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The meeting of the Board of Directors

To be held on Tuesday 22 March 2016 at 9 a.m.

in the Fred and Ann Green Board Room, Montagu Hospital

AGENDA

Enclosures

1. Apologies for Absence

(Verbal)

2. Register of Directors’ Interests and ‘Fit and Proper Person’ Declarations

Enclosure A

3. To approve: Minutes of the meeting held on 23 February 2016

Enclosure B

4. Actions from the Previous Minutes

Enclosure C

5. Matters Arising

(Verbal)

6. Chairman’s Correspondence Chris Scholey – Chair

(Verbal)

7. Chief Executive’s Report including Risk and Exception Report Mike Pinkerton – Chief Executive

Enclosure D

Performance

8. To note: Finance Report as at 29 February 2016 Jeremy Cook – Interim Director of Finance

Enclosure E

9. To note: Business Intelligence Report as at 29 February 2016 David Purdue – Chief Operating Officer Sewa Singh – Medical Director Richard Parker – Director of Nursing, Midwifery & Quality

Enclosure F

10. To note: Nursing Workforce Richard Parker – Director of Nursing, Midwifery & Quality

Enclosure G

11. To approve: Staff survey & action plan Ruth Cooper – Deputy Director of People & Organisational Development

Enclosure H

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Strategy

12. To approve: Strategy & Improvement Report Dawn Jarvis – Director of Strategy & Improvement

Enclosure I

Governance

13. To approve: Board Assurance Framework and Corporate Risk Register Maria Dixon – Head of Corporate Affairs

Enclosure J

14. To note: Trust Seal Maria Dixon – Head of Corporate Affairs

Enclosure K

Sub-committees of the Board

15. To note: Minutes of the Management Board meeting held on 29 February 2016 Mike Pinkerton – Chief Executive

Enclosure L

16. To note: Minutes of the Fred & Ann Green Legacy Sub-committee meeting held on 22 December 2016 Chris Scholey – Chairman

Enclosure M

17. Items escalated from sub-committees

Information items

18. To note: Board of Directors and Board Briefing Agenda Calendars Maria Dixon – Head of Corporate Affairs

Enclosure N

19. To note: Q3 Monitor Feedback Mike Pinkerton – Chief Executive

Enclosure O

20. Any other business

(Verbal)

21. Governor questions regarding the business of the meeting

(Verbal)

22. Date and time of next meeting

Date: 26 April 2016 Time: 09:00 Venue: Boardroom, DRI

(as at 16 March 2016)

Doncaster & Bassetlaw Hospitals NHS Foundation Trust

Register of Directors’ Interests and ‘Fit and ‘Proper Person’ Declarations

Register of Interests Alan Armstrong Head of Governors, Dawn House School Trustee, ICan Charity (organisation that runs Dawn House) Director, Armstrong Logic Limited (consultancy) Geraldine Broderick Property development and holiday lets on North Norfolk coast Director, LB associates ltd (company turnaround and continuous improvement specialists) Jeremy Cook, Interim Director of Finance Managing Director and 50% shareholder, J&CA Limited David Crowe, Non-Executive Director Lay Member, Employment Tribunal Panel, Leeds Member, Central Arbitration Committee Dawn Jarvis, Director of Strategy & Improvement Assessor, Civil Service Fast Stream Martin McAreavey, Non-executive Director Associate Professor, University of Leeds External Examiner, University of York Honorary Consultant, Public Health England John Parker, Non-Executive Director Senior Lecturer, Sheffield Hallam University Mike Pinkerton, Chief Executive Trustee, Well Community Projects, Retford Board representative for CEO South, Yorkshire & Humber Academic Health Science Network Philippe Serna, Non-Executive Director Spouse of director, Premier Care Direct Ltd (renal patient transport provider in Doncaster & Bassetlaw) Chris Scholey, Chairman Director, Sheffield City Region Local Enterprise Partnership Member, Rotherham Economy Board Sewa Singh, Medical Director

(as at 16 March 2016)

Director, Veincure Ltd (the company has currently no conflict of interest with the Trust) The following have no relevant interests to declare: Richard Parker Director of Nursing, Midwifery & Quality David Purdue Chief Operating Officer

(as at 16 March 2016)

Fit and Proper Person Declarations The Trust can confirm that every director currently in post has declared that they: (i) are not an undischarged bankrupt or a person whose estate has had sequestration

awarded in respect of it and who has not been discharged;

(ii) are not the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland;

(iii) are not a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986;

(iv) have not made a composition or arrangement with, or granted a trust deed for, their creditors and not been discharged in respect of it;

(v) have not within the preceding five years been convicted in the British Islands of any offence and a sentence of imprisonment (whether suspended or not) for a period of not less than three months (without the option of a fine) was imposed on them;

(vi) are not subject to an unexpired disqualification order made under the Company Directors’ Disqualification Act 1986;

(vii) have the qualifications, competence, skills and experience which are necessary for the relevant office or position or the work for which they are employed;

(viii) are able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the office or position for which they are appointed or to the work for which they are employed;

(ix) have not been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity;

(x) are not included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland;

(xi) are not prohibited from holding the relevant office or position, or in the case of an individual from carrying on the regulated activity, by or under any enactment;

(xii) have not been convicted in the United Kingdom of any offence or been convicted elsewhere of any offence which, if committed in any part of the United Kingdom, would constitute an offence;

(xiii) have not been erased, removed or struck-off a register of professionals maintained by a regulator of health care or social work professionals; and

(xiv) have not been dismissed from paid employment otherwise than by reason of redundancy, by the coming to an end of fixed term contract or through ill health.

Directors are requested to note the above and to declare any changes to their position as appropriate in order to keep their declaration up to date.

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Minutes of the meeting of the Board of Directors

held on Tuesday 22 February 2016

in the Boardroom, DRI

Present: Chris Scholey Chairman Alan Armstrong Non-executive Director Geraldine Broderick Non-executive Director Jeremy Cook Interim Director of Finance David Crowe Non-executive Director Dawn Jarvis Director of People & Organisational Development Martin McAreavey Non-executive Director John Parker Non-executive Director Richard Parker Director of Nursing, Midwifery & Quality Mike Pinkerton Chief Executive David Purdue Chief Operating Officer Philippe Serna Non-executive Director Sewa Singh Medical Director In attendance: Emma Bodley Head of Communications & Engagement Kate Sullivan Corporate Secretariat Manager Public: Lauren Mugridge Member of the public George Webb Public Governor ACTION

Apologies for absence

16/2/1 Apologies were received from Maria Dixon.

Register of directors’ interests and ‘Fit and Proper Person’ declarations

16/2/2 No amendments were noted.

Minutes of the meeting held on 26 January 2016

16/2/3 The minutes of the meeting held on 26 January 2016 were APPROVED as a correct record of the meeting, subject to the correction of one typographical corrections and the following amendments:

16/2/4 16/1/13 – “due to lack of candidates” to be removed

16/2/5 16/1/37 – “taken and” to be amended to “taken for setting 16/17 budgets and”

16/2/6 16/1/44 – “however, this had” to be amended to “however, when” and the third sentence to be removed.

16/2/7 16/1/54 – “that grip” to be amended to “that additional grip”

16/2/8 16/1/58 – “now included” to be amended to “again included”

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16/2/9 16/1/66 – Last sentence to be replaced with “it was agreed for the CGOC

to consider reporting and triangulation of SI and inquest information.”

Actions from the previous minutes

16/2/10 The action notes from the meeting held on 26 January 2016 were reviewed and updated.

Matters arising

16/2/11 None

Chairman’s correspondence

Chris Scholey reported the following:

16/2/12 National position – The national NHS providers financial position was worsening, standing at a deficit of circa £2.26bn at Q3. Over 1/3 of providers had rejected control totals linked to Sustainability and Transformation (S&T) funding. Philippe Serna queried whether this would result in a review and whether it would impact on the Trust’s control total, which had been accepted by the Trust. This was discussed and it was not known whether a revision was likely.

16/2/13 NHS Improvement Provider Conference – Chris Scholey had recently attended the NHS Improvement Provider Conference hosted by Monitor and the Trust Development Authority (TDA). Keynote speakers had included Jeremy Hunt MP, Secretary of State for Health, Simon Stevens, Chief Executive of NHS England, and Professor Lord Ara Darzi. Over 500 Chairs and Chief Executives had attended the conference. Chris Scholey gave an overview of key messages.

16/2/14 Governors – John Humphrey, Public Governor, had sadly passed away following a period of ill health. John Humphrey had been an active Governor and Chris Scholey had expressed his condolences to John’s family on behalf of the Trust and the board.

16/2/15 Governor meeting with KPMG – The meeting with KPMG to discuss the investigation report had been well attended and there had been positive feedback from Governors.

16/2/16 Timeout – There was a good agenda for the next timeout session, due to be held on 7 March 2016.

16/2/17 Quarterly Meeting with Sheffield Teaching Hospitals – Chris Scholey provided an overview of key issues discussed at the recent meeting.

16/2/18 In response to a query from David Crowe with regard to communications with MPs, Mike Pinkerton advised that he and Chris Scholey had recently met with Rosie Winterton, Caroline Flint and Ed Miliband. Mike Pinkerton had also spoken with John Mann and a meeting was being arranged.

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The Chairman’s correspondence was NOTED.

Chief Executive’s Report

Mike Pinkerton presented the report, highlighting the following:

16/2/19 Performance overview – The Trust continued to deliver well above England national averages in most areas.

16/2/20 Regulator matters - An update on the extent to which Monitor would provide support to the Trust’s turnaround plans would be discussed later in the meeting.

16/2/21 KPMG – The Board had received the final KPMG Financial Misreporting Investigation Report and an update would be provided in part 2 of the meeting. KPMG had provided an update to Governors and the Financial Oversight Committee.

16/2/22 Staff engagement - Mike Pinkerton had started to meet regularly with small groups of consultants to personally brief them on the financial position. It was hoped that some good ideas could be developed from the meetings. This approach was endorsed by David Crowe, although he raised concern that it would take time to see all consultants and this was discussed.

16/2/23 Consultant engagement was critical to future progress, particularly in areas involving the consultant body. Engagement was highly variable and the new meetings had been introduced to help address this. Mike Pinkerton also attended the Trust Medical Committee (TMC) meetings and TMC attendance had increased significantly in recent months.

16/2/24 There was further discussion about consultant engagement and Sewa Singh provided an overview of issues raised at recent TMC meetings. Consultants had requested details of the KPMG investigation and this was discussed. The Trust had taken the decision to share the KPMG investigation report publicly, providing the maximum disclosure possible whilst protecting the identity of individuals and this was endorsed. KPMG were to provide a redacted version of the report for this purpose.

16/2/25 Mutually Agreed Resignation Scheme (MARS) – The Scheme had closed. Circa 30 applications had been accepted and letters had gone out to applicants. In response to a query from Philippe Serna, Dawn Jarvis undertook to provide an update on the financial impact of the MARS scheme outside of the meeting.

DJ

16/2/26 Carter Report - A detailed overview of recommendations and key dates was included in the report. Any recommendations that were not already in the existing programme of workstreams would need to be incorporated, and work to do this was underway. This was endorsed by Geraldine Broderick. In response to a query Dawn Jarvis advised that this work

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would be complete by 1 April 2016.

16/2/27 Annual Operational Plan 2016/17 – The plan had been submitted on 8 February 2016. Geraldine Broderick queried whether this had been developed using a bottom-up process and this was discussed. Jeremy Cook advised that a key issue was to ensure that budgets were realistic and not based on prior year roll over; new processes were in place to ensure this.

16/2/28 Fire improvement notice – Progress was outlined in the report. The fire and rescue service were considering whether the process could be managed by ongoing 3 monthly extensions with regular meetings until the work was complete, confirmation of this was awaited.

16/2/29 Library services – A self-assessment against the NHS Library Quality Assurance Framework had shown the Trust to be 98% compliant, placing the Trust in the top 10% nationally.

16/2/30 UK first for keyhole surgery – The Board commended the DBH team that had performed the UK’s first hernia repair surgery using a pioneering new technique that left no scares for patients.

16/2/31 Executive director appointment – Karen Barnard had been appointed as Director of People & Organisational Development and was due to commence in post on 2 May 2016. On behalf of the board, Mike Pinkerton thanked Dawn Jarvis, Director of Strategy and Improvement, for her work in this role prior to taking up her new position.

16/2/32 Martin McAreavey endorsed the celebration of staff successes in the report. He stated that it was important that this continued and queried how future successes would be picked up. This was discussed and it was agreed that the executive team would continue to focus on highlighting innovation and success across the Trust.

The Chief Executive’s Report was NOTED

Finance Report as at 31 January 2016

16/2/33 Jeremy Cook presented the report and apologised for its lateness. A major contributing factor had been that two members the senior finance team had been off work. This highlighted the lack of resilience within the team and he noted that other staff had worked over the weekend to prepare the Monitor Q3 return. Five new members of the finance team had been recruited to provide greater resilience and to strengthen the team’s skillset. This was in line with KPMG recommendations.

16/2/34 Performance overview - At the time of reporting the trial balance had not been reconciled to the board report and this had meant there had been a risk that the reported position was not as stated. This reconciliation had now been undertaken and the year to date position was as reported.

JC

16/2/35 However, there was an error in the reported planned deficit of £2.2m,

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which was overstated by £1.2m and should have been a planned deficit of £1m. The variance against plan should therefore have been £28.6m and not £27.4m. A revised report would be issued. Philippe Serna endorsed work to ensure the balance sheet reconciled to the Board report.

JC

16/2/36 Run rate - There had been a reduction in the run rate for the second consecutive month and this was welcomed.

16/2/37 Forecast – Work had been undertaken to complete a bottom-up forecast of income and expenditure. This showed a forecast deficit of £38.4m, which was consistent with the top down forecast.

16/2/38 There were ongoing risks connected with the iHospital Programme relating to both revenue and capital and there was more work to do to understand this. This would be undertaken by one of the new interim members of staff.

16/2/39 Alan Armstrong requested that, once this work had been undertaken, assurance be provided to the Board with regard to the benefits delivered by iHospital programme. This was discussed. Dawn Jarvis advised that work was underway to separate the iHospital programme so that each element sat within the relevant work stream, and work was underway to review each business case.

16/2/40 There was further discussion about the delivery of individual iHospital projects including the Electronic Patient Record. Sewa Singh provided an update on progress, commenting that clinical engagement was key and meetings had been arranged to take this forward. It was noted that, as with previous IT projects, all elements of the IHospital Programme would be subject to a post implementation review.

16/2/41 Income – Below plan at £3.9m (M9 £3.4m). The underperformance of other non-NHS income had increased from £2.5m to £2.8m.

16/2/42 Expenditure - £24.9m above plan, with the pay variance continuing to be the key area of concern at £6.7m. As in previous months, pay overspends were primarily driven by medical expenditure pressures. However, medical agency costs had fallen again and were still well below the average for months 6 to 8. This was commended by Chris Scholey.

16/2/43 In response to a query from Alan Armstrong about non-medical staffing overspends, Dawn Jarvis advised that these had primarily been due to medical records and were connected with high levels of staff sickness and support required for the CaMIS implementation, which had resulted in high use of agency staff in this and other areas. There had been a significant improvement in this department recently and work to improve the position was ongoing.

16/2/44 x CIP - It was noted that there were minor errors in table 1 of the report, which would be corrected in a revised report. Work was progressing in

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relation to the 2016/17 CIP plan with project groups being set up for the overarching schemes.

JC

16/2/45 Alan Armstrong asked why there had only been a retraction of the CIP budgets to M12 of £4.9m. Jeremy Cook advised that, as previously reported, a significant element of the CIP plan had not had any substance and there would be no point allocating additional CIP targets to care groups and divisions following the misreporting of CIPs in months 1 to 6. As a result, only £4.9m of budget had been retracted from care groups.

16/2/46 Cash - £4.1m below plan at £2.7m. The balance was not £1.9m as required by Monitor, as a £0.8m direct debit had not been drawn down as a result of national changes to banking arrangements in month. The Trust’s working capital facility had been increased from £32.9m to £33.5m during February, of which £22.4m had been drawn down in January and a further £10.6m drawn down in February.

16/2/47 The expectation was that the total working capital facility drawn down at year end would be converted into a loan, which would carry a lower rate of interest. John Parker asked whether this would be repayable and this was discussed. This would be reviewed in due course once the extent of the loan and repayment terms were known.

16/2/48 Creditors – Aged creditors had reduced and this was welcomed.

16/2/49 Capital expenditure - £4.9m behind plan at £11.5m.

16/2/50 Outsourcing – In response to a query from Alan Armstrong about reported cost pressures generated by outsourcing, Jeremy Cook advised that a review of the SLA with Park Hill Hospital would be undertaken as part of a workstream. John Parker noted that the ANCR had received previous assurance about this and this was discussed. It was agreed that previous assurance should be disregarded.

16/2/51 Care Group performance - The use of mobile scanners was discussed. A business case had recently been approved by the executive team and had been taken forward. The use of mobile CT had reduced and would cease in March 2016. The Trust had been encouraged by work undertaken with the diagnostics team by the Birch Group and would consider how this type of work could be rolled out in other departments.

16/2/52 Martin McAreavey queried whether there was a risk to quality of patient care due to vacancies in therapies. Richard Parker advised that a review of therapies was being undertaken as part of the Length of Stay workstream to understand workforce needs going forward. National benchmarking showed that the Trust had a richer skill mix than the national average and he gave assurance that there was nothing to indicate that the service was anything other than good.

16/2/53 Teaching Hospital Status - In response to a query from Martin McAreavey,

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Mike Pinkerton advised that this would be picked up by Karen Barnard, the new Director of P&OD, when she commenced in post in May.

16/2/54 The Surgical Care Group deficit had doubled and concern was raised about this. David Purdue advised that this was a phasing issue that related to income variances; it was noted that expenditure had reduced.

16/2/55 Philippe Serna asked for assurance with regard to how the budget was phased. Jeremy Cook advised that all phasing should be based on the number of days in the month but that there had been an error in the phasing which had subsequently been corrected. The issue was that this had been corrected as a bottom line adjustment and not against the points of delivery, which made it difficult to identify the true performance by point of delivery. It was agreed that this would be corrected for the 2016/17 plan and correctly reported in 2016/17.

JC

The Finance Report was REVIEWED and NOTED.

Business Intelligence Report as at 31 January 2016

16/2/56 David Purdue, Richard Parker and Sewa Singh presented the report and drew attention to the following:

16/2/57 4hr Access – 92.06% as a Trust for January. Although the target had been failed, the Trust remained the best performing Trust locally, and was above the national position.

16/2/58 Attendances in month had been the highest since 2011 at 13,735. Attendances at Doncaster had been 636 higher than in December 2015. David Purdue gave an overview of action being taken to address the issues. One key issue had been the agency cap, which had affected the ability to cover shifts.

16/2/59 The Trust had met with Doncaster CCG to discuss increased ED attendance. An investigation was to be undertaken to understand the issues outside of the hospital.

16/2/60 RTT – Achieved as a Trust at 92.3%.

16/2/61 Cancer – All targets were achieved for Q3, including the 62 day target.

16/2/62 Stroke – Performance had not improved and David Purdue explained the reasons for failure to meet the admission target and the work being undertake to address this. Stroke nurses attended to patients in the ED and, although patients were not always admitted to the stroke unit within the targeted timeframe, care commenced early within the ED. Outcomes for stroke patients at the Trust were the best in the region.

16/2/63 Diagnostic Waits – Achieved at 99.48%. This was commended by Alan Armstrong.

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16/2/64 DNAs – In response to a query from Alan Armstrong about work to address DNA rates, David Purdue advised that DNA rates were better than they had been for some time. Patients were being sent appointment reminders, including text reminders that highlighted the cost to the Trust of missed appointments.

16/2/65 Cancelled operations – In response to a query from Martin McAreavey about the number of cancellations and reasons for cancelled operations, David Purdue and Sewa Singh provided a detailed overview of the process for admission and reasons for cancellation.

16/2/66 54 operations had been cancelled in January. The figure reported related to cancellations on the day of the operation; where in many cases elective procedures were cancelled to allow for people with urgent life threatening conditions. The availability of ITU and CCU beds was also a factor and this would be considered in the bed plan. Theatre utilisation was being picked up as part of a work stream.

16/2/67 In the context of turnaround, Martin McAreavey asked whether risk had increased in relation to re-admissions. It was reported that this was reviewed by speciality; the Trust was not an outlier and was below the CCG trajectory.

16/2/68 HSMR – There had been continued improvement. The rolling 12 month HSMR to November 2015 stood at 98 and HSMR for the month of November had been 70. Martin McAreavey thanked Sewa Singh and all staff who had worked to improve HSMR performance.

16/2/69 Never event – Sewa Singh provided details of a never event. A retained swab had now been removed and there had been no harm to the patient. An investigation was underway and the case had been discussed with the CQC.

16/2/70 SIs – The Trust was on trajectory to significantly improve on the previous year’s SI rate.

16/2/71 Quality – C.diff performance continued under trajectory at 27% better than the same time the previous year. HAPU performance was 50% better than the same time the previous year.

16/2/72 Friends & Family – A key issue continued to be ED response rates. Richard Parker had met with the Care Group to discuss how this could be improved.

16/2/73 Complaints – A key issue was response times due to the Care Groups undertaking work in other areas. Rick Dickinson, Deputy Director of Quality & Governance, was developing an action plan. Alan Armstrong raised concern around the increase in overall complaints and this was discussed. The rise in complaints was proportional to activity levels. Richard Parker advised that part of the Trust’s strategy was to learn as

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much as possible from complaints and to resolve them early. Although the overall level of complaints had increased, the number of formal complaints had reduced.

The Business Intelligence Report was REVIEWED and NOTED.

Nursing Workforce Update

16/2/74 Richard Parker reported that overall planned versus actual hours worked in December had been 99% in January (97% in December). This included staff for additional escalation beds opened on a number of wards for most of January.

16/2/75 John Parker asked whether it had been appropriate to take beds out of the bed plan as part the savings plan, given the number of escalation beds opened and this was discussed. It was key to ensure that quality of care was maintained and that patients were on the right wards and this required flexibility in the bed plan. It was also key to ensure that opening of escalation beds was supported by an active plan and business case.

16/2/76 Nurse Manager Clinical Time – HoN and Matron clinical time had not been achieved in January for the Children and Families Care Group due to sickness absence.

The Nursing Workforce Update was DISCUSSED and NOTED.

Development of Turnaround Plans / CIP

16/2/77 Dawn Jarvis presented the report, which set out the progress towards readiness for turnaround, progress to deliver Grip & Control and turnaround and progress to deliver the high level CIP plan for 2016/17 and beyond. She reported that since the publication of the papers the number of CIP workstreams rated ‘red’ had reduced from 8 to 3.

16/2/78 David Crowe welcomed the report but raised concern about whether inputs from the Carter Report and other external recommendations had been incorporated into plans. This was discussed and Dawn Jarvis advised that this would be reported through the Financial Oversight Committee. The Financial Oversight Committee agenda would also cover reviews of failing workstreams, and this was welcomed.

16/2/79 Alan Armstrong asked whether there were lessons to be learnt from other trusts and this was discussed. Dawn Jarvis provided an update on issues discussed at Grip & Control meetings and it was noted that there would be a DBH Buzz special update on turnaround.

DJ

The Development of Turnaround Plans / CIP Report was DISCUSSED and APPROVED.

Board of Directors sub-committee structure

16/2/80 Dawn Jarvis presented the paper outlining the proposed committee and

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reporting structure for the operational management of the Trust and delivery of the Turnaround programme. The Board was asked to consider and approve draft revised terms of reference for the Management Board and Financial Oversight Committee.

16/2/81 Care Group performance and quality accountability meetings / financial accountability meetings - Martin McAreavey queried what triggers, in terms of quality, were required in order for Care Groups to move forward through each gateway. This decision was taken by Sewa Singh and Richard Parker; Dawn Jarvis undertook to provide further information on the process outside of the meeting.

DJ

16/2/82 Financial Oversight Committee ToR – It was proposed that the Financial Oversight committee become a permanent sub-committee of the board, reporting directly to the board rather than through the Audit and Non-clinical Risk Committee. The duties and work programme were discussed. It was noted that it had been agreed that the KPMG action plan would be taken to the committee and it was agreed that the committee should also review and monitor the management response to recommendations of other externally commissioned reports relating to the its area of work.

MD

16/2/83 It was noted that the Chief Operating Officer should be removed from the list of attendees.

MD

16/2/84 Management Board ToR – It was agreed that the purpose should include a reference to delivery of quality of care.

MD

The Board of Directors sub-committee structure was DISCUSSED and APPROVED subject to the agreed amendments to the ToRs.

Doncaster & Bassetlaw NHS Foundation Trust Charitable Funds Annual Report and Financial Statements 2014/15

16/2/85 Jeremy Cook presented the report and noted that a formula error on the first table on page 21 would be corrected. He also drew attention to the following:

JC

16/2/86 The Charitable Fund Financial Statements 2014/15 had been audited by PwC. The ISA 260 report had been received after the publication of the papers and would be circulated outside of the meeting. PwC had made minor changes and the report was to be amended accordingly. The paper included a copy of the letter of representation

JC

16/2/87 In response to a query from Martin McAreavey with regard to how charitable funds would be managed in the future, Jeremy Cook advised that a paper to include initiatives to spend charitable funds and how the fund should be managed would be brought to a future meeting. Board comments and concerns would be fed back outside of the meeting.

JC

ALL

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16/2/88 The Doncaster & Bassetlaw NHS Foundation Trust Charitable Fund Annual Report, Financial Statements 2014/15 and letter of representation were APPROVED subject to the reflection of minor changes as set out by PwC in the ISA 260 report.

Minutes of the Clinical Governance Oversight Committee meeting held on 18 January 2016

16/2/89 16/44 – Medical records – Martin McAreavey noted that concerns relating to issues with the availability of medical records following the implementation of CaMIS had been escalated to the CGOC from the Clinical Governance and Quality Committee. He asked for an update on actions taken to address the issues and this was discussed. David Purdue provided a detailed update: all action plans had been updated, there had been a change of leadership in bookings and records, and the percentage of notes delivered to clinics continued to be monitored. It was noted that all clinic notes had been delivered the previous week.

16/2/90 In response to further query, David Purdue advised that a work stream was in place to consider how booking rules could take into account DNA rates.

16/2/91 16/15 to 16/19 – Medicines management - John Parker and Geraldine Broderick raised concern that issues relating to medicines reconciliation and junior doctors were not always fed back to doctors and this was discussed. It was clarified that wherever it was possible to do so issues were fed back at the time, however there were occasions where this was not always possible, for example during a night shift. Sewa Singh undertook to seek assurance from Andrew Barker, Care Group Director, that systems were robust and it was agreed that assurance be provided to the Clinical Governance Oversight Committee.

SS

16/2/92 The minutes of the Clinical Governance Oversight Committee meeting held on 18 January 2016 were NOTED.

Minutes of the Management Board meeting held on 1 February 2016

16/2/93 MB/16/02/21 – The future of Board Briefing sessions had been discussed. It had been queried whether they were a productive use of time and it had been suggested that non-executive directors could attend accountability and management team meetings instead. This was discussed and it was agreed that non-executive directors would consider this further outside of the meeting.

NEDS

16/2/94 MB/16/2/67 – Agency Caps – In response to a query from Philippe Serna, David Purdue advised that all Care Groups had identified staff paid above the agency caps.

16/2/95 The minutes of the Management Board meeting held on 1 February 2016 were NOTED.

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Items for escalation from sub-committees

16/2/96 CGOC 16/15 - 16/19 - Medicines management, as reported above.

Q3 Monitor Declaration

16/2/97 It was noted that the report related to in year financial reporting to December 2015 only. Due to the size and level of detail in the report it agreed not to include hard copies of the declaration in future papers. Comments would be fed back outside of the meeting.

ALL

16/2/98 The Q3 Monitor Declaration was NOTED.

Annual Operational Plan 2016/17 (submitted to Monitor)

The Annual Operational Plan 2016/17 (submitted to Monitor) was NOTED.

Board of Directors and Board Briefing Agenda Calendars

16/2/99 The agenda calendars were NOTED.

Any other business

16/2/100 None.

Governor questions

16/2/101 George Webb endorsed the celebration of successes across the Trust in the Chief Executive’s report.

16/2/102 George Webb commented that one of the Public Governors who had recently suffered from a stroke had highly commended the care they had received at the Trust.

Date and time of next meeting

16/2/103 It was confirmed that the next meeting of the Board of Directors would be held at 9am on Tuesday 22 March 2016 in the Fred and Ann Green Board Room at Montagu Hospital.

………………………………………………… ………………………………………………

Chris Scholey Date Chairman

Action Notes

Meeting: Board of Directors

Date of meeting: 23 Fenruary 2016

Location: Boardroom, DRI

Attendees: CS, AA, GB, JC, DC, DJ, MM, JP, RP, MP, DP, PS, SS

Apologies: None

No. Minute No Action Responsibility Target Date

1. 15/03/75 Staff survey - provide an update, including breakdown by CG / directorate and progress made.

RP BB April 2016

2. 16/01/38 Consider how Care Groups should present budgets to Board following planning process

CGs Early 16/17 (through Board

Brief?)

3. 16/01/62 Circulate information regarding the cost of RTT penalties

DP asap

4. 16/01/66 CGOC to consider reporting & triangulation of SI / inquest information.

MM/SS CGOC April 2016

5. 16/01/96 iHospital/IT infrastructure – confirm the level of investment & work required once review of the programme is complete.

SS tbc

6. 16/02/25 MARS - Provide an update on the financial impact outside of the meeting.

DJ tbc

7. 16/02/35-44 16/02/55

Finance Report

Correct errors and provide revised report

Ensure correct reporting budget phasing from 2016/17

JC

JC

March 2016

April 2016

No. Minute No Action Responsibility Target Date

8. 16/02/81 Provide information on turnaround gateway progression process outside of the meeting.

DJ March 2016

9. 16/02/82-84 Update FinOC & MB ToR as discussed.

MD

March 2016

10. 16/02/85-86 Correct errors on page 21 of Charitable Fund annual report & circulate ISA 260 report

JC

March 2016

11. 16/02/91 Medicines Management & Junior Doctors - Ensure assurance provided by Care Group to CGOC and CG&QC that systems were robust.

SS March 2016

Date of next meeting: 23 February 2016 Action notes prepared by: K Sullivan Dated: 23 February 2016 Circulation: CS, AA, GB, JC, DC, MD, DJ, MM, JP, RP, MP, DP, PS, SS

Title Chief Executive's Report

Report to: Board of Directors Date: 22 March 2016

Author: Mike Pinkerton, Chief Executive

For: Information / Triangulation

Purpose of Paper: Executive Summary containing key messages and issues

Standing item setting out information the Chief Executive wishes the Board to be aware of, including key risks and exceptions. The report briefs on the following areas:

• National 4hr Wait • Turnaround • Monitor • KPMG Report • NHS Improvement • Picker Inpatient Survey 2015

• Baroness Cumberlege Review • Maternity Capital • Student Nurse Feedback • Tour de Yorkshire 2016 • Merging Oncology Letters with Medisec • Working Together • Staff & Appointments

Recommendation(s) The Board is asked to RECEIVE and NOTE the report Delivering the Values – We Care (how the values are exemplified by the work in this paper) We always put the patient first

• By keeping a focus on quality whilst we tackle financial problems Everyone counts - we treat each other with courtesy, honesty, respect and dignity

• By openly and honestly discussing with staff our quality, outcomes and financial position Committed to quality and continuously improving patient experience

• By improving key measure of patient safety Always caring and compassionate

• By focusing on improving the experience of our patients Responsible and accountable for our actions – taking pride in our work

• By working openly with regulators and partners to improve financial governance Encouraging and valuing our diverse staff and rewarding ability and innovation

• By recognising staff efforts through local and national awards

Related Strategic Objectives

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• Provide the safest, most effective care possible • Control and reduce the cost of healthcare • Focus on innovation for improvement • Develop responsibly, delivering the right services with the right staff

Analysis of risks a. Resource b. Governance c. PR & Communications d. Patient, Public & Member Involvement e. NHS Constitution

Board Assurance Framework This report relates to the Strategic Direction as a whole, therefore all risks in the Board Assurance Framework are relevant in addition to the specific ones listed below. 1 Failure to achieve compliance with Monitor Risk Assessment Framework, CQC

and other regulatory standards, triggering regulatory action. 5 x 4 = 20

3 Failure to provide harm free care 3 x 4 = 12 4 Failure to sustain a viable specialist and non-specialist range of services 3 x 4 = 12

5 Failure to deliver financial plan 5 x 5 = 25 6 Failure to ensure that appropriate infrastructure is in place 3 x 4 = 12 10 Inability to recruit right staff and ensure staff have the right skills to meet

operational needs 4 x 3 = 12

13 Breakdown of relationship with key partners 2 x 4 = 8 15 Failure to engage and communicate with staff and representatives 2 x 3 = 6 19 Failure to deliver turnaround / cost reduction programme. 4 x 5 = 20

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Performance Overview

The Business Intelligence and Finance report were not available at the time of writing.

A major performance headline in Q4 is always four hour wait and the NHS in England in now receiving weekly enhanced monitoring of the four hour position by trust from NHS Improvement. The top 30 Trusts in the country who achieved the target in the year to date

including December are not subject to weekly monitoring and DBH is within the top 30 trusts, being 17th best out of 138 Trusts in England at that point. Increasing conversion rate to inpatient admissions is however one of a number of factors that have impacted on our ability to maintain the standard through Q4 which will be explained further in the BIR

report.

Turnaround

A detailed Buzz Special has been issued around the Organisation, setting out the key features and ambitions of the Turnaround approach, including some examples of early progress such as below, this is a small part of a

wider programme of engagement with staff both directly and indirectly, now it has a defined content. The Special also announced to the Organisation the net impact of the MARs scheme, which will see an overall pay cost reduction of £730K recurrent after allowing for a small investment in compensating staff, giving a return on investment of < 1 year, and ended with a thank you for staff suggestions that is helping to

inform and develop the work streams.

