what would happen to his children and this came across very strongly. It was explained that his concerns were that his son would associate an ambulance with him being taken away.

3.5 MW commented that this experience highlighted the value of the work done in

school about the ambulance service and also the awareness of the need for safety netting to ensure that children are cared for.

4. Minutes of the Previous Meeting on 17 September 2015 4.1 It was agreed that the minutes were a true and accurate record of the meeting, and

were signed by the Chairman 5. Action Point Register 5.1 11.12.2014 12.1 – MM explained that recruitment to Governor vacancies was

ongoing. With regard to the Cornwall vacancy, MM had approved the next highest polling candidate from the most recent election who had confirmed that she would be happy to take the on role.

5.2 23.04.2015 17.3 – this is still ongoing. 5.3 09.07.2015 10.2 – MM advised that an initial PPI list had been drawn up with events

booked for 2016 and was available for Governors to take with him and volunteer to attend.

6. Report of the Chairman and Chief Executive 6.1 The Chairman informed the meeting that demand remain incredibly high across the

country. The Board was aware of the pressure that staff were experiencing as a result of sustained demand and that the “Staying Well” initiative had been launched on 1 December. It was noted that 57 referrals had been received during the first few days of the service and that these individuals had been directed towards partner organisations who could provide the appropriate help and support. The Chief Executive confirmed that the system was confidential, however, the Trust had a duty of care and would take any actions which were considered necessary to safeguard staff.

6.2 It was agreed that an update on the Staying Well Service should be brought to

the December 2016 meeting of the Council.

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6.3 CAD Update and Rollout The Chief Executive provided an update on the continued roll out of the new CAD and Gazateer which had almost doubled the number of addresses available to hub staff. It was noted that the entire operating area using the same systems would enable a virtual hub, so standardising procedures and patient experience.

6.4 Electronic Patient Care Record (ePCR) The Chief Executive provided an update on the roll out of the ePCR which provided information electronically between attending clinicians and receiving Emergency Departments. The following points were highlighted: • the ePCR would be operational across the Trust’s entire operating area during

2016; • the technology enabled a wide range of information to be available to attending

clinicians including previous visits, all records, clinical advice, national and Trust guidelines;

• current findings do not indicate that implementation of the ePCR has increased handover times or the time required to complete records;

6.5 Gloucestershire

The Chairman informed the meeting that she had attended the recent meeting of Gloucestershire County Council when the motion to establish a separate ambulance service for the county had been debated. This had provided an opportunity to dispel a lot of misinformation about performance in the county. It was also noted that Gloucestershire CCG had been very positive about the Trust and was not in support of the motion.

6.6 Staffing The following issues were debated: • A turnover rate for NHS111 was high, but not extraordinary for a call centre

environment; • The has been a significant reduction in vacancies as a result of a number of

Trust initiatives including recruitment of Paramedics from Prague and a high percentage intake of university graduate due to offered incentives. The recruitment programme is pragmatic, innovative and competitive.

• There was currently 102% operational cover in place in the North. • The impact of private providers moving into areas which were previously

provided solely by the NHS. 6.7 Performance

The Chief Executive provided an overview of Trust performance and the following issues were highlighted: • The differing performance levels between South and North Divisions and the

impact that Dispatch on Disposition had upon reporting. • The contribution made to performance by CFRs and defibrillators.

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• The impact of the NHS111 service delivered by other providers and the steps taken by the Trust to address these issues.

• The Welsh ambulance response review which has an increase in the number of calls which could be dealt with by way of hear and treat.

7. Board Agenda and Minutes

7.1 AR indicated that attending Board meetings was very useful for Governors and that

if they were unable to attend, the minutes were a good way to obtain an update on the issues currently under consideration. AR also informed the meeting that he had been very impressed with the contribution of the NEDs during meetings of the Board.

7.2 RC recommended that at Governors attended a meeting of the Board of Directors, as all would have their own perspective.

8. Introducing the New Senior Independent Director 8.1 This item was deferred to a future meeting 9. Work of the Audit Committee 9.1 This item was deferred to a future meeting 10. Non-Executive Director Assurance Report 10.1 The Chairman informed the meeting that the Finance & Investment Committee had

met that morning to reviewing planning for the 2015/17 financial year. The following issues were highlighted: • as contract negotiations were an annual occurrence it made long term planning

a challenge; • at present it was anticipated that funding would increase by 3% whilst during the

current financial year demand had increased by some 6%; • financial pressures were being felt across the NHS and the Trust was one of the

few organisations that was not currently running a deficit; • the Dispatch on Disposition trial was having an impact due to the reduced

number of resource dispatches and A&E admissions; • the investments made in staff to ensure that the Trust met its objectives and

targets; and • the cost to keep a fully equipped ambulance on the road for 12 months was

£800,000. 10.2 The Non-Executive Director Assurance Report was noted.

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11. Membership and Governor Updates 11.1 The Trust Secretary introduced a report which provided the Council of Governors

with an overview of the Trust Membership position and the current position as to Governor vacancies. The following points were noted: • Iain Tulley would be leaving his position of CEO of Avon & Wiltshire Mental

Health Partnership in January and so would no longer be a Trust Governor. He had secured a replacement for the remainder of the term of office and this had been taken up by Steve Waite from Livewell South West.

• Harriet Lupton would be resigning from the Council. Harriet was returning to general practice and no longer had the time to commit to her Governor role. An election would be held for her successor.

• Sylvia Hammond would be taking on the role of Governor for Cornwall and would be attending the next meeting of the Council.

• Ann Kesteven would be leaving the Council as she was re-locating and would no longer be eligible to represent Somerset. Officers would invite the next highest polling candidate from the most recent election to take up this role.

• The election for a Governor to represent A&E West was currently underway and the outcome would be reported to the Council.

11.2 The report was noted. 12. Event Feedback 12.1 Dee Nix provided the meeting with feedback from her attendance at the Council of

Governors of the Bath Royal United Hospital. 13. Council of Governors – Succession Planning 13.1 The Trust Secretary introduction a report which set out proposals for the terms of

office of the Council of Governors to be amended as of 2017 to minimise the risk of losing experience gained, whilst retaining the opportunity for the Council to be refreshed with new members. This report followed on from previous discussions with the Council.

13.2 The Council of Governors discussed the benefits of introducing succession planning

and noted that all terms of office would be for three years going forward, once the next phase had been implemented and the staggering of dates achieved.

13.3 The Council of Governors, whilst happy with the process, requested that the Trust

Secretary look further into which constituencies start with the one year rolling process as it appeared to disadvantage one division over another.

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13.4 Subject to the Trust Secretary amending which constituencies had which term of office, the Council of Governors approved the introduction of phased terms of office for the elections in February 2017.

14. Policy for the Composition of the Council of Governors 14.1 The Interim Compliance Manager introduced a draft policy for approval by the

Council of Governors. The policy incorporated all requirements of Schedule 7 of the NHS Act 2006 and included how the Council is representative of the area served by the Trust; the proportion of Governors to be elected; the minimum number of Staff Governors and requirement for at least one member to be appointed by one or more Local Authorities.

14.2 Issues discussed during consideration of this item included:

• the draft policy would be checked to ensure that it was consistent with the Trust Constitution;

• the Trust Constitution was drawn from the national Model Constitution and it was not within the gift of the Trust to make amendments to national requirements; and

• that the Policy would be amended following any amendments to regulatory or legislative requirements or any agreement to amend the composition of the Council.

14.3 The Policy for the Composition of the Council of Governors was approved,

subject to cross-checking with the wording of the Trust Constitution. 15. Policy for the Reimbursement of Governor Expenses 15.1 The Interim Compliance Manager introduced an updated version of the Policy for

the Reimbursement of Governor Expenses for comment prior to its submission to the Board of Directors for approval.

15.2 The following amendments to the policy were noted:

• the Trust Secretary will now be the final arbiter of the Policy; • the expenses which are eligible for approval remain as before; • rates payable for overnight accommodation have been aligned with the Trust’s

Travel & Subsistence Policy; • the use of the Trust’s Electronic Expenses Management System has been

incorporated, including reference to the timescales applicable for the submission of claims; and

• the NHS approved mileage rate for cars is now 56 pence per mile.

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15.3 The issue of the mileage rate was raised, with concern being raised about its tax implications. The meeting was reminded that this issue had been discussed on a number of previous occasions and the decision had always been to keep the rate in line with the NHS approved rate.

15.4 The revised Policy for the Reimbursement of Governor Expenses was noted. 16. Progress from the Remuneration & Recommendations Panel 16.1 The Council of Governors received a short update on the work of the Remuneration

& Recommendations Panel. 17. Progress from the Audit & Planning Sub Group 17.1 The Council of Governors received a short update on the work of the Audit &

Planning Sub Group. 18. Progress from the Membership & Engagement Sub Group 18.1 The Council of Governors received a short update on the work of the Membership &

Engagement Sub Group. 19. Any Other Business 19.1 None. Signed: ________________________________________________ (Chairman of the Council of Governors) Dated: _________________________________________________ A final, signed copy of the minutes is available from the meeting administrator on request

Council of Governors Action Log Actions in progress Date and Reference Topic Action Owner Progress

11.12.2014 12.1

Membership and Vacancies

report

Heather highlighted that there was still a CCG vacancy. And that the current role of the Governor representing the Fire and Safety Service was

under review. Marty to appoint a CCG Governor MM Appointment process

underway

23.04.2015 17.2

Work of the Audit

Committee

Governors to be provided with details of work undertaken during the last year MM Agenda - 7 July

09.07.15 10.4

Membership and vacancies

MM to look at possibility of reducing the number of CCG representatives on the Council MM Appointment process

underway. 10.12.15

6.17 Staying Well

Service CoG Secretary to provide an update on the work of the Staying Well

Service – how it has been managed and if it is working? MM Agenda – 1 Dec 2016

10.12.15 8.1

Introducing the New Senior Independent

Director

Deferred to a future meeting to be added to the next possible agenda MM Agenda 7 July 2016

Actions completed Date and Reference Topic Action Owner Progress11.09.2013

7.2.3 Performance Governors requested that Community First Responders to go to green calls. KW confirmed that he would explore this further.

