AGENDA - dbth.nhs.uk · Update 19/05/2020 – It was agreed that Karen Barnard would liaise with Kirsty Edmondson-Jones to organise a Board Workshop on this topic. Update 11/06/2020

Board of Directors Meeting Held in Public To be held on Tuesday 21 July 2020 at 09:15

Via StarLeaf Videoconferencing

AGENDA

LEAD ACTION TIME / ENC

TIME/MINS

A MEETING BUSINESS 09:15

A1 Apologies for absence SBE Note Verbal

5

A2 Declarations of Interest

SBE Note Verbal

Members of the Board and others present are reminded that they are required to declare any pecuniary or other interests which they have in relation to any business under consideration at the meeting and to withdraw at the appropriate time. Such a declaration may be made under this item or at such time when the interest becomes known. A3 Actions from previous meeting

SBE Review A3

B PRESENTATION

No Presentation

C STRATEGY

09:20

C1 ICS Update

RP Note C1 5

C2 Stabilisation and Recovery / Covid19 Update

JS/MP/RJ

Note C2 15

C3 UEC Procurement

MP Note Verbal 5

D QUALITY, PERFORMANCE AND SAFETY

09:45

D1 Finance Update – June 2020

JS Note D1 10

D2 Performance Update – May 2020

RJ Note D2 10

D3 Nursing, Midwifery and Allied Health Professionals Update ‐ Includes Patient Survey Results

DP Note D3 10

D4 Medical Director Update

TN Note D4 10

D5 People and Organisational Development Update

KB Note D5 10

BREAK 10:35 – 10:45

E CAPACITY AND CAPABILITY

No Items

F FINANCE AND CONTRACT MATTERS

No Items

G GOVERNANCE AND RISK 10:45

G1 Board Assurance Framework and Corporate Risk Register Update

FD Note G1 20

G2

Chairs Assurance Logs for Board Committees: i) Finance and Performance Committee – 30 June 2020 ii) Charitable Funds Committee – 16 June 2020 iii) Audit and Risk Committee – 16 July 2020

NR SM KS

Note G2

G3 Standing Financial Instructions, Standing Orders and Scheme of Delegation

JS Approve G3

G4 Information Governance Assurance Framework (IGAF)

KA Approve G4

H INFORMATION ITEMS (To be taken as read)

11:05

H1 Chair and NEDs Report

SBE Note H1 10

H2 Chief Executives Report

RP Note H2 5

H3 Minutes of the Finance and Performance Committee – 26 May 2020

NR Note H3 5

H4 Minutes of the Charitable Funds Committee – 17 March 2020

SMc

Note H4

H5 Minutes of the Management Board Meeting – 8 June 2020

RP Note H5

H6 SYB Integrated Care Partnership Bulletin

RP Note H6

H7 Healthwatch Doncaster Annual Report 2019‐20

RP Note H7

H8 Board Work Plan

SBE Note H8

H9 Minutes of the Audit and Risk Committee – 4 June 2020 KS Note H9

I OTHER ITEMS

11:25

I1 Minutes of the meeting held on 16 June 2020 (pre‐approved by the Board of Directors)

SBE Note I1

I2 Any other business (to be agreed with the Chair prior to the meeting)

SBE

Note

Verbal

I3 Governor questions regarding the business of the meeting (10 minutes)*

SBE Note Verbal 10

I4 Date and time of next meeting: Date: Tuesday 15 September 2020 Time: TBC Venue: StarLeaf Videoconferencing

SBE Note

Verbal

I5 Withdrawal of Press and Public

Board to resolve: That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.