Monitor On Tuesday 1 March Monitor announced the outcome of its investigation into the potential breach of license relating to finance and governance matters, reaching the conclusion that there had been a breach of license and therefore enforcement action to remedy the breach was in order. The full documentation is attached for information and Board record, but has been previously circulated. Monitor has decided to accept undertakings from the Trust under Section 106 of the Health and Social Care Act 2012 in the following areas:

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• Sustainability • Financial Governance • Distressed Financing and Sustainability and Transformation Fund • General

In parallel, Monitor has added an additional license requirement under section 111 of the Act requiring the Trust as Licensee to ensure it has sufficient and effective Board, Management and Clinical Leadership capacity and capability as well as appropriate governance systems and process to enable it to address breaches of its license and comply with section 106 undertakings. Pursuant to the above requirement, the Trust is now required to appoint a Board Adviser and we welcome Chris Mellor in that role. Much but not all of the undertakings will be delivered in governance terms via the work of the FOC Committee and therefore to ensure comprehensive Board oversight of all the undertakings and their progress, from next month’s board meeting onwards, a tracker will be provided providing oversight of the undertakings and their progress, highlighting any exceptions or concerns. Monitor will now also hold regular, initially bi monthly, Enforcement Progress meetings with the Trust, the first of which is booked for the 31 March 2016. KPMG Report On the day of publication of the Monitor investigation, the KPMG report was published on the Trust website. The aim was to be as open and transparent as possible, commensurate with protecting the confidentiality of individuals during the conduct of disciplinary processes, thereby necessitating a redaction for that purpose. KPMG undertook the redaction. Several well attended staff briefings have been held on all three sites to explain the KPMG conclusions and what the Trust is doing to respond to the recommendations. NHS Improvement On 1 April 2016, NHS Improvement launches, bringing together Monitor, NHS TDA, the Patient Safety Team, the National Reporting and Learning System, the Advancing Change Team and the Intensive Support Teams. The Trust has responded positively to an invitation under NHSI cover to receive external support with its turnaround activities as part of a national programme. This is being centrally procured by NHSI with definition of the outcomes in April or May. Picker Inpatient Survey 2015

The Picker Institute includes 65 questions and the report shows the percentage of patients for each question who, by their responses, have indicated that this particular aspect of their care that could have

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been improved. Below is a summary outlining whether the Trusts scores have improved since the 2014 survey and how the Trust compares with other Trusts. Overall, the position is positive in comparison to other trusts.

The follow up to all surveys of such nature is picked up by the Patient Experience Committee where the opportunity to improve highlighted by the survey will be examined, in particular the question highlighted above where the Trust has worsend significantly since the last survey. The Trust will shortly be piloting a new integrated and specifically trained team to provide specialing to patients, where the aim will be to provide a higher quality more constent service at lower overall cost, and there is some reasonable prospect that this team will improve both care and perceptions of safety in ward environments. Baroness Cumberlege Review of Maternity Services ‘Better Births – Improving outcomes of maternity services in England’ has recently been published. The review was led by Baroness Julia Cumberlege and set out the vision for maternity services across England to become safer, more personalised, kinder, professional and more family friendly. The Board may recall Baroness Cumberledge visited the trust to open new birth pool facilities some months ago. The report will be considered by the Children and families care group and our commissioners. We are in current discussion with local CCGs about how we can progress the outstanding CQC recommendations in terms of improving midwife to birth ratios.

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Better Births – Improving the outcomes of maternity services in England https://www.england.nhs.uk/wp-content/uploads/2016/02/national-maternity-review-report.pdf Maternity Capital Fund I am pleased to announce that the Trust has been successful in securing funding of £25k from the Department of Health from the Preventing avoidable harm in maternity care - Capital Fund for Improving Resources to Assess Foetal Growth and Wellbeing during pregnancy and improving the perinatal morbidly and mortality for the population of Doncaster and Bassetlaw. The funds will be used to purchase new Cardiotocograph monitors “Building on the Best” programme to improve end of life hospital care across the UK DBH has been selected as one of just 10 hospital trusts in England to take part in the ‘Building on the Best’ programme to support improvements in the quality and experience of palliative and end of life care across the UK. The programme is funded by Macmillan Cancer Support and supported by a partnership

between the National Council for Palliative Care, Macmillan Cancer Support, NHS England and the NHS Trust Development Authority in England. Stacey Nutt, Lead Nurse for Cancer and End of Life Care at Doncaster and Bassetlaw Hospitals NHS Foundation Trust led our bid which acknowledges the Trust as one that delivers outstanding end of life care. We now looking forward to being part of this exciting work to transform and develop new areas of focus for improving end of life care, not only for our own patients, but also for the UK as a whole.

Friends & Family A huge thank you and congratulations to all staff involved in achieving excellent response rates, positivity and negativity of experience in the January FFT returns. Moira Hardy, Deputy Director Nursing & Quality has driven work to share learning across the Trust from those areas that had achieved the highest response rates.

Ward Friends and Family response rate %

Friends and Family positivity rate

Friends and Family unlikely to recommend

ITU DRI 57.1 100 0

Mallard 65 100 0

Gresley 62.1 100 0

16 114.6 100 0

CCU/C2 95 100 0

6

25 78.6 100 0

A2L 85.5 99.11 0

Student Nurse Feedback The overall placement satisfaction of student nurses at the Trust in the SHU student nurse feedback report was 97%, the most positive of all the SHU acute placements. This builds on a similar outcome last year and continues to develop the platform for our teaching and training quality to be formally recognized in the future. Tour de Yorkshire 2016 - Otley to Doncaster 30 April 2016 The Tour de Yorkshire will be run again this year with the second stage finishing in Doncaster. This year there will be two races – the women’s race finishes at 13.00 or thereabouts, and the men’s race finishes around 18.00. The race falls on a Saturday and also the Bank Holiday weekend. Each Care Group and Department have been asked to submit a statement of readiness which to demonstrate assurance in preparation and planning for Stage 2 of the event which finishes in Doncaster, addressing those risks highlighted on the risk register, and any others identified by the Care Group/Department during the process. Merging oncology letters with Medisec The automatic merger of oncology letters from Weston Park with the Trust’s Medisec system has been successfully implemented. This is great news which will be will be invaluable from a clinical perspective and will have a real impact on administration and pathway validation time .This holds real potential for the future and could potentially be rolled out to other specialities. This is a bespoke system developed from an idea put forward by Jay Dugar, ENT Consultant, who also supported the implementation. I would also like to thank Joe Joseph, Cancer Lead Clinician, Medisec Trish Fisher, Clinical Director for Oncology at Weston Park and Mr Stephen Stewart, Head of IT at STH for their support with the project implementation. These developments highlight the potential for using IT as a key support to care integration in future. Working Together The latest Working Together newsletter is in the information section, outlining progress in current work streams and future vanguard priorities.

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Staff & Appointments Mr. Muhamad Quraishi has been elected as President at the Royal Society of Medicine, London, Head and Neck Section, a unique achievement for a non-teaching hospital Consultant.

Mike Pinkerton Chief Executive

8

ENFORCEMENT UNDERTAKINGS

LICENSEE:

Doncaster and Bassetlaw Hospitals NHS Foundation Trust (“the Licensee”) Doncaster Royal Infirmary Armthorpe Road Doncaster DN2 5LT DECISION

On the basis of the grounds set out below, and having regard to its Enforcement Guidance, Monitor has decided to accept from the Licensee the enforcement undertakings specified below, pursuant to its powers under section 106 of the Health and Social Care Act 2012 (“the Act”). GROUNDS

1. Licence

The Licensee is the holder of a licence granted under section 87 of the Act. 2. Breaches

2.1. Monitor has reasonable grounds to suspect that the Licensee has provided and is

providing health care services for the purposes of the NHS in breach of the following conditions of its licence: FT4(2); FT4(5)(a),(b),(d) and (f); and CoS3(1) and (2)(c).

2.2. In particular:

2.2.1. The Licensee misreported its financial position for 2014/15, reporting a £1.6m

surplus rather than a substantial deficit. Evidence, subject to further external review, indicates that the deficit should have been £13.6m, a misstatement of £15.2m, indicating serious weaknesses in financial controls and reporting.

2.2.2. The Licensee has now reported a deficit at month 9 of 2015/16 of £27.1m and a Financial Sustainability Risk Rating (FSRR) of 1, and is forecasting a full year deficit of £38.4m (compared to £2.2m surplus forecast in its annual plan).

2.2.3. The Licensee does not currently have a financial recovery plan to return to a

FSRR3. 2.2.4. The findings of an independent external review of the Licensee’s financial

performance indicate that:

(a) the 2014/15 financial position has been materially misstated due to inappropriate journal adjustments, with the external auditors potentially being misled;

(b) the financial information in 2015/16 Board reports up to month 5 did not reconcile to ledgers and was misleading;

(c) financial controls at the Licensee have not been operating effectively; (d) the Licensee’s budget setting process is not adequate, budget holders have

limited information and there has been a lack of scrutiny and challenge of budget holders - this has contributed to the failure to identify the financial misreporting at an earlier stage;

(e) there has been a lack of oversight and effective project management over CIPs; and

(f) internal audit assurance had a narrow focus and did not clearly articulate its limitations.

2.2.5. These failures by the Licensee demonstrate a failure of financial governance

arrangements, in particular but not limited to a failure by the Licensee to:

(a) apply those principles, systems and standards of good corporate governance and of financial management which reasonably would be regarded:

i. as appropriate for a supplier of health care services to the NHS and a provider of the Licensee’s Commissioner Requested Services, and

ii. providing reasonable safeguards against the risk of the Licensee being able to carry on as a going concern; and

(b) establish and effectively implement systems and/or processes:

i. to ensure compliance with the Licensee’s duty to operate effectively, economically and effectively;

ii. for timely and effective scrutiny and oversight by the Board of the Licensee’s operations;

iii. for effective financial decision-making, management and control; and iv. to identify and manage material risks to compliance with the conditions

of its licence. 2.3. Need for action

Monitor believes that the action which the Licensee has undertaken to take pursuant to the undertaking recorded here is action to secure that the breaches in question do not continue or recur.

3. Appropriateness of Undertakings

In considering the appropriateness of accepting in this case the undertakings set out below, Monitor has taken into account the matters set out in its Enforcement Guidance.

UNDERTAKINGS

The Licensee has agreed to give and Monitor has agreed to accept the following undertakings, pursuant to section 106 of the Act: 1. Sustainability

1.1 The Licensee will take all reasonable steps to deliver its services on a clinically,

operationally and financially sustainable basis, including but not limited to the actions in paragraphs 1.2. to 1.10 below. As part of this, the Licensee will take all reasonable steps to improve its financial position and minimise its external funding requirement, as measured by any extent or benchmark which may be specified by Monitor.

1.2 The Licensee will develop and submit to Monitor:

1.2.1 A Short Term Recovery Plan comprising:

1.2.1.1 a recovery plan for 2016/17 to be submitted to Monitor by 29 April 2016, or such other date as may be agreed with Monitor; and

1.2.1.2 a recovery plan for 2017/18 to be submitted to Monitor by 15 July 2016, or such other date as may be agreed with Monitor.

1.2.2 A strategy for financial sustainability and an associated longer-term, five year

financial plan (“the Strategic Plan”), to be submitted to Monitor by 30 September 2016, or such other date as may be agreed with Monitor.

1.3 The Licensee will either deliver, or if Monitor so specifies, demonstrate to Monitor that it can

deliver, each of the plans referred to in paragraph 1.2. 1.4 In relation to the development of both the short term recovery plan and the strategic plan,

the Licensee will consult with its commissioners and ensure that the plans reflect appropriately the views of its commissioners.

1.5 The Licensee will modify the plans if needed in response to any input from Monitor after

Monitor has received and considered the plans, whether such input is provided before or after receipt of the assurance specified in paragraph 1.6.

1.6 The Licensee will obtain assurance that the plans and their delivery will enable it to comply

with paragraph 1.1. The source, scope and timing of that assurance will be agreed with Monitor, and the assurance will be provided to Monitor if Monitor so requests.

1.7 The Licensee will develop and agree with Monitor Key Performance Indicators (“KPIs”) to

assess the effective delivery and impact of the short term recovery plan and strategic plan, by such date as to be agreed with Monitor.

1.8 The Licensee will commission, at any point, the level of external support considered necessary by Monitor to assist the Licensee in the development and delivery of the plans, the scope and the identity of the provider of that support to be agreed with Monitor.

1.9 The Licensee will ensure that it has the necessary personnel, systems and processes to

enable it to deliver the short term recovery plan and the strategic plan, including demonstrating that it has sufficient executive and senior management capacity and expertise to enable delivery. The Licensee will also consult and agree with Monitor:

1.9.1 the appointment and scope of any key advisors in relation to the plans described above, in addition to external support referred to in paragraph 1.8 above;

1.9.2 executive capacity to support the delivery of the plans described above, including key executive appointments; and

1.9.3 finance department capacity to support the delivery of the plans described above.

1.10 The Licensee will keep the short term recovery plan and the strategic plan, and their

delivery, under review. Where matters are identified which materially affect the Licensee’s ability to deliver sustainable services, whether identified by the Licensee or another party, the Licensee will notify Monitor as soon as possible and update and resubmit the short term recovery plan and/or the strategic plan within a timeframe to be agreed with Monitor.

2. Financial Governance

2.1 The Licensee will take all reasonable steps to address the weaknesses in its financial

governance, including but not limited to the actions in paragraphs 2.2 to 2.5 below.

2.2 The Licensee will develop an action plan to address the findings and recommendations arising from KPMG’s Financial Misreporting Investigation. This action plan will be agreed with Monitor. The Licensee will implement the action plan, unless otherwise agreed with Monitor.

2.3 The Licensee will commission a wider governance review, the scope and timing of which is

to be agreed with Monitor. The Licensee will, if required by Monitor, develop an action plan to address any findings and recommendations arising from this review. This action plan will be agreed with Monitor. The Licensee will implement the action plan, unless otherwise agreed with Monitor.

2.4 Following implementation of the action plans referred to in 2.2 and 2.3 above, the Licensee

will, if required by Monitor, commission a follow up review from a source and according to a scope and timing to be agreed with Monitor to test whether the actions are implemented. If such a review is commissioned, the Licensee will provide copies of the draft and final reports to Monitor within a week of receiving them.

2.5 The Licensee will, if required by Monitor, commission an assurance review of the Trust’s

2015/16 financial baseline position, with the scope and timing to be agreed with Monitor. Following this review, the Licensee will, if required by Monitor, develop an action plan to address any findings and recommendations arising. This action plan will be agreed with Monitor. The Licensee will implement the action plan, unless otherwise agreed with Monitor.

3. Distressed Financing and Sustainability and Transformation Fund

3.1 Where- 3.1.1 interim support financing or planned term support financing is provided by the

Secretary of State to the Licensee pursuant to section 40 of the NHS Act 2006, or

3.1.2 the Licensee receives payments under the Sustainability and Transformation Fund,

the Licensee will comply with any terms and conditions which attach to the financing or payments.

3.2 The Licensee will comply with any reporting requests made by Monitor in relation to any financing to be provided to the Licensee by the Secretary of State pursuant to section 40 or 42 of the NHS Act 2006 or payments made under the Sustainability and Transformation Fund.

3.3 The Licensee will comply with any spending approvals that are deemed necessary by

Monitor.

4. General

4.1 The Licensee will implement sufficient programme management and governance arrangements to enable delivery of these undertakings.

4.2 Such programme management and governance arrangements must enable the Board to: 4.2.1 obtain clear oversight over the progress in delivering the undertakings; 4.2.2 obtain an understanding of the any risks to the successful achievement of the

undertakings and ensure appropriate mitigation of any such risks; and 4.2.3 hold individuals to account for the delivery of the undertakings.

4.3 The Licensee will provide regular reports to Monitor on its progress in meeting the

undertakings set out above, in a format to be agreed between the Licensee and Monitor, including reporting against the KPIs agreed pursuant to paragraph 1.7.

4.4 The Licensee will attend meetings, or, if Monitor stipulates, conference calls, as required, to discuss its progress in meeting those undertakings. These meetings will take place once a month unless Monitor otherwise stipulates, at a time and place to be specified by Monitor and with attendees specified by Monitor.

4.5 The Licensee will provide Monitor with the assurance relied on by its Board in relation to its progress in delivering these undertakings, upon request.

4.6 The Licensee will provide to Monitor direct access to its advisors, the Licensee’s board

members, and any other members of the Licensee’s staff considered necessary by Monitor, as needed in relation to the matters covered by these undertakings.

4.7 The Licensee will comply with any additional relevant reporting or information requests made by Monitor.

THE UNDERTAKINGS SET OUT HERE ARE WITHOUT PREJUDICE TO THE REQUIREMENT

ON THE LICENSEE TO ENSURE THAT IT IS COMPLIANT WITH ALL THE CONDITIONS OF

ITS LICENCE, INCLUDING ANY ADDITIONAL LICENCE CONDITION IMPOSED UNDER

SECTION 111 OF THE ACT AND THOSE CONDITIONS RELATING TO:

COMPLIANCE WITH THE HEALTH CARE STANDARDS BINDING ON THE

LICENSEE; AND

COMPLIANCE WITH ALL REQUIREMENTS CONCERNING QUALITY OF CARE.

ANY FAILURE TO COMPLY WITH THE ABOVE UNDERTAKINGS WILL RENDER THE

LICENSEE LIABLE TO FURTHER FORMAL ACTION BY MONITOR. THIS COULD INCLUDE

THE IMPOSITION OF DISCRETIONARY REQUIREMENTS UNDER SECTION 105 OF THE

ACT IN RESPECT OF THE BREACH IN RESPECT OF WHICH THE UNDERTAKING WAS

GIVEN AND/OR REVOCATION OF THE LICENCE UNDER SECTION 89 OF THE ACT.

WHERE MONITOR IS SATISFIED THAT THE LICENSEE HAS GIVEN INACCURATE,

MISLEADING OR INCOMPLETE INFORMATION IN RELATION TO AN UNDERTAKING: (i)

MONITOR MAY TREAT THE LICENSEE AS HAVING FAILED TO COMPLY WITH THE

UNDERTAKING; AND (ii) IF MONITOR DECIDES SO TO TREAT THE LICENSEE, MONITOR

MUST BY NOTICE REVOKE ANY COMPLIANCE CERTIFICATE GIVEN TO THE LICENSEE

IN RESPECT OF COMPLIANCE WITH THE RELEVANT UNDERTAKING.

LICENSEE

Dated: Signed: MONITOR

Dated: Signed: Chair of Provider Regulation Executive

1

Title Financial Performance – February 2016 – M11

Report to: Board of Directors Date: 22 March 2016

Author: Jeremy Cook (Interim Director of Finance)

For: Approval

Purpose of Paper: Executive Summary containing key messages and issues

To update the Board on the financial position for the 10 months to 29 February.

Recommendation(s)

The Board is asked to NOTE that the reported financial position is a deficit of £31.2m which is £30.3m behind the planned deficit to date of a £0.9m. The Board is asked to note the improvement in the forecast from £38.4m to £36.4m The Board is asked to APPROVE the draft financial plan submitted to Monitor on 8 February as the revenue budget for 2016/17 until detailed budget setting has been concluded in May.

Delivering the Values – We Care

Not applicable

Related Strategic Objectives

Provide the safest, most effective care possible

Control and reduce the cost of healthcare

Focus on innovation for improvement

Develop responsibly, delivering the right services with the right staff

Analysis of risks

Due to the deficit the Trust is in breach of its license with Monitor

Board Assurance Framework

1 Failure to comply with the Monitor Risk Assessment Framework, CQC and other regulatory standards, triggering regulatory action.

5 x 4 = 20

2 Failure to deliver the financial plan 5 x 5 = 25

3 Failure to deliver the cost improvement plan 4 x 5 = 20

FINANCIAL PERFORMANCE – FEBRUARY 2016

1. Overview 1.1 As at Month 11 the Trust deficit is £31.2m which is £30.3m behind the planned deficit of £0.9m. As in

previous months medical staff costs continue to be a main area of concern, with adverse variances in a number of specialties with particular focus on the Surgical, Emergency and Children & Families Care Groups who continue to be over established against funded levels. In addition there are large overspends on other non-pay costs and non-delivery of efficiency savings.

1.2 Expenditure in month has remained at the same level as Month 10 of £29.9m. This represents a

reduction of £1.5m since November expenditure of £31.4m 1.3 The forecast for the year has improved by £2m from £38.4m to £36.4m as a result of penalties for

readmissions being waived in Q4, reduced payments under the MARS scheme and improved run rate.

1.4 A disputed debt with NHS England was resolved in the month in the Trust’s favour. At month 9 an accrual of £0.54m was posted as a prior period adjustment and £0.22m accrued for the current year. As these transactions were being concluded it was noticed that the accrual the Trust had made for these transactions (£1.46m) had been moved from accruals to general provisions. The general provision account should only be used where there is an under or over accrual and the net balance is added to or deducted from expenditure at the year end. This has resulted in an additional prior year adjustment of £0.61m which was net of the write back of £0.54m no longer required. In addition a further prior year adjustment has been identified whereby cardiology stock was double counted as a prepayment at last year end resulting in a further adjustment of £0.21m. Therefore the total adjustment to prior years is a further write off of £0.82m.

1.5 There are a further £1.4m of credit balances which have been written off to general provision for which an exercise is being undertaken to identify whether any of the balances are valid which will add to the prior year adjustment.

2. Income 2.1 Income at the end of month 11 (inclusive of Recharges, Education and Outsourcing income) is £3.837m

below plan (£3.856m at month 10) a deterioration of £19k in month. 2.2 NHS clinical income has over-performed by £293k during February, giving a £105k under-performance

for the year to date. This is mainly due to Emergency activity (£2.165k) and other income (£2,668k) which is partly offset by an underperformance on Elective & Daycase activity (£2,593k), both of which under-performed against plan in February. Other areas contributing to the underperformance is the impact of the Outpatient Cap (£886k). NHS clinical income has benefitted in month from an adjustment to reflect no fines for readmissions in Q4 of £787k relating to M10 and M11.

2.3 Outpatient performance in month continues to be behind plan cumulatively, however February’s

performance was ahead of plan, with First activity year to date underperformance reducing to £295k and Follow Up performance now £1,316k below plan due to the application of the Outpatient Cap. The total Outpatient Cap as at month 10 is £886k (£894k at month 10); this is across most specialties with the main ones being Urology £242k, Gynaecology £117k, Dermatology £43k and Respiratory £23k. Valuable capacity continues to be used to deliver unfunded follow up work, whilst pressure remains on both waiting lists and medical staffing to deliver this capacity often at premium rates due to non-substantive cover. This will be a key element of the Trust’s recovery plan.

2.4 The under-performance on other non-NHS clinical income has increased in month to £1,018k, with £379k of the variance being due to the Trust reverting to its previous method of accounting for income receivable from the NHS injury cost recovery scheme. Education and training has improved from an adverse variance of £368k to an adverse variance of £208k due to confirmed student numbers. Other income is under-performing (£1,643k) due to changes in reporting asset sales and donated & government granted assets income; in addition internally generated income continues to under-perform, this is partly offset by over-performance on provider to provider contracts.

3. Expenditure 3.1 Expenditure at month 11 is £28.24m worse than plan (£24.87m at month 10). The pay variance of

£7.31m (last month £6.66m) continues to be the single largest contributory factor. As has been the recent trend pay overspends are primarily driven by medical expenditure pressures of £7.81m (last month £7.22m), due to the use of non-substantive staff. Medical agency costs have fallen further to £1.04m in February, a reduction of £134k on January and are still well below the average for months

six to eight of £1.5m per month. The overspend is inclusive of over-establishment against funded levels, with significant overspends still being reported in; Children’s, Women’s & Maternity, Medical Imaging, A&E, Medical Gastroenterology, T&O, Ophthalmology, GI, Stroke, Diabetes & Endocrinology, Urology, ENT and Anaesthetics.

The run rate across medical staff costs has once again fallen this month this and is £160k better in February than the year to month 10. Headcount over establishment has once again reduced from 35.1 wte in January to 27.1 wte in February.

In addition to over expenditure on medical staff there are also significant overspends on non-medical

staff within; Estates (£243k), Medical Imaging (£283k), Outpatients & Clinical Admin (£224k) and Theatres Day Surgery (£499k).

3.2 There are six material areas of year to date overspends on non-pay categories.

Medical Supplies & Equipment £690k - more than half this value resides within Estates, the majority of it relates to maintenance contracts. Overspends are also present in Cardiology, Surgery & Women’s & Children’s.

Prosthesis £651k - the majority in Trauma & Orthopaedics.

Building costs £428k

Outsourcing £5,305k - £2.26m in Trauma & Orthopaedics, £1.383m in Surgery and £950k in Diagnostic & Pharmacy.

Facilities related expenditure £644k

Office expenses £889k

The variance on Drugs continues to be inclusive of Non PbR drugs underspend together with PbR drugs pressures in several specialities. The continued under performance on CIP schemes also has a significant impact on nther non pay variances. The reported variance on contingencies and reserves continues to reflect both the planned release of general contingency and the impact of the efficiency reserve that hadn’t been retracted from budget.

4. Efficiency

Table 1: CIP delivery to M11 and forecast

4.1 The reported CIP achieved to month 11 is £1,674k, a shortfall to retracted budget of £1,866k. £1,142k of the reported figures relate to procurement savings.

4.2 The current forecast out turn for 2015/16 of £1,850K has a FYE (Full Year Effect) of £2,732k, however

£583k of these has been deemed non-recurrent.

4.3 Work is progressing in relation to the 2016/17 CIP plan with project groups for the overarching schemes

now live and ’local’ schemes being worked up in the individual delivery areas. The target number is now

£11m with an internal stretch target of £13m.

5. Care Group Performance 5.1 Children & Families Care Group - £2,588k net deficit to plan for the year to date. The Care Group has

seen an improvement in income in month along with a continued overspend against expenditure in line with the monthly run rate. The over-spend on pay of £538k is mainly driven by medical agency and additional sessions premiums (£1,481k) due to the backfill of medical vacancies (16.21wte at February). These overspends are currently offset by the large number of nursing and midwife vacancies (28.34wte). Non-pay continues to overspend mainly due to increased activity referred to other NHS trusts £427k (Women’s, Maternity, and Children’s), unachieved CIP’s £492k, volume funding retraction £319k, and drugs and consumables £411k. Income is £36k above plan as at the end of February. This is mainly driven by an over performance against the maternity contract (£259k), offset with a continued underperformance against Paediatric emergency contract (£360k). The outpatient CAP continues to cause a pressure in Gynaecology (£126k) which is currently offset by and over performance on outpatient activity (£385k).

Original

Plan

Budget

Retracted

to M11

Actual to

M11

Variance

to M11

Budget

retracted

to M12

Forecast to

M12

Forecast

Variance

Forecast

FYE

Forecast

Non

Recurrent

Care groups £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

MSK and Frailty 1,776 601 279 -322 1,121 301 -820 697 79

Emergency care 730 347 74 -273 417 91 -326 202 0

Specialty services 602 182 52 -129 215 56 -159 62 18

Children's and Families 846 498 7 -492 608 7 -601 8 0

Diagnostic and Pharmacy 1,064 498 525 28 575 634 59 926 119

Surgical 2,183 845 113 -732 1,014 121 -892 134 11

Corporate

Chief Executive 74 68 68 0 74 74 0 74 0

Facilities, Estates and Hotel services 812 358 84 -274 426 94 -332 83 6

Finance 126 115 313 198 126 324 198 324 324

medical Director 4 3 3 0 3 3 0 3 0

Property 880 0 0 0 0 0 0 0 0

Cross organisational 10,005 25 155 130 0 145 145 218 27

Totals 19,101 3,540 1,674 -1,866 4,579 1,850 -2,729 2,732 583

5.2 Diagnostics and Pharmacy Care Group - £1,137k net deficit to plan for the year to date. The net budgetary position deteriorated by £209k month on month. The most significant cost pressure is the Medical Imaging specialty; where over £678k has been spent year to date on mobile scanning support to meet activity levels. The specialty has plans to employ lean principles to increase the capacity on their in-house scanning. The Outpatients specialty is also underperforming, due to an unachieved CIP from previous years of £218k. These cost pressures are offset by a high performing Pathology specialty which has a net budgetary position of £748k.

5.3 Emergency Care Group - £2,458k net deficit to plan for the year to date. This is mainly driven by an over-

spend on medical staffing equating to £2,635k. There are currently 36.50wte medical vacancies as at February which are being covered by additional sessions and agency staffing. Also, within A & E medical rotas have previously been over recruited to by non-substantive staff. This issue has been rectified in part by removal of consultant and middle grade shifts. Nursing staff are £918k overspent due to bank and agency usage to cover the high number of vacancies (81.08wte at February). Within the Care Group there is £692k of expenditure for Sleepers in/out. The income over performance of £3,286k is partly due to £1,194k over performance on non PbR drug income which is balanced out by a corresponding expenditure over-spend. Acute Medicine emergency activity is over performing by £956k and elective activity by £368k. Accident and Emergency is over performing by £680k which has occurred since the reduction of activity in relation to the Front Door Signposting project. This position is masked by Outpatient CAP (£37k) and under performance against cost per case income targets (£202k) across Respiratory and Acute Medicine.

5.4 MSK Care Group - £2,598k net deficit to plan for the year to date. This is mainly driven by expenditure

overspends across the Care Group. Pay overspends on medical and nursing staff exist across Orthopaedics and Care of the Elderly which are masked by vacancies in Therapies leaving a net pay overspend of £273k. PbR drugs are overspent by £414k and there is an underachievement on CIP of £322k year to date. Prosthesis, implants and patient appliances are overspent by £568k, outsourcing of activity is overspent by £2,232k but covered by the volume funding allocation of £2,655k. Income is under delivering by £936k which is partly due to a variance on non PbR drugs of £420k which is balanced out by a corresponding underspend on expenditure. The main underperformances against contract exist within Trauma & Orthopaedics with a variance on elective of £818k, day case of £385k, outpatient’s of £93k together with activity penalties of £201k.

5.5 Specialty Services Care Group – £2,799k net deficit to plan for the year to date. The Care Group has seen

a significant improvement in income in the month of February along with a reduction in expenditure. The main specialties of concern driving the deficit within the Care Group are Dermatology £417k deficit against plan, Cardiology £466k deficit against plan, Stroke £215k deficit against plan, Diabetes £608k deficit against plan, Breast £384k deficit against plan and Urology £614k deficit against plan.

The Care Group has a pay overspend as at February of £522k, which is spread across the specialities and is mainly driven by medical agency and additional sessions premiums to backfill vacancies. Volume retractions for the care group amount to a cost pressure of £833k as at February. Dermatology is currently behind income plan by £211k (outpatient activity) and significantly overspending against drugs at £115k worse than budget. Stroke and Diabetes continue to overspend in month which is mainly driven by nursing and medical staff vacancies. Breast underperformance against income plan continues in February at £414k worse than budget. The expected increase in activity to be delivered by new consultants has not been realised due to the extra capacity needed from pathology and medical imaging not being available. The Urology deficit is due to expenditure, outsourced activity is £206k worse than budget and additional sessions paid make the position £172k worse than budget.

5.6 Surgical Care Group - £7,406k net deficit to plan for the year to date. The position deteriorated by a further £476k in February. The deficit position is caused by four main pressures; Medical expenditure is £2,778k worse than plan, with the care group having carried 20-25 medical vacancies per month over the past two years a high amount of additional sessions and locums have been required to cover this. The care group is currently focusing on reducing long-term locum placements, and this again had a positive impact in February against run rate, as it had for the previous three months. Income, which is £3,605k worse than plan. The care group is significantly under-recovering on elective, day case and outpatient work while over performing on non-elective. The income position deteriorated by a further £298k in-month but this was an improvement compared to recent months. Outsourcing is £1,258k worse than plan; there has been high usage in both GI and ENT. Underachieving on CIP which is currently £732k worse than budget. The Care Group’s main CIP was to increase income through a new Bowel Scoping programme but so far this has underperformed.

5.7 Estates, Facilities & General Operations - £2,672k net deficit to plan for the year to date. The Estates position worsened to a £1,766k deficit and Hotels services to a £631k deficit, with General operations making up the balance.

Within expenditure previously reported cost pressures continue to be the main contributory factors in the current combined position of £2,300k deficit to date. Estates have a £122k negative variance against unidentified pay efficiencies at month 11, along with year to date overspends on ancillary staff of £94k, which has been mainly caused by unfunded overtime and enhanced hour payments. Utilities are overspent by £337k and building maintenance and repair costs (including medical equipment contracts) by £636k. Hotel services continue to underspend on staff due to a number of vacancies within the catering and service assistant plans, an overall pay under-spend of £186k year to date. Postage costs are significantly overspent at £496k worse than plan, and are currently under review. Cleaning equipment and materials are also contributing towards the position and show a deficit of £102k to date. The combined income position is £372k worse than plan with internally generated income underachieving by £419k. This is due to an under recovery of car parking income of £467k, which is being offset by catering facilities income overachieving by £143k year to date.

6. Capital Expenditure 6.1 Capital expenditure at month 11 of £11.8m is £7.1m behind plan (£4.9m at month 10). The variance

continues to be due to planned slippage on property and replacement medical equipment expenditure partly offset by information technology schemes. The variance above 30% is outside Monitor’s tolerance level but is an integral part of the Trust’s cash recovery plan. The key area of concern is spend on the iHospital projects.

7. Financial Performance 7.1 The aggregated Financial Sustainability Risk Rating (FSRR) rating is a 1 against a plan of 2. All four of the

elements (liquidity, capital servicing capacity, I&E margin and variance from plan) are rated as 1,

reflecting the variance in the overall I&E position.

7.2 The cash position at month 11 is £1.9m which is £5.6m below the plan to date of £7.5m. The variance is due to the significant I&E overspend against plan and slippage on land disposals, partly offset by the early drawdown of the approved ITFF loan and access to Monitor approved temporary working capital facility.

7.3 As a result of the Trust’s financial position external cash support is required during 2015/16 and beyond.

The Trust has secured through Monitor a temporary working capital facility of £33.5m of which £33m has been drawn down by the end of February. Due to improved cash flows fore income no draw down was made during March. The Trust has been granted a loan facility of £7.2m for drawdown in April. Funding will be agreed on a monthly basis until DoH/Monitor agree a more permanent solution for Trust’s receiving distress funding.

8 Budgets 2016/17 8.1 A draft financial plan was submitted to Monitor on 8 February which showed that the Trust achieved a

control total of £27m. A budget setting principles and process paper was approved at the March Financial Oversight Committee which due to the delay in starting budget setting has a final sign off of budgets with budget holders in May. Monitor has provisionally agreed to the Trust submitting a final Monitor plan on conclusion of this process.