NLC Completed

03.07.14 4.3 Minutes

Review the way in which Governors are informed of high profile media coverage and that press releases and statements are

circulated as is reasonable MM Completed

03.07.2014 8.7

NED Activity Report

Job description and terms / conditions of Non-Executive Directors be provided to Governors. MM Completed

03.07.2014 13.4.3

Governor Vacancies

Should a further vacancy occur in the Devon Constituency, again the next highest polling candidate should be approached.

MM Completed

03.07.2014 16.3.5

Future Working Arrangements

Three sub groups to be established themed around the Governor duties in respect of the Chairman & Non-Executive Directors, Audit,

and Member & Public Engagement MM Completed

03.07.2014 12.3 Public Engagement

The public engagement pilot at Derriford Hospital be progressed with the following Governors - Harriet Lupton, David Clare, William

Thomas and Adrian Rutter. MM Completed

03.07.2014 13.4

Governor Feedback

Template to be developed to be used by Governors to raise awareness of their availability to speak to community groups about

their role and the Trust. MM Completed

Actions completed

03.07.2014 16.3.7

Future Working Arrangements Review of working arrangements to be scheduled for July 2015. MM Completed

09.07.15 3.1

Patient Experience Patient experience stories to be emailed out to the Council of Governors

MM Completed

09.07.15 10.4


The next on the electoral list for Public Governor Gloucestershire to be contacted

MM Completed

09.07.15 13.2 Quality Account To send out the Quality Account Priorities for Audit Selection MM Completed

05.12.2013 6.3

2014 Governor Elections

Consideration to be given to the length of terms of office of Governors. MM Completed

03.07.2014 17.1

Any Other Business

That a future development day item be in respect of the Crisis Care Mental Health Concordat.

MM Completed – presentation delivered

11.09.2014 6.1

Report by the Chief Executive

To request an explanation from Health England as to why the call response time for NHS111 was 60 seconds KW Completed

03.07.2014 13.4.4

Governor Vacancies

The Board of Directors be asked to consider the issue of Community First Responders as staff members and, in particular, to consider the

status of Governors who become Community First Responders during their term of office and therefore would currently be ineligible

to remain a Public Governor

MM Completed

11.09.2014 12.1 Public Engagement Presentation on ‘holding the Executives to Account’ be part of the

next development meeting MM Completed

11.12.2014 17.1

Communities First Responders and Public Governors

Marty to report back to the Council of Governors with a formal recommendation. MM Completed

23.04.2015 17.4

Membership and Vacancies report Marty to add a review on Steve Brown MM Completed

by DP at Nov Workshop

23.04.2015 17.3

CoG Workshop Juliet Cross presentation on work that she does or another appointed Governor at the next meeting

MM Completed by John Christensen

09.07.15 10.4


Marty to proceed with Staff Governor Elections for A&E West and UCS (incl 111)

MM Completed – Stephen Gough (A&E) and Steve Frost (UCS)

appointed

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Council of Governors Meeting 21 April 2016

Title:

Report of the Chairman and Chief Executive

Prepared By:

Marty McAuley, Trust Secretary Heather Strawbridge, Chairman Ken Wenman, Chief Executive

Presented By:

Heather Strawbridge, Chairman Ken Wenman, Chief Executive

Main aim:

To support the presentation of the Chairman and Chief Executive at the meeting to inform the Council of Governors of the current performance of the Trust and other key issues based on the February 2016 Integrated Corporate Performance Report.

Recommendations:

The Council of Governors is asked to: (i) note further detail of the Trust’s performance contained

within the Integrated Corporate Performance Report; and (ii) raise any questions on Board actions or decisions with

Non-Executive Directors

Previous Forum:

None

This report references:

Statutory Requirements Met

The Council of Governors has a statutory duty to hold the Non-Executive Directors of the Trust individually and collectively account for the performance of the Board of Directors.

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Report of the Chairman and Chief Executive 1. Ambulance Response Programme 1.1 2. February 2016 – Performance Exception Overview

2.1 The Integrated Corporate Performance Report (ICPR) focuses on exceptional

performance and aims to provide the Trust with an early warning of deteriorating performance. The four reporting categories assigned to individual performance metrics contained within the ICPR are as follows:

Performance in line with plan: • Re-contact rates following treatment at scene were lower (better than) the local

performance threshold; • Percentage of A&E calls abandoned are lower (better than) the local threshold

for the year to date; • Time to answer calls were below (better than) the local threshold measures for

the 50th, 95th and 99th percentile metrics for the year to date; • Ambulance calls closed with telephone advice and managed without transport to

A&E department are above (better than) local thresholds; • ROSC following cardiac arrest was above (better than) local thresholds; • Stroke patients receiving the appropriate care bundle is above local thresholds; • Outcome from cardiac arrest, survival to discharge rates, are above local

thresholds; • Urgent Care Service QR12: In the county of Dorset performance for Less Urgent

Base Consultations and Less Urgent Home Visits were above (better than) the 95% performance target;

• Urgent Care Service QR12: In the county of Gloucestershire performance for Less Urgent Base Consultations were above (better than) the 95%

• performance target; • NHS 111 call abandonment rates were below (better than) the national KPI level

of 5% in February 2016 in the counties of Dorset, Devon and Cornwall; • Tiverton UCC performance against the 4 hour treatment time was above the

95% target; • The Trust continues to perform above (better than) the local Right Care, Right

Place, Right Time trajectories for improvements in non-conveyance rates to Emergency Departments;

• Compliance with Infection Prevention and Control.

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Early Warning: • A&E (999) Activity levels (demand) in February 2016 was 4.93% above

contracted volumes. Year to date activity levels are 1.75% above contracted volumes and 4.77% higher than the activity level seen for the same period in 2014/15;

• There is variability in the activity increases across the Divisions with the North Division being 2.84% above contract for the year to date, compared to 0.03% above contract in West Division and 2.83% under contract in East Division;

• Percentage of A&E calls abandoned and Time to Answer Calls in February 2016 were above (worse than) the local thresholds;

• The staff turnover rate remains high at 15.84% at the end of February 2016 (reducing to 14.20% excluding redundancies);

• Staff Appraisal rates were below the internal KPI target of 85% but this is linked to the Red Measures to Improve Performance Plan;

• Information Governance Toolkit is RAG rated as Amber against the plan to deliver level 2 rating for 2015/16.

Improvement Expected: • Red 1 performance in February 2016 was below (worse than) the national

performance target of 75%; • Red 2 and Red 19 performance were below (worse than) national targets in

February 2016 however this is in part related to the Ambulance Response Programme (ARP).

• Green 1, Green 2, Green 3 and Green 4 call performance in February 2016 was below target;

• The number of frontline operational vacancies has an impact on performance however the position in the East and West Divisions has improved following recruitment delivered in October 2015 (in line with the Trust A&E Operating Plan) with improvements in the North Division during Quarter 4 of 2015/16; NHS 111 call answering performance is below (worse than) the 95% national KPI level in February 2016;

• Re-contact rates following telephone advice were higher (worse than) the local performance threshold;

• Outcome from STEMI PPCI, patients receiving primary angioplasty commencing within 150 minutes;

• Outcome from Stroke, patients receiving thrombolysis at an hyper-acute centre within 60 minutes is below (worse than) local thresholds;

• Acute STEMI patients receiving the appropriate care bundle was marginally below the local threshold;

• Urgent Care Service QR12: An improvement is expected for both the Gloucestershire and Dorset OOH performance for those measures where performance is below the national target levels;

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• Two PTS KPIs in the BNSSG contact are below agreed levels for the period April 2015 to February 2016 but are showing improvement;

• Sickness levels across the trust are improving in line with the A&E Operating Plan for 2015/16.

Escalated Performance Issue • 1,829 of operational resource hours were lost to chargeable handover delays at

acute hospitals in February 2016. This equates to an average of 63 hours lost per day across the Trust.

3. Recommendation 3.1 The Council of Governors is asked to:

(i) note further detail of the Trust’s performance contained within the Integrated Corporate Performance Report; and

(ii) raise any questions on Board actions or decisions with Non-Executive Directors .

Page 1 of 1

Council of Governors Meeting 21 April 2016

Title:

Board Agendas and Minutes

Prepared By:

Marty McAuley, Trust Secretary

Presented By:

Heather Strawbridge, Chairman

Main aim:

To provide Governors with the following information:

Board Agenda and Minutes – 28 January 2016 Attended by Adrian Rutter and Craig Holmes

Board Agenda – 31 March 2016 attended by Rae Care, Torquil MacInnes and Bob Deed

Recommendations:

The Council of Governors is recommended to take assurance from the range of topics considered by the Board of Directors together with the feedback received from Governors who attended the meetings and ask any questions they may have.

Previous Forum:

None



The Council of Governors has a statutory duty to hold the Non-Executive Directors of the Trust individually and collectively account for the performance of the Board of Directors. The Board of Directors is required to provide the agenda and minutes from their meetings to the Council of Governors.