SBE Note Verbal

J MEETING CLOSE

11:35

*Governor Questions The Board of Directors meetings are held in public but they are not ‘public meetings’ and, as such the meetings, will be conducted strictly in line with the above agenda. For Governors in attendance, the agenda provides the opportunity for questions to be received at an appointed time. Due to the anticipated number of governors attending the virtual meeting, Hazel Brand, as Lead Governor will be able to make a point or ask a question on governors’ behalf. If any governor wants Hazel to raise a matter at the Board meeting relating to the papers being presented on the day, they should contact Hazel directly prior to the meeting to express this. All other queries from governors arising from the papers or other matters should be emailed to Fiona Dunn for a written response. In respect of this agenda item, the following guidance is provided:

Questions at the meeting must relate to papers being presented on the day.

Questions must be submitted in advance to Hazel Brand, Lead Governor.

Questions will be asked by Hazel Brand, Lead Governor at the meeting.

If questions are not answered at the meeting Fiona Dunn will coordinate a response to all

Governors.

Members of the public and Governors are welcome to raise questions at any other time, on any other matter, either verbally or in writing through the Trust Board Office, or through any other Trust contact point.

Suzy Brain England, OBE Chair of the Board

Action notes prepared by: Katie Shepherd Updated: 16 June 2020

Action Log

Meeting: Public Board of Directors

Date of latest meeting: 16 June 2020

KEY

Completed On Track

In progress, some issues Issues causing progress to stall/stop

No. Minute No. Action Lead Target Date

Update

1. P20/01/B1 Council Motion on Climate and Biodiversity Emergency - A Board workshop would be planned to further explore Climate Change and Biodiversity – looking at what could be done immediately and what could be done in the future.

KEJ May 2020 July 2020

September 2020

Update 19/05/2020 – It was agreed that Karen Barnard would liaise with Kirsty Edmondson-Jones to organise a Board Workshop on this topic. Update 11/06/2020 – New information would be received during August 2020 which would be required for the Board Workshop on the topic therefore the action would be postponed until September 2020.

2. P20/05/D10 Strategic Director Review Workshop – The Board of Directors would hold a workshop during July 2020 to identify any key principals that might influence the strategic direction based on the initial findings provided by Marie Purdue and Jon Sargeant.

JS/MP July 2020 Progress - An update would be provided as part of Agenda Item C2 – Stabilisation and Recovery. Once final guidance has been received a workshop can be held in July 2020.

A3

Action notes prepared by: Katie Shepherd Updated: 16 June 2020

3. P20/06/C3 True North / Breakthrough Objective – True North / Breakthrough Objective measures of achievement would be added to the Quality and Effectiveness Committee agenda for July 2020.

DP/TN June 2020 Close. This item was added to the Quality and Effectiveness Committee work plan.

4. P20/06/D2 Patient Experience – The Quality and Performance Report would be developed to integrate and report upon the positive aspects of patient experience.

RJ/DP July 2020 Close. Item D3 includes a comprehensive update on patient experience.

5. P20/06/D2 Clinical Governance Report – An update paragraph on nosocomial Covid19 infections be added to the Clinical Governance Report for the Quality and Effectiveness Committee.

TN June 2020 Close. This item was added to the Quality and Effectiveness Committee work plan.

6. P20/06/D2 HSMR Narrative – Associated narrative would be added to the Quality and Performance Report in relation to HSMR for further guidance and clarification on what the graphs received show.

TN July 2020 Close. Narrative had been included in Item D4 – Medical Director Update.

7. P20/06/G1 Review of Strategic Risks - A review of the Corporate Risk Register would be undertaken to identify the strategic risks that link to the True North Objectives via a task and finish group made up of the responsible Executives for the risks.

FD July 2020 Close. A meeting was held on 10/07/2020 to align the strategic risks to the True North Objectives.

8. P20/06/G1 Corporate Risk Register Heat Map Indicator - A written indicator would be added to the numerical indicator on the heat map of the Corporate Risk Register to identify what each risk is, without having to cross reference to the full report (appendix 1).

FD July 2020 Close. This had been included in the Corporate Risk Register.

9. P20/06/G1 Mitigation of Risks – The mitigation of risks relevant to each Committee would be received in further detail at the respective Committee’s.

