4. Board engagement and involvement
4.1 External Stakeholders
Section RAG rating:
Amber/Red
Evidence of compliance with good practice
(Please reference any supporting documentation below and attach with your submission)
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Action Plans to achieve good practice
(Please reference Actions Plans below and attach with your submission)
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Explanation if not complying with good practice
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Q1. The Board has an External Stakeholder Engagement Plan that clearly describes the Trust’s key existing and emerging external stakeholders, their relative priority and the tailored methods used to involve each stakeholder group (stakeholders include PCT Cluster, Clinical Commissioning Groups, Local Authorities and Wellbeing
Boards).
A1 The Board has an External CCG Engagement and a draft Communications strategy was presented to the June Board Development session. A communication strategy is being developed by the Head of Communications. Evidence: GP engagement, Communications/Involvement
Q2. A variety of methods are used by the Trust to enable the Board and senior management to listen to the views of patients, carers, commissioners and the wider public, including ‘hard to reach’ groups like non-English speakers and service users with a learning disability. The Board has ensured that various processes are in place to effectively and efficiently respond to these views and can provide evidence of these processes operating in practice.
A2 The Trust has a range of processes for patient, carer, commissioner and MP engagement including Board Visits, PALS feedback, attendance by Directors at minority group meetings
Evidence: PC/chair met with MPs, SU forums, Carer forums, JG/HM/Salaried GP arrangements. CCG engagement strategy, Involvement strategy, Equality and Diversity Strategy, Lead Director of Partnership, Ward visits, Patient stories. Evidence: Evidence of hard to reach groups – Southall black women, Tamil conference, review of complaints. Board visits. Whistle blowing reviews. FT consultation. New CEO induction visits, EDs attendance at staff forums.
Q3. The Board can evidence how key external stakeholder groups (e.g. patients, carers, commissioners and MPs) have been engaged in the development of their 5 year strategy for the Trust and provide examples of where their views have been included and not included in the IBP.
A3 Engagement in developing Local Services business plans and models/pathways last year. FT Consultation period 2011 and 2012.
Evidence: Consultation FT
Q4. The Board has ensured that various communication methods have been deployed to ensure that key external stakeholders understand the key messages within the IBP (e.g. campaigns in community vantage points, shopping centres, leisure centres; close links with academic institutions and schools; visits to ‘hard to reach ‘groups etc.).
A4 Evidence and action greater communication with public, hard to reach groups, academic institutions etc. Evidence: Consultation documents, summary IBP, MH Matters, Trust website.
Q5. The Trust has constructive and effective relationships with its key stakeholders, especially Lead Commissioners.
A5 The Trust has good relationships with High Secure and Forensic commissioners. Relationships with local services commissioners are changing and improving.
Evidence: Contracts signed, Stakeholder engagement meetings, CEO introductory visits
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Q1. A communication strategy is being developed by the Head of Communications and Involvement
Q2 Evidence hard to reach groups to be clarified and documentation/website needs to be available in other languages. Communications strategy to link with Equality and Diversity strategy
Q4.Development of an action plan following review of external communications
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Red Flags
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Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)
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Notes/ comments
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Q1. The development of the IBP and LTFM has only involved the Board and a limited number of Trust staff.
A1: IBP/LTFM reflects work in CSUs on models and future staffing.
Evidence: Specialist and Forensic, briefing sessions
Q2. The Trust has poor relationships with its commissioners.
A2 A5 The Trust has good relationships with High Secure and Forensic commissioners. Relationships with Local Services commissioners are changing and improving.
Evidence: Commissioner meetings, CEO induction visits.
Q3. The Trust’s latest patient survey results are poor.
A3 There had been poor feedback but the Trust has demonstrated in the annual inpatient and community surveys that improvements have been made. There are ongoing improvement actions to continue this process.
Evidence: Board Reports and action plans
Q4. The Trust has received adverse negative publicity in relation to the services it provides in the last 12 months.
A4 The Trust has not received any adverse publicity in the last 12 months.