Trust Public Board of Directors Meeting – 28 January 2016 Page 1 of 2

Agenda Trust Public Board of Directors Meeting

Date Thursday 28 January 2016 Time 10.00

Venue Boardroom, Trust HQ, Abbey Court, Eagle Way, Exeter EX2 7HY

Chair Mrs H Strawbridge, Chairman

Members:

Mrs H Strawbridge (HS), Mr K Wenman (KW), Mr T Fox (TF), Mr H Hood (HH) Mrs V James (VJ), Mr P Love (PL), Dr I Reynolds (IR), Prof. M Watkins (MW), Mr F Gillen (FG), Mrs J Kingston (JK), Dr A Smith (AS), Mrs J Winslade (JW), Mrs E Wood (EW)

Non Members:

Mr M McAuley (MM), Lord P Tyler (PT), Ms C Warner (CW), Mr N Le Chevalier (NLC)

Circulation Mr C Nelson, Joint Branch Secretary, Unison, Ms J Fowles Joint Branch-Secretary, Unison, Council of Governors

Administration Mrs J Smalley (JS)

Opening business No Topic Format Presenter

1 Welcome, Introduction & Apologies Apologies: Mr Tony Fox Verbal HS

2 Declarations of Interest Verbal All

3 Patient Story Presentation HS

4 Report from the Chairman Verbal HS

5 Report from the Chief Executive Verbal KW

6 Questions from the Public Verbal HS

7 Minutes of Previous Meeting - 26 November 2015 Paper 1 HS

8 Action Point Register Paper 2 HS

Trust Public Board of Directors Meeting – 28 January 2016 Page 2 of 2

Strategic Items for assurance 9 Operational Planning Verbal KW

10 Integrated Corporate Performance Report Paper 3 KW

11 Corporate Risk Register and Board Assurance Framework Paper 4 JW

12 Major Incident Preparedness Statement Paper 5 NLC

13 Developing Forward Plans 2016/17 Paper 6 JK

14 Council of Governors Forward View Paper 7 HS/CH/DN

15 Communication and Engagement Paper 8 CW

16 Information Governance Toolkit Paper 9 FG

Items for approval 17 Standing Financial Instructions of the Trust (SFI) Paper 10 MM

18 Governors Expenses Policy Paper 11 MM

19 Quality Approach Paper 12 JW

Sub Committee reporting for assurance

20 Quality & Governance Committee

• Assurance Report – January 2016 • Final Minutes – October 2015

Paper 13 VJ

21 Audit Committee

• Assurance Report – January 2016 • Final Minutes - November 2015

Paper 14 PL

Items for information 22 Report from West of England Academic Health Science

Network Board Paper 15 HS

Closing business

23

• Any Other Business • Identification of New Risks (incl. Health & Safety) • Identification of New Legislation

Verbal HS

Trust Public Board of Directors Meeting – 28 January 2016

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Minutes Trust Public Board of Directors Meeting Thursday 28 January 2016, 10.00hrs Boardroom, Trust Headquarters, Abbey Court, Eagle Way, Exeter EX2 7HY Chair Mrs H Strawbridge - Chairman Administration Mrs J Smalley – EA & Business Manager to Chairman and Chief Executive Members: Mrs H Strawbridge HS Chairman Mr K Wenman KW Chief Executive Mr P Love PL Non-Executive Director Mr H Hood HH Non-Executive Director Mrs V James VJ Non-Executive Director Mr I Reynolds IR Non-Executive Director Prof M Watkins MW Non-Executive Director Mr F Gillen FG Executive Director of IM&T Mrs J Kingston JK Deputy Chief Executive/Executive Director of

Finance Dr A Smith AGS Executive Medical Director Mrs J Winslade JW Executive Director of Nursing and Governance Mrs E Wood EW Executive Director of HR & OD Non Members: Ms C Warner CW Interim Head of Communications and Engagement Mr N Le Chevalier NLC Director of Operations Mr M McAuley MM Trust Secretary Observers: Mr B McInerney BM Member of the public Mr C Holmes CH Public Governor, Gloucestershire Ms D Nix DN Public Governor, Wiltshire and Swindon


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No Agenda Item Action 1.0 Welcome, Introduction & Apologies 1.1 1.2

HS thanked everyone for attending the meeting. HS welcomed Bren McInerney, Dee Nix and Craig Holmes. Apologies were received from Mr Tony Fox and Lord Paul Tyler.

2.0 Declarations of Conflict of Interest 2.1 No declarations of interest were declared.

3.0 Patient Story 3.1 3.2 3.3 3.3.1 3.3.2 3.3.3 3.3.4

HS gave apologies from the patient speaker who had been due to attend today. The Trust Board of Directors took the opportunity to discuss the recent media coverage received by the Trust. Recent Media Coverage The Trust Board of Directors talked about the recent media coverage. The Board reiterated their focus on patient safety and the quality of services that they provide. The Board acknowledged that tragic circumstances must be learned from and all steps taken to ensure that they are avoided in the future. The Trust Board welcomed the independent review into the allegations that were made and wanted to ensure that all relatives and families of patients and staff were appropriately supported. Dispatches Television Programme South Central Ambulance Service (SECamb) had their CQC Report highlighted in a recent Dispatches Programme. SECamb had received a lot of coverage about their NHS 111 Service and the managing of calls after transfer to the clinical hub. Discussion on above The Board discussed the tragic circumstances surrounding the death of William Mead. The Board recognized that the story had heightened the publics’ awareness of sepsis.


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4.0 Report from the Chairman and Non-Executive Directors 4.1 4.2 4.3

HS reported that she and CW, Head of Communication and Engagement have continued to meet with new MPs within the area. The most recent visit was to Sheryl Murray MP in Liskeard and this meeting was a success. HS has been invited to be a member of the NHS Improvement Joint Advisory Chairs Group. The Group has 25 Chairs from the NHS who will attend regular meetings looking at how Monitor and the TDA will work when brought together. This is important work and HS was pleased to assure the Trust Board of Directors of her involvement. HS reported that the Staff Meetings had received a positive response. This has been substantiated more in the results of the staff survey.

5.0 Report from the Chief Executive 5.1 5.2 5.3 5.4

KW reported to the Trust Board of Directors that since the Board last met Heather Strawbridge had received an OBE in the New Year’s Honours. On behalf of the Trust Board of Directors KW congratulated HS. The Trust has been donating a number of vehicles at end of life in this organistion and equipment to ICT Fire and Rescue, an emergency rescue service provider as well as a training institution based in Thika (Kiambu County) Kenya. The Trust has a memorandum of understanding with the service provider. The Trust supports the training. Two members of staff went to visit. ACTION: KW will email further pictures to the Board. It has been good to receive feedback from the support and development provided by the Trust. The Trust has received the interim response to the Staff Survey 2015. This has been encouraging despite level of pressure staff are under. The return was 40.6%. The Trust has improved on 30 questions out of 60. The Trust was better than most other Trusts on 55 elements. The Survey has been very positive. This will be presented by EW to a future Trust Board of Directors Meeting. ACTION: EW to provide a report on the Staff Survey to the next Trust Board of Directors Meeting in March 2016. KW informed the Trust Board of Directors that the Trust has received notification that the CQC Inspection will take place 6 to 10 June 2016.

KW EW


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6.0 Questions from the Public 6.1 6.2 6.2.1 6.2.2 6.2.3

HS introduced Bren McInerney. BM recognised the immense pressure the service is under and that he had shared the recognition of the leadership delivered by KW across the ambulance service in the South West; and he commended KW for his level of social intelligence. BM gave recognition to CW for supporting Kingfishers and its development. Kingfisher’s has a membership of 144 adults with disabilities. Question from BM James Titcombe is the father of Joshua, a baby boy who died when only nine days old after signs of his deteriorating condition were missed by Morecambe Bay NHS Trust. ‘Whilst this case related to the Maternity Unit this could happen in any area in the NHS and beyond. What is the Trust Board’s view of the content of the book Joshua’s Story which was published in December 2015’: JW responded to the question on behalf of the Trust Board of Directors. JW has the privilege of working in quality and governance. JW commented that it is devastating to hear of situations when there has been a lack of transparency that affects the grieving process. This is a tragic and heartbreaking story followed by catalogue of issues which are not isolated to this case. It takes several years for families to find the truth. This Trust has works hard to maintain an open culture around quality and safety. The Trust has not had any cases of Duty of Candour where the Trust has not met the requirement. The Trust meets with the families to gain their view on the incident and ensure this is embedded within the learning. Staff are always supported whether they are involved with minor or serious incidents. EW is working with the Speak Up Speak Out campaign which came from the Robert Francis Report after Mid Staffs. This is about learning and supporting staff to change. The one thing that JW took away from the meeting with Melissa Mead was that she thanked the Trust for being open and transparent with her. HS noted that the Trust has always encouraged staff to report when things go wrong and also when they nearly go wrong in order to stop things happening and to share learning. It is crucial that the Trust shares this learning across this Trust and further. JW works transparently with other organisations and partners, working with commissioners and other Trusts who have been part of the patient pathway.


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6.2.4 6.2.5 6.2.6 6.3 6.3.1 6.3.2 6.3.3

VJ supported the view that the Trust is a learning organisation. VJ has attended Serious Incident panel reviews and has seen that staff attend. The Trust supportively and carefully takes them through the investigative process and any recommendations of learning. As a Board member VJ is assured by that. BM will be talking to James Titcombe on Friday, 29 January 2016 and the conversation will be around the leadership, culture, attitudes and behaviours and the demonstration of those. James will be visiting in March 2016. HS thanked BM for raising this issue today. Question from Adrian Rutter, Lead Governor and Public Governor for Devon HS noted that AR is not in attendance today but this question is in respect of the Governors’ duty to represent the interests of members of the Trust and the wider public. The question refers to the paper considered by the Trust Board of Directors on 26 November 2015 – “Communication and Engagement Quality and Performance Report” ‘Regarding agenda item 13 “Communication and Engagement Quality and Performance”, which clearly sets out the Trust’s strategy with regard to communicating outwards, could the Board please explain how they satisfy themselves that the Trust meets the challenges endemic to all entities wishing to reply and response to external communications promptly, appropriately and effectively, and therefore builds relationships through two-way ‘push and pull’ communications and engagement.’ HS stated that it would be most appropriate to address this question at a Council of Governors Meeting. DN and CH to report back to AR the recent media coverage of the Trust and also the communications update from today. The Trust Board of Directors agreed that this question would be presented to the Non-Executive Directors at the next Council of Governors Meeting. ACTION: Question to be taken by Non-Executive Directors, MM to add to the Agenda for the Council of Governors Meeting.

NEDs/ MM

7.0 Minutes of the Previous Meeting – 26 November 2015 7.1 The Minutes of the previous meeting of 26 November 2015 were

approved as a correct record of proceedings.


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8.0 Action Point Register 8.1 The Trust Board reviewed the Action Point Register

30 July 2015 (8.10) ICPR – Action completed 30 July 15 (8.12.2) ICPR – Action completed 24 Sep 15 (10.4) Patient Experience report – Action completed 24 Sep 15 (12.5) Learning Disability Programme Report – Action completed 26 Nov 2015 (3.7) – Patiemnt Story – Action complete 26 Nov 2015 (9.5) Rissk Regsiter and BAF – Action complete 26 Nov 2015 (9.311) BAF – Action complete 26 Nov 15 (10.7) Information Governance – Action complete 26 Nov 2015 (16) Audit Committee – Action complete All other risks are in progress and the action point register was updated.