8.2 It is therefore recommended that the Board adopts the draft financial plan submitted to Monitor on 8

February as the revenue budget for 2016/17 until detailed budget setting has been concluded in May.

Jeremy Cook – Interim Director of Finance – March 2016

Statement of Comprehensive Income Variance January 2015

Plan Actual Variance VarianceIncome £000 £000 £000 £000

NHS Clinical Income

Elective 26,761 25,262 -1,499 -1,434Daycase 26,881 25,786 -1,095 -1,075Emergency and Non-Elective 68,987 71,574 2,587 2,066Emergency Threshold Reduction -1,068 -1,489 -422 -304First Outpatients 20,380 20,084 -295 -522FU Outpatients 27,472 26,157 -1,316 -1,338Other (inc A&E) 98,357 101,024 2,668 2,580

Contract Penalties -1,788 -1,430 358 445

CQUINS 6,238 5,614 -624 -567Non PbR Drugs 21,722 21,255 -467 -249

Total 293,941 293,837 -105 -398-105

Non NHS Clinical IncomePrivate Patient Income 760 842 82 76Other Clinical Income 2,523 1,423 -1,100 -752

Total 3,283 2,265 -1,018 -676

Other IncomeEducation and Training 7,362 7,154 -208 -368Other Income 16,121 14,479 -1,643 -1,658Income Recharges 9,905 9,042 -862 -755

Total 33,388 30,675 -2,713 -2,781

Total Income 330,613 326,777 -3,837 -3,856

Expenditure

Pay Costs -219,579 -226,889 -7,310 -6,656Drug Costs -28,442 -29,692 -1,250 -1,405Clinical Supplies and Services -24,941 -27,190 -2,248 -2,253Other Costs -42,199 -51,171 -8,972 -7,701

Total -315,161 -334,942 -19,781 -18,015

Contingency and Reserves 8,539 -785 -9,324 -7,609

Recharges -9,905 -9,042 862 755

Total Expenditure -316,527 -344,769 -28,243 -24,869

EBITDA 14,086 -17,992 -32,078 -28,726

Depreciation -9,037 -8,471 567 532PDC Dividend -5,587 -5,538 49 39Other Finance Costs -352 755 1,107 794

Net Surplus/Deficit (-) -891 -31,245 -30,354 -27,360

Financial Performance - February 2016 - Statement of Comprehensive Income and Risk Rating

As at 29 February 2016

Daycase and Elective activity combined was 1,237 cases under plan in month 11, driven by an under

performance in the majority of specialties due to cancellations for both the strike and bed pressures.

Outpatient first and follow up attendances are also behind plan by 3,976 predominantly whihc has

improved in month due to increased workloads. Emergency activity is 4060 cases above plan, this

increase in month 11 has had an impact on planned work.

Outpatient overperformance against Doncaster CCG plan has increasd in month 11, they are still

over-performing YTD. Daycase and Elective activity continue to show a net overperformance,

which has increased slightly in month with a increase in both daycase and elective activity.

The Q3 position for CQUIN's has now been agreed with Commissioners, the actual performance has

deteriorated more than expected on some specific schemes. These included Paediatric Assessment Tariff,

Mental & Physical Health and both the National AKI & Sepsis. From the results of the Q3 performance the

forecast Q4 performance has been adjusted accordingly to predict a year end under-performance of £1.7

million.

Financial Performance - February 2016 - Income & Activity Analysis

2015/16 Cumulative Activity Variance Activity Variance by CCG - Cumulative to February 2016 CQUINs Forecast 2015/16 Performance

Inpatient activity has increased slightly in month 11 reducing the under-performance, Daycase and

Elective remains behind plan. The over-performance in Emergency income has again increased in

month as a result of activity over-performance and increased casemix.

Doncaster CCG income has overperformed in month with the variance to date of -£0.5m behind

plan. The significant movement is on outpatient & Planned income. Bassetlaw CCG also

overperformed in month 11 giving a YTD overperformance of £192k. NHS England's position has

declined in month 11 due to an reduction in Non PbR drugs.

The contract penalties have been restated for April and May due to national changes in RTT penalties and are

now based on the new guidance. A&E performance has fallen significantly in month 10. RTT has continued at

the increased level seen in month 7 - 11 due to ENT performance and the impact of CaMIS and also due to the

increase in the unit penalty charge.

2015/16 Cumulative Income Variance Income Variance by CCG - Cumulative to February 2016 2015/16 Contract Penalties Performance

-6,000

-5,000

-4,000

-3,000

-2,000

-1,000

0

1,000

2,000

3,000

4,000

5,000

Inp

atie

nt

& O

utp

atie

nt

Act

ivit

y

Daycase & Elective Emergency Outpatient First Outpatient Follow Up

(-1,237) (-3,612) (1,061) (-£1,672) -10,000 -8,000 -6,000 -4,000 -2,000 0 2,000 4,000

Do

nca

ster

Bas

setl

awN

HS

Engl

and

Oth

erA

sso

ciat

es &

NC

A's

Daycase

Elective

Emergency

Outpatient

(£2,500) (£2,000) (£1,500) (£1,000) (£500) £0 £500 £1,000 £1,500 £2,000

Do

nca

ster

Bas

setl

awN

HS

Engl

and

Oth

erA

sso

ciat

es &

NC

A's

£'000's

Daycase

Elective

Emergency

Outpatient

Drugs

Other

-£586,335

£561,488

£192,406

-£272,421

-1,000,000

-800,000

-600,000

-400,000

-200,000

0

200,000

400,000

600,000

-3,000

-2,000

-1,000

0

1,000

2,000

3,000

Ap

ril

May

Jun

e

July

Au

gust

Sep

tem

ber

Oct

ob

er

No

vem

ber

Dec

emb

er

Jan

uar

y

Feb

ruar

y

Mar

ch

Ou

tpat

ien

t In

com

e

Inp

atie

nt

Inco

me

Daycase & Elective Emergency excl threshold adj

Outpatient First Outpatient Follow Up

(-£2,593,368)

(-£531,498)

(£2,563,508)

(-£151,039)

0 200 400 600 800 1000 1200

End of Life Care

Discharge Pathway

Pressure Ulcers

Paediatric Assessment Tariff

Patient Safety

Customer Care & Patient Experience

Mental & Physical Health

Mgt. of Complex Frequent Flyers

National: AKI

National: Sepsis

National: Dermentia

National: UEC

NHS E: QIPP Plans

NHS E: Vascular Services

NHS E: Neonatal Critical Care

NHS E: Dental

NHS E: Public Health

£000's

CQ

UIN

Sch

em

e

CQUINs Performance 2015/16

Expected to Achieve

At RiskLost

-163 -163 163 163 163 163 163 163 163 163 163

16 10 9 1 9

45 37

72

79 105

47

95

12 13 13

21

19

129

34

35

36

26

23

15

93 96 69

77

74

0

50

100

150

200

Pla

n

Act

ual

Pla

n

Act

ual

Pla

n

Act

ual

Pla

n

Act

ual

Pla

n

Act

ual

Pla

n

Act

ual

Pla

n

Act

ual

Pla

n

Act

ual

Pla

n

Act

ual

Pla

n

Act

ual

Pla

n

Act

ual

Apr May Jun July Aug Sept October NovemberDecember January February

£0

00

's

Diagnostic Waits RTT Penalties Ambulance Handover

A&E 4 Hour Waits 2015/16 Plan

-

Care Group Specialties

Contract

Ratio

2015/16

Actual Ratio -

April 15

Actual Ratio -

May 15

Actual Ratio -

June 15

Average

Ratio -

Quarter 1

Actual Ratio -

July 15

Actual Ratio -

August 15

Actual Ratio -

Sept 15

Average

Ratio -

Quarter 2

Actual Ratio -

Oct 15

Actual Ratio -

Nov 15

Actual Ratio -

Dec 15

Average

Ratio -

Quarter 3

Actual Ratio -

Jan 16

Actual Ratio -

Feb 16

Actual Ratio -

YTD

Outpatient

Cap £ - YTD

Children & Families Care Group Womens & Maternity 3.0 3.0 3.4 3.7 3.4 3.6 4.0 3.4 3.7 2.3 5.5 2.6 3.5 3.3 3.0 3.2 (£116,529)Paediatrics 1.6 1.3 1.5 1.5 1.4 1.6 1.5 1.9 1.7 1.8 1.6 1.5 1.6 1.6 1.6 1.6 (£9,774)

Children & Families Care Group Total (£126,303)

Emergency Care Group Emergency Medicine 2.2 2.5 2.8 2.5 2.6 2.3 2.2 2.3 2.3 2.3 2.3 2.1 2.2 1.8 1.8 2.2 (£14,119)

Respiratory Medicine 2.9 2.9 3.4 2.8 3.0 3.7 6.0 3.8 4.5 3.0 3.1 2.8 3.0 2.5 2.3 2.9 (£23,225)

Emergency Care Group Total (£37,344)

MSK & Frailty Care Group Trauma & Orthopaedics 2.2 2.1 2.0 2.0 2.0 2.1 2.0 2.1 2.1 2.4 2.2 1.8 2.1 2.1 1.9 2.1 (£9,717)

T&O - Fracture Clinic 1.6 1.5 1.6 1.5 1.5 1.7 1.6 1.5 1.6 1.6 3.3 1.4 2.1 1.4 1.2 1.5 £0

Care of the Elderly, Rehab, End of Life Care 1.7 1.7 1.7 1.8 1.7 2.3 1.9 2.0 2.1 2.8 2.0 1.8 2.2 1.8 1.7 1.9 (£2,108)

Rheumatology 5.2 5.7 5.3 6.1 5.7 5.4 5.7 4.9 5.3 6.5 5.5 5.2 5.8 5.4 4.9 5.4 (£85,352)

MSK & Frailty Care Group Total (£97,177)

Specialty Services Care Group Haematology 6.2 7.3 6.5 5.1 6.3 5.8 5.7 8.1 6.5 7.1 6.5 7.7 7.1 7.5 6.5 6.6 £0

Dermatology 2.5 3.3 2.6 2.8 2.9 3.1 3.3 2.5 3.0 2.5 2.8 2.5 2.6 2.4 2.3 2.7 (£46,559)

Renal 7.1 8.4 8.7 6.8 8.0 8.2 6.2 8.0 7.5 13.0 7.8 5.7 8.8 14.0 5.9 8.0 (£38,355)

Cardiology 0.9 1.2 1.1 1.0 1.1 0.9 0.9 0.8 0.9 1.3 1.0 1.0 1.1 0.9 0.9 1.0 (£60,936)

Stroke / TIA's 1.6 1.1 2.6 2.9 2.2 2.3 2.7 2.7 2.6 4.4 2.6 1.7 2.9 1.7 1.8 2.4 (£11,483)

Diabetes & Endocrinology 3.6 4.4 4.1 3.9 4.1 3.9 3.3 3.4 3.5 3.6 3.7 4.1 3.8 3.8 3.6 3.7 (£12,339)

Vascular 0.8 0.0 1.3 1.5 0.9 1.6 1.3 1.6 1.5 1.3 1.5 1.5 1.4 1.2 1.7 1.5 (£1,293)

Breast 1.2 1.1 1.0 1.1 1.1 1.1 0.9 1.3 1.1 1.0 1.1 1.2 1.1 1.2 1.1 1.1 (£857)

Urology 2.4 3.2 3.3 3.2 3.2 3.0 3.8 3.4 3.4 3.9 3.3 2.7 3.3 2.9 2.8 3.2 (£241,760)

Specialty Services Care Group Total (£413,582)

Surgical Care Group Ophthalmology 3.0 3.6 2.7 3.3 3.2 2.9 3.3 3.0 3.1 3.2 3.1 3.1 3.1 2.5 2.5 3.0 (£5,907)

Medical Ophthalmology 7.1 4.0 2.2 8.1 4.8 10.1 6.5 7.2 7.9 16.8 6.2 15.8 12.9 6.9 6.6 6.3 (£474)

ENT 2.0 2.2 1.9 2.2 2.1 2.1 2.3 2.1 2.2 1.8 2.0 2.2 2.0 2.2 2.2 2.2 (£70,303)

Anaesthetics, Critical Care & Pain Management 2.7 2.6 2.4 2.3 2.4 2.7 2.6 2.6 2.6 3.1 2.8 3.0 3.0 3.3 3.3 2.9 (£62,800)

Gastro Intestinal Surgery 2.7 2.9 2.5 2.5 2.6 2.6 2.5 2.3 2.5 2.4 2.5 1.9 2.3 2.5 2.3 2.5 £0

Surgical Care Group Total (£139,484)

Corporate Other Other Minor Adjustments

Phasing adjustment in Board position to reflect gradual improvement in ratio's (£107,703)

Corporate Other Total (£107,703)

Trust Total (£921,593)

Outpatient First to Follow Up Ratio & CAP February 2016

Medical -7,813

Nursing -60

Other Staff 564 -7,310

Drugs -1,250 -1,250

Clinical Supplies and Services

MSSE -690

Prosthetics -651

Other -908 -2,248

Efficiency -2,096

Other -1,571 -8,972

Total -19,781

Medical staff expenditure has once again seen a reduction in expenditure month on month (M10 to

Financial Performance - February 2016 - Expenditure Analysis

Expenditure Subjective Variance Analysis (£000s) Nursing Expenditure Nursing Expenditure Analysis (£000s)

Nursing costs have underspent against budgets in month although untrained posts are continuing

to be significantly overspent currently of £2,162k year to date due to over-establishment and non-

substantive costs. MSK (£821k), Emergency (£649k), Specialties (£375k) and Surgical (£364k) are

the key adverse variances within untrained nursing. It should be noted that there are significant

trained vacancies that do offset the cumulative position to an extent resulting in the reported

variance of £60k cost pressure for nursing staff after the first 11 months of the financial year.

Performance in February against Monitor's 3% spending cap on registered nurses was 1.7% and a

cumulative position for October to January of 2.96%, mainly as a result of providing safe and

appropriate cover in A&E.

Pay £000s £000s

Other Employed Nursing Expenditure Analysis (£000s) Total Nursing Expenditure Analysis (£000s)

External

Contracts-5,305

M11 a reduction of£42k), although this remains the single largest area of overspend.At month 11 we were over established by 27.1 wte, a reduction in variance on last month of 8.0 wte.

Medical agency costs have also seen a further month on month reduction of £134k.

last month's level of expenditure.Lastly outsourcing of services to Parkhill, Barlborough and Medinet continues to pose a cost pressurewith income still partially off-setting the impact. CIP continues to under deliver but the focus is now around working up detailed and deliverable schemes for 2016/17.

Nursing expenditure continues to be broadly in line with budget whilst the variance on other staff

although still positive, has diminished in month by £223k.The overspend on drugs had once again reduced, by £119k month on month to £1.25m.

Clinical supplies & services continue to be adverse to budget and have remained consistent with6,600

6,800

7,000

7,200

7,400

7,600

7,800

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

2015/16 2014/15

6,400

6,600

6,800

7,000

7,200

7,400

7,600

7,800

8,000

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

2015/16 2014/15

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

Mar Apr May June July Aug Sep Oct Nov Dec Jan Feb

External Non-Substantive

Internal Non-Substantive

Substantive

Financial Performance - February 2016 - Expenditure Analysis

Medical Staff Analysis Medical Staff Expenditure Analysis (£000s) March 15 - February 16 Additional Session & Overtime Expenditure Analysis (£000s)

Agency Expenditure (£000s) March 15 - February 16 Additional Session Reason February 2016

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Mar Apr May June July Aug Sep Oct Nov Dec Jan Feb

Internal Non-Substantive

External Non-Substantive

Substantive

0

500

1,000

1,500

2,000

2,500

Mar Apr May June July Aug Sep Oct Nov Dec Jan Feb

Other Agency

Nursing Agency

Medical Agency

0

50

100

150

200

250

300

350

400

450

500

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar

2015/16 Overtime 2015/16 Additional Sessions

2014/15 Overtime 2014/15 Additional Sessions

Capacity Gap (Vacancy)

Dental

ENT

GI

Ophthalmology

Orthopaedics

Respiratory

Urology

Anaesthetics

Children's

General Medicine

Gastroenterology

Rheumatology

COTE

Total : £241,591

Specialty Budget (£) WTE

Total WTE

Non-

Substantive

%

Womens & Maternity 4,012,152 43.30 -517,766 -2.16 17.05%

GU Medicine 537,557 6.59 87,543 0.88 4.24%

Childrens 5,202,598 56.76 -938,967 -3.92 35.53%

9,752,307 106.65 -1,369,190 -5.19 26.74%

Pathology 1,574,415 13.61 278,600 3.67 17.68%

Medical Imaging 2,264,270 18.06 -315,352 -3.35 10.40%

3,838,685 31.68 -36,752 0.32 12.84%

Accident and Emergency Department 5,336,565 59.34 -2,169,577 -11.75 60.79%

Emergency Medicine 4,184,453 57.36 -129,424 -1.41 34.23%

Medical Gastroenterology 1,916,647 18.80 -198,436 0.38 29.36%

Respiratory Medicine 2,011,209 21.65 -137,922 -1.29 18.91%

13,448,874 157.15 -2,635,359 -14.07 43.94%

Trauma & Orthopaedics 4,764,356 48.70 -528,248 -1.78 23.84%

Clinical Therapies 6,963 0.06 -2,234 0.00 0.00%

Care of the Elderly/Rehabilitation 1,928,319 20.81 -77,994 -2.25 23.16%

Rheumatology 711,307 6.65 32,751 1.15 3.46%

7,410,945 76.22 -575,725 -2.88 21.91%

Haematology 885,472 7.60 130,523 0.14 3.08%

Dermatology 812,338 7.23 -72,677 -1.95 35.89%

Renal 977,392 12.00 35,755 -0.35 3.76%

Pallative Care 232,142 2.49 -7,186 0.00 0.00%

Cardiology 1,442,829 15.00 54,898 2.42 16.05%

Stroke 667,787 7.00 -213,972 -1.37 49.49%

Diabetes & Endocrinology 1,163,593 12.00 -236,616 -0.84 35.36%

Breast 993,925 9.68 26,514 -0.09 20.09%

Vascular 1,264,234 12.50 -13,882 0.66 3.02%

Urology 1,268,819 12.00 -171,548 -6.74 14.48%

9,708,531 97.50 -468,191 -8.12 19.38%

Ophthalmology 1,977,435 19.50 -594,583 1.17 35.94%

Dental 750,989 8.11 -56,304 -0.32 11.35%

ENT 2,018,129 20.15 -332,150 -0.42 21.81%

Theatres & Day Surgery 12,975 0.00 12,975 0.00 0.00%

Anaesthetics, Critical Care & Pain Management 8,565,506 81.74 -903,835 2.80 18.32%

Gastro Intestinal Surgery 3,434,593 39.99 -904,128 -0.66 27.87%

16,759,627 169.49 -2,778,062 2.57 22.89%

Research 9,177 0.11 176 0.11 0.00%

PGME 155,975 1.92 17,603 0.00 0.00%

Medical Director 339,098 2.30 32,096 0.15 0.00%

504,250 4.33 49,875 0.27 0.00%

61,423,220 643.02 -7,813,403 -27.10 27.06%

Variance

WTE Net Budgetary Position

Children & Families Care Group £000s £000s £000s £000s £000s £000s £000s

Children & Family Services Care Group - Management 8.87 0 0 0 -97 521 -618 -618 Womens & Maternity 328.54 26,769 27,090 321 20,576 21,757 -1,181 -860

GU Medicine 33.10 5,048 4,913 -135 3,878 3,880 -2 -137

Childrens 249.50 14,851 14,702 -149 13,337 14,161 -824 -973

Total Children & Families Care Group 620.01 46,668 46,705 36 37,694 40,319 -2,625 -2,588

Diagnostic & Pharmacy Care Group

Diagnostic & Pharmacy Care Group - Management 3.72 0 0 0 280 262 18 18Pathology 192.33 6,126 6,479 353 11,620 11,225 395 748

Medical Imaging 209.66 5,222 5,280 58 11,483 13,000 -1,517 -1,459 Outpatient & Clinical Admin 233.35 132 128 -4 4,754 5,187 -433 -437 Pharmacy & Medicines Management 112.31 717 726 9 4,066 4,083 -17 -7

Total Diagnostic & Pharmacy Care Group 751.37 12,197 12,613 416 32,203 33,757 -1,553 -1,137

Emergency Care Group

Emergency Care Group - Management 6.96 0 0 0 209 416 -207 -207 Accident and Emergency Department 290.46 18,302 18,949 647 17,320 19,729 -2,409 -1,762 Emergency Medicine 303.32 33,821 36,292 2,471 13,675 16,380 -2,706 -234

Medical Gastroenterology 94.66 0 0 0 4,824 4,805 19 19

Respiratory Medicine 145.43 2,481 2,648 168 6,452 6,894 -442 -274

Total Emergency Care Group 840.84 54,603 57,889 3,286 42,480 48,225 -5,745 -2,458

MSK & Frailty Care Group

MSK & Frailty Care Group - Management 8.06 0 0 0 546 512 35 35

Trauma & Orthopaedics 265.11 34,851 34,113 -738 21,873 23,278 -1,404 -2,143

Clinical Therapies 332.42 8,216 8,183 -33 12,304 12,022 282 249

Care of the Elderly/Rehabilitation 247.09 12,015 12,277 262 9,317 10,316 -999 -738

Rheumatology 15.78 9,751 9,325 -426 8,501 8,077 424 -1

Total MSK & Failty Care Group 868.46 64,833 63,897 -936 52,542 54,205 -1,663 -2,598

Specialty Services Care Group

Specialty Services Care Group - Management 26.43 0 0 0 887 848 39 39

Neurology 7.63 465 466 2 155 171 -17 -15

Haematology 31.74 10,922 10,276 -647 7,603 7,225 378 -269

Dermatology 29.63 3,233 3,022 -211 1,708 1,914 -206 -417

Renal 75.23 7,200 7,216 16 6,116 5,997 118 134

Pallative Care 15.71 127 142 15 918 872 46 61

Cardiology 145.65 7,732 7,728 -5 7,732 8,192 -461 -466 Corporate Cancer 3.67 0 0 0 87 87 -0 -0 Stroke 56.82 2,944 3,327 382 2,146 2,743 -597 -215

Actual to

date Variance Variance

Income Expenditure

Specialties

Average

Actual

Worked 15/16

Budget to

date

Actual to

date Variance

Budget to

date

Financial Performance - February 2016 - Specialty Performance Summary (+ Favourable / - Unfavourable)

WTE Net Budgetary Position

Actual to

date Variance Variance

Income Expenditure

Specialties

Average

Actual

Worked 15/16

Budget to

date

Actual to

date Variance

Budget to

date

Diabetes & Endocrinology 74.09 6,582 6,471 -111 3,325 3,822 -497 -608 Breast 29.73 4,235 3,821 -414 2,205 2,174 31 -384 Vascular 47.50 4,777 4,984 207 3,281 3,534 -252 -46 Urology 62.64 8,065 7,789 -276 3,391 3,729 -338 -614

Total Specialty Services Care Group 606.47 56,284 55,241 -1,042 39,551 41,308 -1,757 -2,799

Surgical Care Group

Surgical Care Group - Management 18.44 0 0 0 787 1,005 -218 -218

Ophthalmology 81.22 13,225 12,069 -1,156 8,156 8,375 -219 -1,375

Dental 27.76 2,936 2,584 -352 1,973 2,138 -165 -517

ENT 63.42 7,848 7,355 -493 3,620 3,932 -312 -805

Audiology 29.65 2,043 2,080 37 2,042 2,138 -96 -59

Theatres & Day Surgery 262.80 77 73 -4 12,171 12,266 -95 -99

Anaesthetics, Critical Care & Pain Management 297.92 12,558 12,331 -227 18,486 19,336 -850 -1,077

Gastro Intestinal Surgery 215.30 24,642 23,232 -1,410 11,688 13,317 -1,629 -3,039

Endoscopy 79.17 0 0 0 3,126 3,344 -218 -218

Total Surgical Care Group 1,075.67 63,330 59,725 -3,605 62,049 65,849 -3,801 -7,406

Corporate Directorates & RechargesNursing Services 46.31 44 44 0 2,117 2,068 50 50Research 6.53 213 193 -20 229 242 -12 -33 PGME 42.42 78 57 -22 2,244 2,242 2 -20 Hotel Services, Estates & General Operations 714.49 4,983 4,612 -372 27,938 30,238 -2,300 -2,672 People and Organisational Development 56.58 1,936 2,108 173 2,158 2,101 57 230Legal 7.35 0 0 0 2,400 2,441 -41 -41 Chief Executive 18.60 461 461 -0 1,782 1,959 -177 -178 Medical Director 5.24 0 0 0 447 433 13 13Performance Management 56.86 44 41 -3 1,920 1,971 -51 -54 Finance & Healthcare Contracting 162.23 131 179 48 7,219 7,514 -294 -246 Strategy and Improvement 3.10 0 0 0 190 290 -101 -101

Total Corporate Directorates & Recharges 1,119.68 7,891 7,695 -196 48,644 51,498 -2,854 -3,050

24,807 22,898 -1,909 1,366 9,610 -8,245 -10,154

32,699 30,593 -2,105 50,009 61,108 -11,099 -13,204

5,882.50 330,613 326,663 -3,950 316,527 344,769 -28,243 -32,192 Trust Total

Plan phasing adjustment (Monitor plan) and

Total Corporate Directorates, Recharges and Contingency

Recharges and Contingency

Plan Actual The key risks identified in the 2015/16 Business Plan were;

3 1

3 1 - Care Group and Specialty Overspends Care Group and Specialty financial performance is set out on the previous page. Plan Actual

3 1 The Care Group and Specialty financial performance is inclusive of funding adjustments for;

activity and drug growth in line with the Trusts clinical activity projections, pay and non pay - Stock Days 18.1 15.8

3 1 inflation, historic cost pressures, CIP and CCG and Trust developments which are

consistent with the income plans for each Specialty. The performance to date is poor.

3 1 - NHS Trade Debtor Days 13.4 6.1 - CIP Performance

The CIP plans were generated as part of the 2015/16 Business Planning process and the

detailed plans have been reviewed and signed off by the Board. - Non NHS Trade Debtor Days 4.0 2.8 The CIP schemes have been phased as per the agreed projections with Care Group Managers.

CIP performance to date has been very disappointing with the majority of schemes not

delivering the planned level of savings. - Trade Debtor Days 17.4 8.9

- CCG Affordability Doncaster CCG is £198k ahead of plan to date (inclusive of 2015/16 assumed activity) primarily - Trade Creditor Days 60.2 29.5 driven by the Outpatient and offset by Non PbR drugs underperformance.

Bassetlaw CCG are now £307k ahead of plan. This has increased mainly due to Emergency.

Liquidity ratio

Financial Performance - February 2016 - Key Financial Indicators

Capital Spend Profile Against Plan (£000s) 2015/16 Cash Profile Against Plan (£000s) 2015/16 Daily Actual Cash Balances - February 2016

Capital expenditure at month 11 of £11.8m is £7.1m behind plan (£4.9m at month 10). The variance

continues to be due to planned slippage on property and replacement medical equipment expenditure

partly offset by information technology schemes. The variance above 30% is outside Monitor’s

tolerance level but is an integral part of the Trust’s cash recovery plan.

The cash position at month 11 is £1.9m which is £5.6m below the plan to date of £7.5m. The variance is due to

the significant I&E overspend against plan and slippage on land disposals, partly offset by the early drawdown of

the approved ITFF loan and access to Monitor approved temporary working capital facility.

Financial Sustainability Risk Rating (FSRR) to 31st March 2016) Key Financial Risks to February 2016

Financial Sustainability Risk Rating

Key Financial Metrics to February 2016

Capital servicing capacity

I&E Margin

The aggregated Financial Sustainability Risk Rating (FSRR) rating is a 1 against a plan of 3. All four of the

elements (liquidity, capital servicing capacity, I&E margin and variance from plan) are rated as 1,

reflecting the variance in the overall I&E position.

Variance from Plan

Overall FSRR

31 March 31 March

2015 2015 CommentaryActual Actual (Restated) Plan Actual Variance£000 £000 £000 £000 £000

Non-current assets

Intangible assets 3,498 3,498 2,948 2,750 (198)

Property, plant and equipment 201,632 201,632 208,407 206,658 (1,749)

Trade and other receivables 1,993 1,993 1,968 1,976 8

Total non-current assets 207,123 207,123 213,323 211,384 (1,939)

Current assets

Inventories 5,476 5,476 5,501 5,556 55

Trade and other receivables 16,562 14,602 23,399 19,732 (3,667)

Cash and cash equivalents 11,706 11,706 7,535 1,897 (5,638)

Total current assets 33,744 31,784 36,435 27,185 (9,250)

Non-current assets held for sale 350 350 - - -

Current liabilities

Trade and other payables (31,579) (45,892) (28,929) (32,047) (3,118)

Borrowings (2,483) (2,483) (2,483) (2,860) (377)

Provisions (442) (442) (142) (404) (262)

Total current liabilities (34,504) (48,817) (31,554) (35,311) (3,757)

Total assets less current liabilities 206,713 190,440 218,204 203,258 (14,946)

Non-current liabilities

Borrowings (15,460) (15,460) (24,970) (59,651) (34,681)

Provisions (590) (590) (590) (462) 128

Total non-current liabilities (16,050) (16,050) (25,560) (60,113) (34,553)

Total assets employed 190,663 174,390 192,644 143,145 (49,499)

Financed by (taxpayers equity)

Public dividend capital 128,755 128,755 128,755 128,755 -

Income and expenditure reserve 25,555 9,282 27,536 (21,763) (49,299)

Revaluation reserve 36,353 36,353 36,353 36,153 (200)

Total taxpayers equity 190,663 174,390 192,644 143,145 (49,499)

As at 29th February 2016

Statement of Financial Position

Balance Sheet - February 2016

Tangible assets are below plan due to the reduced capital expenditure programme and cash restriction.

Trade and other receivables are lower than plan due to prior year adjustments, the prompt payment of monies

by NHS Trusts and CCGs; and prepayments being lower than expected as a result of a revised payment schedule

with NHS Litigation Authority.

Cash is below plan due to the significant I&E overspend against plan and slippage on land disposals, partly offset

by the early drawdown of the approved ITFF loan and access to Monitorapproved temporary working capital

facility.

Trade and other payables are above plan due to prior year adjustments to trade payables and accruals,the

extension of trade creditors, which is slightly offset by lower than expected capital creditors due to the slippage in

the capital programme.

Borrowings are above plan due to the earlier drawdown of the approved ITFF loan and loans provided as the

temporary working capital facility.

Income and expenditure reserve variance reflects the prior year adjustments and significant in-year overspend

against the planned surplus position.

The level of trade creditors reduced in August (month 5) following receipt of the ITFF loan.

Aged Creditor Analysis - February 2016

NHS - Creditor Analysis Non NHS - Creditor Analysis

0

1500000

3000000

4500000

6000000

7500000

9000000

10500000

12000000

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

201601 201602 201603 201604 201605 201606 201607 201608 201609 201610 201611

Not Yet Due/Data Quality

0-29

30-59

60-89

90-120

>120

Grand Total

-2000000

0

2000000

4000000

6000000

8000000

10000000

12000000

14000000

16000000

-1000000

0

1000000

2000000

3000000

4000000

5000000

6000000

7000000

8000000

201601 201602 201603 201604 201605 201606 201607 201608 201609 201610 201611

Not Yet Due/Data Quality

0-29

30-59

60-89

90-120

>120

Grand Total

1

Title Business Intelligence Report

Report to: Board of Directors Date: 22.03.2016

Author: David Purdue, Chief Operating officer

Sewa Singh, Medical Director

Richard Parker, Director of Nursing, Midwifery and Quality

Jeremy Cook, Interim Director of Fianance

For: Approval

Purpose of Paper: Executive Summary containing key messages and issues

The Business intelligence report highlights the key performance and financial targets required by the Trust to maintain Monitor compliance. The report gives insight into current issues and pressures faced during the current increase of emergency activity. The drill down for March focuses on the actions underway to improve stroke performance. The report reviews the actions being taken to address for all performance, quality and financial indicators.

Recommendation(s)

To approve

Delivering the Values – We Care (how the values are exemplified by the work in this paper)

We always put the patient first

By ensuring the correct capacity and pathways are in place to allow for treatment in the right place, first time. To ensure quality care is at the centre of all we do to provide the most efficient service.

Everyone counts – we treat each other with courtesy, honesty, respect and dignity

By ensuring that all parties have contributed to the planning and delivery of services Committed to quality and continuously improving patient experience

By delivering new ways of working across health and social care to ensure compliance withal quality indicators

Always caring and compassionate

By ensuring staff are committed to working with partners to improve services. Responsible and accountable for our actions – taking pride in our work

By being accountable for delivery of the efficient and effective services Encouraging and valuing our diverse staff and rewarding ability and innovation

By ensuring engagement in planning and delivery of services

Related Strategic Objectives

2

Provide the safest, most effective care possible

Control and reduce the cost of healthcare

Focus on innovation for improvement

Develop responsibly, delivering the right services with the right staff

Analysis of risks

Resource – Key financial issues related to additional funding streams to support planning for surge capacity.

Governance – The Trust needs to maintain compliance framework with monitor

Equality and Diversity – No known issues or risks.

PR and Communications – Need for continued appropriate communication to ensure ongoing performance

Patient, Public and Member Involvement – Public attendance at System Resilience Groups

Risk Assessment – The risks to the Trust’s performance are very high 2015/16, at this stage especially in relation to 4hr access

NHS Constitution - Rights and Pledges – No known issues or risks.