Evidence: Media monitoring
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Q1: Additional briefing sessions planned. Standard presentations to be developed
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4. Board engagement and involvement
4
Section RAG rating:
Amber/ Red
.2 Internal Stakeholders
Evidence of compliance with good practice
(Please reference any supporting documentation below and attach with your submission)
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Action Plans to achieve good practice
(Please reference Actions Plans below and attach with your submission)
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Explanation if not complying with good practice
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Q1. A variety of methods are used by the Trust to enable the Board and senior management to listen to the views of staff, including ‘hard to reach’ groups like night staff and weekend workers. The Board has ensured that various processes are in place to effectively and efficiently respond to these views and can provide evidence of these processes operating in practice.
A1 A variety of mechanisms are used to listen to staff and service users views.
Q2. The Board can evidence how staff have been engaged in the development of their 5 year strategy for the Trust and provide examples of where their views have been included and not included in the IBP.
A2 There is evidence of staff views influencing FT strategy.
Evidence: See consultation feedback, CSU meetings with staff, staff forums
Q3. The Board ensures that staff understand the Trust’s key priorities and how they contribute as individual staff members to delivering these priorities.
A3 The Board ensures staff understand objectives via communications and PDR processes, link to PDRs, monthly team brief, intranet articles.
Evidence: Attendance at Board by Communications team, Team brief and Monday matters
Q4. The Trust uses various ways to celebrate services that have an excellent reputation and acknowledge staff who have made an outstanding contribution to patient care and the running of the Trust.
A4 The trust recognises quality services through Employee of the month, Quality Awards and notifying/acknowledgement of the Board on awards.
Evidence: Mental health matters, Employee of the month
Q5. The Board has communicated a clear set of values/ behaviours and how staff that do not behave consistent with these values will be managed. Examples can be provided of how management have responded to staff that have not behaved consistent with the Trust’s stated values/ behaviours.
A5 Board expected behaviours promoted via values statement, employee of the month, Exchange examples, Board etiquette etc. Examples of part 2 CEO reports on staff issues.
Evidence: Board minutes
Q6. There are processes in place to ensure that staff are informed about major risks that might impact on patients, staff and the Trust’s reputation and understand their personal responsibilities in relation to minimising and managing these key risks.
A6 The Trust’s communication processes do ensure staff know of key risks e.g. move out of John Conolly Wing.
Evidence: local news, Medical Director’s bulletin, Monday matters, The Exchange, Risk Management training, Risk registers to level 4, IPR and scorecards discussed and available.
Q7. The Board can demonstrate that clinicians play a key role in management and decision-making within the Trust.
A7. The Board can demonstrate the role clinicians play in management and decision making e.g. TMT, CELF, R&D strategy, safeguarding, CIPs etc.
Evidence: Board papers, TMT ToR and papers, CELF agendas
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Q1. Development of a staff engagement action plan
Q2 The Board can evidence how staff have been engaged in the development of their 5 year strategy for the Trust and provide examples of where their views have been included and not included in the IBP.
Q3) Staff survey action plan incorporating discussion on vision and values
Q5) See action on question 3 on vision and values work
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Red Flags
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Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)
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Notes/ comments
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Q1. The Trust’s latest staff survey results are poor.
A1 Trust staff survey results have improved but are still low. They are in line with other London Trusts.
Evidence: Board report and action plan
Q2. There are unresolved staff issues that are significant (e.g. the Board or individual Board members have received ‘votes of no confidence’ by the clinical community, the Trust does not have productive relationships with staff side/ trade unions etc.).
A2 There are significant change and restructuring requirements. The Trust has updated change policy. Relationships with Staff Side are positive.
Evidence: Joint staff minutes, Directorate business planning meetings.
Q3. There are significant unresolved quality issues.
A4 All quality risks are on the Risk Register. The Trust has embarked on a system wide transformation and modernisation process across all areas. There is a requirement to invest significantly in workforce and organisational development.