9.0 Operational Planning 9.1 KW provided an update on Operational Planning to the Trust Board of

Directors. KW advised that the Trust’s Operational Plan has yet to be confirmed. The Trust is participating in the Ambulance Response Programme (ARP). ARP has created an environment where there have been a number of unknowns both with performance standards and categories of calls. Involvement in this trial has been essential and the Trust has driven this on behalf of national services. NHS England has now taken the lead. The latest aspect of the trial which the Trust has been promoting moves into a number of the 4,000 codes being split so that the Trust can respond in a number of different ways. As the criteria are unknown it has been impossible to prepare an appropriately informed Operational Plan. The start date for the second phase of the pilot is unknown. Therefore the Operational Plan has been delayed. The Trust Board of Directors noted the current position.

10.0 Integrated Corporate Performance Report 10.1 10.2

KW presented the Integrated Corporate Performance Report for assurance to the Board of Directors. KW gave a national update. NHS England commenced 2016 with a new set of Ambulance Quality Indicators (AQIs) for Ambulance Services across the Trust with implementation from January 2016. KW has received responses from 50% of Ambulance Trusts that they have not implemented them fully yet. This Trust has implemented them. Report is


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10.3 10.4 10.5 10.6

last week’s performance for the country. Only two ambulance services delivered Red 1; South East Coast Ambulance Service (SECamb) was one but they had not applied the new AQI guidance. West Midlands Ambulance Service (WMAS) achieved 76% and had applied the guidance. WMAS have dropped 4-5% as a result of the implementation. For Red 2 no service in the country achieved last week. Year to date for Red 2 WMAS is achieving. For Red 1 only this Trust, WMAS and North West Ambulance Service are achieving year to date. The position nationally is very fluid. This is not just about how AQIs are measured; there is a huge amount of pressure on the ambulance service. The system is under enormous pressure. KW reported a correction under the ICPR Handover Delay Section. It is stated that hours lost over 15 minutes were 1,432 hours of cover lost in December 2015 over 15 minutes turnaround time. The figure shows the hours that the Trust charges for which are those lost to Emergency Department handover delays. If the Trust reported all hours of cover lost this figure would be 2,316. The Trust cannot charge for those associated with Medical Assessment Unit handovers or those for the Intensive Therapy Unit. The total figure equates to 200 12 hour shifts lost in December 2015 or 2,500 shifts over a year. JK and NLC met with Commissioners on 27 January 2016 and delivered a presentation on the Trust Investment Strategy. They informed the Commissioners what it is like for the service at the moment. It was noted that Emergency Departments are under pressure and handover delays are a consequence of that pressure. This is about ensuring that Commissioners and Acute Trust are aware of the difficulties faced by the Service. This is about working together and ensuring that there are good relationships at a strategic and local level. JK advised that there is an agreed consistent generic template across Acute Trusts and the trajectory for improvement has been agreed with each Acute Trust. Handover delays have deteriorated by approximately 30% during Quarter 3. Headlines Over New Year the Trust had 3,500 incidents; this is 1,000 more calls than on a normal (day?). The Trust was 13% above core resourcing. The Trust did not achieve key performance targets at 72.6% for Red 1, 62% for Red 2 and just below 90% for A19. There are concerns that quarter to date will not be delivered and that response times may not be achieved. Current Red 1 performance for West is 77.2%, East 77.02%, North 64%. There have been historical issues with resourcing in the North Division


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10.7 10.8 10.9 10.10 10.11 10.12 10.13 10.14

even prior to the acquisition of Great Western Ambulance Service but there has also been a rise in activity in those areas and the percentage of Red calls from NHS 111 in the North has added to this and is causing significant issue. The Trust is not able to re-triage these calls once they are passed to the Clinical Hub a resource has to be dispatched. By having to dispatch a resource immediately the Trust is responding to potentially non-life threatening cases whilst compromising life threatening calls. FG stated that Red calls from NHS 111 equate to 33% in the North Division compared to 26% in the East and West Divisions. This is reported to Care UK who provide the NHS 111 Service in the North and to Commissioners in detail. MW sought assurance that the Commissioners know that there are problems with some of the Providers? The Trust has offered to work in partnership and offered potential solutions which have been rejected. JK reported that there had been an improvement from Care UK prior to Christmas 2015, but this has decreased in January 2016. At the Commissioners Meeting on 27 January 2016 the Trust presented different narrative, focusing on demand on 999. North activity is above contract and the source of this demand is from NHS 111. Initiatives Last week the Trust introduced five extra 24-hour Rapid Response Vehicles (RRVs) over and above resource in the North Division. The new Meal Break Policy in the North commences shortly. Work is taking place on having a mobile Make Ready Team to clean vehicles quickly. New standby points have been introduced in Bristol and these are being monitored closely. Collaboration with Emergency Services continues. Fire Service Response Teams have been increased, particularly in Gloucestershire. The Trust has appointed a Tri Service Manager to collaborate with the Fire and Rescue Service and the Police Service on the introduction of more initiatives. Clinical Quality Indicators (CQIs) will be reviewed in more detail. The ICPR details these up to August 2015. The Trust receives the data three months in arrears. The latest figures show that on two CQIs the Trust made an improvement on outcomes towards cardiac arrests and return of


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10.15 10.16 10.17 10.18 10.19 10.20 10.21

spontaneous circulation (ROSC). Three indicators were compromised and these are where the patient needs to get to a Treatment Centre at a given time e.g. for stroke. The Trust is governed by the level of resource and whether local facilities are open. The Trust stayed the same for three of the CQIs. PL commended the step improvement. There has been a positive benefit from the Ambulance Response Programme with the Hear and Treat rate at 13.33%. There has been investment of clinicians in the hubs. The Ambulance Quality Indicators are being reviewed and AGS is chairing the National Group leading on these. Major changes are expected in this area over the coming months. HS invited Craig Holmes, Public Governor Gloucester to inform the Trust Board of Directors regarding Community First Responder activity in the Gloucester area. CH reported that the number of incidents attended by the CFRs has decreased. KW acknowledged that the North Division is under pressure with resource delivery and activity increase. CFR availability is being reviewed by the Director of Operations along with the Community Responder Manager. ACTION: MM to forward CH’s concerns to FG/KW. NLC to provide a report on utilisation of CFRs for review at the next Trust Board of Directors Meeting in March 2016. HS thanked CH for raising this with the Trust Board of Directors. Workforce Update - EW provided an update on Trust vacancies. The Trust had expected to be over established by the end of March 2016 but will be slightly under by 20-30 vacancies. The reason for this is not based around recruitment but around internal moves with secondments out of staff from frontline duties. The next steps are to work around tolerance with development of staff off frontline. Staff sickness – EW reported that staff sickness has reduced. There has been improvement in the management of long term sickness. Good practice has been encouraged with return to work interviews. There has been improved reporting through the Global Rostering System (GRS). These reports give more visibility around triggers and certain parameters. Comparative data is provided. Staff can be held to account. Appraisals – WE reported that appraisals have remained an issue due to the Trust being at Amber and at REAP Level 4 for the majority of 2015. Discussions are taking place with staff side colleagues.


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10.22

Trust financial position – JK reported that the Trust’s financial position has been positive. For Quarter 3 Monitor awarded the Trust a green status. JK advised there has been dialogue between national lead organisations and leaders within the NHS. The Trust is planning for a small surplus but this will be subject to further discussions. This is with the agreement to reinvest penalties. Internal meetings continue to ensure a full understanding of financial dynamics. The Trust Board of Directors took assurance from the Integrated Corporate Performance Report.

11.0 Corporate Risk Register and Board Assurance Framework 11.1 11.2 11.3 11.4 11.5 11.6

JW presented the Corporate Risk Register and Board Assurance Framework for assurance to the Trust Board of Directors. JW stated as previously reported that the Risk Register is changing. The new narrative was noted. The new risk platform tender goes out on 1 February 2016. The tender will drive the new risk strategy for risk scoring and mechanisms for the risk register. Deep dives will be undertaken in A&E Operations and then IM&T Risks which will form part of the risk assurance process moving forward. There is a different approach to the Board Assurance Framework (BAF). With a summary of all risks. NHS 111 call answering is broadly delivering against trajectory. Focus is on Red 2 targets which remain high risk for the Trust with increased activity. The Forecast Score is unknown. There has been a deep dive on the increase in activity. There has been no increase in score. The biggest issue is around how the system outside of the Trust manages patients who are needing urgent and emergency care support. From June to December 2015 there was an increased forecast score and this has not reduced due to confidence in being able to manage patients outside the system. JW stressed the commitment with Commissioners to work with the Trust on the two risks of activity and Red 2. KW reported there is a national position on paramedic banding. At the National Ambulance Services Partnership Forum on 4 February 2016 two ambulance services will be nominated to NHS Employers who will send the Job Evaluation Team to interview staff in those services. The Trust Board of Directors took assurance from the Corporate Risk Register and Board Assurance Frame.


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12.0 Major Incident Preparedness Statement 12.1 12.2

KW presented the Major Incident Preparedness Statement. This is an assurance statement following the Paris attacks to ensure emergency services are able to respond to attacks. This report provides assurance to the Trust Board of Directors on a number of areas where awareness and training has increased. The Trust Board of Directors approved and took assurance from the Major Incident Preparedness Statement.

13.0 Developing Forward Plans 2016/17 13.1 13.2 13.3 13.4 13.5

JK presented the Developing Forward Plans 2016/17 to provide the Trust Board of Directors with the sense of process and development of plans for 2016/17. The Trust is required to plan for 2016/17 and to develop a system plan for 2016/21. JK drew attention to the role of NHS Improvement. NHS Improvement will be reviewing the Trust’s Plan. The Trust is in dialogue with Monitor and has flagged with them the challenges with producing the plan. The first deadline is for the Trust Board of Directors to receive the unapproved submission on 8 February 2016. This would have been shared on 5 February 2016 with the Chairman. There will be an opportunity for the Trust Board of Directors to discuss the plan at the Trust Seminar on 25 February 2016. The final approved version will be submitted in April 2016. JK clarified that the plan is drafted under Monitor’s guidance. The approach for 2016/17 is to take the first six months as work plan to understand the evidence base from the Ambulance Response Programme. The Trust will then produce an 18 month plan running from 1 October 2016 to 31 March 2018. JK noted that the 5% tolerance for the Ambulance Response Programme will be removed. The Trust Board of Directors took assurance from the discussion regarding the plans for 2016/17.