Board Assurance Framework

1 Failure to achieve performance and compliance targets and processes 4x3= 12

2 Failure to match capacity with demand, particularly during winter 4 x 4 = 16

3 Failure to maintain appropriate organisational corporate governance systems 5x 4 = 20

Sewa Singh Medical Director

Richard Parker Director of Nursing

David Purdue Chief Operating Officer

Jeremy Cook Interim Director Of Finance

Doncaster and Bassetlaw Hospitals NHS Foundation Trust

Board of Directors Meeting

Performance - February 2016 - (Month 11)

1

Executive summary - Performance - February 2016

The performance report is against operational delivery in January/February 2016 Provide the safest, most effective care possible Monitor governance compliance is rated against 3 National targets, 4hr Access, Referral to Treatment, which includes diagnost ic waits and Cancer Targets. The targets are all monitored quarterly, both 4hr access and cancer are averaged over the quarter b ut referral to treatment is monitored each month of the quarter and must be achieved each month. The business intelligence report also highlights key National and local targets which ensure care is being provided effective ly and safely by the Trust. 4hr Access The target is based on the number of patients who are treated within 4hrs of arrival into the emergency department and set at 95 and reported Quarterly as an average figure. This target is for all urgent care provided by the Trust for any patient who wa lks in. We have 2 type 1 facilities, ED at BDGH and DRI and 1 type 3 facility at MMH. The Trust does not count any GP admissions areas within its target. January Performance Trust 92.48% Year 94.70% National Performance 84.8% February attendances 13176, on a daily average attendance figures continue to increase in both main departments. A total of 991 patients failed to be treated within 4hrs Doncaster achieved 89.24%, 836 patients failed to be treated within 4hrs, which is 112 less than in January. The number of br eaches due to internal ED waits decreased by 107 compared to January and bed waits decreased by 7. Key to current performance is the increases in patient acuity, the average number of attendances where the patient was seen i n a resus or major location per day has risen from 89.8 per day in Q2 to 94.5 per day in Q3 to 99.9 per day in the first two mont hs of Q4. As a percentage of all attendances, the percentage of patients treated in a Resus or Major location has risen from 34.9% in Q2 to 36.5% in Q3 to 37.3% in the first two months of Q 2. February saw 7.2% of attendances treated in a Resus location. Bassetlaw achieved 96.02%, 155 patients failed to be treated within 4hrs, which was 11 more than in January. The number of br eaches due to internal ED waits increased by 21 compared to January. Bassetlaw only saw 27 patients less in February compared to January showing the continued rise in attendances. The average number of attendances per day to BDGH’s A&E Department where the patient was treated in a Resus or Major location has risen f rom 42.5 per day in Q2 to 44.8 per day in Q3 to 48 in the first two months of Q4 ( the average number of Resus/Major attendances in February was just over 50). As a percentage of all attendances Resus or Major attendances made up 31.7% of attendances in July 2015, rising to 37.3% in February 2016 Ambulance Handover times have deteriorated in January following the increases in attendances of more acuity. This was compoun ded by EMAS stopping using the RFID to manage waiting times and currently this is dependent on a manual process and the Trust is unable to fully validate the ambulance data. Electronic Handover screens are now in place but February data will be a manual process. Referral to Treatment The target is now measured against incomplete pathways only at 92%. The grace period for failing the target has now been lifted and fines for speciality failure have increased to £300 per patie nt. Monitor compliance is against the Trust total position. For quarter 4 all contract penalties are not being actioned following guidance from NHSE. As part of the National incentive to reduce waiting times, the Trust was successful in securing funding for additional valida tion of over 18 week waiters. The need for additional resource was as a direct result of the change from Total care PAS to caMI S. February, achieved 92.1% 4 specialities failed the target; Trauma and Orthopaedics, 90.8% General Surgery, 90.9% ENT, 89.4% Urology 88.4% The specialities with the exception of T&O will be compliant by the end of April 2016. A review of MSK is being undertaken by both CCGs as referral levels are above national averages in to the acute sector. No patients waited over 52 weeks Diagnostic waits ended at 99.7% against the target of 99% The numbers waiting over 6 weeks was 23. Cancer Performance January performance for 62 day pathways was not achieved locally. The target failed Nationally in January at 81% The report identifies 62 day performance broken down into tumour sites as directed by the new Cancer high impact intervention s. Urology remains the key speciality both locally and from a tertiary perspective to fail the target. Actions are being underta ken to ensure improvements in the internal pathways from decision to refer and transfer pathways are being agreed with the tertiary providers. 2 week-wait performance was achieved for both CCGs. Stroke The key pathway which fails to improve despite additional bed capacity and increased hours within the Stroke nurses cover is direct admission. 18 out of a total of 45 patients failed to be admitted within 4 hrs, though this improves to 11 in 5 hrs. 9 pa tients clinical presentation was not suggestive of a stroke, and 2 were clinically unstable. Scan in 24hrs failed due to the clinical presentation of the patients and scans were only ordered following continued symptom s whilst an in patient. Cancelled Operations Cancelled operations performance, is those patients cancelled on the day of the procedure and is split into theatre and non -theatre cancellations. Theatre cancellations increased mainly due to bed pressures particularly in gynaecology and orthopaedics. Non-theatre cases increased due to staff sickness. David Purdue Chief Operating Officer February 2016

2

Page IndicatorCurrent

MonthMonth Actual Page Current Month

Month

Actual

(TRUST)

Month Actual

(DRI)Month Actual (BDGH)

31 day wait for second or subsequent treatment: surgery 94.0% M 100.0% Feb-16 42.2% 46.9% 30.8%

31 day wait for second or subsequent treatment: anti cancer drug treatments 98.0% M 100.0%

31 day wait for second or subsequent treatment: radiotherapy 94.0% M 100.0% 66.6% 65.6% 69.2%

62 day wait for first treatment from urgent GP referral to treatment 85.0% M 76.3% 90.9% 96.9% 69.2%

62 day wait for first treatment from consultant screening service referral 90.0% M 82.4% 93.3% 96.9% 84.6%

31 day wait for diagnosis to first treatment- all cancers 96.0% M 97.6% 86.7% 84.4% 92.3%

Two week wait from referral to date first seen: all urgent cancer referrals (cancer

suspected)93.0% M 93.5% 95.6% 100.0% 84.6%

Two week wait from referral to date first seen: symptomatic breast patients (cancer

not initially suspected)93.0% M 94.9% 6.55% 2.60% 1.19%

Infection Control C.Diff4 Per Month for

Qtr 2 - 45 full

year

M Feb-16

Infection Control MRSA 0 L Feb-16

16 HSMR (rolling 12 Months) 100 N Nov-15

Never Events 0 L Feb-16

VTE 95.0% N Jan-16

Pressure Ulcers12 Per Month

144 full YearL

Total time in A&E: 4 hours (95th percentile) HH:MM 04:00 N 06:16 Falls that result in a serious Fracture 2 Per Month 23

full YearL

A&E Admitted patients total time in A&E (95th percentile) HH:MM 04:00 N 10:49

A&E: Time to treatment decision (median) HH:MM 01:00 N 01:00

A&E unplanned re-attendance rate % 5.0% N 0.4%

A&E: Left without being seen % 5.0% N 3.6%

Ambulance Handovers Breaches -Number waited over 15 & Under 30 Minutes 821

Ambulance Handovers Breaches-Number waited over 30 & under 60 Minutes 239

Ambulance Handovers Breaches -Number waited over 60 Minutes 40

Proportion of Stroke patients scanned within one hour of arrival at hospital 50.0% N 51.1%

Proportion of Stroke patients scanned within 24 hours of arrival at hospital 100.0% N 93.3%

Proportion of high-risk TIA patients investigated and treated within 24 hours of first

contact with a health professional60.0% N 72.2%

Cancelled Operations 0.8% N 2.1%

Cancelled Operations-28 Day Standard 0 N 2

Out Patients: DNA Rate L 7.6%

Out Patients: Hospital Cancellation Rate L 16.6%

Total Number of DNAs L

Total Number of DNW L

Did Not Wait Rate L

Best Practice Criteria

Feb-16Frac

ture

d N

eck

of

Fem

ur

Indicator

Jan-16

A&E: Maximum waiting time of four hours from arrival / admission / transfer /

discharge (Trust)95.0%

17

% of Patients waiting less than 6 weeks from referral for a diagnostics test 99.0% N 99.7%

M

Page Month ActualCurrent Month Data Quality RAG Rating

Safe

Snap shot auditCatheter UTI

At a Glance - February 2016 (Month 11)

Standard (Local,

National Or Monitor)Data Quality RAG Rating

0

Mo

nit

or

Co

mp

lian

ce F

ram

ew

ork

Jan-16

Feb-16 92.5%

Mortality-Deaths within 30 days of procedure

% of patients receiving a bone protection medication assessment

% of patients who underwent a falls assessment

% of patients who underwent an MDT assessment

72 hours to geriatrician assessment Performance

36 hours to surgery Performance

Maximum time of 18 weeks from point of referral to treatment- incomplete pathway 92.0%

A&

E P

erf

orm

ance

Ind

icat

ors

N

% of patients achieving Best Practice Tariff Criteria

Standard (Local,

National Or Monitor)Indicator

Effe

ctiv

e

Emergency Readmissions within 30 days (PbR Methodology) L Jan-16 6.7%

The

atre

s &

Ou

tpat

ien

ts

Feb-16

Data

Unavailable

M

Feb-16

92.1%

Proportion of patients admitted to an acute Stroke unit within 4 hours of arrival 90.0% N

Stro

ke

A&E Non-admitted patients total time in A&E (95th percentile) HH:MM 04:00 N 03:58Feb-16

60.0%

Dec-15

5

1

Liabilities to Third Parties Scheme (LTPS)

19

Rag RatingCurrent MonthIndicatorPage

Co

mp

lain

ts &

Cla

ims

20

580Complaints received

Feb-16

Feb-16

0.23%

2

2

Concerns Received 865

Complaints Performance 19.80%

Claims per 1000 occupied bed days 0.35

Clinical Negligence Scheme for Trusts (CNST)

Total number of open and active claims with the NHSLA (as at 31 May 2015)

4

95.0%

98.94

2

LTPS: 51

CNST: 216

3

Context

Reasons for Success/Failure

Actions being taken to address any issues

Standard Jan-15QTR 3

2015-16Nov-15 Dec-15 Jan-16

Expected date to

meet standard

94.0% 100.0% 100.0% 90.0% 100.0% 100.0%98.0% 100.0% 100.0% 100.0% 100.0% 100.0%94.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Tumor TypeBreast 94.6% 100.0% 100.0% 100.0% 92.0%Gynaecological 87.5% 78.3% 62.5% 66.7% 100.0%Haematological 100.0% 82.4% 100.0% 80.0% 100.0%Head & Neck 100.0% 87.5% 100.0% 62.5%Lower Gastrointestinal 57.1% 88.2% 80.0% 100.0% 85.6%Lung 80.0% 75.0% 80.0% 100.0% 83.3%Other 88.9% 100.0% 100.0%Sarcoma 0.0% 66.7% 66.7%Skin 100.0% 96.3% 100.0% 89.5% 100.0%Upper Gastrointestinal 87.5% 88.4% 84.6% 86.7% 91.7%Urological 75.7% 65.5% 57.9% 70.3% 50.0%

All Cancers 83.3% 86.1% 81.5% 89.3% 76.3% Q4Tumor TypeBreast 100.0% 100.0% 100.0% 100.0% 100.0%GynaecologicalHaematological 100.0%Head & NeckLower Gastrointestinal 50.0% 57.1% 0.0% 66.7% 50.0%LungOtherSarcomaSkinUpper GastrointestinalUrologicalAll Cancers 94.1% 95.2% 91.5% 95.8% 82.4% Q4

96.0% 100.0% 98.7% 98.2% 99.4% 97.6% Standard Met93.0% 93.7% 95.0% 95.0% 95.0% 93.5%93.0% 92.9% 95.4% 94.6% 93.3% 94.9%

62 day wait for first treatment from consultant screening service referral 90.0%

Monitor Compliance Framework: Cancer - January 2016 (Month 10)

Cancer targets are reported quarterly as an average position. Nationally 62 target has been failed and the Trust has developed a 62 day cancer plan to be compliant by April 2016

62 day pathways failed in month due to continued capacity and pathway issues primarily with urology.

The Trust reports weekly at the PTL all 62 day target performance

Electronic system flags delays in individual pathways to the relevant consultant, MDT coordinator and performance manager are in place flagging at day 28. 40 and 50

Individual breach reports are discussed with the MDTs to ensure learning is in place

Urology pathways changed to allow for earlier tests and these commenced at MMH on the 11th September.

Additional urology slots made available and reviewing straight to test pathways, identified clinics for prostate cancers now in place.

Agreeing handover criteria for electronic referrals to tertiary centre

Improved access to diagnostics and cancer patients flagged through the diagnostic system. CT/MRI capacity identified for urology.

Changes to access from the NICE guidance has led to redesigned referral proformas and guidance to GPs

Renewed systems in booking with named individuals responsible for 2 week wait appointments

Patients being contacted when they delay their appointment outside of 14 days

Indicator

31 day wait for second or subsequent treatment: surgeryStandard Met31 day wait for second or subsequent treatment: anti cancer drug treatments

31 day wait for second or subsequent treatment: radiotherapy

31 day wait for diagnosis to first treatment- all cancersTwo week wait from referral to date first seen: all urgent cancer referrals (cancer suspected) Standard MetTwo week wait from referral to date first seen: symptomatic breast patients (cancer not initially suspected)

62 day wait for first treatment from urgent GP referral to treatment 85.0%

4

Monitor Compliance Framework: Cancer - Graphs - January 2016 (Month 10)

5

Context

Reasons for Success/Failure

Actions being taken to address any issues

Feb-15 Qtr 3 2015-16 Nov-15 Dec-15 Feb-16

92.1% 95.1% 95.5% 92.1% 92.5%

94.5% 96.0% 96.1% 95.2% 95.7%

88.8% 93.8% 94.6% 89.7% 90.2%

06:16 04:47 04:00 06:11 06:16

10:36 08:15 07:48 10:20 10:49

03:59 03:57 03:56 03:58 03:58

00:58 00:53 00:53 00:57 01:00

0.4% 0.6% 0.3% 0.4% 0.4%

0.3% 2.7% 3.0% 3.0% 3.6%

Jan-15 Qtr 3 2015-16 Nov-15 Dec-15 Jan-16

688 1770 515 743 821

326 179 50 72 239

44 15 9 4 40

A&E: Left without being seen % 5.0%

Indicator Standard

Ambulance Handovers Breaches -Number waited over 15 & Under 30 Minutes

Ambulance Handovers Breaches -Number waited over 30 & under 60 Minutes

Ambulance Handovers Breaches -Number waited over 60 Minutes

01:00

A&E unplanned re-attendance rate % 5.0%

A&E Non-admitted patients total time in A&E (95th percentile) HH:MM 04:00

Monitor Compliance Framework: A&E - February 2016 (Month 11)

February performance Trustwide at 92.48%, DBHFT remained the best performing Trust locally and above the National performance

DRI performance dropped to 89.24%, including MMH, 90.32%. 836 patients failed to be treated within 4hrs

Bassetlaw CCG performance 96.02%, 155 patients breached the target.

Patient flow particularly at DRI was affected by the increase in emergency activity throughout February. Average conversion rate from ED to admission increased from an average of 20.5% to 27.2%

Staffing in both departments has been an issue following the February reduction in agency CAPs. The department has had staff leave to surrounding Trusts as a result of them breaking CAP rates. This has been raised

at Working together for a unified approach. A number of initiatives are underway to improve staffing levels.

Streaming at DRI improved slightly in month to 12.31% to unplanned care.

Improved Trustwide escalation plans for care groups are now formally approved

Medical rotas have been reviewed to match capacity and additional support staff put in place to improve flow in the department.

Symphony in ED has been simplified to improve productivity of the medical staff in the department. Electronic discharge summaries are now in place for GP follow up.

Indicator Standard

A&E: Maximum waiting time of four hours from arrival/ admission/ transfer/ discharge (Trust)

95.0%

A&E: Maximum waiting time of four hours from arrival/ admission/ transfer/ discharge (Bassetlaw CCG)

A&E: Maximum waiting time of four hours from arrival/ admission/ transfer/ discharge (Doncaster CCG)

Total time in A&E: 4 hours (95th percentile) HH:MM 04:00

A&E Admitted patients total time in A&E (95th percentile) HH:MM 04:00

A&E: Time to treatment decision (median) MM

6

Monitor Compliance Framework: A&E - Graphs - February 2016 (Month 11)

7

Context

Reasons for Failure (if applicable)

Actions being taken to address any issues

Indicator Standard Feb-15 Qtr 3 2015-16 Dec-15 Jan-16 Feb-16

Maximum time of 18 weeks from point of referral

to treatment- incomplete pathway92.0% 93.7% 92.1% 92.1% 92.3% 92.1%

Indicator Standard Feb-15 Dec-15 Jan-16 Feb-16

% of Patients waiting less than 6 weeks from

referral for a diagnostics test99.0% 95.2% 96.5% 99.5% 99.7%

Diagnostics Waits 345 241 35 23

Monitor Compliance Framework: 18 Weeks & Diagnostics -February

2016 (Month 11)

National reporting changes for RTT have come into effect from October 2015. The changes implemented this month are:

1. Removal of the submission of Admitted Adjusted Clock Stops (only Non-Admitted and Admitted (Unadjusted) are submitted but no target applies).

2. Additional item submitted on the number of “Incomplete Pathways with a Decision to Admit for Treatment” (no target applies)

3. Additional item submitted on the number of “New RTT Periods” in the month (number of clock starts in the month).

Incomplete pathways in January ended at 92.1%,

4 specialities failed to meet the 92% target,

Trauma and Orthopaedics 90.8%

General Surgery 90.9%

ENT 89.4%

Urology 88.4%

Diagnostic waits achieved at 99.7%, 23 patients in total waited over 6 weeks

Trajectories have been set for all the 4 specialities to be compliant by April 2016.

General Surgery will be compliant at the end of March, issues with cancellations in February caused a deterioration in the position. Key pathway is upper GI surgery

all other sub specialities are compliant.

A review of orthopaedic productivity is underway, detailed work with the commissioners in in progress to review orthopaedic pathways

ENT have a Trust locum in place who is addressing the ENT backlog, which has been caused with increased referrals.

The launch of caMIS has caused a number of pathways to be incorrectly recorded. Additional DoH support has been secured to improve the position by the end of

March.

Expected date to meet

standard

Standard Met

Expected date to meet

standard

Standard Met

8

Monitor Compliance Framework: 18 Weeks & Diagnostics -February (Month 11)

9

Context

Reasons for Failure (if applicable)

Actions being taken to address any issues

Indicator Standard Dec-14Qtr 3

2015-16Oct-15 Nov-15 Dec-15

Proportion of patients admitted to an acute Stroke

unit within 4 hours of arrival90.0% 95.8% 61.3% 66.7% 58.2% 60.0%

Proportion of Stroke patients scanned within one

hour of arrival at hospital50.0% 37.5% 52.1% 54.8% 50.9% 51.1%

Proportion of Stroke patients scanned within 24

hours of arrival at hospital100.0% 97.9% 95.8% 95.2% 98.2% 93.3%

Proportion of high-risk TIA patients investigated and

treated within 24 hours of first contact with a health

professional

60.0% 95.8% 74.5% 80.6% 71.0% 72.2%

Stroke - December 2015 (Month 9)

Stroke Targets are now reported against the SSNAP data, and 90% on a stroke unit is no longer collected

The key pathway remains direct admission to a hyper acute stroke bed. The reporting of SSNAP data is refreshed each month up to 3 months so the latest

figures are from December, of the 45 discharged, only 60% were admitted in 4hrs, 76% were admitted within 5hrs.

The new assessment beds on the stroke unit are in operation.

The overall number of stroke beds has increased to 49 across the Trust

Improved teaching in ED, to identify the key signs of strokes

Pathways for the stroke service out of the hospital to MMH and early supported discharge are being reviewed to ensure adequate bed capacity

Expected date to meet

standard

Mar-16

Standard Met

Jan-16

Standard Met

10

Stroke - Graphs December 2015 (Month 9)

11

Stroke - Graphs South Yorkshire October - December 2015

12

Alert ReasonTrend (October -

December)

Methodology

Reason for Failure

Actions being taken to address the issue

OctoberNovemb

er

Decembe

r

January

Predict

Trend

(October -

December)

66.7% 58.2% 60.0% 74.9%

42 55 45 50

28 32 27 37

95.2% 98.2% 93.3% 93.9%

42 55 45 50

40 54 42 47

OctoberNovemb

er

Decembe

rJanuary

Trend

(October -

December)

89.5% 89.6% 95.8% 84.6%

57 48 48 52

51 43 46 44

100.0% 97.9% 97.9% 98.1%

57 48 48 52

57 47 47 51

OctoberNovemb

er

Decembe

rJanuary

Trend

(October -

December)

59.3% 73.5% 71.4% 61.4%

59 49 49 44

35 36 35 27

100.0% 100.0% 98.0% 95.5%

59 49 49 44

59 49 48 42

This Indicator has alerted due to the failure to meet the National TargetProportion of stroke Patients admitted to an acute

Stroke unit within 4 hours of arrival90.0% 60.0%

* Proportion of stroke Patients admitted to an acute Stroke unit within 4 hours of arrival

* Proportion of stroke patients scanned within 24 hours of arrival at hospital

Indicator Target Month Actual (December)

Proportion of stroke Patients admitted to an

acute Stroke unit within 4 hours of arrival74.1%

Proportion of stroke patients scanned within 24 hours of

arrival at hospital100.0% 93.3%

The Stroke National Auit Programme figures are now used to report stroke data. This metholody is causing issues against the Stroke Indicator Data which was previously used. Data validation is required to ensure the figures are accurate and currently the August position remains unvalidated.

Direct Access to a stroke unit remains uncompliant, thsis is mainly in relation to early identification of strokes within ED.

4 additional beds opened to allow for direct assessment beds on the stroke unit, weekly audits have shown improved results compared to the SNAP data which needs to be validated. The site team are aware of the need to allow assessments beds on the stroke unit to be protected and this is agreed.

2015/16Predicted Year End

Total

Proportion of stroke patients scanned within 24

hours of arrival at hospital96.2%

Total Patients 588

Total admitted within 4 hours of arrival 435

Total Patients 590

Total scanned within 24 hours 568

2014/15 2014-15

Proportion of stroke Patients admitted to an

acute Stroke unit within 4 hours of arrival78.5%

Total Patients 568

Total admitted within 4 hours of arrival 446

Proportion of stroke patients scanned within 24

hours of arrival at hospital98.6%

Total Patients 562

Total scanned within 24 hours 554

Total admitted within 4 hours of arrival 386

2013/14 2014-15

Proportion of stroke Patients admitted to an

acute Stroke unit within 4 hours of arrival67.7%

Total Patients 570

Total scanned within 24 hours 560

Proportion of stroke patients scanned within 24

hours of arrival at hospital98.2%

Total Patients 570

13

Indicator Standard Feb-15Qtr 3

2015-16Dec-15 Jan-16 Feb-16

Cancelled Operations (Total) 0.8% 1.0% 1.5% 2.0% 2.9% 2.1%

Cancelled Operations (Theatre) 0.9% 1.0% 1.4% 2.0% 1.7%

Cancelled Operations (Non Theatre) 0.2% 0.6% 0.6% 0.9% 0.5%

Cancelled Operations-28 Day Standard 0 2 3 2 5 2

Outpatients: DNA Rate Total 7.9% 9.7% 9.5% 7.9% 7.6%

Outpatients: DNA Rate First 7.4% 8.7% 9.5% 8.3% 7.8%

Outpatients: DNA Rate Follow Up 8.1% 10.2% 9.5% 7.8% 7.5%

Outpatients: Hospital cancellation Rate 15.0% 16.2% 17.5% 16.3% 16.6%

Outpatients: Patient cancellation Rate 16.6% 16.0% 18.0% 16.2% 15.5%

Outpatients: Patient died cancellation Rate 0.4% 0.1% 0.1% 0.1% 0.1%

Indicator

Total Number of DNAs (Refreshed Each Month)

Total Number of DNW (Refreshed Each Month)

Did Not Wait Rate (Refreshed Each Month)

Theatre & Outpatients - February 2016 (Month 11)DNA Rate: Benchmarking data taken from Healthcare Evaluation Data (HED) (December 2014 to November 2015)

Data Unavailable

14

Bed Plan 2015/16

April May June July August Sept Oct Nov Dec Jan Feb MarchDRI

Bed requirement for medical and care of the elderly patients based on current

average length of stays for each main specialty 348 352 328 314 323 316 329 321 359 352 329 327Total Beds available within medicine/cote. This allows for 16 escalation beds

to close for 7 months and 20 restricted beds closed to keep wards at optimum

numbers 328 312 312 312 312 312 312 312 328 328 320 320

Specialty medicine bed requirement ( Cardiology, stroke, Renal, Haematology) 58 51 56 52 62 58 64 63 51 43 51 54

Specialty beds available 65 65 65 65 65 65 65 65 65 65 65 65

Total medical patient beds required 406 403 384 366 385 374 393 384 410 395 380 381

Beds position against funded -15 -24 -7 11 -8 3 -16 -7 -17 -2 13 12

Surgical Bed requirements 93 87 86 95 93 83 89 80 74 93 95 89

Surgical beds available 99 99 99 99 99 99 99 99 99 99 99 99Specailty surgical bed requirements (excluding breast services which are on

G5) 33 39 35 37 26 33 35 35 33 29 39 33

Specialty beds available 39 39 39 39 39 39 39 39 39 39 39 39

Total surgical bed requirements 126 126 121 132 119 116 124 115 107 122 134 122

Bed position against funded 12 12 17 6 19 22 14 23 31 16 4 16

Orthopaedic Bed requirements 60 55 62 62 59 53 51 53 51 53 64 55

Total beds available(excluding TAU) 62 62 62 62 62 62 62 62 62 62 62 62

Bed position against funded 2 7 0 0 3 9 11 9 11 9 -2 7

Gynaecology bed requirement including breast services 16 17 15 14 18 18 17 19 16 18 19 17Gynaecology beds available including daycase 26 26 26 26 26 26 26 26 26 26 26 26Beds against funded 10 9 11 12 8 8 9 7 10 8 7 9

Total adult bed requirement against funded beds 11 2 21 27 22 42 18 32 35 31 22 44

Paediatric bed requirement 21 25 24 25 22 26 29 26 30 30 26 26

Paediatric Beds Available 39 39 39 39 39 39 39 39 39 39 39 39

Bed against funded 18 14 15 14 17 13 10 13 9 9 13 13

Bassetlaw

Medicine bed requirements 109 107 102 99 108 110 109 97 103 103 104 106

Medical beds available 110 107 107 107 107 107 107 107 107 110 110 110

Beds against funded 1 0 5 8 -1 -3 -2 10 4 7 6 4

Surgery bed requirements 23 27 22 25 26 26 23 27 21 23 26 26

Surgical beds available 31 31 31 31 31 31 31 31 31 31 31 31

Beds agsinst funded 8 4 9 6 5 5 8 4 10 8 5 5

Orthopaedic bed requirements 33 27 28 31 29 26 30 26 31 24 24 30

Orthopaedic beds available 35 35 35 35 35 35 35 35 35 35 35 35

Beds against funded 2 8 7 4 6 9 5 9 4 11 11 5

Bed total available 176 173 173 173 173 173 173 173 176 176 176 176

Bed difference against beds 11 12 21 18 10 11 11 23 18 26 22 14

Paediatric bed requires 8 10 7 9 6 6 8 10 12 9 8 8Paediatric beds available 14 14 14 14 14 14 14 14 14 14 14 14

Beds against funded 6 4 7 5 8 8 6 4 2 9 6 6

8 beds have been removed from medicine at DRI, throughout February. Escalation beds have been restricted in areas to ensure adequate staffing levels. 8 beds have been closed on S12 over the weekends to protect elective capacity.

15

Daily averageMost Sleepers-out in

February 2016Least Sleepers-out in February 2016

Medicine to Ortho 6 10 3Medicine to S12 5 9 2Medicine to Surgery 12 19 8Medicine to Gynae 9 15 3

Medical Outliers by Specialty -February 16 (Month 11)

16

Executive summary - Safety & Quality - February 2016 (Month 11)

HSMR: Overall HSMR continues to improve. Crude mortality has risen in December, January and February. This is mirrored nationally and is likely to be a reflection of high non-elective activity leading to cancellation of elective activity. Fractured Neck of Femur: Performance has been poor two months running. The action plan has been refreshed and we are implementing an electronic recor d for #NOF which will aid clinicians in progressing patients along their care pathway. Serious Incidents: There has been an increase in the number of SIs reported in February. Despite this, we remain on trajectory for a reduced number of SIs for the financial year. Claims: We remain on trajectory for a reduction in claim numbers at year end. Executive Lead: Mr S Singh Infection Control: C- diff performance has been maintained in February and the Trust remains on target to achieve a significnat improvement on per foramnc ein 2015/ 2016. An MRSA bacteraemia has been recorded in February , which brings the year to date performance to two cases. A PIR has not yet been conducted. Hospital Acquired Pressure Ulcers : Perfomance has been mainatined in February and the Trust remains on target to achieve the local stretch standard. Falls: Performance has been maintained in February and the Trust is on target to achive the full year standard. Complaints and concerns: The expected improvments in response times has not been achived and remedial action will be required. Friends & Family Test: Actions to improve the response rate in the Emergecney Departments have been agreed and will be implemented with the aim of a chieiving natioanl response rates from April. Executive Lead: Mr R Parker

17

2014 2015

115.45 115.57

99.11 99.16

102.91 91.51

110.49 108.00

90.93 102.95

113.74 80.18

109.94 92.91

120.18 99.17

110.10 93.13

106.58 90.42

106.84 89.06

116.40

Hospital Standardised Mortality Ratio (HSMR) - November 2015 (Month 7)

Overall HSMR (Rolling 12 months) HSMR - Non-elective Admission (Rolling 12 months) HSMR - Elective Admission (Rolling 12 months)

HSMR Trend (monthly) Crude Mortality (monthly) - February 2016 (Month 11)(number of deaths/number of patient discharged)

January

February

March

April

May

June

July

August

September

October

November

December

98.94 96

98

100

102

104

106

108

110

Jan

14

- D

ec 1

4

Feb

14

- J

an 1

5

Mar

14

- F

eb 1

5

Ap

r 1

4 -

Mar

15

May

14

- A

pr

15

Jun

14

- M

ay 1

5

Jul 1

4 -

Ju

n 1

5

Au

g 1

4 -

Ju

l 15

Sep

14

- A

ug

15

Oct

14

- S

ep 1

5

No

v 1

4 -

Oct

15

Dec

14

- N

ov

15

98.98 96

98

100

102

104

106

108

110

Jan

14

- D

ec 1

4

Feb

14

- J

an 1

5

Mar

14

- F

eb 1

5

Ap

r 1

4 -

Mar

15

May

14

- A

pr

15

Jun

14

- M

ay 1

5

Jul 1

4 -

Ju

n 1

5

Au

g 1

4 -

Ju

l 15

Sep

14

- A

ug

15

Oct

14

- S

ep 1

5

No

v 1

4 -

Oct

15

Dec

14

- N

ov

15

89.83

40

50

60

70

80

90

100

110

Jan

14

- D

ec 1

4

Feb

14

- J

an 1

5

Mar

14

- F

eb 1

5

Ap

r 1

4 -

Mar

15

May

14

- A

pr

15

Jun

14

- M

ay 1

5

Jul 1

4 -

Ju

n 1

5

Au

g 1

4 -

Ju

l 15

Sep

14

- A

ug

15

Oct

14

- S

ep 1

5

No

v 1

4 -

Oct

15

Dec

14

- N

ov

15

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Crude Mortality (Trust)

0.0050.01

0.0150.02

0.025

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Crude Mortality (BDGH)

0.01

0.013

0.016

0.019

0.022

Ap

r-1

5

May

-1

5

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Crude Mortality (DRI)

18

NHFD Best Practice Pathway Performance - February 2016 (Month 11)

Best Practice Criteria Performance 36 Hours to Surgery Performance MDT Assessment Performance

72 Hours to Geriatrician Assessment Performance Falls Assessment Performance

Bone Protection Medication Assessment Deaths within 30 days of procedure (Rolling 12 months)

42.20%

46.90%

30.80%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

% achieving best practice tariff criteria (Trust)

% achieving best practice tariff criteria (DRI)

% achieving best practice tariff criteria (BDGH)

66.60%

0.656

0.692

40%

60%

80%

100%

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Trust DRI BDGH

0.909

0.969

0.692

40%

60%

80%

100%

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Trust DRI BDGH

93.30%

0.969

0.846 80%

90%

100%

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-15

De

c-1

5

Jan

-16

Feb

-16

Trust DRI BDGH

0.867

0.844

0.923

80%

90%

100%

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Trust DRI BDGH

95.60%

1

0.846 80%

90%

100%

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Trust DRI BDGH

2.00%

2.60%

1.19%

0.0655

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

Mar

14

- F

eb 1

5

Ap

r 1

4 -

Mar

15

May

14

- A

pr

15

Jun

14

- M

ay 1

5

Jul 1

4 -

Ju

n 1

5

Au

g 1

4 -

Ju

l 15

Sep

14

- A

ug

15

Oct

14

- S

ep 1

5

No

v 1

4 -

Oct

15

Dec

14

- N

ov

15

Jan

15

- D

ec 1

5

Feb

15

- J

an 1

6

Mar

15

- F

eb 1

6

Trust (rolling 12 months) DRI (rolling 12 months) BDGH (rolling 12 months) Trust Benchmark Data

19

Current YTD reported SI's (Apr 15 - Feb-16) 138 163

Current YTD delogged SI's (Apr 15 - Feb-16) 40 68

Serious Incidents - February 2016 (Month 11)(Data accurate as at 03/03/16)

Please note: At the time of producing this report the number of serious incidents reported are prior to the RCA process being completed.