Evidence: Board and quality minutes show quality priorities in line with Quality Strategy, Risk register, Quality Governance self assessment and action plan is in place
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RF Q1 Staff survey results action plan/evidence of progress in some areas. Staff engagement action plan to be developed and implemented for latest results
RF Q2 Engagement to be reviewed as part of the staff engagement work in the staff survey action plan
RF Q3 Implementation of Quality Strategy and key priorities
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4. Board engagement and involvement
4.3 Board profile and visibility
Section RAG rating:
Green/Amber
Evidence of compliance with good practice
(Please reference any supporting documentation below and attach with your submission)
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Action Plans to achieve good practice
(Please reference Actions Plans below and attach with your submission)
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Explanation if not complying with good practice
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Q1. There is a structured programme of events/ meetings that enable NEDs to engage with staff (e.g. quality/ leadership walks; staff awards, drop-in sessions) that is well attended by Board members and has led to improvements being made.
A1 Board visits, Attendance by Board members at events/meetings is good e.g. Quality Awards, AGM, conferences. Chairman leads service user and carer forum. Service users attend committee meetings
Evidence: As above
Q2. There is a structured programme of meetings and events that increase the profile of key Board members, in particular, the Chair and CEO, amongst external stakeholders.
A2 There is a structured programme of events e.g. visits to services. CEO /Chair SU and Carers Involvement meetings and staff forums, Chairs meeting and external meetings for CEO. Formal feedback process in place.
Evidence: As above
Q3. Board members attend and/or present at high profile events.
A3 Board members do attend high profile events e.g. Nursing conferences, summer BBQs.
Evidence: Director of Nursing attends events regularly. Also, the Trust has two professorships.
Q4. NEDs routinely meet patients and carers.
A4 NEDs meet carers and service users pre and post Board meetings, at events and on visits. Service users and carers are invited to attend the Service User and Carer Forum led by the Chairman of the Trust. Service users and carer representatives sit on Board committees.
Evidence: Board visits
Q5. The Board ensures that its decision-making is transparent. There are processes in place that enable stakeholders to easily find out how and why key decisions have been made by the Board without reverting to freedom of information requests.
A5 Board decisions are transparent and easy to review as all minutes are on the website and intranet. Also articles produced on Board meetings in all Trust media.
Evidence: Website & Trust media
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Q2. The engagement and communication strategies will include actions to raise the profile and visibility of the Trust’s activities. This will include a review of the Board visit programme and further information and articles in mental health matters.
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Red Flags
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Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)
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Notes/ comments
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Q1. With the exception of Board meetings held in public, there are no formal processes in place to raise the profile and visibility of the Board.
A1 Trust has formal programme of visits and events in place. The Trust also attends and presents at a wide range of external events, networks and pan London groups.
Evidence: Visit programme, SMT and committee meetings
Q2. Attendance by Board members is poor at events/ meetings that enable the Board to engage with staff (e.g. quality/ leadership walks; staff awards, drop in sessions).
A2 Attendance and engagement levels are good.
Evidence: Service user and carer forum, Board visits, AGM
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4
Section RAG rating:
Amber/Red
. Board composition and commitment
4.4 Future engagement with FT Governors
Evidence of compliance with good practice
(Please reference any supporting documentation below and attach with your submission)
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Action Plans to achieve good practice
(Please reference Actions Plans below and attach with your submission)
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Explanation if not complying with good practice
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Q1. The Board has a plan in place to form a Council of Governors which is representative of the staff and community served by the Trust and partner organisations. The Board has considered the size of the Council of Governors to ensure it is not unwieldy and how the Council will be structured in order to discharge its statutory duties.
A1 Completed awaiting outcome of second consultation.
Roles and responsibilities of the Council of Governors agreed and out for second consultation
Evidence: Board paper February 2012
Q2. There is a statement in place that sets out the roles and responsibilities of the Council of Governors and how these are distinct from, but complementary to, the roles and responsibilities of the Board. The statement also considers the role of specific groups of governors (e.g. staff governors) and how they will be used to best effect.