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14.0 Council of Governors Forward View 14.1 14.2 14.3 14.4 14.5

Craig Holmes, Public Governor Gloucestershire and Deputy Chair of the Audit and Planning Sub Group of the Council of Governors and Dee Nix, Public Governor Wiltshire & Swindon and member of the Audit and Planning Sub Group presented the Council of Governors and Members of the Public View on the Forward Plans of the Trust for consideration by the Trust Board of Directors. CH reported that 44% of the public stated that response time was key for them. They accepted that the quality of the person attending them would be good. They want a resource to turn up when they are in need. Utilisation of Community First Responders (CFRs) was discussed. HS advised that she has attended CFR Meetings. KW and HS are supporting an Awards Evening for Community First Responders as they are so valued. NLC advised there has been an increase in Responder Managers across the Trust to support this work. The Trust has recently appointed a joint manager via joint funding as a point of contract with St John Ambulance. With regard to response times CH suggested that this could be incorporated into the Governor Engagement Survey. The last ones were developed with William Thomas as the Chair of the Membership and Communications sub group of the Council fo Governors. HS thanked the Council of Governors for the valuable feedback that they had got from time spent with the public. DN commented that in the area North East of the Trust there have been a lot of private defibrillators (defibs) installed. DN reported that the communities are full of praise for the Trust but do have concerns that they may wait longer for a response because they have a defib. KW responded that wherever a public access defib is placed has no bearing on how quickly an ambulance responds. It was noted that the 19 minutes target does not include defibs. The whole issue of whether a defib stops the clock in terms of performance standards is with the government for review. The Association of Ambulance Chief Executives has been lobbying the government. The purpose of the model of change of service with the change in codes sets is to review the service model delivered. Trusts may need to move to more ambulances than cars. ACTION: DN to provide details of any incidents with regard to defibs or response delays for the Trust Board of Directors to investigate. It was noted that community defibs are not instead of they are as well as and it would be helpful if the Governors could ensure this message is fed back.

DN


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14.6 14.6 14.7 14.8

Education was discussed and the misuse of the service was feedback along with the fact that it is not a taxi service. DN reported that at a recent Emergency Planning Meeting for her area there had been a positive message from the Fire Service about working with the Trust. HS gave thanks to DN and CH. HS asked them to forward thanks from the Trust Board of Directors to all the Governors for the work they do. The Board received the Council of Governors Forward view

15.0 Communication and Engagement 15.1 15.2 15.3 15.3.1 15.3.2 15.3.3 15.4

CW provided an update on Communication and Engagement for assurance to the Trust Board of Directors. The Trust Board of Directors noted the Quarter 3 objectives. CW highlighted the following; Stay Well This Winter Campaign This was rolled out before the real definition of Winter. There has been a blended approach with NHS and Social Care colleagues to make use of pulling together national campaigns. This has worked well with positive coverage. Launch of Staying Well Service The Staying Well Service has generated positive news coverage and has received excellent feedback from staff. Patient Stories This has been opportunity with positive coverage. The team is following up with the stories. Frontline staff are good at informing the team about these stories and the patients are given the opportunity to meet with the crews. The Trust Board of Directors Too assurance from the Communications and Engagement update.


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16.0 Information Governance Toolkit 16.1 16.2 16.3 16.4 16.5 16.6

FG presented the Information Governance Toolkit Report. FG reported increases in Freedom Of Information Requests. These are being managed by the Information Governance Team. Information Governance Training of staff is at 60%. The target is for 95% of staff to complete the training by year end. Discussions are taking place with Directors. Networking is taking place with regard to the Care Record Programmes. Dorset and Gloucestershire are in the process of procuring care systems following on from the BNSSG Connecting Care System. FG is involved with work nationally with regard to ECS. This work is sponsored by HSCIC. HS asked if there would be a revision of categories for Information Governance Adverse Incidents. FG responded that these are National categories. JW advised that the platform for incidents will change in Quarter 1. Successful bidders may be able to change the code sets. The Trust Board of Directors took assurance from the Information Governance Toolkit Update.

17.0 Standing Financial Instructions of the Trust (SFI) 17.1 17.2 17.3 17.4

MM presented the Standing Financial Instructions of the Trust for approval from the Trust Board of Directors. MM reported on the changes to in-house limits. These are based on information provided by the Procurement Team and have been reviewed by the Audit and Assurance Committee. MM recommended to that the Trust Board of Directors approved the changes to the in-house limits. MW agreed with the SFIs but commented that for euros to pounds conversion rate fluctuation there should be an extra line so that this does not have to be written in every time the bandings change. PL commented that this would still keep it below the OJEU level. There should be a line to state that it is below. The Trust Board of Directors agreed that this is simpler in the longer term but if there is significant change this would be brought back to the Trust Board of Directors. The Standing Financial Instructions of the Trust were approved by the Trust Board of Directors.


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18.0 Governors Expenses Policy 18.1 18.2 18.3

MM presented the Governors Expenses Policy. Amendments and the small housekeeping update to the Policy Register were noted by the Trust Board of Directors. The Trust Board of Directors noted the fundamental change in the mileage rate from 53p to 56p in line with the NHS approved mileage rate. It was noted that if the Government rate reduces this will reduce the NHS approved mileage rate. The Trust Board of Directors approved the Governors Expenses Policy.

19.0 Quality Approach 19.1 19.2 19.2.1 19.2.2 19.2.3 19.3 19.4

JW presented the Quality Approach for assurance to the Trust Board of Directors. HS praised JW and her team for this report which is outstanding. JW highlighted the following three points; The Quality Forum has been developed where discussions on risks and work on this will be discussed. Chris Nelson, Staff Side Branch Secretary attended the last meeting and was supportive of the direction of travel. It was noted that patients are at the centre of this. It has been agreed that learning and improvement has to be the basis of quality be able to utilise learning nationally and locally. System information will be used where possible. Further developments will take place. The Trust demonstrates the value of quality. Staff involved with the Quality Forum felt that if quality continues to develop there will be a financial value seen. JW will present the full Quality Strategy to the next Trust Board of Directors in March 2016. The full Quality Strategy would be presented to the Quality Committee for approval. ACTION: JW to take this forward. The Trust Board of Directors took assurance from the Board and approved the strategic approach to development.

JW


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20.0 Quality Committee • Assurance Report – January 2016 • Final Minutes – October 2015

20.1 20.2 20.3 20.4 20.5 20.6 20.7

VJ presented the Quality Committee Assurance Report following the meeting on 14 January 2016. VJ reported that the meeting in January 2016 had been well attended. The new style of reporting had been introduced to the committee. Presenters had been provided with the template which makes for a more concise and easier report. This had been well received. The Committee had felt that there were three key areas that the Directors Group should review. These were the increasing referrals to the safeguarding team, medicine management and compliance with the medicines management policy across the entire trust and Infection Control, particularly the deep clean programme for vehicles particularly through December 2015. NLC reported that the Trust was at REAP 4 in December 2015 and the Make Ready Operatives (MROs) were used to move the vehicles around more and they had to get all available vehicles on the road. The MROs have been doing overtime during January 2016 in order to deal with the backlog and maintain the excellent standard provided by the Trust. VJ asked that it was noted that no harm or risk to patients had taken place in the above areas. ACTION: Directors Group to review Safeguarding, Medicines Management and Infection Control. JS to discuss with KW and add to further Directors Group Agendas. Key achievements were noted with Right Care 2 and CQUINs on track for full achievement this year. ACTION: MM to add the list of papers that were submitted to the Quality Committee to the Assurance Report. The Quality Committee had commended the Staying Well Service which has been well received across the organisation with a lot of positive feedback. The Quality Committee had received an update on learning disability and had commended work undertaken by South Western Ambulance Group led by Sara Coburn, Patient Engagement Manager. The Visitor Access Policy had been amended and approved at the Quality Committee. The Minutes of the Quality and Governance Committee Meeting of 8 October 2015 were noted by the Trust Board of Directors. It was noted that the Quality and Governance Committee Minutes from 17 December

JS MM


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20.8

2015 have been submitted for approval at the next Quality Committee in April 2016. The Trust Board of Directors noted the report of the Quality Committee for assurance.

21.0 Audit Committee • Assurance Report – January 2016 • Final Minutes – November 2015

21.1 21.2 21.3 21.4

PL presented the Audit and Assurance Committee Assurance Report following the meeting on 14 January 2016. This was the first meeting of the newly reshaped Committee. PL noted that the Executive Directors have been asked to produce a mission statement on areas relevant to the Trust to feed into risk mapping and development. PL noted that the timeliness of Audit Reports has improved. Following internal audit the Urgent Care Service had received a rating of amber. There is a detailed action response plan for that report and JW is reviewing the areas and see if areas can be accelerated. External Audit outlines Audit Plan had been review. PL reported that as part of the independence test they require a declaration from the Non-Executive Directors regarding engagement with PwC. The Minutes of the Audit Committee on 12 November 2015 were noted by the Trust Board of Directors. The Trust Board of Directors took assurance from the Audit and Assurance Committee Assurance Report.

22.0 For Information • Report from West of England Academic Health Science

Network Board

22.1 MW asked whether the Academic Health Science Network (AHSN) is of value. FG advised that the West of England AHSN have provided some funding for reporting on ECS. West of England stands above with their support. MW commented that the report does not reflect this. FG advised this is specific to the West of England. ACTION: JK to compile a list of subscriptions to organizations for presentation to the Trust Board of Directors in March 2016.

JK

23.0 Any Other Business


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23.1 There was no further business. 24.0 Identification of New Risks (incl. Health & Safety) 24.1 No new risks were identified.

