Agenda and supporting papers - Plymouth Hospitals NHS Trust

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Item 17, Annex 1 recent meeting with Diversity Practice. • JM stated that an area that was highlighted as requiring action during the EDS assessment and the setting of equality objectives, was that of the positioning of equality strategically at Board and senior management level. • The Committee supported the recommendation in relation to the Board Inclusion Development Programme. • It was noted that the membership of the Equality and Diversity Steering Group would need to be reviewed with stronger clinical representation required. • In response to a question from ER about the reported lack of equality information on patient complaints, LB responded that the process for collection of ethnicity information was currently not robust enough. 34/2013 Health and Safety Committee • The Committee was unclear as to why the Health and Safety Committee minutes were presented at the HR&OD Committee meeting. HS explained that there had been some previous discussion over which Committee these minutes should report in to, and agreed to discuss with Executive Director colleagues and clarify. HS 16/8/2013 35/2013 Communication ER confirmed the key issues that would be included in feedback to the Trust Board included: • Recruitment • Training • The Francis Report • Equality and Diversity In terms of learning, it was agreed it had been a productive meeting, which had covered a number of important issues. ER asked that moving forward we are clearer on the purpose of reports submitted to the Committee. 36/2013 Any Other Business The meeting closed at 11:30hrs 39/2013 Date and Time of Next Meeting The next meeting will be held Friday 16 th August 1000-1200 in the Board Room DHLC. 5
Item 18 SUMMARY REPORT Trust Board 5 July 2013 Subject Prepared by Approved by Presented by Audit Committee Chair’s Report Board Secretary Margaret Schwarz, NED Chair Margaret Schwarz, NED Chair Purpose This paper provides a summary of assurances received and issues or concerns that the Audit Committee feels should be brought to the attention of the Trust Board, or to other Board Committees, resulting from the Audit Committee meeting on 31 May 2013. Corporate Objectives Decision Approval Information Assurance Quality Care Inspired People Healthy Organisation Innovate & Collaborate • Executive Summary The Committee received internal management, Internal Audit and External Audit reports. CQC Outcome Review In accordance with its forward work plan, at each meeting the Committee tests the adequacy of assurance and the process for testing compliance of a CQC outcome. The Committee assessed Outcome 21 Records, an issue of longstanding concern. The review had been scheduled as a result of known focus by the Care Quality Commission. The Director of Planning & Site Services reported on evidence of compliance, gaps in assurance or areas where evidence of compliance could be strengthened and the actions in place to address these issues. Three issues identified by a CQC inspection in 2012 remain a concern: • Security of case notes on wards. • Updating case notes in a timely manner. • Treatment Escalation Plans not being completed consistently in respect of DNAR. The Committee received limited assurance that the planned actions would achieve compliance and no assurance on the timescale for achieving compliance. Health records was again raised as a concern in verbal feedback from the CQC following a recent inspection and the Committee noted that their written report of their findings was imminent. The Safety & Quality Committee would continue to oversee this issue. Bevan Brittan Risk update This covered key points from the Francis Report, focusing on the requirement for NHS trusts to consider the Report’s recommendations and to decide how, and to what extent, to apply them to their respective organisations. Key advice for the Board was to avoid complacency through over-reliance on positive feedback from patient surveys. More generally, in terms of the Board’s responsibility to ensure the provision of safe patient care, the advice was for the Board to be mindful of the pressure in the wider health system and to ensure that its decisions were based on reliable data. Annual Reports The Committee reviewed three annual reports for the year 2012/13; Counter Fraud, Internal • 1
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Trust Board Friday 5 July 2013, 9.0
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Members of Plymouth Hospitals NHS T
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Item 3 observer. The Chairman requi
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Item 3 Board oversight of contribut
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Item 3 the Board next month. • Th
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Item 3 been involved and there was
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Item 3 continuing to build. Mr Babe
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Item 3 to Norovirus, Professor Lewi
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Item 3 • Careful communication of
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Item 3 • Approved the writing off
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Updated: prior to July Board Item 4
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Updated: prior to July Board Item 4
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Item 8 Quality Impact Assessment Pa
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Item 8 3.2 Quarterly Summary Hospit
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Item 8 4.4 Monthly Proportion of Pa
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Item 8 Inpatient falls are currentl
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Item 8 REI signage PALS were contac
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Item 8 Complaints received listed b
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Item 8 The graphs below illustrate
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Item 8 5.5 Friends and Family Test
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Item 8 1. Pressure Ulcers (EoC) 2.
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Item 8 Observations The essence of
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Item 8a SUMMARY REPORT Trust Board
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Annex 2 Item 8a Summary of Serious
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Item 9 Key Recommendations The Trus
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Item 9 Effective Care (Section B2 o
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Item 9 Description 31 days from 'de
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Item 9 4.6 Non Elective Activity is
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Item 9 Summary of performance excep
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Item 9 Ensure that all patients adm
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Item 9 Forecast Significant progres
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Item 9 Update on previous actions C
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Contents EXECUTIVE SUMMARY D FINANC
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B1 Safe care Description Hospital S
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Response Rate Recommender Score B3
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B5 Other safety & quality metrics D
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C2 Non-Elective Activity Descriptio
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C4 Referral To Treatment (RTT) Desc
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C6 Other access & activity metrics
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D2 Cost improvement programme (CIP)
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D4 Cash Management Description Revi
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E1 Staffing numbers Description Est
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E3 Sickness absence PERFORMANCE IND
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Risk Rating F2 Monitor's Financial
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Item 10 DETAILED REPORT Trust Board
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Item 10 4. Key Issues for the Board
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Item 11 SUMMARY REPORT Trust Board
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Page 97 and 98: Item 11 • Challenge in respect of
Page 99 and 100: Item 11 Over the past two years, me
Page 101 and 102: Item 11 Getting it Right Charter An
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Page 109 and 110: Item 12 Next Steps 1. Conversation
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Page 113 and 114: Item 12 EDS Grades and E & D Object
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Page 117 and 118: Item 12 3.6 The workforce is suppor
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Page 121 and 122: Item 13 Telephone conversations.
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Page 125 and 126: Item 14 SUMMARY REPORT Trust Board
Page 127 and 128: Item 15 incident investigations to
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Page 131 and 132: Item 15, Annex 1 • Top three issu
Page 133 and 134: Item 15, Annex 1 The Chair asked SS
Page 135 and 136: Item 16 COMMITTEE MINUTES Finance,
Page 137 and 138: Item 16 pay and staffing, highlight
Page 139 and 140: Item 16 • PACS contract - likely
Page 141 and 142: Item 17 Terms and Conditions of Emp
Page 143 and 144: Item 17, Annex 1 29/2013 Minutes an
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Page 149 and 150: Item 18 Next Steps The Audit Commit
Page 151 and 152: Item 18, Annex 1 Matters arising 4/
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Page 155 and 156: Item 18, Annex 1 Payroll & Expenses
Page 157 and 158: Item 18, Annex 1 The Committee note
Page 159 and 160: Item 18, Annex 1 Going Concern Revi
Page 161: Item 18, Annex 1 if Internal Audit
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Agenda and supporting papers - Plymouth Hospitals NHS Trust

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