Overall Serious Incidents

Number reported SI's (Apr 14 - Feb-15)

Number delogged SI's (Apr 14 - Feb-15)

Themes

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

0.5

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Pressure Ulcers - Category 3 & 4 (HAPU)

Pressure Ulcers HAPU 3 & 4 per 1000 occupied bed days

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Care Issues

Care Issues per 1000 occupied bed days

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Serious Falls

Serious Falls per 1000 occupied bed days

0

0.2

0.4

0.6

0.8

1

1.2

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Serious Incidents per 1000 occupied bed days

Reported Si's per 1000 occupied bed days

Reported Si's per 1000 occupied bed days - Previous years performance

0

5

10

15

20

25

30

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-15

De

c-1

5

Jan

-16

Feb

-16

Number Serious Incidents Reported (Trust & Care Group)

Emergency Care Group MSK & Frailty Care Group

Surgical Care Group Children & Family Services

Diagnostic & Pharmacy Speciality Services

Number Reported SI's Number Reported SI's - Previous years performance

20

Standard Q1 Q2 Q3 Jan Feb YTD

2015-16 Infection Control - C-diff 40 Full Year 9 7 10 1 2 29

2014-15 Infection Control - C-diff 45 Full Year 15 11 6 5 2 39

Trust Attributable 13 3 1 1 0 0 5

Standard Q1 Q2 Q3 Jan Feb YTD

2015-16 Serious Falls 20 Full Year 3 1 4 1 2 11

2014-15 Serious Falls 23 Full Year 7 2 1 0 1 11

Standard Q1 Q2 Q3 Jan Feb YTD

2015-16 Pressure Ulcers 82 Full Year 22 9 11 4 2 48

2014-15 Pressure Ulcers 106 Full Year 32 26 25 8 8 99

Monitor Compliance Framework: Infection Control C.Diff - February 2016 (Month 11)

(Data accurate as at 14/03/2016)

Pressure Ulcers & Falls that result in a serious fracture - February 2016 (Month 11)

(Data accurate as at 3/3/2016)

Please note: At the time of producing this report the number of serious falls reported are

prior to the RCA process being completed.

Please note: At the time of producing this report the number of pressure ulcers reported

are prior to the RCA process being completed.

0

10

20

30

40

50

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

C-diff 2015-16

C-diff Cumulative Total Standard

0

5

10

15

20

25

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Falls that result in a serious fracture

Falls Cumulative Total Standard

0

20

40

60

80

100

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Mar

-16

Pressure Ulcers (Ungradeable, Cat 3 & Cat 4)

Pressure Ulcer Cumulative Total Standard

0

5

10

15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Trust Attributable C-diff 2015-16

Trust Attributable Cumulative Total Standard

21

Month

3

1

1

1

YTD

60

28

Complaints - Resolution Perfomance (% achieved resolution within timescales)

Parlimentary Health Service Ombusdman (PSHO)

Complaints & Claims - February 2016 (Month11)(Data accurate as at 14/03/2016)

Complaints

Please note: Performance as a percentage is calculated on the cases replied and overdue, compared to the due date. Any current investigations that have not gone over

deadlines are excluded data.

Number of cases

referred for

investigation

Number Currently Oustanding

February 4 7

Number referred for

investigation

YTD

Outcomes

YTD

13

Fully / Partially Upheld

Not Upheld

No further Investigation

Case Withdrawn

Claims

Current Month Month Actual

Clinical Negligence Scheme for Trusts (CNST) Feb-16 4

Liabilities to Third Parties Scheme (LTPS) Feb-16 5

Total Number of open/active claims with the NHSLA (as at 29/02/16)CNST: 216

LTPS: 51

February 2016 Complaints Recieved

Risk Breakdown

Low Risk

Moderate Risk

High Risk

Year to Date Complaints Recieved

Risk Breakdown

0

10

20

30

40

50

60

70

80

90

Ap

r 2

01

4

May

20

14

Jun

20

14

Jul 2

01

4

Au

g 2

01

4

Sep

20

14

Oct

20

14

No

v 2

01

4

Dec

20

14

Jan

20

15

Feb

20

15

Mar

20

15

Ap

r 2

01

5

May

20

15

Jun

20

15

Jul 2

01

5

Au

g 2

01

5

Sep

20

15

Oct

20

15

No

v 2

01

5

Dec

20

15

Jan

20

16

42

40

1

Complaints Received

Complaints Mean UCL LCL

0

20

40

60

80

100

120

Ap

r 2

01

4

May

20

14

Jun

20

14

Jul 2

01

4

Au

g 2

01

4

Sep

20

14

Oct

20

14

No

v 2

01

4

Dec

20

14

Jan

20

15

Feb

20

15

Mar

20

15

Ap

r 2

01

5

May

20

15

Jun

20

15

Jul 2

01

5

Au

g 2

01

5

Sep

20

15

Oct

20

15

No

v 2

01

5

Dec

20

15

Jan

20

16

42

40

1

Concerns Received

Concerns Mean UCL LCL

0%

10%

20%

30%

40%

50%

60%

70%

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Complaints Resolution Performance

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Number of Claims per 1000 Occupied bed days

Number of claims per 1000 occupied bed days 22

Accident & Emergency

Please note: At the time of producing this report no further benchmarking data is available from NHS England.

Friends & Family - February 2016 (Month 11)(Data accurate as at 11/03/2016)

Inpatients

Please note: At the time of producing this report no further benchmarking data is available from NHS England.

00.05

0.10.15

0.20.25

0.30.35

0.40.45

0.5

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Response Rates (%)

Trust England

0.91

0.92

0.93

0.94

0.95

0.96

0.97

0.98

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Likely to recommend (%)

Trust England

0

0.05

0.1

0.15

0.2

0.25

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Feb

-16

Response Rates (%)

Trust England

00.10.20.30.40.50.60.70.80.9

1

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

De

c-1

5

Jan

-16

Likely to recommend (%)

Trust England

23

2

Title Nursing Workforce Information

Report to: Board of Directors Date: 22 March 2016

Author: Richard Parker - Director of Nursing, Midwifery and Quality

Moira Hardy – Deputy Director of Nursing, Midwifery and Quality

For: Information

Purpose of Paper: Executive Summary containing key messages and issues

This paper updates the Board of Directors on key issues relating to the Nursing Workforce, using information from the February 2016 UNIFY return which relates to February actual and planned hours:

Workforce information and variances between planned and actual hours worked

Update Workforce information and Quality and Safety profile meeting requirements of NHS England (NHSE), including How to ensure the right people, with the right skills, are in the right place at the right time (2013) and Safe staffing for nursing in adult inpatient wards in acute hospitals (2014) relating to Hard Truths

Update of Trust position regarding safe nurse staffing and efficiency (Agency Capping) from TDA, Monitor, NHSE, CQC and NICE

Key issues and actions

Recommendation(s)

The Board of Directors is asked to NOTE the content of this paper and SUPPORT the actions identified to ensure that the risks associated with inappropriate nurse staffing levels are appropriately managed.

Delivering the Values – We Care (how the values are exemplified by the work in this paper) We always put the patient first

By delivering safe and effective care by providing staff who can be responsive and well led Everyone counts – we treat each other with courtesy, honesty, respect and dignity

By listening to staff and patients when developing and evaluating quality and safety of care.

Monitoring that care is delivered with compassion Committed to quality and continuously improving patient experience

By developing and monitoring safe staffing levels and the quality of care provision Always caring and compassionate

By providing staff with the right skills and ensuring that they are in the right place at the right time.

We monitor care is delivered with compassion Responsible and accountable for our actions – taking pride in our work

By assuring ourselves that the quality of care meets the CQC standard. Having escalation processes in place when staffing, safety and quality vary from optimum levels

Encouraging and valuing our diverse staff and rewarding ability and innovation

3

By setting up systems and processes that avoid duplication and reward good practice

Related Strategic Objectives

Provide the safest, most effective care possible

Control and reduce the cost of healthcare

Focus on innovation for improvement

Develop responsibly, delivering the right services with the right staff

Analysis of risks

Risks associated to the inability to recruit to establishment and develop staff to provide harm free care, delivered with compassion and of appropriate quality. Risk associated with not meeting regulatory and commissioner requirement.

Board Assurance Framework

3 Failure to provide harm free care.

3 x 4 = 12

5 Failure to deliver financial plan.

5 x 5 = 25

10 Inability to recruit the right staff and ensure that staff have the right skills to meet operational needs.

4 x 3 = 12

4

1. INTRODUCTION

This paper provides the Board of Directors with detailed information relating to the Nursing Workforce; highlighting issues, which may impact upon the Trusts ability to provide appropriate staffing levels and skill mixes. This report also provides the Board of Directors with the Trust position in relation to the Agency Capping from TDA, Monitor, NHSE, CQC and NICE. 2. BACKGROUND Following guidance from NHS England, the National Quality Board and NICE (National Institute for Health and Care Excellence) on the actions which need to be taken to ensure that nurse staffing levels are reviewed by Boards of Directors on a regular basis, this paper provides the DBHFT Board of Directors with the information to consider staffing levels and skill mixes across the Trust. It provides the planned and actual workforce information for February 2016, which has been submitted to the UNIFY system, with additional information relating to the February Quality Metrics dashboard for each ward.

3. WORKFORCE INFORMATION Appendix 1 provides the data submitted to UNIFY with a comparison to the local quality and outcome measures recorded in February, confirming the actual hours worked in February 2016 by registered nurses and health care support workers compared to the planned hours. The Trusts overall planned versus actual hours worked in February was 98% (99% January).

3a. Actual versus planned staffing levels (based on daily data capture)

The actual staffing levels for February were collected manually, mostly contemporaneously, and validated by the Matrons and Heads of Nursing (HoNs) retrospectively. The Matrons based the planned levels on the agreed planned staffing levels in the 2015/2016 funded establishments. The planned hours are adjusted each month to account for the number of days in the month. Data collection for the planned staffing levels for intensive care, paediatric and midwifery areas has led to planned staffing levels being based on actual acuity and dependency requirements on a day by day basis to reflect occupancy levels. In the absence of national guidance each ward has been RAG rated against a local framework; Green where actual available hours are within 5% of planned, Amber within 5% and 10% and Red above 10%. The RAG rating applies equally to over establishments. The data demonstrates:

Escalation beds have been opened on Wards C1, A4, 17, 24, 25, 26, 32 and CCU/C2 for most of February, requiring additional staffing

Despite closing beds to 16 on Ward 25 on 1st February due to staffing concerns, the reduction did not occur until the end of the month.

Ward A3 at Bassetlaw closed on occasions throughout February due to medical and nursing staff shortages.

Ward S12 commenced closure of 8 beds at the weekend (Friday pm to Monday am) from 18 December; however the beds have remained open for 3 of the 4 weekends in February.

Ward G5 has a ring-fenced number of beds (8) for outliers from other bed holding Care Groups, however this was not adhered to during January and this has continued throughout February.

5

23 wards were within 5% of the planned staffing hours (1 more than in January)

14 wards were within 5% and 10% of the planned staffing hours (1 less than in January)

4 departments had deficits of 10% or more of the planned staffing hours (the same as January). These units were the Children’s Ward, Children’s Observation Unit, Ward M2, and Labour Ward at BDGH.

The lower than planned fill rates in these areas were related to vacancy levels, sickness and maternity leave absence and moving staff to maximise workforce where required to support patient acuity and dependency.

Four wards actual worked hours had surpluses over 10% of the planned staffing hours (the same as January). The higher than planned staffing levels were on Ward 17 due to the opening of escalation beds throughout the month and dependency of patients requiring 1:1 care and Ward 6, St Leger and Gresley also due to the dependency of patients requiring 1:1 care.

During February Matrons were concerned that despite the implementation of the escalation plans the acuity and dependency was greater than the available staffing on some shifts. This is highlighted by incident reporting during February with 58 incident reports highlighting nurse and midwifery staffing concerns in wards and departments. 51 incident forms reported high acuity and dependency levels for the number of staff available, but no harm events. Seven incident form reported low harm; delayed care and staff not being able to take a break. All incident reports are investigated by the Head of Nursing and Matrons to ensure that all possible actions had been taken and any learning points have been identified.

Nurse staffing incidents reported during the first 11 months of the year is tabled below.

3b. Safe Staffing and Efficiency A cap of agency expenditure for registered general and specialist nursing staff, midwives and health visitors has been in place since October 2015. The annual ceiling for DBHFT has been set at the lowest level of 3% which is a reflection of the relatively low level of bank and agency usage when compared to the national picture. The February figure was 1.7%, which is a significant improvement from the January position of 3.2% despite there being significant registered nurse vacancies across the trust. The reduction in the use of agency staff in February is due in the main to three factors within the Emergency Department:

6

Last month saw an increase as backdated charges for December were paid that NHSP had not notified the trust about in December.

• Increase in substantive ED staff due to new starters in month. • ED at Bassetlaw stopped using one of the ENP’s at the end of January that was from Hallam and was at a very high rate.

There are currently 81.75wte registered nurse vacancies (5%) across the trust split across the following Care Groups;

Emergency 37wte

Specialty Services 15.61wte

MSK & Frailty 23.65wte

Surgical 1.6wte

Children and Families 3.89wte Information relating to the use of off-framework, high cost nursing agency staff is being reported to MONITOR on a weekly basis. Work has been undertaken to eliminate the use of off framework agencies so that the Trust is compliant with the guidance. Following the introduction of the price cap in November 2015 the maximum payment to agency workers reduced to 75% above substantive basic pay from 01 February, with a further reduction to 55% on 01 April 2016. Ongoing work is being undertaken by the contracting and procurement teams to meet the planned capping. 3c. Nurse Manager Clinical Time To ensure that the HoNs and Matrons have a visible presence in the clinical areas HoNs have identified that they are aiming to work at least one clinical shift a month in one of their clinical areas, with the Matrons working two clinical shifts a month. This information is collected as part of the monthly Hard Truths returns. In addition senior sisters/charge nurses are expected to have 2 days per week as managerial/supernumerary time and this information is also being recorded monthly. The Clinical and Supervisory Time in February 2016 was:

Care Group HoN Clinical Time Matrons Clinical Time Ward Supervisory Time

Surgical

MSK and Frailty

Specialty Service

Emergency

Obstetrics and Gynae

Children’s

With the exception of the HoN for MSK & Frailty Care Group, who is currently seconded to the Directorate of Strategy and Improvement, the majority of HoNs have maintained their clinical time, as have Matrons. The majority of senior sisters/charge nurses have been unable to completely maintain their 2 days a week supernumerary time as they have been working clinically due to staffing pressures. Ward managers in paediatrics have again this month been unable to achieve any of their managerial/supernumerary time due to significant long term sickness absence, despite this being appropriately managed.

7

3d. Quality and Safety Profile The data for the 2015/2016 Quality Assurance tool is now being collected monthly through the patient, staff, visiting staff, Matrons surveys and the Ward Sister programme of activities. Assessments have been scheduled for each ward and department. The monthly Quality Metrics results will be reviewed in April 2016 and scores adjusted to reflect the whole year’s results. Results are displayed in the Hard Truth’s appendix 1, identifying six wards have been assessed as Blue; 26 wards have been assessed as Green and one ward has been assessed as Amber. Seven wards are still to be assessed and dates are scheduled to undertake these assessments before 31 March. The Quality Metrics for adult wards have been agreed by the HoNs, which include 15 indicators that cover each of the five CQC Key Assessment Criteria (safe, effective, caring, responsive and well led). Each metric has a rating, some with individual ward improvement targets based on out turn in 2014/15. Quality Metrics are being agreed by the HoNs for the specialist areas, including paediatrics and midwifery; in the meantime, the adult ward metrics continue to be used. Appendix 1 shows the summary workforce and quality and safety indicators. Results for the month of February were:

Green/ Green 18 Green/ Red 5 Amber/ Green 13 Amber/Red 1 Red/ Green 6 Red/ Red 2

Eight wards, as discussed above, were red risk rated against the workforce metric.

Of these, four wards had a surplus assessed as red against the workforce metric.

18 wards were assessed as green against workforce and quality metrics a slight decrease from January where 20 wards were rated green for both metrics.

A total of 37 wards were assessed as green for quality, compared to 39 in January (37 in December), with all wards in both the Surgical and Specialty Services Care Groups scoring green for quality.

8

A total of 8 wards were assessed as red for quality compared to 5 in January (8 in December)

Two wards, Gresley and Ward 6, have been assessed as red against both the workforce and quality metrics; the same as in January. This is the second consecutive month that Ward 6 has triggered on both metrics and specifically against the safe criteria for the safety thermometer new harms. Both wards will be reviewed at a Quality Summit led by the Deputy Director of Quality & Governance.

The remaining 5 wards that were red against quality in February were Wards G5, B5, 25, Rehab 1, Rehab 2 and AMU. These departments are also being addressed through Quality Summits with previous actions being reviewed by the Deputy Director of Quality and Governance with the Matron and ward manager. PLANNED ACTIONS AND KEY RISKS

The major issue facing most acute hospitals nationally, and locally, continues to be the challenge of filling qualified vacancies. The actions to mitigate the risks which have been detailed in previous papers are continuing, along with systems and processes to meet the expectations outlined in the safe staffing and efficiency correspondence. These are:

The Trust has put measures in place to reduce use of non-framework agencies and to minimise the breaching of the price cap

Monitoring and use of escalation processes are in place to tightly control use of registered and non-registered agency usage

2016/ 2017 nursing budget setting will be based upon 20.96% uplift adjustments

Implement recommendations from Lord Carters report specifically in relation to optimising clinical resources as further guidance becomes available

Undertake a Non-Medical workforce utilisation programme as part of DBH Strategy and Improvement programme utilising enabling tools e.g. Calderdale Framework to include;

Challenging and reviewing skill mix to make better use of Non-registered staff exploring the development of extended roles

Reviewing the non-ward staff roles and responsibilities

Continual monitoring of e-Roster efficiency with quarterly follow up meetings 4. RECOMMENDATION

The Board of Directors is asked to NOTE the content of this paper and SUPPORT the identified actions.

Workforce /Quality/Safety Profiles February 2016 Data

WQAT annual

assessment 2014/5

WQAT annual

assessment 2015/6

Care Group Matron Ward

No of

Funded

Beds

Hours Total

Planned

Days reg

nurse/mwfe

Hours Total

Actual reg

nurse/mwf

Hours total

planned

support staff

Hours

Actual

Support

Staff

Hours Total

Planned

Days reg

nurse/mwfe

Hours

Total

Actual reg

nurse/mwf

Hours total

planned

support

staff

Hours

Actual

Support

Staff

Total

Planned

Hours

Total

Actual

Hours

Variance WorkforceQuality

DashboardRating Rating

Surgical NS B6 30.5 1278 1249 912 817 900 859.5 498 498 3588 3423.5 95% Jan-15 Jan-16

NS 20 27 1566 1350 913.5 1106 667 667 667 713 3813.5 3836 101% Jun-14 Dec-15

NS 21 27 1537 1366 884.5 998 667 667 667 724 3755.5 3755 100% Nov-14 Jan-16

LM S12 24 1309.5 1210 372 536 638 649 319 313 2638.5 2708 103% Mar-15

RF SAW 21 1605 1384 705 642 667 667 705 650 3682 3343 91% Feb-16

LC ITU DRI 20 5690 5272 696 394 4884 4576 0 0 11270 10242 91% Jan-14 Nov-15

LC ITU BDGH 6 1609 1525 348 251 1419 1331 0 0 3376 3107 92% Dec-14

32124 30415 95%

MSK and Frailty SS A4 24 1262 1058 1044 801.5 696 703 696 805 3698 3367.5 91% Nov-14 Mar-16

SS B5 30.7 1549.5 1469 1044 1030 1508 1417 754 761 4855.5 4677 96% Mar-15 Feb-16

AH St Leger 35 1740 1462 1392 1815.5 1044 1044 1044 1488 5220 5809.5 111% Dec-14

AH 1&3 22 1392 1359 884.5 945 696 684 1044 1212 4016.5 4200 105% Dec-14 Nov-15

AH 6 11 853.5 829 484.5 528 696 684 0 288 2034 2329 115% Oct-14 Nov-15

SS Mallard 16 1044 1023 1044 1024 696 708 884 1044 3668 3799 104% Dec-14 Nov-15

SS Gresley 32 1392 1142 1392 1947 1044 1037 1044 1388 4872 5514 113% Apr-15 Feb-16

SS Stirling 16 1044 976 1044 1121 696 696 696 840 3480 3633 104% Oct-14 Oct-15

KM Adwick (rehab2) 29 1073 940 913.5 904 696 696 696 696 3378.5 3236 96% Aug-14 Feb-16

KM Wentworth (rehab1) 29 1450 1252 884.5 922 696 708 696 895 3726.5 3777 101% Dec-14 Feb-16

38949 40342 104%

Specialty Service JP 18 12 1296 1066 96 231 696 684 348 360 2436 2341 96% Feb-15 Nov-15

JP 18 CCU 12 1245 1184 495 383 580 570 290 290 2610 2427 93% Dec-14 Oct-15

AW 32 18 1644 1257 684 836 696 696 348 382 3372 3171 94% Feb-15 Nov-15

AW 16 24 1609 1535 696 936 1044 1044 1044 1032 4393 4547 104% Feb-15 Nov-15

RM 17 26 1131 1073 754 1039 696 984 696 1068 3277 4164 127% Mar-15 Feb-16

JP CCU/C2 18 1044 1102 696 808 696 711 696 733 3132 3354 107% Nov-14 Nov-15

RM S10 20 1376 1313.25 930 1060.5 580 580 290 300 3176 3253.75 102% Mar-15 Nov-15

RM S11 19 1175 1118 1087.5 937.5 638 638 319 616 3219.5 3309.5 103% Feb-15 Dec-15

25616 26567 104%

Emergency MH ATC 21 1392 1210 1044 1044 1044 966 696 768 4176 3988 95% Jan-15 Dec-15

SS AMU 45 2436 2386 2088 2052 2436 2400 2088 2355 9048 9193 102% Nov-14 Feb-16

MH A5 18 1044 840 884.5 896 696 703.5 696 745.5 3320.5 3185 96% Jun-14 Jan-16

MH C1 24 1261.5 1122 1044 942 1044 1008 1044 912 4393.5 3984 91% Oct-14 Dec-15

SS 22 16 696 684 696 696 696 696 696 732 2784 2808 101%

SC 24 24 1261.5 984 1044 1129 1044 984 1044 1212 4393.5 4309 98% Feb-15 Nov-15

SC 25 24 913.5 924 1032 954 696 780 1044 1092 3685.5 3750 102% May-15 Nov-15

SC 26 28 1261.5 1059 1044 1001 1044 1032 1044 1048 4393.5 4140 94% Mar-15 Nov-15

SC 27 28 1261.5 1054 1044 954 1044 949 1044 1080 4393.5 4037 92% Jul-14 Nov-15

40588 39394 97%

Children and Families AB SCBU 8 798 787 0 4 638 638 0 0 1436 1429 100% n/a n/a

AB NNU 18 2258 2062 175 149 1806 1639 298 253 4537 4103 90% n/a n/a

AB CHW 18 1129 905 694 676 957 781 319 275 3099 2637 85% n/a n/a

AB A3 14 821 802 632 575 638 594 319 297 2410 2268 94% n/a n/a

AB COU/CSU 21 1698 1473 950 888 638 727 638 319 3924 3407 87% n/a n/a

SS G5 24 1359 1192 660 595.5 984 862 348 419 3351 3068.5 92% Apr-14

SS M1 26 1315 1278.25 666 663.25 638 633 319 316 2938 2890.5 98% Jan-15 Nov-15

SS M2 18 775.75 702 216.75 156.75 743 629.5 319 308 2054.5 1796.25 87% Jan-15 Nov-15

SS CDS 14 2103.15 1976.4 674.4 515.5 1848 1732 583 528 5208.55 4751.9 91% Jan-15 Oct-15

SS A2 18 731 740 419.25 419.25 616 598.5 308 286 2074.25 2043.75 99% Jan-15

SS A2L 6 1305 1086.55 434 368.75 957 935.25 319 291 3015 2681.55 89% Jan-15

34047.30 31076.45 91%

Trust Position 171323 167794 98%

Profile

APPENDIX 1: HARD TRUTHS February 2016

Workforce Information - Days Workforce Information - Nights Planned v Actual

1

Title Staff Survey 2015 Action Plan

Report to: Board of Directors Date: 22 March 2016

Author: Ruth Cooper, Interim Director of People and OD

For: Approval

Purpose of Paper: Executive Summary containing key messages and issues

This paper provides formal notification of the outcomes of the Trust’s 2015 NHS wide staff survey, recommends the key actions to be taken at both corporate and local level.

Recommendation(s)

The Board of Directors is asked to NOTE the outcomes and APPROVE the actions.

Related Strategic Objectives

Provide the safest, most effective care possible

Control and reduce the cost of healthcare

Focus on innovation for improvement

Develop responsibly, delivering the right services with the right staff

Delivering the Values – We Care – how value is exemplified by the work in this paper

We always put the patient first

By having an engaged and motivated workforce Everyone counts – we treat each other with courtesy, honesty, respect and dignity

By focussing on improving the responses to related questions Committed to quality and continuously improving patient experience

By improving the response rates to questions relating to incidents and care Always caring and compassionate

By improving the response rates to related questions Responsible and accountable for our actions – taking pride in our work

By having more engaged and motived staff and capable managers Encouraging and valuing our diverse staff and rewarding ability and innovation

By ensuring all areas of our workforce feel rewarded, valued and engaged

Analysis of risks

Risk associated with employee relations, recruitment and retention success and negative publicity should we do nothing to improve. In addition the areas where we have lower scores attract negative CQC risk ratings and though need improving for their own end, will also have a positive impact on our risk rating.

Board Assurance Framework

10 Inability to recruit right staff and ensure staff have the right skills to meet operational needs

3x4=12

14 Breakdown of employee relations 2x3=6 Equality Impact Assessment

N/A as generic EA completed by NHS Employers for staff survey and FFT – staff.

2

1. Introduction

1.1. Between October and November 2015, 2788 or 44% of DBH staff completed the NHS staff survey. This was the third year using a completely online survey of all staff (a census) and showed a continuing improvement on last year’s 42% and the previous 34%. The national NHS response rate for acute trusts is 41%.

1.2. We remain committed to driving the rate up beyond 50% so that we can have an even greater confidence that the views expressed represent the whole of DBH.

1.3. Full results of the survey are available online at the NHS Staff Survey website 2. Background and outcomes of the 2015 survey

2.1. The survey results are important as they are used both internally and by our key partners and stakeholders to assess our capability as an employer: - by the Trust to measure engagement, satisfaction and make improvements to the working lives of employees; - by the CQC to measure and report on Trusts’ compliance with their standards, using the findings to inform their Annual Health Check and CQC Risk Rating; and - by NHS England and The DoH who will assess the effectiveness of national NHS staff policies, as well as to inform future developments in these areas.

2.2. We remain convinced that effective staff engagement is best supported by a full census, but this information places an interesting context on the comparative results. We have again compared our results with both neighboring and best practice acute trusts. These again show that, although many of the better reporting trusts rely on a sample survey, the outcomes can offer only limited assurance. Sheffield Teaching Hospital, for example, reports a 51% response rate against a sample of just 825. While our results will be much more representative of our whole workforce, it is probable that some of our responses therefore provide a less positive but more representative picture. A comparison table which illustrates this point is as annex 1.

2.3. The survey shows a broadly stable picture overall, maintaining the results achieved in 2014.

Given the timing of the survey, which coincided with the first announcements of our financial difficulties, this is a good overall outcome. Compared to all acute Trusts, of the 32 key findings areas this year (with 2014 results in brackets, when only 29 key findings were reported):-

o 1 (1) issue in the best 20% o 8 (8) issues better than average o 9 (5) issues at the average o 10 (10) issues worse than average o 4 (5) issues in the worst 20%

2.4. Compared with the Trust’s 2014 results, 6 issues improved, 15 stayed the same and 1 issue

deteriorated. Because of changes to the format of survey questions this year, comparisons with 2014 are not available for all issues. The key findings presentation at annex 2 lists all results.

2.4. The survey again shows that the corporate initiatives mounted last year in response to the 2014 survey have proved to be successful. The focus on appraisal in the last twelve months is reflected in KF11 where 88% reported an appraisal in the last twelve months. This places us

3

above the national average for acute trusts compared to the 2014 result of 65% which was the worst of all acute trusts. This activity is also likely to have impacted on increases in KF4 (staff motivation) and KF10 (support from line managers).

2.5. There are also a cluster of good results around safety and incident reporting (KFs 28-31) and around bullying, harassment and discrimination (KFs 20-27). However, there is some inconsistency here as KF21 shows a slight reduction in staff believing that the organisation provided equal opportunities for career progression or promotion. Similarly, closer analysis of results from our Black and Asian minority ethnic staff (BAME) are less positive and require further investigation.

2.6. This is the first full year of operating in our new Care Group structure so offers a more robust comparison of results across DBH. The RAG report at annex 3 suggests significant discrepancy in performance which merits further consideration by Executive and Care Group Directors.

3. Planned actions

3.1. As noted above, these results offer some encouragement given the broader context and that message will be shared with staff. The focus for the coming months must be on turnaround and we would not wish to significantly divert attention. Reflecting the stable position and progress made, there is a compelling argument to continue for the next twelve months with the current staff survey priorities of:

3.2. Appraisal The Appraisal Project Board has, in its first year, overseen a significant increase in the numbers of staff receiving appraisal. We would want to maintain that progress and begin to address quality across the organisation.

3.3. Statutory & Essential to Role training (SET)

We now have in place a framework for identifying and completing SET. The awareness level booklet is available for all staff to complete. For 2016, we need to increase take-up and agree requirements and source the relevant learning solutions for the higher levels (enhanced, advanced and expert).

3.4. Management Skills/Leadership The Management Skills Programme now provides the basis for line manager development. But we need to draw together and review our current offer on management skills, leadership and management coaching. The Deputy Director of Education will lead this work by completing a training needs analysis. We will also focus attention on turnaround and managing projects.

3.5. Health and Wellbeing We have had to scale back expenditure in this area, but we need to develop low cost and collaborative schemes and products to ensure we maintain an appropriate level of support to our staff.

3.6. The RAG rating report shows significant differences across Care Groups and Directorates that merit additional local action. Supported by their HR Business Partners, we will require individual Care Groups and Directorates to sense check results and agree actions to address local priorities.

4

3.7. BAME Listening Groups The detailed analysis of results from our Black and Asian minority ethnic staff show some disproportionate responses. To better understand the experience of these colleagues, the Chief Executive will lead initially two sessions. One outcome may be the establishment of an ongoing network to engage this group of staff.

4. Friends and Family Test (FFT) and preparations for the coming year

4.1. Since April 2014 we have been required to carry out the Friends and Family Test (FFT) on our staff four times a year, all staff once a year and a proportion the other three times. The two questions are already part of the annual staff survey, around recommending the Trust as a place to work and a place to receive care or treatment. We can also add additional questions and free text.

4.2. Our plan moving forward is as for 2015/2016:- o Q1 – all staff able to access FFT and also include additional questions to track in-year

actions in response to previous year’s full staff survey. Survey in May, reporting in July. o Q2 – sample of staff, targeting red response rate areas – reporting in October. o Q3 – annual full staff survey in October/November– reporting in February/March. o Q4 – recent new starters to capture views from people not in post for the full staff

survey, and to specifically test recruitment and induction arrangements. Survey in February, report in March.

5. Recommendations 5.1. We recommend that the Board of Directors

o note the outcome of the 2015 staff survey, the broad consistency in results this year (paragraphs 1 and 2)

o approve the areas for action (paragraphs 3.1 – 3.7) o approve the plans for the FFT and survey cycle (paragraph 4.2)

6. Action and next steps

6.1. If approved, People and OD will implement the recommendations reporting the outcomes quarterly to the Board in the P&OD Quarterly Update, or by exception in the Chief Executives Report. This will be enhanced by an annual report each March/April following the national feedback from the main staff survey.