25.0 Identification of New Legislation 25.1 No new legislation was identified.

Signed: (Chair) Dated: A final, signed copy of the minutes are available from the meeting administrator on request

Trust Public Board of Directors Meeting – 31 March 2016 Page 1 of 2

Agenda Trust Public Board of Directors Meeting

Date Thursday 31 March 2016 Time 10.00

Venue Boardroom, Trust HQ, Abbey Court, Eagle Way, Exeter EX2 7HY

Chair Mrs H Strawbridge, Chairman

Members:

Mrs H Strawbridge (HS), Mr K Wenman (KW), Mr T Fox (TF), Mr H Hood (HH) Mrs V James (VJ), Mr P Love (PL), Dr I Reynolds (IR), Prof. M Watkins (MW), Mr F Gillen (FG), Mrs J Kingston (JK), Dr A Smith (AS), Mrs J Winslade (JW), Mrs E Wood (EW)

Non Members:

Mr M McAuley (MM), Lord P Tyler (PT), Ms L Bowden (LB), Mr N Le Chevalier (NLC)

Circulation Mr C Nelson, Joint Branch Secretary, Unison, Ms J Fowles Joint Branch-Secretary, Unison, Council of Governors

Administration Mrs J Smalley (JS)

Opening business

No Topic Format Presenter

1 Welcome, Introduction & Apologies Apologies: Mary Watkins

Verbal HS

2 Declarations of Interest Verbal All

3 Patient Story Presentation HS

4 Report from the Chairman Verbal HS

5 Report from the Chief Executive Verbal KW

6 Questions from the Public Verbal HS

7 Minutes of Previous Meeting – 28 January 2016 Paper 1 HS

8 Action Point Register Paper 2 HS

Trust Public Board of Directors Meeting – 31 March 2016 Page 2 of 2

Strategic Items for assurance

9 Integrated Corporate Performance Report Paper 3 KW

10 Corporate Risk Register and Board Assurance Framework Paper 4 JW

11 2015 Staff Survey Update Paper 5 EW

12 Patient Safety and Experience Report Paper 6 JW

13 Information Governance Year to Date Report Paper 7 FG

14 Communication and Engagement Paper 8 LB

15 Draft Regulatory Framework 2016/17 Paper 9 JW

16 Board Annual Declarations Paper 10 MM

Items for approval

17 Membership Engagement Strategy Paper 11 MM

18 Code of Conduct for Trust Governors Paper 12 MM

19 Speak Up, Speak Out Policy Paper 13 MM

20 Committee Terms of Reference Paper 14 MM

Sub Committee reporting for assurance

21 Audit Committee Assurance Report – March 2016 Verbal PL

Closing business

22

Any Other Business

Identification of New Risks (incl. Health & Safety)

Identification of New Legislation

Verbal HS

Council of Governors Meeting – 21 April 2016

Page 1 of 6

Council of Governors 21 April 2016

Title:

Membership & Governor Update

Prepared By:

Marty McAuley, Trust Secretary Peter Dixon, Governance Support Manager

Presented By:


Main aim:

To provide Governors with an overview of Trust Membership, vacancies on the Council of Governors and other updates of note.

Recommendations:

The Council of Governors is asked to take assurance from the information provided.

Previous Forum:

None.



Appendix 3 to Annex 5 of the Trust’s Constitution sets out the role of Governors in respect of developing a representative membership. Appendix 4 to Annex 5 of the Trust’s Constitution sets out the role of the Council of Governors in respect of filling vacancies on the Council.


Page 2 of 6

Membership & Governor Updates 1. Membership Overview 1.1 We continue to recruit new members and will continue to target recruitment to areas

of the Trust where we are under-represented. 1.2 Governors’ local knowledge has been used to identify additional opportunities for

PPI events in 2016/2017 as well as informing the Membership and Engagement Strategy.

1.3 The focus going forward will be on engagement instead of recruitment.

2. Membership Levels

Members 31.03.2014 31.03.2015 31.03.2016

Public 14,188 14,327 14,250

Staff 4,379 4,388 4,914

Total 18,567 18,722 19,164 2.1 As at 31 March 2016 the Trust had a public membership of 14,250. Whilst this

figure exceeds the target of 0.24% across the entire region, there are a number of individual constituencies where the target has not been met these being Bristol and Bath & North East Somerset; Dorset; Gloucestershire; and Wiltshire and Swindon.

Constituency Number of

Governors Minimum No. of

Members required for an election

Actual Number of Members

Bristol and Bath & North East Somerset 2 320 1,224 Cornwall 2 272 3,103 Devon 4 580 3,204 Dorset 2 360 1,585 Gloucestershire (incl South Gloucestershire)

3 436 1,474

Isles of Scilly 1 25 73 Somerset (incl North Somerset) 3 375 2,554 Wiltshire and Swindon 2 336 1,032


Page 3 of 6

3. Membership Data

Public Membership 2014/15 2015/16 Recruited 261 121

Lost 121 198

Net change in public membership +140 -77

Staff Membership 2014/15 2015/16 Recruited 392 1,453

Lost 373 927

Net change in staff membership +19 +526 4. An Engaged Membership 4.1 The Trust recognises that members will want to have varying levels of involvement

with the Trust. Accordingly, Trust Membership is split into three levels ranging from simply receiving information through to becoming a Governor. The table below sets out the number of members signed up to each level of membership as at 31 March 2016 and how many of those members have provided an email address to enable electronic communication.

Membership Level Number

of Members

% of Membership

Number of Email

Addresses One – Informed Receive newsletters and information about the Trust

11,533 80.93% 3,289

Two – Involved Also take part in surveys, consultations and events

1,885 13.23% 880

Three – Influential Might also consider becoming a Trust Governor

833 5.84% 474


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5. Staff Governors and Membership

Staff Constituency Membership 31.03.2016

Governors

Accident & Emergency: East Division 754 David Shephard

Accident & Emergency: North Division 1,474 Alan Peak

Accident & Emergency: West Division 1,176 Stephen Gough

Urgent Care Services (inc NHS111) 697 Steve Frost

Administration, Support and Other Services

670 Neil Hunt

Volunteers 143 Mark Norbury

Total 4,914 6 6. Public Governors and Membership

Public Constituency Membership 31.03.2016 Governors

Bristol, Bath & North East Somerset 1,224 Rae Care and Vacancy

Cornwall 3,103 Sylvia Hammond and William Thomas

Devon 3,204 Adrian Rutter, Paul Young, Bob Deed and Phil Ford

Dorset 1,585 Robert Day and Jim Duffie

Gloucestershire (incl South Gloucestershire) 1,474 Andrew Gravells, Craig Holmes

and Jerry Pallister

Isles of Scilly 73 Chris Mills

Somerset (incl North Somerset) 2,554 Terry Beale, Jeff Liddiatt and

Anthony Leak

Wiltshire and Swindon 1,032 Torquil MacInnes and Dee Nix

Total 14,250 18


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6.1 Following the resignation of Harriet Lupton, Governor for Bristol and Bath & North East Somerset, the Trust commenced the election process and undertook work to raise awareness of the vacancy. The Trust wrote to all members in the constituency via email and a press release was issued across the area. Regrettably there were no nominations forthcoming. As a result the election will be re-run and a timetable is currently being agreed with the Trust’s election service provider.

7. Appointed Governors

Appointed Governors Governor Local Authorities Doug Hellier Laing

Clinical Commission Groups – North Division Vacancy

Clinical Commissioning Groups – East & West Divisions Vacancy (x2)

Police Forces Vacancy

Fire and Rescue Services Paul Walker

Acute Trusts Vacancy

Mental Health Partnerships Stephen Waite

Air Ambulance Charities John Christensen 7.1 The Trust is currently working to ensure that the appointed vacancies will be filled. Clinical Commissioning Groups 7.2 The Clinical Commissioning Groups (CCGs) have all been contacted to request

nominations for the seats. Not all CCGs have engaged with the process and the Trust is currently in communication with two CCG’s to obtain a nomination.

7.3 In light of the current and historic difficulties in filling the CCG appointments, the

CoG may wish to consider in the future the amalgamation of the three CCG seats into one appointment which would cover the entire geography of the Trust.

Emergency Services 7.4 The Trust successfully appointed Chief Fire Officer Paul Walker to the position of

Fire and Rescue Service Governor. 7.5 As of 12 April 2016 the Trust had received no response from the Police Forces in

respect of their vacancy. This position has been vacant since the resignation of Sally Crook last July.


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7.6 Due to the difficulties in appointing a Governor for the Police Forces and their lack of engagement on the matter, the CoG may wish to consider future alterations to the position. It may be of benefit to the CoG to combine the seats of the Fire and Rescue and Police Force into a new ‘Emergency Services’ appointment. This would also allow the Trust to include the Coastguard.

NHS Acute Trusts 7.7 Following the resignation of Juliet Cross, the Trust has made contact with the Acute

Trusts and is currently in discussion with two Trusts regarding possible nominations. NHS Mental Health Partnerships 7.8 Following the resignation of Iain Tulley from the role of appointed Governor for Mental

Health Partnerships, the Trust successfully appointed Stephen Waite to the position. 8. New Governors 8.1 Since the Council of Governor meeting on 10 December 2015 we have welcomed

five new Governors: • Paul Walker – Fire and Rescue Services • Sylvia Hammond – Cornwall • Jeff Liddiatt – Somerset and North Somerset • Stephen Gough – A&E West • Stephen Waite – Mental Health Partnerships

9. Governor Attendance Report 9.1 Annex A sets out the attendance of Governors at CoG meetings; Board meetings;

patient and public involvement events and any additional events organised or attended by a Governor in their own area. The period covered is from 1 December 2015 to12 April 2016. During this time there was one full Council of Governors meeting, one CoG workshop, two Board meetings and two SWASFT PPI events.

9.2 In March 2016 each Governor was sent the updated Declaration of Interests form to

complete in order for the Trust to remain compliant with the NHS Act 2006. As of the 12 April 2016, 17 have been returned completed.