FD August 2020

1

Enclosure C

CHIEF EXECUTIVE REPORT

July 2020

Author(s) Andrew Cash, Chief Executive Officer

Sponsor Andrew Cash, Chief Executive Officer

Is your report for Approval / Consideration / Noting

For noting and discussion

Links to the STP (please tick)

Reduce

inequalitiesJoin up health

and care

Invest and grow

primary and

community care

Treat the whole

person, mental

and physical

Standardise

acute hospital

care

Simplify urgent

and emergency

care

Develop our

workforce

Use the best

technology

Create financial

sustainability

Work with

patients and the

public to do

Are there any resource implications (including Financial, Staffing etc)?

N/A

Summary of key issues

This monthly paper from the System Lead of the South Yorkshire and Bassetlaw Integrated Care System (SYB ICS) provides a summary update on the work of the SYB ICS for the month of June 2020. Recommendations

The SYB ICS Health Executive Group (HEG) partners are asked to note the update and Chief Executives and Accountable Officers are asked to share the paper with their individual Boards, Governing Bodies and Committees.

C1

2

South Yorkshire and Bassetlaw Integrated Care System

CHIEF EXECUTIVE REPORT

July 2020 1. Purpose

This paper from the South Yorkshire and Bassetlaw Integrated Care System System Lead provides an update on the work of the South Yorkshire and Bassetlaw Integrated Care System for the month of June 2020. 2. Summary update for activity during June 2020 2.1 Coronavirus (Covid-19): The South Yorkshire and Bassetlaw position There continues to be an ongoing decline in new cases, including the number of Covid-19 cases in South Yorkshire and Bassetlaw. This sustained reduction in new cases allows the system to firmly look ahead towards Phase Three from August 2020 to April 2021 - resetting the NHS. There are a number of key concerns for health leaders as the NHS recovery process looks to restore services. Issues raised include restoring the NHS amidst workforce challenges, potential lengthening of waiting lists, and strict infection control measures – all of which will significantly impede capacity. Supplies of Personal Protective Equipment (PPE) have improved significantly, particularly sterile gowns and sterile gloves and alternative suppliers through the support of Heads of Procurement have been sourced. General PPE continues to improve though there remain some concerns about the supply of PPE in Primary Care, and this remains a high priority. PCR testing (testing of swabs to see if people have the virus) continues to be in a strong position. SYB labs have capacity to undertake testing of NHS and social care patients and staff. In addition, members of the public with symptoms have access to swabbing via the regional testing sites at Doncaster Airport and Meadowhall as well as via the mobile testing units (MTUs) that are sited most days at Barnsley County Way, Rotherham AESSEAL stadium and Dearne Valley Leisure Centre. The MTU at Meadowhall continues to be one of the five busiest in England, typically undertaking more than 400 swabs per day. For antibody testing, approximately 50% of all NHS staff in SYB have now been tested (up to 22nd June) although this varies between each of SYB's five Places; Doncaster and Bassetlaw were first to have the analytical capacity in the lab and most staff there have been tested. With regards to the NHS reset, there is now a very strong case being considered for returning to fewer hospital Covid treatment sites in SYB. This would see the scale-down of the Covid surge capacity response, mirroring the original scaling up in March. At the same time, partners are now resuming some services, focusing on clinical priorities for those who most urgently require treatment. Cancer care continues to be one of the main priorities in SYB’s system recovery plans and partners are working to review and reprioritise patients. The System also has a role in supporting reset in the community. Working with partners in primary care and the community there is a need to ensure that population health and the needs of our communities post-Covid are understood and supported. This includes the plans that are underway for how to manage the follow-up and rehabilitation needs of patients who have had Covid. Each of SYB’s Local Authorities has a robust Local Outbreak Plan which is supported by a regular flow of data and led by Directors of Public Health. With the recent further easing of lockdown