National NHS

Staff Survey

2015 Annex 1

Percentage

that

responded

from total

recipients

Base

(total

number

of

recipients

21a,

21c-d

3c, 6a,

6c 6b 2a-c

5a, 5f,

7g 8a-d

4a, 4b,

4d

3a, 3b,

4c, 5d,

5e 4h-j

5b, 7a-

e 20a 20b-d 18b-d

4e-g,

5c 5h

% n scale scale % scale scale % % scale scale scale % scale scale scale %ALL

ORGANISATIONS41 722,811 3.76 3.89 88 3.93 3.51 36 72 3.89 3.78 3.79 85 3.13 4.01 3.36 56

ALL TRUSTS 41 715,859 3.72 3.91 90 3.92 3.44 31 70 3.89 3.76 3.74 86 3.05 4.02 3.30 51

ACUTE TRUSTS 41 322,746 3.75 3.94 90 3.94 3.43 31 70 3.92 3.74 3.70 85 3.06 4.03 3.31 49

Doncaster and Bassetlaw Hospitals NHS Foundation Trust44 6,372 3.72 3.88 89 3.94 3.37 33 66 3.88 3.67 3.68 88 3.03 4.03 3.28 47

Barnsley Hospital NHS Foundation Trust46 2,801 3.60 3.87 88 3.84 3.40 29 68 3.87 3.72 3.75 93 2.94 3.93 3.33 53

Chesterfield Royal Hospital NHS Foundation Trust56 3,627 3.71 3.89 88 3.93 3.35 27 64 3.87 3.71 3.67 86 2.97 3.99 3.26 43

Northern Lincolnshire and Goole NHS Foundation Trust34 1,236 3.51 3.87 87 3.95 3.33 26 67 3.85 3.70 3.63 85 3.01 4.07 3.28 41

United Lincolnshire Hospitals NHS Trust33 832 3.53 3.87 89 3.88 3.36 24 63 3.81 3.66 3.60 83 2.95 4.01 3.23 49

Sheffield Children's NHS Foundation Trust45 2,842 3.97 3.80 88 3.89 3.54 30 73 3.94 3.79 3.77 82 3.15 4.00 3.25 58

Sheffield Teaching Hospitals NHS Foundation Trust51 825 3.82 3.88 86 3.82 3.38 29 63 3.87 3.66 3.59 88 2.94 3.88 3.35 48

The Rotherham NHS Foundation Trust42 3,953 3.52 3.85 88 3.79 3.33 24 65 3.82 3.70 3.67 94 2.92 3.97 3.27 47

Beacon Trust

Salford Royal NHS Foundation Trust44 821 3.87 3.93 92 3.89 3.38 27 70 3.79 3.75 3.68 86 2.92 4.11 3.26 51

Wrightington, Wigan and Leigh NHS Foundation Trust36 848 4.02 4.29 93 4.13 3.71 49 78 4.05 3.88 3.96 91 3.21 4.17 3.65 51DBH Relative

Position With Local

Doncaster and Bassetlaw Hospitals NHS Foundation Trust4th 1st 3rd 2nd Joint1st Joint 2nd 4th 1st 4th 2nd 6th 3rd 3rd 2nd 2nd 3rd Joint5th Joint

National NHS

Staff Survey

2015 Annex 1

Percentage

that

responded

from total

recipients

Base

(total

number

of

recipients

with

ineligible

staff

removed)

10b,

10c 9c 9d-g 7f, 9a

17a,

17b 16 14a

14b,

14c 14d 15a

15b,

15c 15d

11a,

11b 11c 12a-d

13b,

13c

21b,

22b,

22c

KF1,

KF4,

and

KF7

% n % % % scale % % % % % % % % % % scale scale scale scaleALL

ORGANISATIONS41 722,811 73 36 56 3.65 10 87 12 2 60 25 23 38 25 89 3.72 3.70 3.71 3.82

ALL TRUSTS 41 715,859 73 37 59 3.59 11 86 15 2 61 29 24 39 28 90 3.69 3.63 3.66 3.78

ACUTE TRUSTS 41 322,746 72 35 59 3.57 11 87 15 2 54 28 26 35 31 90 3.70 3.62 3.69 3.80

Doncaster and Bassetlaw Hospitals NHS Foundation Trust44 6,372 72 38 58 3.49 8 87 17 2 50 26 23 36 30 88 3.71 3.69 3.64 3.77

Barnsley Hospital NHS Foundation Trust46 2,801 69 41 57 3.59 9 88 16 1 47 23 24 37 30 90 3.75 3.63 3.68 3.71

Chesterfield Royal Hospital NHS Foundation Trust56 3,627 71 37 61 3.52 7 90 17 1 41 26 20 16 28 85 3.65 3.63 3.75 3.75

Northern Lincolnshire and Goole NHS Foundation Trust34 1,236 69 34 61 3.47 10 88 16 2 49 30 26 19 34 93 3.64 3.62 3.51 3.69

United Lincolnshire Hospitals NHS Trust33 832 70 31 50 3.32 7 88 13 0 29 25 28 32 25 88 3.50 3.55 3.55 3.67

Sheffield Children's NHS Foundation Trust45 2,842 74 37 54 3.67 5 90 10 1 54 20 20 40 28 92 3.72 3.73 3.64 3.89

Sheffield Teaching Hospitals NHS Foundation Trust51 825 65 37 64 3.52 10 89 13 2 53 23 21 45 29 88 3.68 3.55 3.52 3.74

The Rotherham NHS Foundation Trust42 3,953 68 37 63 3.59 7 89 12 1 48 23 21 20 23 88 3.60 3.56 3.58 3.63

Beacon Trust

Salford Royal NHS Foundation Trust44 821 71 39 55 3.58 11 85 14 3 52 21 21 45 27 89 3.73 3.70 3.82 3.80

Wrightington, Wigan and Leigh NHS Foundation Trust36 848 57 31 47 3.83 7 93 11 1 50 18 19 39 18 85 3.88 3.79 3.91 4.00

Doncaster and Bassetlaw Hospitals NHS Foundation Trust. . 7th 7th 5th 6th 4th 8th 8th 6th Joint 3rd 6th 4th 4th 2nd 4th Joint 3rd 2nd 3rd joint 2ndK

F32. E

ffective

use o

f patient /

serv

ice u

ser

Overa

ll

engagem

ent score

DBH Relative Position With Local NHS Trust - Out of

KF

26. %

experiencin

g

hara

ssm

ent,

KF

27. %

of

sta

ff/c

olle

agues

report

ing m

ost

KF

28. %

witnessin

g

pote

ntially

harm

ful

KF

29. %

report

ing

err

ors

, near

mis

ses o

r

KF

30. F

airness

and e

ffectiveness

of pro

cedure

s for

KF

31. C

onfidence

and s

ecurity

in

report

ing u

nsafe

KF

20. %

experiencin

g

dis

crim

ination a

t

KF

21. %

belie

vin

g

that th

e

org

anis

ation

KF

22. %

experiencin

g

physic

al vio

lence

KF

23. %

experiencin

g

physic

al vio

lence

KF

24. %

of

sta

ff/c

olle

agues

report

ing m

ost

KF

25. %

experiencin

g

hara

ssm

ent,

KF

12. Q

ualit

y o

f

appra

isals

KF

13. Q

ualit

y o

f non-

mandato

ry tra

inin

g,

learn

ing o

r

KF

14. S

atisfa

ction

with r

esourc

ing a

nd

support

KF

15. %

satisfied

with the o

pport

unitie

s

for

flexib

le w

ork

ing

Response Rate

KF

16. %

work

ing

extr

a h

ours

KF

17. %

suffering

work

rela

ted s

tress

in last 12 m

onth

s

KF

18. %

feelin

g

pre

ssure

in the last

3 m

onth

s to a

ttend

KF

19.

Org

anis

ation a

nd

managem

ent

KF

6. %

report

ing

good c

om

munic

ation

betw

een s

enio

r

KF

7. %

able

to

contr

ibute

tow

ard

s

impro

vem

ents

at

KF

8. S

atisfa

ction

with level of

responsib

ility

and

KF

9. E

ffective team

work

ing

KF

10. S

upport

fro

m

imm

edia

te m

anagers

KF

11. %

of sta

ff

appra

ised in last 12

month

s

Response Rate

KF

1. R

ecom

mend a

s

a p

lace to

work

/receiv

e

KF

2. S

atisfa

ction

with the q

ualit

y o

f

work

and c

are

they

KF

3. %

agre

ein

g that

their r

ole

makes a

diffe

rence to p

atients

KF

4. S

taff

motivation a

t w

ork

KF

5. R

ecognitio

n

and v

alu

e o

f sta

ff b

y

managers

and the

NHS National Staff Survey 2015

Key Findings

(February 2015)

Background

• DBH undertook the NHS National Staff Survey 2015 between October and December for a census of its staff.

• The data is used by the Survey Coordination Centre (Picker Institute) in the NHS Benchmark Reports.

• In the 2015 reports there are 32 key findings (scores) and a measure of staff engagement. (2014 there were 29 key findings).

• Data is weighted each year to ensure comparable occupational groupings between acute trusts – therefore data comparisons are taken from the current 2015 results only.

Background • The response rate for DBH was 44% in 2015, which is

average for acute trusts in England.

• The 2015 response rate is a slight improvement on 42% in 2014.

• The NHS Benchmark Report presents the data under four Staff Pledges and three additional themes of Equality & Diversity, Errors & Incidents, and Patient Experience Measures.

• This presentation highlights the key findings from the NHS Benchmark Report.

Summary of Key Findings • 1 issue in the best 20%

• 8 issues better than average

• 9 issues at the average

• 10 issues worse than average

• 4 issues in the worst 20%

• 6 issues improved since 2014

• 1 issue deteriorated since 2014

• 15 issues showed no statistically significant change since 2014.

Key findings where DBH is in the best 20% of acute trusts in 2015

1. KF20 - % experiencing discrimination at work in last 12 months – (9%)

Key findings where DBH is in the worst 20% of acute trusts in 2015

1. KF3 - % agreeing that their role makes a difference

to patients / service users – (89%) 2. KF9 – Effective team working – (3.68) 3. KF7 - % able to contribute towards improvements

at work – (66%) 4. KF29 - % reporting errors, near misses or incidents

witnessed in last month – (88%)

Key findings where DBH has improved (statistically significantly) since 2014

1. KF1 – Staff recommendation of the organisation as a place to

work or receive treatment – (3.72)

2. KF4 – Staff motivation at work – (3.94)

3. KF10 – Support from immediate managers – (3.68)

4. KF11 - % appraised in last 12 months – (88%)

5. KF18 - % feeling pressure in last 3 months to attend work when feeling unwell – (57%)

6. KF28 - % witnessing potentially harmful errors, near misses or incidents in last month – (29%)

Key findings where DBH has deteriorated (statistically significantly) since 2014

1. KF21 - % believing the organisation provides equal opportunities for career progression/promotion – (87%)

2015 – Overall Staff Engagement

• Overall staff engagement score is 3.77. DBH is below (worse than) average when compared with trusts of a similar type.

• The engagement score for 2014 was 3.72. • There are 3 sub-dimensions to staff engagement:

Key Finding Change since 2014

Ranking compared with all acute trusts

KF1 – Staff recommendation of the trust as a place to work or receive treatment

Increase (better than 2014)

Average

KF4 – Staff motivation at work Increase (better than 2014)

Average

KF7 – Staff ability to contribute towards improvements at work

No Change Lowest (worst) 20%

2015 RAG Percentage Difference from Acute Average 3 52 10 5 18 12 28 43 33 45 16 64 15

National Staff Survey 18 47 25 49 24 30 38 27 21 21 19 61

10 29 56 19 50 27 5 22 18 46 3 10

6 1 4 2 3

Question Topic Q Positive Score Text

Organisation

Average %

Chief Executive

Directorate

Children & Family

Care Group

Diagnostic &

Pharmacy Care

Group

Emergency Care

GroupEstates & Facilities

Finance &

Healthcare

Contracting

MSK & Frailty Care

GroupNursing Services

People &

Organisational

Development

PerformanceSpeciality Services

Care Group

Surgical Care

Group

2a Often/always look forward to going to work 58 74 53 49 65 56 44 61 76 61 46 64 61

2b Often/always enthusiastic about my job 76 78 78 65 82 69 69 77 77 75 70 85 77

2c Time often/always passes quickly when I am working 78 78 76 70 78 75 72 82 71 80 68 87 78

3a Always know what work responsibilities are 87 87 90 83 89 78 86 88 78 73 74 95 91

3b Feel trusted to do my job 92 91 91 89 95 85 91 93 93 81 82 96 93

3c Able to do my job to a standard am pleased with 79 91 65 80 75 78 77 78 87 81 82 86 85

4a Opportunities to show initiative frequent in my role 71 87 72 60 74 62 70 76 76 74 64 79 70

4b Able to make suggestions to improve the work of my team/dept 71 100 70 61 71 59 74 78 84 75 67 77 70

4c Involved in deciding changes that affect work 50 91 46 36 49 43 52 55 59 62 41 56 50

4d Able to make improvements in my area of work 51 87 48 39 51 43 61 53 71 68 51 59 49

4e* Able to meet conflicting demands on my time at work 44 65 31 38 45 49 48 43 42 51 51 49 50

4f Have adequate materials, supplies and equipment to do my work 57 87 47 58 50 51 65 51 59 74 50 72 59

4g Enough staff at organisation to do my job properly 29 61 19 27 24 25 39 25 33 40 31 36 33

4h* Team members have a set of shared objectives 70 82 70 65 67 56 75 70 73 74 69 76 75

4i* Team members often meet to discuss the team's effectiveness 52 77 38 37 47 49 56 64 69 66 62 56 53

4j* Team members have to communicate closely with each other to achieve the team's objectives 77 91 73 69 81 67 78 80 73 81 72 82 78

5a Satisfied with recognition for good work 48 77 39 32 48 53 56 54 51 60 44 56 45

5b Satisfied with support from immediate manager 64 71 60 51 67 61 71 67 57 73 53 74 65

5c Satisfied with support from colleagues 79 74 79 75 75 69 86 84 80 75 72 84 80

5d Satisfied with amount of responsibility given 73 78 71 65 71 62 76 79 64 68 53 82 75

5e Satisfied with opportunities to use skills 69 61 72 60 70 52 70 73 66 70 62 80 72

5f Satisfied with extent organisation values my work 42 65 33 30 43 42 47 43 47 58 31 51 42

5g Satisfied with my level of pay 34 61 31 34 31 31 37 36 27 46 26 38 32

5h* Satisfied with opportunities for flexible working patterns 47 87 41 37 50 37 67 46 60 67 38 53 43

6a Satisfied with quality of care I give 70 52 61 76 67 59 27 77 58 42 74 84 84

6b Feel my role makes a difference to patients/service users 82 74 83 85 84 73 44 88 60 59 87 88 90

6c Able to provide the care I aspire to 58 48 49 61 54 43 21 62 49 34 56 74 72

7a Immediate manager encourages team working 72 87 72 59 80 60 72 80 70 79 64 76 71

7b Immediate manager can be counted upon to help with difficult tasks 69 83 67 59 73 61 77 75 64 78 59 74 66

7c Immediate manager gives clear feedback 57 71 57 42 60 50 64 62 57 69 56 65 55

7d Immediate manager asks for my opinion before making decisions that affect my work 52 55 51 39 52 45 54 58 52 64 50 61 49

7e Immediate manager supportive in personal crisis 71 78 72 64 69 64 72 76 75 81 49 80 68

7f Immediate manager takes a positive interest in my health & well-being 62 74 61 48 64 59 71 67 67 74 49 69 58

7g* Immediate manager values my work 66 77 63 55 66 56 70 73 64 70 51 74 67

8a I know who senior managers are 82 91 86 76 82 75 89 87 84 93 85 84 78

8b Communication between senior management and staff is effective 41 74 31 26 49 38 39 49 39 58 38 55 35

8c Senior managers try to involve staff in important decisions 32 61 23 23 35 26 35 39 41 53 31 42 25

8d Senior managers act on staff feedback 32 64 27 20 36 27 38 38 39 57 26 39 24

9a* Organisation takes positive action on health and well-being 88 100 86 82 83 91 92 91 95 93 97 93 85

9b* In last 12 months, have not experienced musculoskeletal (MSK) problems as a result of work activities 72 70 72 69 68 77 81 68 89 85 79 73 71

9c Not felt unwell due to work related stress in last 12 months 62 87 49 60 61 66 66 63 64 71 50 65 63

9d In last 3 months, have not come to work when not feeling well enough to perform duties 39 35 32 40 31 45 39 40 47 44 24 40 41

9e Not felt pressure from manager to come to work when not feeling well enough 64 87 61 52 66 67 62 67 78 73 64 74 57

9f Not felt pressure from colleagues to come to work when not feeling well enough 76 73 72 73 66 84 87 81 83 85 86 75 73

9g Not put myself under pressure to come to work when not feeling well enough 7 13 6 3 8 12 10 7 4 3 11 11 5

11a In last month, not seen errors/near misses/incidents that could hurt staff 82 86 83 88 65 74 90 83 88 95 94 84 83

11b In last month, not seen errors/near misses/incidents that could hurt patients 75 82 74 73 58 87 95 78 80 94 85 75 70

11c Last error/near miss/incident seen that could hurt staff and/or patients/service users reported 88 * 89 87 91 71 53 89 * * * 91 90

12a* Organisation treats fairly staff involved in errors 42 55 28 44 47 40 32 47 30 50 32 49 41

12b* Organisation encourages reporting of errors 88 95 88 84 87 77 81 91 95 85 97 96 88

12c* Organisation takes action to ensure errors not repeated 65 55 69 65 67 56 54 65 64 58 68 73 67

12d* Staff given feedback about changes made in response to reported errors 49 33 52 46 50 34 33 52 43 45 34 60 56

13a Know how to report unsafe clinical practice 86 91 92 83 88 64 69 91 77 80 89 90 92

13b Would feel secure raising concerns about unsafe clinical practice 70 77 72 64 72 56 47 75 75 73 70 79 73

13c Would feel confident that organisation would address concerns about unsafe clinical practice 58 68 54 53 59 49 54 62 64 70 62 68 55

14a Not experienced physical violence from patients/service users, their relatives or other members of the public 83 100 94 94 53 94 99 74 98 99 79 80 85

14b* Not experienced physical violence from managers 100 100 100 100 99 99 100 99 100 99 97 100 100

14c* Not experienced physical violence from other colleagues 98 100 99 100 95 97 100 97 100 99 97 99 99

14d+ Last experience of physical violence reported 58 * 71 37 62 54 * 70 * * * 48 39

15a Not experienced harassment, bullying or abuse from patients/service users, their relatives or members of the public74 86 65 79 53 87 93 70 95 94 74 74 76

15b* Not experienced harassment, bullying or abuse from managers 88 90 88 83 89 86 87 93 86 92 81 89 87

15c* Not experienced harassment, bullying or abuse from other colleagues 83 86 83 83 78 82 85 88 85 87 73 85 78

15d+ Last experience of harassment/bullying/abuse reported 40 * 43 23 46 41 29 38 * 30 64 48 43

16 Organisation acts fairly: career progression 60 73 59 53 62 52 68 63 51 59 43 71 57

17a Not experienced discrimination from patients/service users, their relatives or other members of the public 96 100 98 98 90 100 99 95 100 99 95 96 96

17b Not experienced discrimination from manager/team leader or other colleagues 94 95 94 95 93 94 96 96 93 93 100 96 91

18a* Had training, learning or development in the last 12 months 72 68 74 64 81 56 64 79 68 73 74 72 75

18b* Training helped me do job more effectively 81 93 77 76 83 73 72 87 83 82 75 89 80

18c* Training helped me stay up-to-date with prof. requirements 84 87 86 80 89 67 64 87 83 75 71 90 89

18d* Training helped me deliver a better patient / service user experience 78 80 77 73 83 58 45 86 77 62 57 88 83

19* Had mandatory training in the last 12 months 91 91 96 92 84 87 97 94 86 93 92 90 88

20a Had appraisal/KSF review in last 12 months 86 95 85 91 84 76 92 86 77 95 95 78 91

20b* Appraisal/review helpful in improving how do job 71 80 67 56 78 68 62 80 76 73 58 83 70

20c* Clear work objectives agreed during appraisal 83 85 82 75 86 75 79 88 79 82 72 91 84

20d* Appraisal/performance review: left feeling work valued 70 95 65 59 75 65 68 77 68 72 61 85 68

20e* Appraisal/performance review: organisational values discussed 73 85 72 65 73 70 66 78 62 82 60 83 71

20f Appraisal/performance review: training, learning or development needs identified 68 74 68 64 73 48 67 77 61 60 59 72 69

20g* Supported by manager to receive training, learning or development identified in appraisal 91 92 90 81 91 92 92 95 95 91 74 93 91

21a Care of patients/service users is organisation's top priority 75 95 70 74 73 68 73 79 93 90 61 79 75

21b Organisation acts on concerns raised by patients/service users 74 76 75 65 76 64 61 76 82 88 76 80 74

21c Would recommend organisation as place to work 60 77 49 48 64 59 58 63 57 70 55 70 61

21d If friend/relative needed treatment would be happy with standard of care provided by organisation 64 82 58 56 63 56 59 63 59 71 68 75 69

22a Patient/service user feedback collected within directorate/department 65 27 88 41 81 39 11 84 27 34 58 85 68

22b Receive regular updates on patient/service user feedback in my directorate/department 53 * 58 39 43 52 40 54 67 49 41 59 59

22c Feedback from patients/service users is used to make informed decisions within directorate/department 47 * 53 37 44 51 13 47 58 49 41 52 47

Disability 27b Disability: organisation made adequate adjustments(s) to enable employee to carry out work 34 * 52 35 30 34 33 41 * 19 * 24 31

3.77 4.24 3.68 3.56 3.79 3.65 3.66 3.84 3.99 3.95 3.68 3.95 3.79

Response Rate 44% 77% 47% 40% 42% 24% 67% 50% 75% 92% 55% 49% 41%

* = Not comparable to 2014 or earlier scores

Overall Staff Engagement

Training

Appraisals

Organisation

Your job

Management

Health, Well-being

and Safety

Bullying, Harassment

and Whistleblowing

Title Turnaround and Cost Improvement Plans

Report to: Board of Directors Date: 22 March 2016

Author: Dawn Jarvis – Director of Strategy and Improvement

For: Discussion

Purpose of Paper: Executive Summary containing key messages and issues

This paper provides updates on three things:- 1. Progress towards readiness for Turnaround 2. Progress to deliver Grip and Control and Turnaround 3. Progress to deliver our high level CIP Plan for 16/17 and beyond

Recommendation(s)

The Committee is asked to DISCUSS the progress reported.

Delivering the Values – We Care (how the values are exemplified by the work in this paper)

We always put the patient first

By focusing on efficiency and financial stability to deliver care going forward Everyone counts – we treat each other with courtesy, honesty, respect and dignity

By having clear and transparent processes and policies and by living our values Committed to quality and continuously improving patient experience

By ensuring we are continuously improving our financial position Always caring and compassionate

By protecting the future of the Trust by caring about how we become more efficient Responsible and accountable for our actions – taking pride in our work

By having clear objectives and actions to improve our financial performance Encouraging and valuing our diverse staff and rewarding ability and innovation

By ensuring everyone’s ideas count and everyone’s views are heard

Related Strategic Objectives

Provide the safest, most effective care possible

Control and reduce the cost of healthcare

Focus on innovation for improvement

Develop responsibly, delivering the right services with the right staff

Analysis of risks

The main risk of not moving to a new way of working is that we will not have a credible and supported plan to deliver the savings necessary to reduce the financial deficit of the Trust. As a subset of this our key stakeholders and partners may lose faith in our ability to manage our own response to this issue and will take more direct ownership and control. Board Assurance Framework

1 Failure to achieve compliance with Monitor Risk Assessment Framework, CQC and

other regulatory standards, triggering regulatory action.

5 x 4 = 20

5 Failure to deliver financial plan. 5 x 5 = 25

19 Failure to deliver turnaround / cost reduction programme. 4 x 5 = 20

2

i. Introduction As the Board is aware we are currently engaged on three main tasks; readiness for Turnaround; delivering Turnaround itself and creating a credible, risk adjusted and deliverable CIP Plan for 16/17 and beyond. The purpose of this paper is to provide a progress update on all three areas as follows (the categories below were outlined in previous papers to this Board and to the Financial Oversight Committee in January and an update was provided at both meetings in February):- Readiness for Turnaround:-

a. Setting Turnaround principles and culture b. Introducing standard governance and accountability c. Setting roles and responsibilities d. Standardising project management e. Implementing accountability arrangements f. Running Quality and Performance Impact Assessment processes g. Introducing the Gateway Process, and h. Securing enough resources to ensure successful delivery

Turnaround:- i. Regaining “Grip and Control” j. Implementing “Grip and Control Meetings” k. Running a Mutually Agreed Resignation Scheme (MARS), and l. Early set up of some quick win projects (for delivery 15/16)

Creating a credible, risk adjusted and deliverable CIP Plan for 16/17 and beyond:- m. Financial monitoring and accountability of delivery, particularly at SRO level, and n. Outline of major work streams and the key issues they address

ii. Readiness for Turnaround is, from the delivery perspective, almost at an end. It

should be noted that many of the specific actions under this first section, are ongoing especially engagement and continuing to embed processes; these are being implemented at a differential and appropriate rate. There are five areas that are proving problematic and which require escalation at the meeting to ensure the Committee are aware of them but they do not pose a terminal threat to delivery at this stage.

Universal medical staff engagement and some other pockets of the workforce;

Consistent delivery of work stream timescales and support for different ways of working;

Lack of adherence to a total focus on the work streams with some other key projects still having resources assigned to them outside of this process;

Some lack of engagement with the accountability process, though this is generally going well;

Resourcing the Programme.

3

iii. Turnaround itself is going much better than we planned in many respects. The in year savings from M9 show a wide level of engagement of all areas of the Trust to curb spending, reduce the use of temporary staff (and adhere to agency cap rates) and the vast majority of the Trust is fully engaging, with enthusiasm in turning around the Trust’s financial deficit. Regaining grip and control Each month we are seeing a reduction in our run rate as follows:- For December (M9) we know that we spent over £700k less once the final movements settled (last month I reported this as £655k but the saving has gone up). In January (M10) we can see a further reduction expenditure of £830k In February (M11) we are seeing a pleasingly sustained position on expenditure with a small addition reduction of £26k. Therefore overall since M8 we are seeing a total reduction in expenditure of £1,559,421.

Nov-15 Dec-15 Jan-16 Feb-16

Pay 21,105,876 20,629,766 20,577,815 20,676,136

Drugs 2,903,241 2,944,224 2,565,193 2,445,864

Clinical Supplies & Services 2,574,291 2,719,470 2,110,039 2,126,098

Other non-pay 4,855,052 4,442,066 4,652,032 4,630,942

Total as per CSU's - BR Categories 31,438,460 30,735,527 29,905,079 29,879,039

There is a concerted effort going on across the Trust at all levels to really consider what needs to be spent now, or at all, and this is being supported by a close scrutiny of all budget lines in the detailed “Grip and Control” meetings outlined below. The only specific update to escalate to the Committee from last month’s report is that the saving on Clinical Excellence Awards was pre-emptive and agreement has not yet been reached with our consultant body, this puts in doubt the saving of £130k; the spend had been accrued for, so is already in our plans. “Grip and Control Meetings” We now have a planned approach to “Grip and Control” and have completed our first set of meetings, which have brought about four main outcomes.

i. Proposals for a timetable, requests from attendees are to maintain these over the coming year. We intend to run the next series once M1 reports are out then three more series over the financial year to maintain focus.

4

ii. Financial training for all budget holders which my team is planning.

iii. Several cross cutting smaller projects which are being incorporated into a “grip and control” PID which will be reviewed next month at the Financial Oversight Committee. For example payment for home phone lines, management of mobile contracts, printers and related consumables and the centralisation/reduction of ward environment budgets and the centralisation of some other budgets to enable purchasing power.

iv. Budgetary changes for the coming year, around recharging and internal trading processes, how capital spend is recorded and shown in budgetary lines, what type and level of information budget holders get etc.

The MARS scheme has concluded which will see 29 members of staff leave at the end of March which will show a recurrent saving of £738k. At a one off cost in March of £568k (budget of £1.5m was set aside). Six posts are being replaced but at a much lower and reconfigured level and the repayment of the MARS amount will be recouped for these six posts within 18 months – there is a 30th member of staff to add in, the figures associated with that case have not been included in the calculations.

Annual salary £707,278.06

Estimates replacement costs £86,749.08

Total saving £620,528.98

On costs of staff leaving £140,109.99

On cost for replacements £22,554.76

Total saving £738,084.21

Total cost of MARS in 15/16 £568,131.37

Early outcomes from projects Car parking charge increases for staff were reduced from the initial increase and calculations are underway to assess the impact on the smaller increase, and work continues to arrange discussions with staff side about further changes. Increases to public parking are now planned for 30 April 2016. Staff in our Pay and Pensions team have now been informed that their work will be outsourced to Shared Business Services, an arm’s length part of the NHS who provide payroll and HR admin services to around 200,000 NHS employees, the staff are covered by TUPE and the offices are in Sheffield. CIP Plans 16/17 We have made good progress across many more of the work streams since the last report and now have two of them signed off at Executive Team and proceeding to the Quality and Performance Impact Assessment Stage (Length of Stay/Bed Plans and Theatres). These PIDs were discussed at the Financial Oversight Committee at an overview level, and are being sent to members for familiarization purposes.

5

There are a good number that are just about to reach this stage having defined, phased and risk adjusted savings (Non-medical Clinical Productivity, Procurement, Income, Care Group and Corporate Local, Corporate Directorates Review, Management Review). There are some that are a little behind the curve and which are having some intensive work done on them to ensure we can identify and phase the savings over the next two years (Infrastructure – following the launch of the Car Parking savings where the financial modelling is being reviewed, Medical Productivity – we don’t have a work stream lead, Clinical Admin – we don’t have an SRO or work stream lead and Outpatients – where the delivery plans need wider focus). During the meeting more detail can be provided. We also have a work stream that the Directorate of Strategy and Improvement are leading, on Grip and Control and the savings in here are added on top of those in the 12 work streams, this PID will be provided at the next meeting of this Committee. We are close to sign off of our CIP tracker which has been populated with the two signed off PIDs, again this was reviewed at draft stage at the Financial Oversight Committee and once signed off by the Director of Finance will be on the agenda of that meeting each month. Remaining plans and timescales for delivery There are a series of plans required to the following deadlines which will build on the initial

plan submitted to Monitor in February:-

16/17 operation plan – to Monitor by 11 April 2016 (extraordinary Board meeting 7

April)

Recovery plan for 2016/17 - to Monitor by 29th April 2016 (April Board)

Recovery plan for 2017/18 by 15th July 2016 (June Board)

Strategy for financial sustainability and an associated longer-term five year financial

plan (“the Strategic Plan”) by 30 September 2016 (August and September Board)

In addition to this is the overlay of the Carter requirements, which we have fed into the

various work streams.

Summary

In summary, we continue to recieve positive feedback from Monitor, external companies

that are providing support to us and more importantly we are showing savings can be

delivered and change in behaviour can be swift, supportive and sustained. However, the

longer term changes and the Trust’s ability to adapt in a sustained way are still to be tested

and however positive we might be about progress there is still a long way to go to deliver

sustained financial health.

1

Title Board Assurance Framework and Corporate Risk Register

Report to: Board of Directors Date: 22 March 2016

Author: Maria Dixon, Head of Corporate Affairs

For: Review

Purpose of Paper: Executive Summary containing key messages and issues

The Board is required to receive and approve the Board Assurance Framework. The framework is underpinned by the Corporate Risk Register, and is used to inform the Annual Governance Statement. Review The attached framework and risk register will be subject to a detailed end of year review, with all executives present on 29 March 2016. Since the Board last received the BAF, it has been reviewed by a sub-committee of the Board on two occasions (below). The Corporate Risk Register has also been reviewed by the Management Board each month.

18 January 2016 – Clinical Governance Oversight Committee

18 March 2016 – Audit & Non-clinical Risk Committee Sub-committee activity / Assurance received The Audit & Non-clinical Risk and Clinical Governance Oversight committees have received reports which have provided assurance or advice in relation to a number of BAF risks and controls. Specifically, the committees received audit reports on the following areas since the Board last received this report:

Ophthalmology (Follow up review) (Follow up review) 1 medium risk action ongoing

Complaints (Follow up review) (Follow up review) 7 medium risk actions ongoing

CQC Mock Inspection Process Significant assurance 1 medium risk and 3 low risk issues

Information Governance Toolkit Significant assurance 3 recommendations made

Theatres Utilisation (Follow up review)

No opinion Limited progress had been made due to the actions being incorporated into the 2020 elective care workstream programme.

Governance (restructure) - Clinical governance review

Significant Assurance / Limited Assurance

2 medium risk actions

Local Training Arrangements (Follow up review) 2 medium risk actions outstanding

2

(Follow up review)

Early warning systems (Follow up review)

(Follow up review) 2 medium risk & 1 low risk actions outstanding

(where the assurance level is ‘n/a’ this indicates that the audit was for advisory or benchmarking purposes)

Recommendation(s)

The Board is asked to RECEIVE and APPROVE the attached framework.

Delivering the Values – We Care (how the values are exemplified by the work in this paper)

We always put the patient first

Through our commitment to managing and mitigating risks to our patients, and our focus on reducing clinical risk.

Committed to quality and continuously improving patient experience

By proactively working to identify and manage all risks to service quality. Responsible and accountable for our actions – taking pride in our work

By ensuring that every corporate risk has an accountable executive, and continuously seeking assurance that risk is well managed.

Related Strategic Objectives

Provide the safest, most effective care possible

Control and reduce the cost of healthcare

Focus on innovation for improvement

Develop responsibly, delivering the right services with the right staff

Analysis of risks

a. Resource – No known issues or risks. b. Governance – The framework is an essential part of the Board’s governance arrangements. c. PR and Communications – No known issues or risks. d. Patient, Public and Member Involvement – No known issues or risks. e. NHS Constitution - Rights and Pledges – No known issues or risks.

Board Assurance Framework

This report relates to the Board Assurance Framework as a whole, therefore all risks are relevant in addition to the one listed below.

11 Failure to maintain appropriate corporate governance systems to ensure the effectiveness of the Board of Directors and Board of Governors.

3 x 4 = 12

1

Board Assurance Framework Summary Please note that where assurance is listed as ‘limited’, this may be due to a number of different reasons. Assurance activities may indicate that controls are inadequate, but assurance may also be limited simply by scope or date. The notes column provides further context where required.

Risk

Co

mm

.

Inherent Rating

Residual Rating

Sources and levels of assurance Overall Notes / context

2015/16 Internal audit plan – future

audits Operational / Management

Internal audit

Other independent

1 Failure to achieve compliance with Monitor Risk Assessment Framework, CQC and other regulatory standards, triggering regulatory action

CGOC 25 20 Significant / None

Significant/ None

Significant/ None (a, b)

Significant/ None

Significant in relation to performance and quality metrics and CQC compliance. No assurance in relation to finance aspects of the RAF.

2 Harm resulting from failure to safeguard patients and families.

CGOC 25 12 Significant Limited Significant (a, b)

Significant

3 Failure to provide harm free care.

CGOC 25 12 Significant Limited Significant (a, b, c, d, f)

Significant IA assurance is limited by scope. Significant assurance in BIR in general although some areas are of concern.

Serious Incidents Handover/ Team

Working

4 Failure to sustain a viable specialist and non-specialist range of services.

CGOC 20 12 Limited Limited (b, d, e)

Limited Assurance is limited by scope and date.

5 Failure to deliver financial plan

ANCR 25 25 Limited None Assurance is absent due to evidence of lack of financial control and current financial position.

2

Risk

Co

mm

.

Inherent Rating

Residual Rating

Sources and levels of assurance Overall Notes / context

2015/16 Internal audit plan – future

audits Operational / Management

Internal audit

Other independent

6 Failure to ensure that appropriate infrastructure is in place

ANCR 20 12 Significant

Limited Limited (b)

Limited Current assurance is limited by scope.

7 Risk of Fraud ANCR 25 8 Limited Significant Significant (b, f)

Significant Risk has increased due to evidence of lack of financial control.

8 Failure to deliver accurate and timely management information

ANCR 16 16 Limited Significant Significant (b, f)

Limited Assurance is limited due to evidence of inaccurate financial reporting.

10 Inability to recruit right staff and ensure staff have the right skills to meet operational needs

ANCR 20 12 Significant Limited Significant (b, c)

Significant Internal audit assurance expected to increase due to work planned for 2015/16.

Appraisals

11 Failure to maintain appropriate corporate governance systems to ensure the effectiveness of the Board of Directors and Board of Governors

ANCR 16 12 Limited Significant Limited (b)

Significant Assurance is limited due to evidence of poor financial governance and assurance processes. KPMG review underway.

Risk Management and Board Assurance Framework

13 Breakdown of relationship with key partners

ANCR 20 8 Limited Significant (b, d, e)

Significant External partners were consulted as part of CQC inspection process.

15 Failure to engage and communicate with staff and representatives

ANCR 15 6 Limited Limited (c)

Limited Limited assurance due to scope of current reporting.

Communications/ Engagement

16 Failure to ensure business continuity / respond appropriately to major incidents

ANCR 20 8 Significant Limited Significant (d, e)

Significant Limited IA assurance due to scope of work.

Business Continuity

3

Risk

Co

mm

.