10. Recommendation 10.1 The Council of Governors is asked to take assurance from the information provided Marty McAuley Peter Dixon Trust Secretary Governance Support Manager

Annex A - Governor Attendance Governor CoG (1) % Workshop (1) % Board Meetings (2) PPI Events Other Events Surveys Completed Terry Beale 0 0 1 100 Rae Care 1 100 1 100 1 1 John Christensen 0 0 1 100 Robert Day 1 100 0 0 Bob Deed 1 100 0 0 1 Jim Duffie 0 0 1 100 Phil Ford 1 100 0 0 Steve Frost 1 100 1 100 Stephen Gough NIP 0 NIP 0 Andrew Gravells 0 0 0 0 Sylvia Hammond NIP n/a 1 100 1 Doug Hellier Laing NIP n/a 1 100 Craig Holmes 1 100 1 100 1 Neil Hunt 1 100 0 0 Anthony Leak 1 100 0 0 Jeff Liddiatt NIP 0 1 100 Torquil MacInnes 1 100 1 100 1 Chris Mills 0 0 0 0 Dee Nix 1 100 1 100 Mark Norbury 1 100 1 100 Jerry Pallister 1 100 1 100 Alan Peak 1 100 1 100 Adrian Rutter 1 100 1 100 1 David Shephard 1 100 1 100 William Thomas 1 100 1 100 Stephen Waite NIP 0 NIP 0 Paul Walker NIP 0 NIP 0 Paul Young 0 0 0 0


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Title:

Policy of Engagement

Prepared By:

Marty McAuley, Trust Secretary Helen Braid, Governance & Assurance Manager

Presented By:


Main aim:

To inform Governors of the development of a Policy of Engagement and seek nominations to a Policy Development Working Group.

Recommendations:

The Council of Governors is asked to nominate three Governors to the Policy Development Working Group.

Previous Forum:

None.


Statutory Requirements Met The NHS Foundation Trust Code of Governance


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Policy of Engagement 1. Background 1.1 The NHS Foundation Trust Code of Governance requires the Council of Governors

to establish a Policy of Engagement with the Board of Directors which can be applied when the Council has concerns about the performance of the Board of Directors, compliance with the provider licence or other matters related to the overall wellbeing of the Trust.

1.2 The Policy will be distinct from the procedure for dispute resolution between the

Council of Governors and the Board of Directors which is covered in Annex 8, Appendix 4 of the Trust’s Constitution

2. Development of the Policy of Engagement 2.1 In order to develop the Policy it is proposed that a small working group be

established to produce a draft of the Policy for presentation to the July meeting of the Council of Governors.

2.2 It is proposed that the working group comprises:

• Trust Chairman • Trust Secretary • One Non-Executive Director • Three Governors.

3. Recommendation 3.1 The Council of Governors is asked to nominate three Governors to the Policy

Development Working Group. Marty McAuley Helen Braid Trust Secretary Governance & Assurance Manager


Page 1 of 3


Title:

Council of Governors – Succession Planning

Prepared By:


Presented By:


Main aim:

To provide revised proposals for succession planning in respect of the Council of Governors.

Recommendation:

The Council of Governors is asked to agree to moving to phased terms of office for Governors as set out at Annex A, with these terms of office being effective as of 1 March 2017.

Previous Forum:

Council of Governors – 9 July and 10 December 2015.



The NHS Act 2006 requires NHS Foundation Trusts to have a Council of Governors, the structure of which is detailed within the Trust Constitution.


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Council of Governors – Succession Planning 1. Introduction 1.1 The NHS Act 2006 requires NHS Foundation Trusts to have a Council of Governors

(CoG). 1.2 The Trust established its CoG (in shadow form) in February 2011, with all

Governors having a three year term of office. Following the acquisition of Great Western Ambulance Service NHS Trust the CoG was expanded to include the Northern area, with those Governors having a one year term of office. This resulted in the term of office for all Governors ending in February 2014.

1.3 Following “all out” elections and appointments, the current term of office for all

Governors runs until the end of February 2017. 2. Purpose 2.1 At its meeting on 10 December 2015 the Council of Governors agreed to move to

phased elections with effect from February 2017 in order to minimize the risk of losing all the experience gained in the previous three years, whilst retaining the opportunity for the Council of Governors to be refreshed with new members.

2.2 There was, however, concern at the way in which the proposed terms of office for

Public Governors appeared to favour constituencies in the south of the region. Accordingly, the proposed terms of office have been reviewed and are presented for approval (Annex A.)

3. Recommendation 3.1 The Council of Governors is asked to agree to moving to phased terms of office for

Governors as set out at Annex A, with these terms of office being effective as of 1 March 2017.

Marty McAuley Trust Secretary


Page 1 of 2


Title:

Register of Interests of the Council of Governors

Prepared By:


Presented By:


Main aim:

To provide the Council of Governors with the Register of Interests prior to its publication.

Recommendations:

1. The Council of Governors is asked to note the Register of Interests for the Council of Governors.

2. Governors who have not provided a 2016 update are requested

do so as soon as possible so as to comply with their legislative responsibilities.

Previous Forum:

None.



The NHS Act 2006 Trust Constitution Governors Code of Conduct


Page 2 of 2

Register of Interests of the Council of Governors 1. Background 1.1 The NHS Act 2006 requires all Governors of NHS Foundation Trusts to make a

declaration of interests at the time that they are elected or appointed and as soon as any additional interest arises.

1.2 The Trust is required to record of interests in a register and this document available

to the public. Accordingly, it is published on the Trust’s website. 2. Register of Interests 2.1 The current draft of the Register of Interests is at Annex A. This document contains

the most recent declarations made by Governors. 2.2 All Governors were contacted on 23 March 2016 and requested to update their

declaration. Where updates have been received, these have been included. 2.3 A number of declarations remain outstanding. 3. Recommendation 3.1 Governors are asked to note the Register of Interests for the Council of Governors. 3.2 Governors who have not provided a 2016 update are requested do so as soon as

possible so as to comply with their legislative responsibilities. Marty McAuley Helen Braid Trust Secretary Governance & Assurance Manager

Council of Governors – Register of Interests 12 April 2016

The Regulatory Framework for NHS Foundation Trusts (2006 Act, the Constitution and the Terms of Authorisation) requires each Governor to declare to the Trust Secretary: • Any actual or potential interest, direct or indirect, which is relevant and material to the business of the Trust, as described in

Standing Order (SO) 7.2.1; • Any actual or potential pecuniary interest, direct or indirect, in any contract, proposed contract or other matter concerning the

Trust, as described in SOs 7.2.2 and 7.2.3; • Any actual or potential family interest, direct or indirect, of which the Governor is aware, as described in SO 7.2.5.

Such a declaration shall be made either at the time of the Governor’s election or appointment or as soon thereafter as the interest arises, and in a form prescribed by the Trust Secretary. In addition, if a Governor is present at a meeting of the Council of Governors and has an interest of any sort in any matter which is the subject of consideration, he shall at the meeting and as soon as practicable after its commencement disclose the fact and shall not vote on any question with respect to the matter. Subject to SO 7.2.4, if a Governor has declared a pecuniary interest (as described in SOs 7.2.2 and 7.2.3) he shall not take part in the consideration or discussion of the matter. At the time the interests are declared, they should be recorded in the Governor's meeting minutes. Any changes in interests should be officially declared at the next relevant meeting following the change occurring. This SO 7 applies to any committee, sub-committee or joint committee of the Council of Governors and applies to any member of any such committee, sub-committee, or joint committee (whether or not he is also a Governor).


The Trust is required to maintain a register of interests for the members of the Council of Governors. This shall contain: • The name of each Governor; and • Whether they have declared any interests and, if so, the interests declared in accordance with the Trust Constitution and the

Standing Orders for the Council of Governors. The following register represents the interests held by Governors throughout 2016/17. Constituency Name Interests Declared Public – Bristol and Bath & North East Somerset

Rae Care Member of Bristol Area Cardiac Support

Public – Bristol and Bath & North East Somerset

Vacancy n/a

Public – Cornwall Sylvia Hammond Personal Relationship; Family operate the Plymouth Knee and Foot Clinic Ltd

Public – Cornwall William Thomas None Public – Devon Bob Deed Mid Devon District Councillor

Former Chair of Choice – Lay body working to improve services at Tiverton Hospital

Public - Devon Phil Ford None

Public – Devon Adrian Rutter Chair and Trustee of Ottery St Mary Hospital League of Friends Public – Devon Paul Young None


Constituency Name Interests Declared Public – Dorset Robert Day None Public – Dorset Jim Duffie None Public – Gloucestershire Andrew Gravells Elected Member, Gloucestershire County Council Public – Gloucestershire Craig Holmes None Public – Gloucestershire Jerry Pallister None Public – Isles of Scilly Christopher Mills Personal Relationship; family member works for NHS England (Deputy

Finance Controller - Procurement) Public – Somerset Terry Beale Director Tone FM Ltd, Trustee of Winged Dreams Charity, District

Councillor for Taunton Deane Borough Council Public – Somerset Anthony Leak None Public – Somerset Jeff Liddiatt None Public – Wiltshire Torquil MacInnes Personal Relationship; family member works for the Trust (ECA) Public – Wiltshire Dee Nix Chair, Pewsey Community Area Partnership Health Forum

Chair, Wilcot and Huish Parish Council Staff – Accident & Emergency (East) David Shephard None Staff – Accident & Emergency (North) Alan Peak Councillor, Weston Super Mare Town Council Staff – Accident & Emergency (West) Stephen Gough Ministry of Justice, Voluntary Position (Justice of the Peace) Staff – Administration, Support & Other Services

Neil Hunt None


Constituency Name Interests Declared Staff – Urgent Care Services (including NHS 111)

Steve Frost Awaited

Staff – Volunteers Mark Norbury Employee of West Midlands Ambulance Service NHS Foundation Trust National Ambulance Resilience Co-Ordinator, National Ambulance Resilience Unit

Clinical Commissioning Groups (Cornwall, Devon & Somerset)

Vacancy n/a

Clinical Commissioning Groups (Bristol, Gloucestershire, North Somerset, Swindon & Wiltshire)

Vacancy n/a

Local Authority Doug Hellier Laing Appointed Governor, South West Council (Teignbridge District Council Local Authority)

Partnership – Fire & Rescue Paul Walker Partnership – Police Vacancy n/a Partnership – Mental Health Partnerships

Stephen Waite Chief Executive, Livewell Southwest

Partnership – Acute Trusts Vacancy n/a Partnership – Air Ambulance Charities

John Christensen Chief Executive, Great Western Air Ambulance Charity


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Title:

Policy for the Composition of the Non-Executive Directors

Prepared By:


Presented By:


Main aim:

To provide Governors with the draft Policy for the Composition of the Non-Executive Directors for approval.

Recommendations:

The Council of Governors is asked to approve the Policy for the Composition of the Non-Executive Directors.

Previous Forum:

None.