A2 The Board has agreed a code of conduct for Governors and will work with members to develop a job description and etiquette in summer and autumn 2012
Evidence: Constitution
Q3. There are robust plans in place to elect, induct and develop governors once the Trust is authorised.
A3 The Board has agreed first past the post and had an initial discussion on commencing work with Governors but more work is planned in summer and autumn 2012
Evidence: Constitution
Q4. There are robust plans in place to show how the Board will communicate with and engage governors, in particular, in the areas of strategy development, service change and quality issues.
A4 The Board has had an initial discussion on commencing work with Governors but more work is planned in summer and autumn 2012
Evidence: Future board paper
Q5. The Board has a Membership Strategy that describes the number of members required, how that target will be reached, how the Trust will ensure that its membership is representative and how the membership will be maintained going forward.
A5 The Membership strategy is in place and regularly reviewed.
Evidence: Membership strategy
Q6. The Board has a strategy for engaging with its membership, including describing the kinds of issues it will consult with members on and how the views of hard-to-reach groups in the community will be represented.
A6 The Membership strategy is in place and regularly reviewed, including a communication and engagement plan.
Evidence:
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Q1 Additional actions may arise following the completion of the second consultation exercise
Q3 Plans to be developed and agreed in relation to governor development and engagement with the Board
Q4 The Board to agree communication and engagement plans and the definition of a significant transaction
Q6 Review Membership and Involvement Strategy
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Red Flags
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Action plans to remove the Red Flag(s) or mitigate the risk presented by the Red Flag(s)
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Notes/ comments
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Q1. The Board has not yet considered the roles and responsibilities of the Council of Governors.
A1 The Board has not yet considered the induction and development programme for Governors. First past the post election process agreed in constitution.
Evidence: Board forward plan
Q2. The Board has not yet considered how best to communicate with and engage the Council of Governors.
A2 Evidence: later in 2012 see A1
Q3. The Board has not yet considered how to elect, induct and develop governors.
A3 Evidence: See A1
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Q1-Q3 Board development session and supporting papers on approach to Governors. Planned sessions in summer 2012
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5. Board impact case studies
5.1 Case Study 1
Performance Issues in the area of quality
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Quality: Response to delays in implementing actions to Serious Incident Reporting
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Brief description of issue
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In 2010 a high number of actions resulting from Serious Untoward Incident actions were outstanding. Progress against these actions was reportable to NHS London and this position had contributed to a condition under the Trust’s CQC Registration Regulation 16.
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Outline Board’s understanding of the issue and how it arrived at this
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The Board raised this issue as part of the monthly review of progress and noted that a number of actions exceeded current timescales. The Board requested action to be taken to improve performance in this area and highlighted the patient safety issues resulting from these delays.
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Outline the challenge / scrutiny process involved
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The Board requested additional information and changes to reporting processes to enable evidence to be provided on the level of performance. The Board requested evidence of improvement via an action plan and chose to monitor performance on a monthly basis. The actions were led by the Executive Director of Nursing and Patient Experience and involved changes to Trust policies (I8), improved RCA training, changes to report formats and adjustments in the operation of key sub committees. A clear direction from the Board was given in relation to the required performance standards.
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Outline how the issue was resolved
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The Trust has changed existing governance structures. Reporting arrangements were also changed to enable the Board to review performance in this area. All Grade 1 and Grade 2 incidents are reported to the Board. There have been substantial improvements in performance and the Trust meets the required standards of performance for reporting within timescales. The Trust meets the requirements of CQC Regulation 16
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Summarise the key learning points
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The key learning points were the development of appropriate systems and processes to manage and assure the Board that the implementation of action plans are well managed
The Trust has in place a forward plan and mapped governance arrangements.
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Summarise the key improvements made to the Trust’s governance arrangements directly as a result of the above
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Senior Clinicians attend Serious Incident review discussions at the Board to listen and contribute to the Board discussions in relation to the findings and action plans.
The Trust has developed a Learning Lessons forward plan. This is linked to the Clinical Audit programme and the Board visit programme and presentations by clinical services to Executive Directors/NED ward visit programmes
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