Inherent Rating

Residual Rating

Sources and levels of assurance Overall Notes / context

2015/16 Internal audit plan – future

audits Operational / Management

Internal audit

Other independent

19 Failure to deliver turnaround / cost reduction programme.

ANCR (FOC)

20 20 Limited Limited Limited assurance due to early stage of work and scope of current assurance.

Sources of assurance used in ‘Other independent’ column:

(a) Inspections/ reviews by regulators

(b) Reviews / inspections / assessments by other external bodies

(c) Patient or staff surveys

(d) Independent empirical evidence / outcome measures

(e) Partnership exercises / peer reviews

(f) External audit

CORPORATE RISK REGISTER(last reviewed and approved by Management Board: 29.02.16)

Summary of proposed changes / risks under review:None

Summary of recent change/escalated risks:16.02.16 Risk 4 Actions updated.27.11.15 Risk 1 Risk upgraded to 20, assurances updated, to reflect change to COSRR & Monitor position30.11.15 Risk 2 Controls and assurance updated.30.11.15 Risk 3 Controls and assurance updated.27.11.15 Risk 5 Controls & assurance updated, risk upgraded to 25 in the light of material mis statement of the financial results and likely year end deficit. 27.11.15 Risk 6 Controls & assurance updated. 27.11.15 Risk 7 Risk upgraded to 8 in light of inherent risk of weak financial controls.27.11.15 Risk 8 Risk upgraded to 16 in light of inaccurate financial information. Controls and assurance updated.27.11.15 Risk 11 Controls & assurance updated. Risk upgraded to 12 to relfect concerns relating to governance and control.27.11.15 Risk 16 Assurances updated30.11.15 Risk 19 Risk reframed in light of current position, actions updated and risk upgraded to 20.Aug-15 Controls, assurance & actions reviewed for all risks, no changes to ratings.Jun-15 Controls, assurance & actions reviewed for all risks, no changes to ratings.Jun-15 Risk 5 (Failure to deliver financial plan) - risk rating downgraded to 12 (high).29.04.15 Risk 22 (Nutrition) Likelihood reduced to 3, giving a rating of 12 (high), and removed from the corporate risk register.29.04.15 Risk 21 (Histopathology reporting) Likelihood reduced to 3 or below, and removed from the corporate risk register.29.04.15 Risk 20 (Anticoagulant dosing) Likelihood reduced to 3 or below, and removed from the corporate risk register.29.04.15 Risks 18 & 19 (Innovation / DBH2020) Risks merged, with an overall risk rating of 12 (high).29.04.15 Risks 16 & 17 (Business continuity / major incidents) Risks merged, with an overall risk rating of 8 (high).29.04.15 Risk 15 (Staff engagement) Likelihood reduced to 2, giving a rating of 6 (moderate). Risk remains on the BAF, but removed from corporate register.29.04.15 Risk 9 (Ophthalmology) Risk rating reduced to 6 and removed from the corporate risk register.

Low: 1 – 3 Moderate: 4 – 6 High: 8 – 12 Extreme: 15 – 25

Likelihood: 1 – Rare; 2 – Unlikely; 3 – Possible; 4 – Likely; 5 – Almost certain

Consequence: 1 – Insignificant; 2 – Minor; 3 – Moderate; 4 – Major; 5 – Catastrophic

Strategic Objectives:1 - Provide the safest, most effective care possible2 - Control and reduce the cost of healthcare3 - Focus on innovation for improvement4 - Develop responsibly, delivering the right services with the right staff

Page 1

No. Risk

CR

R

BA

F Lead

Director

Risk

Source

Existing Controls Gaps in Control Gaps in Assurance Actions to address gaps Milestones / timescale for

completion

Previous / Proposed

Changes

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Potential Actual

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

1 Failure to achieve

compliance with

Monitor Risk

Assessment

Framework, CQC

and other

regulatory

standards,

triggering

regulatory action

1,

3,

4

CR

R

BA

F COO Exec

Team

5 4 20 12 (i) Performance Management and

Accountability Framework.

(ii) Business planning processes

(iii) Relevant policies and procedures

(iv) Daily, weekly & monthly

monitoring of targets

(v) Regular monitoring of compliance

(vi) Data analysis of trends and action

to address shortfalls

(vii) Continued liaison with leads to

identify risks to delivery

(viii) CQC Compliance Governance and

Assurance Process

(ix) External reviews policy

(x) Monitoring at monthly Care Group

accountability meetings.

(xi) A&E QAT process

(xii) Demand and capacity planning

proccesses

(xiii) Weekly review of A&E Action plan

in accountability meeting chaired by

COO.

Shortfalls in capacity

identified.

Lack of robust financial

controls.

- Quarterly CQC

compliance reports

- Compliance

performance reported in

Care Group dashboards /

BIR

- Business Intelligence

Reports

- Quarterly Monitor

declarations

- Annual reports

- 2014/15 Monitor declarations

(with 'Green' governance rating)

(i-vii)

- Full and unconditional

registration with CQC (viii)

- CQC Inspection result, April

2015 (viii)

- Business Intelligence Reports

(BoD 23.06.15; 28.07.15;

25.08.15) (i-vii)

- Annual Report & Quality

Account 2013/14 (i-vii)

- CQC health-wide inspections of

safeguarding 2014 & 2015 (viii)

- CE quarterly objectives report

(BoD 27.01.15; 28.04.15) (i-ix)

- CQC internal audit (viii)

- Infection Control internal audit

(i-vii)

- CQC Intelligent Monitoring

reports & risk ratings (viii)

- ECIST Report (Dec 2014) (iv)

- Duty of Candour Update Report

(Feb 2015) (viii)

- Lack of robust financial

information.

- Financial performance

2015/16

- Cancer 62 day waits Q2

2015/16

- Outsourcing of work to

address shortfalls in

capacity, alongside work to

recruit staff

- 'Grip & Control' plan /

turnaround plan

- Q4 2016 2 4 8 27.11.14 - Risk rating

upgraded to 20 to

reflect regulatory

position.

07.11.14 - actions

updated

08.09.14 - Risk rating

increased from 8

(high) to 12 (high)

2 Harm resulting from

failure to safeguard

patients and

families.

1

CR

R

BA

F DNMQ Exec

Team

3 4 12 10 (i) Safeguarding adults and childrens

teams (strengthened in 2014/15)

(ii) Safeguarding Supervision policy &

implementation plans

(iii) Safeguarding guidance, policies &

procedures

(iv) DBS checks

(v) Revised training in place

(vi) Monitoring of all social care

referrals by Safeguarding team.

(vii) Quarterly report on the status of

DBS checks to commissioners.

(viii) Use of NHS Professionals to

ensure DBS checks & training

completed.

(ix) ED controls due to Symphony

system

(x) Named Midwife, Nurse &

Doncaster

- Not all training

recorded

- Risk escalating

overall due to

demographic changes

- Non-compliance with

statutory requirements

(training, DoLs

requirements)

- Peer review

- NHSLA / CQC

assessments

- Clinical audits

- annual OFSTED

inspections

- Safeguarding annual

Report

- DBS Checks &

safeguarding training

confirmed by NHSP

- Strategic Safeguarding People

Annual Report (CGSC 18.07.14) (i-

vii)

- Safeguarding metrics in BIR

(BoD 23.06.15; 28.07.15;

25.08.15) (i-viii)

- Annual CP1 audit (i-vii)

- Annual Safeguarding audit (i-vii)

- Security Arrangements internal

audit

- CQC safeguarding inspections,

Doncaster (2014) & North

Nottinghamshire (2015)

- CQC inspection, April 2015

- Ofsted review of Children’s

services in Doncaster

- Peer review of adult services in

Doncaster

- Poor attendance at

training, and inability to

evidence training.

- Lack of processes to

deliver assurance

regarding compliance

with policies & statutory

obligations.

- Some gaps identified

by CQC review of local

safeguarding

arrangements

- Ongoing work to improve

recording and attendance at

safeguarding training,

monitored by Strategic

Safeguarding Board.

- Safeguarding action plan in

place.

- action plan regarding

outcomes of visit in place.

- Recorded attendance

rates continue to

improve. Revised

training strategy

including e-learning

options is being

developed.

- Progress reviewed at

the Strategic

Safeguarding Board.

2 3 6 26.08.15 - actions

updated.

14.04.15 - actions

updated.

Dec 14 -

Safeguarding risk

register reviewed

and 4 risks escalated.

Risk ratings

confirmed as 'high'

rather than extreme.

Target Risk

Rating

Current Risk

Rating

Assurance

Pre

vio

us

Ris

k R

atin

g

Stra

tegi

c G

oal

s

Page 2

No. Risk

CR

R

BA

F Lead

Director

Risk

Source

Existing Controls Gaps in Control Gaps in Assurance Actions to address gaps Milestones / timescale for

completion

Previous / Proposed

Changes

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Potential Actual

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Target Risk

Rating

Current Risk

Rating

Assurance

Pre

vio

us

Ris

k R

atin

g

Stra

tegi

c G

oal

s3 Failure to provide

harm free care:

• Pressure ulcers

• Falls

• Complaints

• Poor experience

• Claims

• SHMI / HSMR

• serious incidents /

adverse events

• quality outcome

indicators

• inquests

• harms

1C

RR

BA

F DNMQ /

MD

Exec

Team

3 4 12 8 (i) HSMR /SHMI alerts

(ii) Emergency pathway redesign

(iii) Review of Mortality Initiatives

(iv) Reporting and investigation of SIs,

complaints & inquests, and action

plans

(v) NPSA local reporting process

(vi) Action plan monitoring through

PSRG

(vii) NICE Guidance Policy

(viii) Monitoring and audit by Clinical

Audit & Effectiveness Group

(ix) Care Group accountability process

(x) Complaints processes & policy

(xi) Action plans to address quality &

experience issues

(xii) Pressue ulcer action plan and

Tissue Viability Strategy

(xii) Agreed outcomes of 'sign up for

safety pledge'

(xiii) Safety thermometer processes

(xiv) A&E governance assurance

processes

(xv) A&E Symphony system

(xvi) QAT process

(xvii) Action plan follow-up monitoring

process through CGQC

(xviii) Learning by Experience team

established in Emergency Care

(xix) HED system

- Progress made to

implementing 24/7 GI

bleed rota but some

gaps still remain due to

unfilled vacancies.

- Business Intelligence

reports

- Complaints Internal

Audit Report

- Quality Account

- Quarterly DATIX

Reports

- External and internal

patient experience

surveys

- Compliance with NHSLA

standards

- Clinical audits

- NHSLA assessment of

claims

- Care Group

Accountability meetings

- Clinical Audit Annual

Report

- Reports to Clinical Audit

& Effectiveness meetings

- Serious Incident reports

- CHKS Mortality coding

audit

- Safety Thermometer

performance

- Performance against

'sign up for safety' pledge

outcomes

- QAT assessments

- Business Intelligence Reports -

Continued progress in HAPU,

C.Diff and HSMR (BoD 23.06.15;

28.07.15; 25.08.15) (i-xiii)

- CGSC/CGQC exception reports

to CGOC (20.10.14; 19.01.15;

20.04.15; 20.07.15) (i-xiii)

- Quality account 2013/14 (BoD

06.05.14) (i-xiii)

- Francis Report Trust response

(final report May 2014) (xi)

- DIPC Annual Report (BoD, July

2014) (xi)

- Ward Quality Assurance Toolkit

inspection reports (BoD, monthly,

in nursing workforce report) (i-

xiv)

- CE Objectives report (BoD,

quarterly) (i-xiv)

- National A&E Survey (BoD, Nov

2014) (ii, iv, xi, xiv)

- PHE review feedback (with

regards to IPC programme)

- ECIST Report (Dec 2014) (ii)

- Internal Audits (NICE Guidance;

Infection Control;

Ophthalmology; Early Warning

Signs; Complaints; Outpatients)

(i-xiv)

- CQC inspection report (2015)

- Issues highlighted by

trauma peer review (Feb

2015)

- 24/7 GI bleed rota:

recruitment underway.

- Action plan in response to

issues raised following

trauma peer review.

- Appoint falls practitioner to

accelerate the improvement

work in Care of the Elderly.

Delivery by end of Q3

2015/16.

Commenced in post

September 2015

2 4 8 26.08.15 - actions

updated.

08.09.14 - Current

risk rating increased

from 8 (high) to 12

(high); target risk

rating increased

from 4 (moderate) to

8 (high)

Page 3

No. Risk

CR

R

BA

F Lead

Director

Risk

Source

Existing Controls Gaps in Control Gaps in Assurance Actions to address gaps Milestones / timescale for

completion

Previous / Proposed

Changes

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Potential Actual

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Target Risk

Rating

Current Risk

Rating

Assurance

Pre

vio

us

Ris

k R

atin

g

Stra

tegi

c G

oal

s4 Failure to sustain a

viable specialist and

non-specialist range

of services.

[Transition of

aspects of

specialised

commissioning to

CCGs is underway,

therefore this risk

will be kept under

review in light of

this.]

1,

3,

4

CR

R

BA

F MD Exec

Team

3 4 12 12 (i) Membership of SYCOM

(ii) Local commissioner

Meetings

(iii) Specialty based project boards

(e.g. cardiac)

(iv) Engagement in procurement

exercises

(v) Care Group performance

management

(vi) Involvement in AHSN development

process

R&D support for specialist service lines

(vii) Process to develop a Specialist

Cancer Service Partnership /Alliance

with STH. Plan agreed internally, with

specialist commissioners and STH for

interim support before full

mobilisation.

(viii) 1 in 5 consultant interventional

radiologist rota now in place

Transition of Specialist

Care commissioning

from SCGs and PCTs to

the National

Commissioning Board

and other

commissioning

agencies.

Expectation that

Specialist Service

definition will be

revised.

Reorganisation of

clinical networks to

AHSN footprint.

- Board of Directors

reports

- Contract & review

Outcomes

- External reviews

- CE Reports (BoD 23.06.15;

28.07.15; 25.08.15) (i-vii)

- Oncology Training contract (iv)

- Vascular Services Accreditation

(iii--vi)

- National Cancer Peer Review

programme (vii)

- Outcome of radiotherapy

review (to develop 2nd

radiotherapy site at DBH) and

subsequent updates (i-vii)

- Tier 3 Weight Management

service secured via competitive

tender (i-vii)

- Memorandum of Understanding

agreed between DBH, STH and

Chesterfield to explore a joint

approach to Histopathology. (i-

vii)

- External QA/accreditations

/reviews in 2014 (Endoscopy,

Breast Screening, Trauma, Post

Mortem Licence, Bowel Cancer

Screening, Pharmacy, HSDU,

Paediatric Diabetes, Diabetes Eye

Screening, Cancer) (v)

- Upper GI services at

risk through lack of

surgical volumes

- SYCOM recommends

centralised service at

Sheffield.

Morbid obesity:

volumes currently too

low

Vascular: Y&H stocktake

findings - not compliant

with national service

specification

- Ongoing participation in

Working Together

programme to deliver

collaborative service model

Morbid obesity: exploring

work with Barnsley to

increase volumes. Decision

has been made that this

surgery will be

commissioned by local

commissioners rather than

NHS England

Vascular: discussions with

STH regarding a

collaborative service model.

Senate Council currently

reviewing the provision of

vascular services in Y&H.

Advice expected in March.

Renal dialysis: Received

derogation from

commissioners.

- Strategic review of

specialised services in

Y&H currently in

progress.

End 2015

3 4 12 16.02.16 - actions

updated.

14.04.15 - actions

updated.

10.10.14 - actions

updated.

Page 4

No. Risk

CR

R

BA

F Lead

Director

Risk

Source

Existing Controls Gaps in Control Gaps in Assurance Actions to address gaps Milestones / timescale for

completion

Previous / Proposed

Changes

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Potential Actual

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Target Risk

Rating

Current Risk

Rating

Assurance

Pre

vio

us

Ris

k R

atin

g

Stra

tegi

c G

oal

s5 Failure to deliver

financial plan

2C

RR

BA

F DF Exec

Team

5 5 25 12 (i) Business Plan reviewed by Internal

Audit and Monitor, and developed

with engagement from Care Groups /

departments.

(ii) Monthly monitoring, from Board

report to Care Groups to individual

cost centres.

(iii) Uncommitted general contingency

reserve of a minimum 1% included in

forward financial plans. Further

contingency through service

development reserve, committed

throughout year subject to the overall

financial position.

(iv) CIP delivery supported by:

- full Quality Risk Assessment and

operational deliverability assessment

of plans.

- Monthly monitoring at individual

scheme, Care Group / Directorate and

Trust levels.

- Collaboration with other providers, to

identify joint opportunities.

- Development of patient-level costing

and service line reporting to support

identification of future opportunities.

(iv) Monitoring of potential areas of

concern, including commissioner

affordability

A number of balance

sheet control

reconciliations have

not been reconciled

along with supplier

statement

reconciliations.

- Board discussion and

approval of Business Plan

(including two year

Operational Plan to

Monitor)

- Board briefings from

Care Groups include

financial performance

- Monthly Board Finance

reports

- Internal Audit reports

- External Audit review of

financial performance

(within Annual Accounts

work)

There have been

significant weaknesses

in internal controls

which has led to a

material mis statement

of the financial position.

Control account and supplier

statement reconciliations

complete.

Financial Oversight

Committee will review

progress to adjust the

accounts, address

weaknesses and provide

assurance to the Board on

the accuracy of the financial

records.

External investigation by

KPMG into the

circumstances that have

resulted in the material mis-

statement of the financial

results.

January 2016

Nov 15 onwards

Reported February

2016. Action plan to

FinOC 14.03.16.

3 4 12 November 2015 -

Risk increased to 25

in the light of the

level of mis

statement of the

financial results and

likely year end

deficit.

June 2015 - Risk

downgraded to 12

(high) in light of new

financial year.

04.02.15 - risk rating

upgraded to 16

(extreme); gaps and

actions updated.

Page 5

No. Risk

CR

R

BA

F Lead

Director

Risk

Source

Existing Controls Gaps in Control Gaps in Assurance Actions to address gaps Milestones / timescale for

completion

Previous / Proposed

Changes

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Potential Actual

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Target Risk

Rating

Current Risk

Rating

Assurance

Pre

vio

us

Ris

k R

atin

g

Stra

tegi

c G

oal

s6 Failure to ensure

that appropriate

infrastructure is in

place

2,

3C

RR

BA

F DNMQ /

MD

Exec

Team

3 4 12 12 (i) Annual business plan supports

identification issues by Care Groups /

Directorates

(ii) Periodic assessment of existing

infrastructure (inc. ERIC return)

(iii) Multi year capital plans underpin

service strategy, including capital

investments in Estate, IM&T and

medical equipment

(iv) Business planning process supports

development of business cases for

infrastructure issues

(v) Defined resources to support

maintenance of key infrastructure,

including:

* Estates and facilities staff and

management of external maintenance

contractors

* IM&T - maintenance contracts, plus

in house support resource

* Medical Equipment - BME team, plus

range of external maintenance

contracts

(vi) Business continuity and disaster

recovery plans

(vii) Process for post project

implementation review for all major

schemes.

(viii) Corporate Investment Committee

(combining capital and revenue

- Annual business plan to

Board

- Board briefing sessions -

opportunity for Care

Groups / Directorates to

raise issues

- Capital Expenditure

reports (qtrly)

- Internal Audit reports

- iHospital Programme

updates to Board

- Internal audit of IM&T

infrastructure risk

- Capital Expenditure reported in

BIR (BoD 23.06.15; 28.07.15;

25.08.15) (i-v)

- iHospital Programme updates to

Board (i, iii)

- Approval of Site Development

Plans, funding and subsequent

updates (Jun & Dec 2014, Jan

2015) (ii-iv, vii)

- Bed replacement strategy

business case approved (v, viii)

- Quarterly Security management

report (ANCR) (v)

- Bed plan updates (i-v)

- Implementation of A&E

Symphony system (ix)

- Day Surgery Unit 12 Month

Review (Aug 2014) (iii)

- 2014 PLACE Assessment &

update report (Nov 2014) (ii)

- CE Objectives report (quarterly)

(i-ix)

- Internal audits in 2014

(Ophthalmology, Security

Arrangements, Outpatients, E-

expenses) (i-v)

- NHS Protect visit (May 2014)

2014 external report

(Canty) highlighted

compliance issues

reporting remedial

action.

The financial position

will result in capital

spend having to be

scaled back to a

minimum to preserve

cash. This will increase

the risk of failures within

the Trust's

infrastructure.

Action plan monitored

weekly by Senior Estates

Team, Included within

Directorate risk register.

Excellent progress to date.

2018-20 2 4 8 04.02.15 - gaps and

actions updated.

7 Risk of Fraud 2

BA

F DF Exec

Team

4 2 8 6 (i) Local Counter Fraud Specialist work

plan and investigations

(ii) Fraud awareness training.

(iii) DH Counter-Fraud regime and

oversight

Weaknesses in internal

financial controls will

increase the risk of

fraud.

- Quarterly Reports to

ANCR

- Annual Report to ANCR

- Annual NHS Protect

Quality Assessment SRT

- External Audit opinion

- Quarterly and annual LCFS

reports (ANCR 26.09.14;

12.12.14; 20.03.15; 19.06.15) (i-

iii)

- Achievement of satisfactory

NHS Protect Quality Assessment

outcome (i-iii)

- Clean External Audit opinion

(ANCR 22.05.15) (i-iii)

Control account and supplier

statement reconciliations

completed.

Financial Oversight

Committee will review

progress to adjust the

accounts, address

weaknesses and provide

assurance to the Board on

the accuracy of the financial

records.

January 2016

Nov 15 onwards

3 2 6 November 2015 -

Risk increased to 8

due to control

weaknesses which

inherently increase

the risk of fraud.

Page 6

No. Risk

CR

R

BA

F Lead

Director

Risk

Source

Existing Controls Gaps in Control Gaps in Assurance Actions to address gaps Milestones / timescale for

completion

Previous / Proposed

Changes

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Potential Actual

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Target Risk

Rating

Current Risk

Rating

Assurance

Pre

vio

us

Ris

k R

atin

g

Stra

tegi

c G

oal

s8 Failure to deliver

accurate and timely

management

information

1,

2,

3

CR

R

BA

F DF Exec

Team

4 4 16 8 (i) Continued development of

Performance Management

Information Systems

(ii) Key strategies & implementation

plans:

- IM&T

- Data Quality

(iii) PRINCE Project Management in IT

Procurement and Implementation

(iv) Data quality checks and

procedures

(v) Key policies:

- Confidentiality

- Safe Haven

- IM&T Security

- Data Protection Policies

(vi) Information Governance

Framework.

(vii) Mandatory IG Training

(viii) Caldicott Guardian, SIRO & formal

Registration Authority hierarchy

(ix) Clinical Safety Officer for IT

Systems

(x) Information Governance clause in

all staff contracts

(xi) Data Quality assessment of key

metrics in BIR presented alongside

performance information

(xii) Ward Dashboard

Work required to

consolidate

information provided

to Care Groups and

enhance intelligence

provided.

- Finance reports

- Business Intelligence

Reports

- Performance

management information

reported internally and

externally

- Audit Commission

reviews of coding and

PbR

- External Audit Report

on Quality Account.

- Head of Internal Audit

Opinion

- ISA260

- Internal Audit reports

- reports to Information

Governance &

Information Strategy

Groups.

- Information

Governance reports to

ANCR

- Coding Audits

- Records audits

- Business Intelligence Reports

(BoD 23.06.15; 28.07.15;

25.08.15) (i-iv, xi)

- External review of coding

(February 2015) (i-iv)

- AGS and Head of Internal Audit

opinion (ANCR 22.05.15) (i-iv)

- ISA260 Report (ANCR May 2014)

(i-iv)

- Annual Information Governance

Toolkit Assurance (at level 2) (v-x)

- Quality account 2014/15

external audit (ANCR 22.05.15) (i-

iv)

- Clinical Coding independent

audit (BoD 04.02.14)

- Nursing workforce reports (BoD

23.06.15; 28.07.15; 25.08.15) (i-

iv)

- Internal audits in 2014 (Data

Quality – Clinical Therapies,

Mortality & Kite marking;

Theatres Utilisation; Information

Governance toolkit) (i-xii)

- DoH sponsored RTT data quality

review (in which DBH was

identified as a positive outlier)

The material

misstatement in the

financial results has

resulted in low

confidence in the

accuaracy of the

financial information.

Control account and supplier

statement reconciliations

completed.

Financial Oversight

Committee will review

progress to adjust the

accounts, address

weaknesses and provide

assurance to the Board on

the accuracy of the financial

records.

Work with Care Groups and

information team to develop

Care Group dashboards to

consolidate existing

information.

January 2016

Nov 15 onwards

2 4 8 November 15 - risk

increased to 16 due

to financial

information which is

not accurate

Page 7

No. Risk

CR

R

BA

F Lead

Director

Risk

Source

Existing Controls Gaps in Control Gaps in Assurance Actions to address gaps Milestones / timescale for

completion

Previous / Proposed

Changes

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Potential Actual

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Target Risk

Rating

Current Risk

Rating

Assurance

Pre

vio

us

Ris

k R

atin

g

Stra

tegi

c G

oal

s10 Inability to recruit

right staff and

ensure staff have

the right skills to

meet operational

needs

1,

4C

RR

BA

F DPOD Exec

Team

4 3 12 12 (i) HR policies and procedures

(ii) Monitoring of use of agency staff

(iii) Medical staff recruitment action

plans

(iv) Care Group Business Plans –

workforce plans

(v) E-Rostering processes (and

implementation of eRoster v10)

(vi) VCF processes

(vii) Consultant appointment approval

processes

(viii) NHS Professionals processes &

management information

(ix) New recruitment processes

(x) Calderdale framework - 9 funded

training places for DBH staff,

commenced Oct 2014

(xi) DBH 2020 - Workforce workstream

(xii) Processes to ensure compliance

with 'Hard Truths'.

- Training needs

analysis required

- Lack of processes to

support values based

recruitment

- robust workforce

planning processes

required

- Business Intelligence

Report

- P&OD reports

- Nursing workforce

reports

- Achievement of

eRostering KPIs

- Compliance reports

- OLM reports

- Nursing Workforce Reports

(BoD 23.06.15; 28.07.15;

25.08.15) (i-vii)

- P&OD reports (BoD, 29.01.15;

28.04.15) (i-vii)

- Quarterly suspensions &

exclusions report (ANCR) (i)

- Revalidation and Appraisals

annual report (BoD, July 2014) (i)

- E-roster Project Update (BoD,

Nov 2014) (v)

- CE Objectives report (BoD,

quarterly) (i-xii)

- HEE Y&H Quality Management

Visit 2014 (and follow-up training

survey) (iii-iv)

- Staff survey 2013 & 2014 (i-xii)

- RCP national audit of NICE

public health guidance for the

workplace (i)

- GMC Trainee Surveys 2014 (iii-

iv)

- Workforce data quality audit

(ANCR Dec 2015)

Increase in use of

agency due to nurse

staffing levels and

difficulties recruiting to

AUKUH/Safer Nursing

Care standards.

- lack of robust financial

information

- e Roster / NHSP system

interface implementation

- Cohort recruitment for

HCA, NQ and RN.

- Establish processes to

support values based

recruitment

- International recruitment

- Transactional recruitment

process redesign DBH2020

project

- TNA underway

- Development of robust

workforce planning

processes

- 2015/16 (date tbc)

- Complete for HCA &

NQ. Late summer 2015

for RN.

- November 2015

- Recruited staff to have

passed NMC tests by

early 2016

- Phase 1 Dec 2015

- September 2015

- March 2016

3 3 9 14.04.15 - actions

updated.

08.09.14 - Likelihood

increased to 4 and

consequence

reduced to 3; risk

rating of 12 (high)

unchanged.

11 Failure to maintain

appropriate

corporate

governance

systems to ensure

the effectiveness of

the Board of

Directors and Board

of Governors

1,

2,

3,

4

CR

R

BA

F Chair Exec

Team

3 4 12 8 (i) Risk Management and Risk

Assessment Policies

(ii) Policies regarding internal and

external assurance

(iii) Ongoing review and monitoring of

processes by Trust Board Secretary

(iv) Trust Constitution review

procesess.

(v) External governance reviews

(vi) electronic reporting and recording

of risk through datix established at CG

level

Gaps in compliance

with risk management

policy following

transition to Care

Groups, and risk of

drop in compliance

during roll-out of

integrated risk

management system.

- Internal audits

- annual Report

declarations

- AGS

- BAF audit 2014

- 2013/14 Annual Report

declarations (i-v)

- KPMG report of governance

review & management response

reported through ANCR (BoD

04.02.14) (i-v)

- Quarterly risk register and

Board Assurance Framework

reports (BoD, quarterly) (i-ii)

- 2015 Constitution revision to

enable improved compliance

with Code of Governance (iv)

- Internal audits 2014/15

(Assurance Framework, Annual

Plan Self Certification, Risk

Management. KPMG Governance

Review against the Well-led

Framework) (i-v)

- Risk Management

audit 2014

- Material mis-

statement of financial

position indicating

issues with governance

and control.

- Plan for datix roll-out at

specialty / ward level to be

developed following

implementation at CG level.

- Committees policy being

revised following

restructure.

- tbc

- June 2016

1 4 4 Nov 2015 - Risk

upgraded to 12 to

reflect concerns

relating to

governance and

control.

04/12/14 - Proposal

to upgrade risk to

relfect ongoing work

required to ensure

compliance with risk

management policy.

Page 8

No. Risk

CR

R

BA

F Lead

Director

Risk

Source

Existing Controls Gaps in Control Gaps in Assurance Actions to address gaps Milestones / timescale for

completion

Previous / Proposed

Changes

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Potential Actual

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Target Risk

Rating

Current Risk

Rating

Assurance

Pre

vio

us

Ris

k R

atin

g

Stra

tegi

c G

oal

s13 Breakdown of

relationship with

key partners

4

BA

F CEO Care

Group

2 4 8 4 (i) Partnership working processes

(ii) Engagement in Working Together

programme (chairing CE Steering

Group and HR Group)

(iii) Engagement with Commissioners

& other local trusts

(iv) Engagement with 2 Health and

Wellbeing Boards

(v) Attendance at CCG governing body

meetings

(vi) CE meetings with NHS England

(vii) Regular briefings to local

authorities

(viii) Partner Governor seats on the

Board of Governors

- Level of engagement

not fully consistent

across all three local

authorities

- CE Reports

- Outcomes of contracts

negotiations

- Peer reviews of local

authority services

- Peer reviews of Health

and Wellbeing Board

- Feedback from CCGs

- CQC Visit Report

- Feedback from Bassetlaw CCG

(to Chair, 2014) (i)

- CE Reports (BoD 23.06.15;

28.07.15; 25.08.15) (i-viii)

- Updates on HWB activity (BoD,

monthly) (iv)

- Updates regarding Working

Together programme via CE

report (BoD) (ii)

- Doncaster Better Care Fund

application approved

- Nottinghamshire Better Care

Fund approved

- Successful Working Together

Vanguard New Care Model

application (Sep 2015)

MP briefs resumed since

November 2014

2 4 8 08.09.14 - Likelihood

increased to 2,

resulting in a current

and target risk rating

of 8 (high).

15 Failure to engage

and communicate

with staff and

representatives

4

BA

F DPOD Care

Group

2 3 6 9 (i) HR/Communication plans

supporting change

(ii) Process to engage with LNC

(iii) Process to engage with JSCC

(iv) HR policies and procedures

(v) staff engagement project strands

(vi) monitoring and challenge of staff

survey actions via accountability

meetings

(vii) engagement of staffside

representatives in Trust Management

Forum

People & OD and

Communications

Strategy reference

internal engagement,

but formal/informal

interaction with staff

relates only to Buzz

and Staff Brief and

irregular roadshows.

Wider engagement

strategy with more

consistent interactions

planned, currently

being developed.

- Staff Survey results

- Grievance and

employment tribunal

rates

- Outcomes of

negotiation & work with

staff side.

- Delivery of engagement

plan KPIs.

- 2014 Staff survey results (BoD

24.03.15) (i-iv)

- 2014 /15 and 2015/16 Staff FFT

results show marked

improvement

- Casework reports (ANCR,

quarterly) (iv)

- CQC 2013 visit report on

engagement levels rising (i-v)

- P&OD reports (BoD, quarterly) (i-

v)

- Briefings regarding staff

engagement during restructure

(i)

- Records of ongoing engagement

via JSCC (iii)

Aspects of the Staff

Survey results 2014.

- Staff survey action plans

(corporate & local). Care

Group action plans being

developed.

- Staff side engagement

project, inc. review of formal

staff side agreements.

- Development of

engagement plans as part of

People & OD Strategy

- Communications strategy

action plan under revision

- Monthly monitoring.

- March 2016

- March 2016

- July 2015

2 3 6 28.04.15 - risk rating

downgraded to 6

following executive

team review.

14.04.15 - actions

updated.

08.09.14 - Risks 14

and 15 merged, with

an overall risk rating

of 9 (high)

Page 9

No. Risk

CR

R

BA

F Lead

Director

Risk

Source

Existing Controls Gaps in Control Gaps in Assurance Actions to address gaps Milestones / timescale for

completion

Previous / Proposed

Changes

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Potential Actual

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Target Risk

Rating

Current Risk

Rating

Assurance

Pre

vio

us

Ris

k R

atin

g

Stra

tegi

c G

oal

s16 Failure to ensure

business continuity

/ respond

appropriately to

major incidents

1,

4

BA

F COO Exec

Team

2 4 8 5 (i) Business continuity plans

(ii) Business Continuity Policy

(iii) Statement of Compliance against

National Core Standards for EPRR

(iv) Severe Weather Plan

(v) BRSG which monitors BC planning

progress

(vi) Business Continuity Group linked

to operational structures

(vii) Major Incident Plan

(viii) Training of A&E staff on CBRN

incidents

(ix) Emergency response plans in place

(annually reviewed)

- Evacuation of a hospital site

- Mass Casualty Plan

- Pandemic Influenza Plan

- Prison Plan

- CBRNE plan

(x) Statement of Compliance against

National Core Standards for EPRR

(xi) Incident Control Room in line with

EPRR Command and Control guidelines

(xii) Communications exercises

undertaken twice yearly as required by

statute

(xiv) Command & control training for

BoD & senior managers on-call

(xv) Revision of plans following test

exercises.