The NHS Act 2006 NHS Foundation Trust Code of Governance Trust Constitution


Page 2 of 2

Policy for the Composition of the Non-Executive Directors 1. Background 1.1 The NHS Act 2006 specifies the required composition of the Non-Executive

Directors of NHS Foundation Trusts. 1.2 The Council of Governors is required to prepare and from time to time review the

Trust’s policy for the composition of the Non-Executive Directors (NEDs) to ensure that at all times, its composition accords with the requirements of Schedule 7 of the National Health Service Act 2006 (as amended) and the Trust’s Constitution.

2. Policy for the Composition of the Non-Executive Directors 2.1 The draft policy is at Annex A. The policy sets out the requirements of the NHS Act

and the NHS Code of Governance and how the Trust meets these requirements. 2.2 The policy also sets outs the responsibilities of the Council of Governors in

reviewing the policy and the Trust Secretary for ensuring that the policy remains compliant with legislative requirements.

3. Recommendation 3.1 The Council of Governors is asked to approve the Policy for the Composition of the

Non-Executive Directors. Marty McAuley Helen Braid Trust Secretary Governance & Assurance Manager

Policy for the Composition of the

Non-Executive Directors

Version: 1

Status: Draft

Title of originator/author: Governance & Assurance Manager

Name of responsible officer: Trust Secretary

Developed/revised by group/committee and Date:

Approved by group/committee and Date:

Council of Governors

Effective date of issue: (1 month after approval date)

Next review date:

Date Equality Impact Assessment Completed:

Regulatory Requirement: NHS Act 2006 NHS Foundation Trust Code of Governance

Page 1 of 7 Policy for the Composition of the Non-Executive Directors

Trust Policy Foreword SWASFT has a number of specific corporate responsibilities relating to patient and staff safety and wellbeing which should be included within all Trust policy and strategy, as a foreword inside the front cover: Code of Conduct and Conflict of Interest Policy - The Trust Code of Conduct for Staff and its Conflict of Interest and Anti-Bribery policies set out the expectations of the Trust in respect of staff behaviour. SWASFT employees are expected to observe the principles of the Code of Conduct and these policies by declaring any gifts received or potential conflicts of interest in a timely manner, and upholding the Trust zero-tolerance to bribery. Compassion in Practice – SWASFT will promote the values and behaviours within the Compassion in Practice model which provide an easily understood way to explain our role as professionals and care staff and to hold ourselves to account for the care and services that we provide. These values and behaviours reflect the Trust’s commitment to developing an outstanding service through the conduct and actions of all staff. SWASFT will encourage staff to demonstrate how they apply the core competencies of Care, Compassion, Competence, Communication, Courage, and Commitment to ensure our patients experience compassionate care. Duty of Candour – SWASFT will, as far as is reasonably practicable, apply the statutory Duty of Candour to all reported incidents where the Trust believes it has caused moderate or severe harm or death to a patient. This entails providing the affected patient or next of kin (within strict timescales) with: all information known to date; an apology; an explanation about any investigation; written follow-up; reasonable support; and the outcome fed back in person (unless they do not want it). The only exception is where making contact could have a negative impact upon the next of kin. SWASFT employees are expected to support this process by highlighting (early) any incident where they believe harm may have been caused. Equality Act 2010 and the Public Sector Equality Duty - SWASFT will act in accordance with the Equality Act 2010, which bans unfair treatment and helps achieve equal opportunities in the workplace. The Equality Duty has three aims, requiring public bodies to have due regard to: eliminating unlawful discrimination, harassment, victimization and any other conduct prohibited by the Act; advancing equality of opportunity between people who share a protected characteristic and people who do not share it; and fostering good relations between people who share a protected characteristic and people who do not share it. SWASFT employees are expected to observe Trust policy and the maintenance of a fair and equitable workplace. Fit and Proper Persons – SWASFT has a statutory duty not to appoint a person or allow a person to continue to be an executive director or equivalent or a non-executive director under given circumstances. They must be: of good character; have the necessary qualifications, skills and experience; able to perform the work they are employed for (with reasonable adjustments); able to provide information required under Schedule 3 (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). The definition of good character is not the test of having no criminal convictions but instead rests upon judgement as to whether the person’s character is such that they can be relied upon to do the right thing under all circumstances. This implies discretion for boards in reaching a decision and allows that people can change over time. Health and Safety - SWASFT will, so far as is reasonably practicable, act in accordance with the Health and Safety at Work etc. Act 1974, the Management of Health and Safety at Work Regulations 1999 and associated legislation and approved codes of practice. It will provide and maintain, so far as is reasonable, a working environment for employees which is safe, without risks to health, with adequate facilities and arrangements for health at work. SWASFT employees are expected to observe Trust policy and support the maintenance of a safe and healthy workplace. Information Governance - SWASFT recognises that its records and information must managed, handled and protected in accordance with the requirements of the Data Protection Act 1998 and other legislation, not only to serve its business needs, but also to support the provision of highest quality patient care and ensure individual’s rights in respect of their personal data are observed. SWASFT employees are expected to respect their contact with personal or sensitive information and protect it in line with Trust policy. NHS Constitution - SWASFT will adhere to the principles within the NHS Constitution including: the rights to which patients, public and staff are entitled; the pledges which the NHS is committed to uphold; and the duties which public, patients and staff owe to one another to ensure the NHS operates fairly and effectively. SWASFT employees are expected to uphold the duties set out in the Constitution. Risk Management - SWASFT will maintain good risk management arrangements by all managers and staff by encouraging the active identification of risks, and eliminating those risks or reducing them to the lowest level that is reasonably practicable through appropriate control mechanisms. This is to ensure harm, damage and potential losses are avoided or minimized, and the continuing provision of high quality services to patients, stakeholders, employees and the public. SWASFT employees are expected to support the identification of risk by reporting adverse incidents or near misses through the Trust web-based incident reporting system.


CONTENTS

1.PURPOSE ........................................................................................................................ 32.SCOPE ............................................................................................................................. 33.DEFINITIONS ................................................................................................................... 34.DUTIES, RESPONSIBILITIES AND REPORTING .......................................................... 35.LEGISLATIVE AND STATUTORY REQUIREMENTS ..................................................... 36.COMPOSITION ................................................................................................................ 47.APPROVAL OF CHANGES ............................................................................................. 48.TRAINING REQUIREMENTS .......................................................................................... 49.MONITORING .................................................................................................................. 410. REFERENCES ........................................................................................................... 511. ASSOCIATED DOCUMENTS ..................................................................................... 5VERSION CONTROL SHEET .............................................................................................. 6

Page 3 of 7


1. Purpose 1.1 The Council of Governors is required to prepare and from time to time review the

Trust’s policy for the composition of the Non-Executive Directors (NEDs) to ensure that at all times, its composition accords with the requirements of Schedule 7 of the National Health Service Act 2006 (as amended) and the Trust’s Constitution.

1.2 This policy provides guidance on the composition of the NEDs as well as the background and abilities required for the role. This policy should be considered by the Remuneration & Recommendations Panel of the Council of Governors when the appointment or re-appointment of NEDs is under consideration.

2. Scope 2.1 This policy applies to Non-Executive Directors of the South Western Ambulance

Service NHS Foundation Trust.

3. Definitions 3.1 NHS Act 2006 (as amended) is the key legislation governing the Council of

Governors which was updated following the enactment of the Health and Social Care Act 2012.

4. Duties, Responsibilities and Reporting

Council of Governors 4.1 The Council of Governors will be responsible for reviewing this policy periodically and

no less than every three years.

4.2 When undertaking its review, the Council of Governors shall have regard to appropriate legislation and guidance, including the NHS Foundation Trust Code of Governance published by Monitor, as well as emerging best practice.

4.3 The Council of Governors shall also take into consideration the outcome of any assessment of the Board’s effectiveness and appraisals of the Non-Executive Directors since this policy was last reviewed.

The Trust Secretary

4.4 The Trust Secretary will be responsible for maintaining and updating this policy to ensure that it remains compliant with legislative requirements, is reviewed in accordance with the Trust’s timetable for review and that incidents of non-compliance are reported to the Council of Governors.

5. Legislative and Statutory Requirements 5.1 Schedule 7 of the NHS Act 2006 (as amended) requires that the Trust has a Board of

Directors which comprises both Executive and Non-Executive Directors, with one Non-Executive Director being the Chairman.


5.2 The NHS Foundation Trust Code of Governance requires that at least half of the Board of Directors (excluding the Chairman) should comprise Non-Executive Directors.

5.3 Schedule 7 of the NHS Act 2006 (as amended) also states that a person may only be

appointed a Non-Executive Director if they are a member of the Trust’s public constituency.

6. Composition 6.1 The Trust’s Constitution sets out that the Board of Directors is to comprise:

• A Non-Executive Director Chairman; and • Up to a maximum of 7 other Non-Executive Directors; and • Up to a maximum of 7 Executive Directors.

6.2 The Board of Directors shall determine any change in the number of Directors

provided that: • Any change in the number is within the range set out at 6.1 above; and • There shall be a majority of Non-Executive Directors (including the Chairman).

7. Approval of Amendments 7.1 Any changes to the composition of the Non-Executive Directors shall require formal

amendment of the Trust’s Constitution in order to take effect.

7.2 Amendments to the Trust’s Constitution require the approval of both the Council of Governors and the Board of Directors.

7.3 Amendments to the Constitution must be notified to Monitor within the timescales

identified within the Trust’s NHS provider licence. 8. Training Requirements 8.1 None. 9. Monitoring 9.1 The Council of Governors will review this policy:

• Following any amendment to the legislative and regulatory requirements governing the composition of the Trust Board or of the Non-Executive Directors.

• Following any agreement to amend the composition of the Trust Board or the Non-Executive Directors to ensure that the interests of the community served by the Trust are appropriately represented.

• No less than every three years.


10. References 10.1 The following documents have been used to create this policy.

• NHS Act 2006, Schedule 7 (as amended) • Health & Social Care Act (2012) • Trust Constitution • NHS Foundation Trust Code of Governance

11. Associated Documents 11.1 The following documents should be read in conjunction with this policy:

• Trust Constitution • Code of Conduct for Directors • Board Remuneration Policy


Version Control Sheet

Version Date Author Summary of Changes

1 April 2016

Governance & Assurance Manager

New Policy