3

measures at the beginning of July, partners’ Plans took into account the potential for increase in demand, particularly in relation to urgent and emergency services. 2.2 National update On June 9th, there was a joint session between ICS and STP Independent Chairs and Executive leaders with senior colleagues at NHSE where the future of system working was discussed. The event was one of a broader conversation on the future of systems, alongside further opportunities to be involved in the coming months. 2.3 Regional Update

The North East and Humber Regional ICS Leaders continue to meet weekly with the NHS England and Improvement Regional Director to discuss where support during Covid-19 should be focused. Discussions during June focused on improving BAME inclusion, outbreak management arrangements, support for care homes, supporting urgent and emergency care as public confidence returns and planning for Phase Three. 2.4 Planning for Phase 3 and Phase 4

Further NHS planning guidance and a financial framework are expected in mid-July. A first draft SYB System Plan, which is an amalgamation of all five Place Plans, is currently in development. It takes into account constraints such as workforce, estates management, infection control and PPE while also incorporating examples of best practice in SYB and nationally. There will be a final submission at the end of July. To support the planning process, a workshop to stress test the restoration of broader health and sustainment of care services in a COVID environment with partners took place on June 1st. This valuable exercise explored four possible scenarios across Places, offering opportunities for colleagues across health and care to analyse local plans in order to make improvements. Feedback from the session was very positive, with the learning now being built into local plans. 2.5 Identifying and embedding transformational change across SYB and capturing

learning from the Covid-19 crisis The ICS Programme Management Office is working with the Yorkshire and Humber Academic Health Science Network to capture views of senior leaders and colleagues from across SYB's health and social care organisations to feed into the joint project: ‘Identifying and embedding transformational change across SYB and capturing learning from the Covid-19 crisis’. To accurately capture and understand the innovation that is emerging, views are being gathered from those directly involved in the implementation of the rapid changes through an extensive consultation exercise. 2.6 Cancer update Cancer care continues to be one of the main priorities in SYB’s system recovery plans. Partners are working to review and reprioritise patients who have previously been on waiting lists. Those patients who have waited for a long time already and are a priority clinically are very much at the forefront of efforts to receive fast-track diagnostic and treatment services. The results of the recently published NHS England and Improvement commissioned National Cancer Patient Experience Survey saw SYB 2% above the national average in the areas of patients thinking they were seen ‘as soon as necessary’ (86%) and the length of time ‘waiting for tests to be done being about right’ (90%). The survey monitors national progress on the patient’s experience of cancer care and acts as a driver to improve quality at local level. This is strong evidence of the excellent work taking place across SYB.

4

2.7 Planning for Flu Modelling for influenza infections in the UK is now starting to take place as preparations for winter get underway, with a recognition that this could occur alongside a further Covid-19 peak. This is firmly on the radar of SYB’s testing cell which has started to devise a winter testing strategy to support the system level planning. Supporting this work will be a system level flu strategy, which will be made up of five Place plans and a SYB Flu Board. 2.8 Accelerating NHS progress on health inequalities during the next stage of COVID