- Actual management

and testing of business

continuity plans

- joint desk top testing of

Care Group plans as part

of annual programme of

testing

- peer review of plans

- working with SY&B

Area Team on National

Exercise Cygnus

(Pandemic Influenza)

October 2014

- Revision of Pandemic

Influenza plan post

October 2014 national

exercise

- Working with Area

Team EPRR and local

peers to implement

LHRP action plan

- Completion of

Evacuation Plan 2014

- EPRR assurance process

(Q4 2015-16)

– Exercise Rutland Flooding Jan

2014 (i-v)

- Joint multi-agency desk top

exercise March 2014 testing the

management of significant staff

shortages (i-v)

- Response to incidents &

business continuity challenges

2014 (power outage, fire, flood,

industrial action etc.) (i-iii)

- Positive Internal Audit follow-

up review (ANCR 20.06.14) (i-ii)

- Annual confirmation of

compliance against National Core

Standards for Emergency

Preparedness, Resilience and

Response (BoD, Nov 2015) (i-vi)

- Internal Audit follow-up review

of business continuity

arrangements (i-vi)

- EMERGO event September

2014

- Operation Albireo March 2015

(flu pandemic test)

- risk assessment of major

incident and business continuity

plans with NHS England (May

2015)

-Y&H peer review of major

incident plans 2015.

- further work required

to expand training and

exercising schedule

beyond the minimal

requirements.

- evacuation exercise

required.

- Working with Care Groups

to develop relevant desktop

exercises.

End 2015 2 4 8 29.04.15 - Business

continuity and major

incident risks

merged.

02.01.15 - Actions

updated.

08.09.14 - Likelihood

increased to 2 and

consequence

reduced to 4,

resulting in a current

and target risk

rating of 8 (high).

Page 10

No. Risk

CR

R

BA

F Lead

Director

Risk

Source

Existing Controls Gaps in Control Gaps in Assurance Actions to address gaps Milestones / timescale for

completion

Previous / Proposed

Changes

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Potential Actual

Like

liho

od

Co

nse

qu

en

ce

Rat

ing

Target Risk

Rating

Current Risk

Rating

Assurance

Pre

vio

us

Ris

k R

atin

g

Stra

tegi

c G

oal

s19 Failure to deliver

turnaround / cost

reduction

programme.

2,

3,

4

CR

R

BA

F DSI Exec

Team4 5 20 12 (i) Engagement in working together

programme

(ii) Engagement with healthcare

partners.

(iii) PMO, with associated

management processes, key

deliverables, risk logs and reporting to

FinOC.

(iv) Implementation of innovation from

external reviews

(v) PMO structure established:

- Executive lead, finance support and

external support for specialist input.

- Governance structure inc. bi-weekly

Delivery and Accountability and bi-

weekly Finance Accountability

meetings led by TD and DOF.

- Workstreams, SRO's, Workstream

leads, PMO lead and PM's in place.

PIDS in place at Gateway 0 and 1.

(vi) Confirmation of the collective

value of Divisional Cost Improvement

Schemes and the value of Turnaround

Workstreams

(vii) Grip and Control meetings with

focus on pay costs

- Availability of

internal skills

- Limited resources

- CE Reports to BoD

- Finance reports

- Business Intelligence

Reports

- FinOC cost reduction

reports

- Internal & external

audits

- Paper received by BoD on

26.01.16 detailing Rapid Cost

Reduction for remainder of

15/16, togther with Turnaround

programme development for

16/17 and robust CIP for 16/17

and 17/18.

- Run rate reduced by £655k at

month 9.

- Cost reduction

initiatives not currently

at delivery/outcomes

stage.

- ability to reverse run

rate

- Capacity and capability

of internal finance team

to support rapid

turnaround programme

- work progressing to

confirm the value of

cost reductions

presented in PIDS

- Development of PMO

team to drive urgent cost

reduction & turnaround

programmes.

- Turnaround/cost reduction

plans being developed

- Rapid cost reduction or

income projects accelerated

ie: car parking price

increase, temp staffing,

ward closures, estate

disposal

- plans in place to provide

additional support for

Finance Team and Interim

DOF

Q4 2015/16 2 4 8 30.11.15 - Risk

reframed & rating

upgraded to 20.

26.08.15 - actions

updated

29.04.15 - Innovation

& DBH2020 risks

merged.

14.04.15 - actions

updated.

08.09.14 - Target

likelihood increased

to 2 and target

consequence

reduced to 4

resulting in a target

risk rating of 8 (high).

Page 11

Board of Directors – 22 March 2016

Register of Sealing Summary The Board of Directors is asked to RECEIVE and NOTE the following, relating to the Register of Sealing as per Standing Orders section 14: Custody of Seal and Sealing of Documents.

Sealing No. Description of Document Sealed Signature Status Date

74 Disposal by sale of residential property known as 14 Dargle Avenue, Doncaster

M Pinkerton Chief Executive

19/02/16

J Cook Interim Director of Finance 19/02/16

75* Lease of substation accommodation and easements at DRI

R Parker

Director of Nursing, Midwifery & Quality

25/02/16

D Purdue Chief Operating Officer 25/02/16

Compliance with Standing Orders The Board of Directors should note that sealing number 75 (marked ‘*’) was not carried out in compliance with the Standing Orders. The departure from the Standing Orders was that the use of the seal was signed by the Director of Nursing, Midwifery & Quality, who is the executive lead for the originating directorate (see SO 14.4). Process and controls In light of the above, the Head of Corporate Affairs has reviewed controls and made changes as follows: Existing controls (since November 2015)

1

• The seal is kept in a locked cabinet in the Head of Corporate Affairs’ office, and therefore not within any department which may be the originating department for a transaction.

• Anyone accessing the Seal must do so via the Head of Corporate Affairs, or other staff in the Secretariat team in the absence of the Head of Corporate Affairs.

• The Register of Sealing: o has bound, numbered pages (the previous register did not); o contains explicit instructions for use of the Seal, and an up to date extract from

the Standing Orders regarding restrictions on its use; o requires the user to enter 2 signatures in separate boxes; and o requires the user to enter the date on which the sealing is reported to the Board.

• Electronic records of all sealed documents are retained. • All Secretariat staff have been instructed in the use of the Seal.

Controls introduced in March 2016

• A laminated sheet is kept with the Seal, instructing anyone accessing it to read the instructions for the use of the Seal as set out in the Register of Sealing.

• All executive directors and secretariat staff will be asked to sign a declaration to confirm that they understand the rules for the use of the Seal, and undertaking to comply with them.

Recommendation The Board of Directors is asked to RECEIVE and NOTE the schedule of the use of the Seal, and the instance of non-compliance.

2

APPENDIX: Extract from the Standing Orders of the Board of Directors

14. CUSTODY OF SEAL AND SEALING OF DOCUMENTS 14.1 Custody of Seal

The Common Seal of the Trust shall be kept by the Secretary in a secure place. 14.2 Sealing of Documents

The Seal of the Trust shall not be fixed to any documents unless the sealing has been authorised by a resolution of the Board of Directors or of a committee, thereof or where the Board of Directors has delegated its powers.

14.3 The legal requirement to "seal" documents executed as a deed has been removed. The

Board of Directors’ may however, choose to continue to use the seal. 14.4 Before any building, engineering, property or capital document is sealed it must be

approved and signed by the Director of Finance & Infrastructure (or an officer nominated by him) and authorised and countersigned by the Chief Executive (or an officer nominated by him who shall not be within the originating directorate).

14.5 Register of Sealing

An entry of every sealing shall be made and numbered consecutively in a book provided for that purpose, and shall be signed by the persons who shall have approved and authorised the document and those who attested the seal. A report of all sealing shall be made to the Board of Directors at least quarterly. (The report shall contain details of the seal number, the description of the document and date of sealing).

3

UNAPPROVED Minutes of the Meeting of the Management Board of

Doncaster and Bassetlaw Hospitals NHS Foundation Trust on

Monday 29 February 2016 at 2pm in the Boardroom, DRI

Present: Mike Pinkerton Chief Executive (Chair) Andrew Barker Care Group Director - Diagnostics & Pharmacy Jeremy Cook Interim Director of Finance Dawn Jarvis Director of Strategy & Improvement (Chair) Thrinath Kumar Care Group Director - MSK & Frailty Tim Noble Care Group Director - Emergency Richard Parker Director of Nursing, Midwifery and Quality Gillian Payne Care Group Director - Specialty Services Woolagasen Pillay Care Group Director - Surgical David Purdue Chief Operating Officer Sewa Singh Medical Director

In attendance: Maria Dixon Head of Corporate Affairs Leanne Shaw Executive PA

Apologies: Eki Emovon Care Group Director – Children & Families Action Minutes of the previous meeting

MB/16/03/1 The minutes of the meeting held on 1 February 2016 were approved as an accurate record of the meeting with the following amendments:

MB/16/03/2 MB/16/02/61 - “The Department of Health would be setting the target nationally at 94.8%” to be amended to “The Department of Health’s expected average performance target would be 94.8% nationally”.

Matters arising from the minutes

MB/16/03/3 MB/16/02/6 - Consultant Recruitment, Rheumatology - The business case had been approved at the Executive Team meeting on 10 February 2016 and the recruitment process was underway.

MB/16/03/4 MB/16/02/17 - Jeremy Cook confirmed that the Cash Committee would report in to the Financial Oversight Committee.

MB/16/03/5 MB/16/02/19 - Dawn Jarvis confirmed that the Terms of Reference had been amended as recommended.

MB/16/03/6 MB/16/02/21 - Dawn Jarvis confirmed that Board Briefing meetings would 1

continue bi-monthly with Non-Executive and Executive Directors, but not in their current format. Care Groups would only be invited to discuss specific topics and they would be informed well in advance. This had been agreed at the Board of Directors meeting on 23 February 2016.

MB/16/03/7 MB/16/02/29 - Mike Pinkerton reminded the group that due to sensitive information frequently contained within the Management Board papers, circulation of such papers was only permitted within senior management teams and not to a wider audience.

All

MB/16/03/8 Mike Pinkerton agreed that Assistant Care Group Directors would be added to the circulation list.

LS

MB/16/03/9 MB/16/02/50 - It was confirmed that revised graphs for ‘Activity Variance by CCG’ and ‘Income Variance by CCG’ had been circulated.

MB/16/03/10 MB/16/02/51 - Jeremy Cook confirmed that CIPs for the Emergency Care Group had been revised to include savings.

MB/16/03/11 MB/16/02/62 - Jeremy Cook confirmed that the budget setting principles would be circulated later that week.

MB/16/03/12 Corporate Investment Committee - Tim Noble raised a query in relation to the discontinuation of the Corporate Investment Committee and asked if there was a requirement for business cases to have Care Group representation at the Executive Team meetings.

MB/16/03/13 Mike Pinkerton advised that the ‘revised meeting arrangements’ paper presented to the Management Board on 1 February 2016 outlined that all business cases, projects, ideas, vacancies would go through Executive Team on a weekly basis, for decision, approval or next course of action, including recommendation to the Management Board. Relevant leads would be asked to attend if required.

MB/16/03/14 In response to a query from Andrew Barker about medium to long term capital requirements, including medical equipment replacement, Richard Parker reported that a meeting had taken place to discuss minor and major equipment replacement. Jeremy Cook asked for a list of requirements to be sent to him in the first instance, in order for prioritisation to take place.

JC

Update on Financial Oversight Committee activity

MB/16/03/15 Jeremy Cook gave an update from the Financial Oversight Committee meeting held on 8 February 2016 and reported that the main focus of the meeting had been the final investigation report from KPMG. The committee had also been updated on the processes for developing the PMO and CIPs.

MB/16/03/16 Moving forward, the Financial Oversight Committee would focus on monitoring the implementation of the recommendations of the report.

2

The Financial Oversight Committee update was NOTED.

Consultant Recruitment

MB/16/03/17 Willy Pillay presented the business case for the recruitment of a replacement consultant anaesthetist with an interest in intensive care medicine for DRI. A discussion took place in relation to job plans and capacity and demand work.

MB/16/03/18 The recruitment of a consultant anaesthetist was APPROVED, subject to the following:

• Review of demand and capacity to be carried out, including the mitigation of risk by upcoming retirement

• Minor amendments to the job description including reference to the Trust’s financial position

WP

MB/16/03/19 Mike Pinkerton requested that a standard corporate message in relation to the Trust’s current financial position be included in all job descriptions.

DJ

Finance Report

MB/16/03/20 Jeremy Cook reported that there were errors in the finance report that had been presented to the Board of Directors on 23 February 2016, and that this would be updated and reissued as soon as possible.

JC

MB/16/03/21 An update on the financial position was provided and it was reported that the deficit at month 10 was £29.5m, an increase of £2.4m, although the run rate had reduced by 900k compared with the previous month. Jeremy Cook was hopeful this reduction would continue. The deficit for 2015/16 was forecasted at £38.4m.

MB/16/03/22 Bottom up expenditure forecasts had been undertaken by senior management accountants and income forecasts had been updated. Jeremy Cook was confident that forecast processes were now more robust and would be frequently monitored.

MB/16/03/23 It was reported that income was £3.5m below plan and NHS clinical income had under-performed by £0.4m. Expenditure was £24.9m.

MB/16/03/24 Delivery of CIPs had slightly increased in month 10 and the 2015/16 forecast was £2.4m, although the non-achievement of recurrent CIP remained a major contributory factor to the deficit against plan.

MB/16/03/25 Capital expenditure at month 10 was £11.5m, with the key area of concern continuing to be iHospital projects.

MB/16/03/26 Jeremy Cook confirmed that the temporary working capital facility secured through Monitor had been increased from £22.9m to £33.5m during February, with drawdowns of £22.4m to the end of January, £10.6m in February, and a further £7.9m planned in March.

3

MB/16/03/27 Mike Pinkerton commented on the slight increase in the delivery of CIPs and acknowledged that this was a positive step forward. He also highlighted that HSMR was at 98. This was an extraordinary achievement, as the Trust was below 100 for the first time ever.

MB/16/03/28 In response to a query from Willy Pillay in relation to the run rate reduction, Jeremy Cook reported that robust financial systems would need to be in place to ensure that stock was counted on a monthly basis and to enable expenditure reporting to be accurate.

MB/16/03/29 In response to a query from Tim Noble, Mike Pinkerton confirmed that the final investigation report from KPMG would be made available to all staff on 1 March 2016, in a redacted format in order to maintain confidentiality and protect named individuals who were subject to disciplinary processes. Monitor would release their compliance action at 12noon on the same day, followed by DBH’s press release. Following a request, Mike Pinkerton agreed to circulate the redacted report to the Care Group Directors straight away.

MP

MB/16/03/30 Staff engagement sessions with Executive Directors would be arranged in the forthcoming two weeks, to discuss the report further and explain the Trust’s response to the recommendations.

MB/16/03/31 Mike Pinkerton reported that the regulatory action issued to the Trust by Monitor was to ‘accept voluntary undertakings by the Trust’ which was a positive position to be in. An additional licence condition would provide the oversight and governance for the approach the Trust would take, in order to ensure the undertakings were carried out.

The Finance Report was NOTED.

Feedback from Accountability Meetings

MB/16/03/32 David Purdue reported that the main focus of the accountability meetings had been price caps for agency staff from 1 April 2016 and how the risks would be mitigated. Mike Pinkerton explained the importance of complying with agency caps in order to access funds or loans available for trusts in deficit.

MB/16/03/33 Dawn Jarvis reported that all shifts worked by NLMS agency staff would be classed as breaches from 1 April 2016, and agreed to liaise with Andrea Smith in relation to a tendering exercise for future agency staff.

DJ

MB/16/03/34 David Purdue discussed how grip and control and CIP linked into the accountability meetings and that financial representation at the meetings would be important going forward.

MB/16/03/35 In response to a query from Sewa Singh, David Purdue confirmed that medical records would be co-located with the booking department and options were being explored as part of the outpatient work stream. Once the options were finalised a paper would return to the Management Board.

DP

4

The Feedback from Accountability Meetings was NOTED.

Corporate Risk Register

MB/16/03/36 Maria Dixon reported that the register would be updated and recirculated. A detailed review of the risks would be undertaken by the Executive Team within the next month.

MD

Executive Team Action Log

MB/16/03/37 Mike Pinkerton presented the action logs from the Executive Team meetings that took place on 3, 10 and 17 February 2016, provided for information. Further details were requested and provided on the following cases:

MB/16/03/38 Car Parking - Discussions were still ongoing. In response to a query from Andrew Barker, Mike Pinkerton provided clarification in relation to the park and ride options.

MB/16/03/39 It was agreed that the action logs would be circulated to the Care Group Directors on a weekly basis to ensure decisions were cascaded in a timely manner.

MP

The Executive Team Action Log was NOTED.

Chief Executive’s Report

MB/16/03/40 The Chief Executive’s report was provided for information and NOTED.

Business Intelligence Report as at 31 January 2016

MB/16/03/41 David Purdue reported that the RTT target had been failed nationally for the first time in December 2015.

MB/16/03/42 The Trust had been successful in its bid for validation funding of £36K.

MB/16/03/43 Monitor was concerned that the Trust had reported the highest number of attendances to ED in January 2016 in Doncaster since 2011.

MB/16/03/44 In response to a query from Gillian Payne in relation to AOC, David Purdue agreed to review the process to ensure the information and income was correct.

DP

MB/16/03/45 In response to a query from Thrinath Kumar, David Purdue requested some information from the MKS & Frailty Care Group regarding back door entry, in order to review.

TK

The Business Intelligence Report was NOTED.

Any Other Business

MB/16/03/46 Parenteral Nutrition Team - In March 2014 the case to establish a hospital nutrition team was approved by the Business Support Group to trial as a pilot

5

for 6 months. After a 6 month period the effectiveness of the team would be reviewed. Due to a delay in recruitment, the review was due to take place in February 2016.

MB/16/03/47 Richard Parker asked for any feedback or comments on the team and the joint leadership, to be provided to himself or Sewa Singh to enable next steps to be determined and agreed.

MB/16/03/48 Junior Doctors Strike - Sewa Singh reminded members of the forthcoming 2-day strike on 9 and 10 March 2016, and asked for plans to be formulated and elective surgery to be cancelled.

Items for escalation to the Board of Directors

MB/16/03/49 Nothing to report.

Date and Time of Next Meeting:

MB/16/03/50 Date: 29 March 2016 Time: 2pm Venue: Learning Room 1, Education Centre, DRI

6

Minutes of the Fred & Ann Green Legacy Sub-Committee Meeting held on Tuesday, 22nd December 2015 in the Boardroom, Bassetlaw Hospital

Present: Mr C Scholey (Chairman) Mr A Armstrong Mr P Brindley Mr J Cook

Mr R Parker Mr M Pinkerton Mr S Singh In Attendance: Mr M Rhodes

ACTION 15/12 MINUTES OF THE MEETING HELD ON 23rd JUNE 2015

The Minutes of the meeting held on 23rd June 2015 were approved as a correct record of proceedings.

15/13 MATTERS ARISING FROM THE MINUTES 13.1 Chief Executives Discretionary Fund Reference was made to the concern raised by the Fred and Ann Green Legacy Advisory Group that the amount of money the Chief Executive had under the Discretionary Element of the Legacy could effectively be re-set in the event that the Advisory Group formally approved a scheme funded in this way retrospectively. Mr Pinkerton confirmed that he had no objection to the £150,000 limit for the Chief Executive to use under Discretionary terms being set as a limit per annum. It was agreed that the Chief Executives Discretionary Fund therefore be limited to £150,000 in any one year.

Mr Pinkerton Mr Rhodes

1

15/14 CHIEF EXECUTIVE’S DISCRETIONARY FUND

14.1 Authorised Funding

It was noted that the Chief Executive had authorised the following funding from the Discretionary Fund of the Legacy since the previous Fred & Ann Green Legacy Sub Committee meeting on 23rd June 2015 :-

• Transperineal MR Ultrasound Fusion Directed Prostate Biopsy - £120,000

• Genesis Inventory Management System £92,000 • Oversees nurse recruitment costs £15,000

ALL

15/15 VALUE OF INVESTMENTS PORTFOLIO AT 30th September 2015 Mr Cook presented a report identifying the total value of Trust Charitable

funds as at 30th September 2015 as £10,193,000 and that of this amount the value of the Fred and Ann Green Legacy was £7,682,979. Of particular note between the reported values at 31st March 2015 and 30th September 2015 was the valuation change of -£639,000 which was attributable to the decline in the stock market over this period. In answer to a point raised, Mr Cook explained that the value and performance of investments were discussed separately at the Charitable Funds Sub-Committee of the Board.

15/16 SUMMARISED PROGRESS REPORT ON APPROVED SCHEMES

Mr Rhodes presented a report showing progress on each of the Legacy funded schemes. 16.1 Hospital Shuttle It was noted that plans were being progressed to re-tender the shuttle at the same time as the Park & Ride facility in an attempt to secure a more competitive price. In answer to a query raised by Mr Pinkerton, Mr Rhodes explained that the tender process could be adapted in the event that the Park & Ride facility was not continued. 16.2 Transperineal MR Ultrasound Fusion Directed Prostate Biopsy The introduction of the scheme to enable transperineal MR ultrasound fusion directed biopsy to be undertaken at the Montagu Hospital for patients with suspected prostate cancer had already showed real benefits

2

to patients who were being treated locally and in a more timely manner. Currently the backlog for patients waiting for this procedure had been eliminated.

15/17 REQUESTS FOR FUNDING 17.1 Proposal to Enhance Chaplaincy Spiritual Care Facilities &

Resources at the DRI and Montagu Hospitals

The Fred and Ann Green Legacy Sub-Committee considered a

report seeking Legacy funding of £20,560 for the development of a small scale peripatetic “Pop-Up” or capsule setting which would enable the staging of Chaplaincy activities and other initiatives at the DRI and Montagu Hospitals. Whilst the proposal was considered a very good resource for patients, carers and staff and supported, it was not considered suitable for Legacy funding. The Sub-Committee therefore did not agree to fund the proposal through Legacy monies but asked that Mr Parker sought suitable charitable funding from elsewhere.

Mr Parker

17.2 Proposal to Provide a New Ophthalmology Outpatients

Department at Doncaster Royal Infirmary

The Fred and Ann Green Legacy Sub-Committee considered a

report seeking legacy funding to provide a new Ophthalmology Outpatients department at the DRI at a cost of £2,560,000. Note was made that the Board of Directors had considered the full Business Case earlier the same day and that they had approved the case, subject to the capital element of the initiative being funded by the Fred and Ann Green Legacy. The benefits of the new Ophthalmology Outpatients Department were fully understood and documented. The Fred and Ann Green Advisory Group had considered the proposal at an additional meeting of the Group on 17th December 2015. Whilst supporting the scheme overall, support was given on the basis that the Legacy be replenished in some way. Whilst supporting the proposal, Mr Armstrong expressed his concern that with this and other schemes recently approved or in the pipeline, the amount of Legacy funds available was diminishing at an alarming rate and would not be able to support ongoing schemes in the future like covering the costs of the Fred and Ann Green Shuttle Bus. This view was also endorsed by Mr Brindley.

3

Mr Brindley also referred to the scheme recently highlighted to conclude the Rehabilitation development at the Montagu Hospital which he considered should be given preference over the Ophthalmology project given the terms of Mr Green’s will which identified a preference to the Montagu Hospital. He considered it most important that Mexborough and Mexborough people should not be failed. It was noted that the Ophthalmology Business Case was made on the basis that it would generate significant additional revenues to the Trust by a combination of increased activity and reduced staffing costs by re-designing the Ophthalmology pathway. It was questioned whether it would be possible to share the benefit to the Trust with the Legacy and replenish the Fund somehow. Mr Cook advised caution that the Trust would be able to replenish a charitable fund from NHS funding streams. A number of ideas were put forward as to how some form of replenishment of the Legacy could be achieved. Mr Cook was asked to identify an appropriate methodology that would be acceptable. The Sub-Committee therefore approved the proposal to provide a new Ophthalmology Outpatients Department at the DRI at a cost of £2,560,000. It was noted that the new department would have “Fred and Ann Green” in the naming of the facility.

Mr Cook

Mr Rhodes

17.3 Proposal to Establish Endobronchial Ultrasound (EBUS)

The Fred and Ann Green Legacy Sub-Committee considered a report seeking Legacy funding to establish Endobronchial Ultrasound, (EBUS) within the Trust to improve the standard of care for patients with lung cancer at a cost of £192,000. Purchase of this equipment would improve the 62 day cancer target and the 2 week cancer target as well as improve the patient experience. Currently patients had to travel to Sheffield to receive this treatment. The case had been considered and supported by the Fred and Ann Green Legacy Advisory Group at its meeting on 20th November 2015. The Sub-Committee approved the proposal to establish Endobronchial Ultrasound at the DRI at a cost of £192,000 on the basis that the CCG would fund the revenue costs through tariff arrangements.

Mr Rhodes

4

15/18 CONTINUATION OF APPROVED SCHEMES

18.1 Legacy Project Manager and Associated Professional Support The Fred and Ann Green Legacy Sub-Committee considered a report seeking funds to continue funding of up to £30,000pa for the next 2 years (December 2015 to November 2017) to cover the costs of the Legacy Project Manager and other associated professional support (eg Finance and Estates) for Fred and Ann Green Legacy sponsored schemes. The proposal was supported by the Fred and Ann Green Legacy Advisory Group at its meeting on 7th August 2015. The continuation of funds in support of the Project Manager and other professional support was approved. 18.2 Radiotherapy Project Manager The Fred and Ann Green Legacy Sub-Committee considered a report seeking continuation of the part funding of the Radiotherapy Project Manager post for a further twelve month period at a cost of £21,000. The proposal was supported by the Fred and Ann Green Legacy Advisory Group at its meeting on 7th August 2015. The continuation of funds to support the partial funding of the radiotherapy Project Manager was approved. 18.3 Extension of Funding for Diabetes Nurse Specialists in Doncaster The Fred and Ann Green Legacy Sub-Committee considered a report seeking continuation of the previously approved pilot to employ an additional three specialist diabetes nurses for a further nine months at a cost of £90,126. The overarching reason for the funding extension was as a result of the National Diabetes Inpatient Audit (NADIA) being undertaken in September 2015 which would officially be published in March 2016. There was no national audit in 2014. The extension would enable the existing specialist diabetes nursing team to continue until after the publication of the NADIA survey in March 2016 and allow a fully informed Business Case to be submitted to the Corporate Investment Committee later on in 2016 for recurrent funding. The proposal was supported by the Fred and Ann Green Legacy Advisory Group at its meeting on 20th November 2015.

Mr Rhodes

Mr Rhodes

5

The continuation of funds to support the funding of the Diabetes Nurse Specialists in Doncaster was approved.

Mr Rhodes

15/19 15/20

FRED AND ANN GREEN LEGACY ADVISORY GROUP - DRAFT TERMS OF REFERENCE The Fred and Ann Green Legacy Sub-Committee considered a report to update the Terms of reference of the Fred and Ann Green Legacy Advisory Group. The draft Terms of Reference had previously been considered and approved by the Fred and Ann Green Legacy Advisory Group at its meeting on 20th November 2015. The Terms of reference were agreed. SUMMARY OF FRED & ANN GREEN LEGACY SCHEMES

Mr Rhodes

A schedule showing actual and planned expenditure on approved schemes was presented. This showed cumulative planned expenditure of £11,658,700 (apportioned £7,942,500 to Montagu Hospital and £3,716,200 to the DRI). The report was noted.

15/21 MINUTES OF THE FRED AND ANN GREEN LEGACY ADVISORY GROUP MEETINGS

The Minutes of the Fred and Ann Green Legacy Advisory Group meetings held on 7th August and 20th November 2015 were noted.

15/22 ANY OTHER BUSINESS

None recorded.

15/23 DATE OF NEXT MEETING The date of the next meeting was identified as Tuesday, 28th June 2016 at 12.30pm in the Fred & Ann Green Boardroom, Montagu Hospital.

Circulation

FAGLSC Members Mr M Rhodes Mr R Paskell

6

Board of Directors Agenda Calendar

STANDING ITEMS OTHER / AD HOC ITEMS MONTHLY QUARTERLY BIANNUAL / ANNUAL APRIL 2016 CE Report ANCR minutes (18.03.16) Draft Annual Report Mandatory training update Business Intelligence Report Chief Executive’s Objectives Draft Quality Account Nursing Workforce Complaints, Compliments, Concerns and

Comments Report Budget Setting / Business Planning / Final Annual Plan

MB Minutes R&D Strategy metrics (in BIR) SOs, SFI, Scheme of Delegation HWB Decision Summary Safeguarding & maternity metrics (in BIR) Statement of Compliance – Elimination of

Mixed-Sex Accommodation

Financial Oversight Minutes P&OD Quarterly report Monitor Quarterly Results Notification MAY 2016 CE Report Monitor Quarterly Declaration Q4 Annual Report Review the appointment of Executor

of Fred and Ann Green Will Business Intelligence Report CGOC Minutes (18.04.16) Quality Account Nursing Workforce Charitable Funds minutes MB Minutes CGOC Annual Report HWB Decision Summary Financial Oversight Minutes JUNE 2016 CE Report Board Assurance Framework Review of the Appointment of the Executor of

the Fred & Ann Green’s Will

Business Intelligence Report MB Annual Report Nursing Workforce Bed Plan MB Minutes HWB Decision Summary Financial Oversight Minutes JULY 2016 CE Report Chief Executive’s Objectives Annual Security Report Business Intelligence Report Complaints, Compliments, Concerns and Infection Control Annual Report

1 As at 16 February 2016

STANDING ITEMS OTHER / AD HOC ITEMS MONTHLY QUARTERLY BIANNUAL / ANNUAL Comments Report

Nursing Workforce R&D Strategy metrics (in BIR, to include R&D annual summary)

ANCR Annual Report

MB Minutes Safeguarding & maternity metrics (in BIR) HWB Decision Summary P&OD Quarterly report ANCR Minutes (20.06.16) Monitor Quarterly Results Notification AUGUST 2016 CE Report Monitor Quarterly Declaration Q1 Proposed AMM arrangements Annual Revalidation update(medical) Business Intelligence Report CGOC minutes (18.07.16) Nursing Workforce MB Minutes HWB Decision Summary SEPTEMBER 2016 CE Report Board Assurance Framework & risk register Risk Policy Business Intelligence Report Fred & Ann Green Legacy minutes Nursing Workforce MB Minutes HWB Decision Summary OCTOBER 2016 CE Report ANCR minutes (23.09.16) Charitable Funds minutes Business Intelligence Report Chief Executive’s Objectives Nursing Workforce Complaints, Compliments, Concerns and

Comments Report

MB Minutes R&D Strategy metrics (in BIR) HWB Decision Summary Safeguarding & maternity metrics (in BIR) P&OD Quarterly report NOVEMBER 2016 CE Report CGOC minutes (17.10.16) Annual Compliance against the National Core

Standards for Emergency Preparedness, Resilience and Response (EPRR)

CaMIS 12 months post-implementation review

Business Intelligence Report Monitor Quarterly Declaration Q2

2 As at 16 February 2016

STANDING ITEMS OTHER / AD HOC ITEMS MONTHLY QUARTERLY BIANNUAL / ANNUAL Nursing Workforce MB Minutes HWB Decision Summary DECEMBER 2016 CE Report Board Assurance Framework & risk register Team Doncaster Update Business Intelligence Report Monitor quarterly results notification Nursing Workforce Grip & Control Plan MB Minutes HWB Decision Summary Financial Oversight Minutes JANUARY 2017 CE Report ANCR minutes (16.12.16) Budget Setting / Business Planning / Annual

Plan

Business Intelligence Report Chief Executive’s Objectives SOs, SFI, Scheme of Delegation Nursing Workforce Complaints, Compliments, Concerns and

Comments Report

MB Minutes R&D Strategy metrics (in BIR) HWB Decision Summary Safeguarding & maternity metrics (in BIR) Financial Oversight Minutes P&OD Quarterly report FEBRUARY 2017 CE Report CGOC Minutes Budget Setting / Business Planning / Annual

Plan

Business Intelligence Report Monitor Quarterly Declaration Q3 Nursing Workforce MB Minutes HWB Decision Summary Financial Oversight Minutes MARCH 2016 CE Report Board Assurance Framework & risk register Budget Setting / Business Planning / Draft

3 As at 16 February 2016

STANDING ITEMS OTHER / AD HOC ITEMS MONTHLY QUARTERLY BIANNUAL / ANNUAL Annual Plan

MARCH 2017 Business Intelligence Report Staff Survey Nursing Workforce Statement of Compliance – Elimination of

Mixed-Sex Accommodation

MB Minutes Corporate Risk Register HWB Decision Summary SOs, SFI, Scheme of Delegation Financial Oversight Minutes Fred & Ann Green Legacy minutes

OTHER ITEMS Review the appointment of Peter Brindley (Executor of Fred and Ann Green Will) 3 yearly (May 2018) Constitution review 3 yearly (Jan 2018)

4 As at 16 February 2016

1 March 2016 Mr Mike Pinkerton Chief Executive Doncaster & Bassetlaw Hospitals NHS Foundation Trust Doncaster Royal Infirmary Armthorpe Road Doncaster South Yorkshire DN2 5LT

Dear Mike Q3 2015/16 monitoring of NHS foundation trusts Our analysis of your Q3 submissions is now complete. Based on this work, the trust’s current ratings are:

Financial sustainability risk rating: 1 Governance rating: Red

These ratings will be published on Monitor’s website later in March. The trust is subject to formal enforcement action in the form of an additional licence condition and enforcement undertakings. In accordance with Monitor’s Enforcement Guidance, such actions will be published on our website. Monitor will raise any concerns arising from our review of the trust’s Q3 submissions as part of our regular Progress Review Meetings, that will shortly commence. A report on the aggregate performance of all NHS providers (Foundation and NHS trusts) from Q3 2015/16 will be available in due course on our website (in the News, events and publications section), which I hope you will find of interest. For your information, we will be issuing a press release in due course setting out a summary of the report’s key findings. If you have any queries relating to the above, please contact me by telephone on 020 3747 0245 or by email (Michael.Duff@Monitor.gov.uk).

Wellington House 133-155 Waterloo Road London SE1 8UG T: 020 3747 0000 E: enquiries@monitor.gov.uk W: www.gov.uk/ monitor

Yours sincerely

Michael Duff Senior Regional Manager cc: Mr Chris Scholey, Chairman,

Mr Jeremy Cook, Interim Director of Finance