recovery The disproportionate impact on people from Black, Asian and minority ethnic communities, people living in areas of high deprivation and inclusion health groups shows starkly the health inequalities which persist in England today. The NHS Long-Term Plan commits the NHS to addressing health inequalities and much excellent work is underway already, particularly focused on medium and long-term action. But progress needs to be accelerated; responding to and recovering from COVID calls for more focused, additional and immediate actions. To address this, NHS England and Improvement have established a Task and Finish Group, composed of a range of system leaders and voluntary sector partners, to focus on what specific, measurable actions should be taken by the NHS in the next few months. The Group will take account of feedback and ideas already received from BAME organisations, the VCSE sector, local systems and others. This work is distinct from but complementary to the dedicated work on the NHS as an employer being led by the Chief People Officer on supporting our BAME NHS staff and implementing the NHS Workforce Race Equality Standard. In SYB, the response to health inequalities is being taken forward by Workforce Leads, Kevan Taylor and Dean Royles. 2.9 Support for the Centre for Child Health Technology (CCHT) The Sheffield MPs wrote to the Government to outline their support for a new world class research and innovation facility in Sheffield. The Sheffield Children’s Hospital sponsored Centre for Child Health Technology (CCHT) at the Sheffield Olympic Legacy Park would be a multi-million transformational project supported by regional partners and international businesses including IBM Watson Health, Cannon Medical, Phillips and the South Yorkshire and Bassetlaw Integrated Care System. The site would span over 51,000 square metres, delivering world-class clinical and technical innovations to support children’s health and wellbeing in SYB and beyond. 2.10 Sheffield City Region devolution deal agreed South Yorkshire’s devolution deal has finally been agreed and brought to the House of Commons. This is a significant step forward for South Yorkshire’s economy and our congratulations go to Dan Jarvis, Mayor of the Sheffield City Region, and his team on this fantastic achievement. Once passed into law, an additional £30million pounds will be allocated to Sheffield City Region for regeneration projects supporting local growth and transformation. This is a great example of partnership working and its long-term impact is likely to shape the lives of the population for years to come. 2.11 Volunteers and Carers Partners recognised the thousands of carers in SYB during Carers Week (8-14 June). Many of the patients who visit GP surgeries or go into hospital are cared for by a relative or have caring responsibilities themselves. Carers Week was a timely opportunity to thank them for all they do and particularly for their vital role in helping vulnerable people manage their health and care needs during the coronavirus outbreak.

5

It was also National Volunteers Week 1-7 June. Likewise, volunteers bring significant added value to health and care organisations with their experience and talent and the week was a great opportunity to thank the many thousands of volunteers in South Yorkshire and Bassetlaw for all they do. 3. Finance update A new national financial framework is being developed to cover the period from August 2020 to March 2021 which is built upon the financial framework adopted for the period from April 2020 to July 2020. This will form part of the planning guidance is due to be released shortly. The system has submitted capital plans to the region which total £47.1m which cover both the ‘base case’ and ‘stepped up case’ planning assumptions provided for this exercise. Further work is being undertaken to prioritise these schemes if the system is provided with a cash limited financial envelope to cover such expenditure. From March to July 2020, commissioners and providers have been funded at actual cost to enable a break even position each month. From August 2020 to March 2021 this will be replaced with a cash limited sum which will replace the retrospective top-ups to commissioners and providers to allow them to break even and to reimburse costs associated with COVID 19. The intention is to provide systems rather than organisations with a financial envelope. Andrew Cash System Lead, South Yorkshire and Bassetlaw Integrated Care System Date: 6 July 2020

Title Stabilisation, Recovery and Reset Planning Update

Report to Board of Directors Date 21st July 2020

Author Marie Purdue, Director of Strategy & Transformation

Jon Sargeant, Director of Finance

Purpose Tick one as appropriate

Decision

Assurance

Information x

Executive summary containing key messages and issues In June 2020, the Board of Directors received a paper updating on the approach to planning for Stabilisation, Recovery and Reset and to identify the progress made and governance of the process. The purpose of this paper is to update Board on further progress as the process moves from a stabilisation and planning phase to operationalising the recovery phase. At the point of writing this paper the further national planning guidance expected in early June has not yet been issued, however, draft projections have been discussed with the regional NHSI/E team and the South Yorkshire & Bassetlaw Integrated Care System (SYB ICS).

Key questions posed by the report Is the Board assured that robust planning processes are being applied to enable stabilisation, recovery and reset following the COVID-19 pandemic?

How this report contributes to the delivery of the strategic objectives This report is outlining the processes required to plan for reinstatement of services – that can impact and can be measured in all four domains – quality, morale, demand and cost.

How this report impacts on current risks or highlights new risks This report impacts on the risks associated with the COVID-19 pandemic

Recommendation(s) and next steps Board is asked to note the content of the report.

C2

DBTH Stabilisation, Recovery and Reset Planning

Background

In response to the COVID19 pandemic, a plan was developed by Doncaster and Bassetlaw Teaching

Hospitals NHS Foundation Trust (DBTH) with the aim of protecting patients and staff throughout this

challenging time. After the peak of COVID-19 admissions, this was followed by a process to plan for

both the continuing care of patients diagnosed with/suspected of having the virus and future

reinstatement of services that have been paused where possible.

In June 2020, Board of Directors received a paper updating on the approach to planning for

Stabilisation, Recovery and Reset including the progress made and governance of the process. The

purpose of the current paper is to update Board on further progress as the planning process moves

from a “Stabilisation” phase (May – July 20) that included medium term planning, to operationalising

the “Recovery” phase (August 20 – March 21).

Operationalising the Plan – delivery work streams

As identified previously, the approach to planning will be through the following work streams as

illustrated below.

Progress

The planning inputs and enabling workstreams have now been developed and include the ethical

framework to guide decision making and the clinical model for each site. These have been used to

develop a robust framework to guide the development of the detailed delivery plans for: Cancer;

Elective and Daycase; Emergency Pathways; Critical Care; Diagnostics; Outpatients and Maternity

and Children’s Services. Supporting governance structures have also been established i.e. a clinical

assurance group to manage the consistent prioritisation of patients.

The Senior Responsible Officer for the delivery work-streams is the Chief Operating Officer, however

the Director of Nursing is leading on recovery plans for Critical Care and Maternity services. A

number of stand-alone cases have been produced and approved by the stabilisation and recovery

group to date including the reinstatement of AAA and breast screening.

For the wider cases which impact across divisions holistic plans are being created to ensure a

systematic approach and manage interdependencies. The list below details the target data for

ratification of each of these:

- Outpatients reinstatement plan – 20th July

- Daycase and elective reinstatement plan – 3rd August

- Diagnostic reinstatement plan – 3rd August

The plans are also being supported by work on capacity and demand that has been sourced

externally given the significant work required to undertake this at pace and to address changes in

capacity as a result of infection control practices such as donning and doffing of personal protective

equipment and cleaning schedules.

Any impact on capital requirements has been fed into the ICS where a prioritisation process is

underway.

Future Management

The Stabilisation and Recovery Group consisting of the Executive team and Divisional Directors will

continue until all the operational plans are complete and have been agreed. This is a temporary

arrangement to implement governance of the process and as soon as practicable the delivery of

plans will revert back to every day operations and implementation will be monitored via the

accountability meetings using data from the performance dashboard. Work is underway to modify

the performance monitoring process to ensure it measures any new areas of concern and challenge.

As previously noted plans have been developed in line with regional and ICS guidance and these

could require review and potential amendment in light of any national changes.

Recommendation

Board is asked to note the content of this report.

1

Title Financial Performance – Month 3 June 2020

Report to Trust Board Date 21st July 2020

Author Alex Crickmar – Deputy Director of Finance

Jon Sargeant - Director of Finance


Decision

Assurance

Information X

Executive summary containing key messages and issues

The Trust’s deficit for month 3 (June 2020) was £449k before the retrospective top up (the month 1-2 average

financial position was a £286k deficit before retrospective top up). The main movement in month was an

increase in pay costs relating to Covid for junior doctors, student nurses and enhancements for shielding staff.

As has been the case in previous months, the Trust (in line with national guidance) has accrued a central

retrospective top up payment of £449k in order to report a break even financial position at Month 3. The year to

date financial position is a £1,021k deficit before the retrospective top up.

It should also be noted that the Trust is yet to receive planning guidance or updated financial arrangements post

July at the time of writing. A verbal update will be provided at the meeting.

Key questions posed by the report

N/A

How this report contributes to the delivery of the strategic objectives

This report relates to strategic aims 2 and 4 and the following areas as identified in the Trust’s BAF and CRR.

F&P 1 - Failure to achieve compliance with financial performance and achieve financial plan and subsequent cash implications

F&P 3 - Failure to deliver Cost Improvement Plans in this financial year

F&P 19 - Failure to achieve income targets arising from issues with activity

D1

2

F&P 13 - Inability to meet Trust's needs for capital investment

F&P – 14 - Reduction in hospital activity and subsequent income due to increase in community provision

F&P 16 - Uncertainty over ICS financial regime including single financial control total

How this report impacts on current risks or highlights new risks

Update on risk relating to delivery of 2020/21 financial position.

Recommendation(s) and next steps

The Board is asked to note:

The Trust’s deficit for month 3 (June 2020) was £449k before the retrospective top up. However, in line

with national guidance the Trust has accrued a central retrospective top up payment of £449k in order

to report a break even financial position at Month 3. The year to date financial position is a £1,021k

deficit before the retrospective top up. It should also be noted that the Trust is yet to receive planning

guidance or updated financial arrangements post July at the time of writing.

3

FINANCIAL PERFORMANCE

Month 3 - June 2020

4

Performance Indicator Performance Indicator Annual

Actual Actual Actual Actual Plan

£'000 £'000 £'000 £'000 £'000

I&E Perf Exc Impairments & top up 28 (1,654) F 56 (5,285) F 2,131 Employee Expenses

Income (34,659) 108 A (103,735) 527 A (35,108) Drugs

Donated Asset Income (28) (28) F (56) (56) F 0 Clinical Supplies

Operating Expenditure 33,783 (1,948) F 101,093 (6,032) F 341 Non Clinical Supplies

Pay 23,798 (291) F 70,512 (1,757) F 24,090 Non Pay Operating Expenses

Non Pay & Reserves 9,985 (1,657) F 30,580 (4,275) F 10,004 Income

Financing costs 1,353 (28) F 3,719 (56) F 1,353 Mixed

I&E Performance excluding top up449 (1,682) F (5,341) F

Retrospective top up (449) (449) F (1,021) (1,021) F

I&E Performance including top-up(0) (2,131) F (0) (6,362) F 2,131 Total 0 0 A 0 0 A 0

Financial Sustainability Risk Rating Plan Actual

Risk Rating 3 3 Annual

Plan Plan Plan

£'000 £'000 £'000

Cash Balance 21,924

Capital Expenditure 784 3,153 29,402

Non Current Assets 1,018 Funded Bank Total in

Current Assets 22,577 WTE WTE Post WTE

Current Liabilities -24,979

Non Current liabilities -79 Current Month 5,954 254 5,772

Total Assets Employed -1,463 Previous Month 5,955 257 5,803

Total Tax Payers Equity 1,463 Movement 1 2 31-331

Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust

P3 June 2020

1. Income and Expenditure vs. Plan 2. CIPs

YTD Performance

Variance to

budget

Variance to

budget Plan

Variance to

budget

Variance to

budget

Monthly Performance YTD Performance Monthly Performance

£'000 £'000 £'000 £'000 £'000

1,021 2,131

F = Favourable A = Adverse

4. Other

Performance Indicator

Monthly Performance YTD Performance

Actual Actual

3. Statement of Financial Position

£'000 £'000

65,214 25,213

All figures £m

Opening

Balance

Closing

balance

Movement in

year

690 3,266

5. Workforce

Agency

63,216 85,793 WTE

213,162 214,180 Actual

WTE

-130,077 -155,056

5,412 106

129,644 128,181 5,444 103

-129,644 -128,181

-16,657 -16,736

Summary Income and Expenditure – Month 3

The Trust’s deficit for month 3 (June 2020) was £449k before the retrospective top up (the month 1-2 average

financial position was a £286k deficit before retrospective top up). The main movement in month was an increase in

pay costs relating to Covid (see section below for further details). As has been the case in previous months, the Trust

(in line with national guidance) has accrued a central retrospective top up payment of £449k in order to report a

break even financial position at Month 3. The year to date financial position is now a £1,021k deficit before the

retrospective top up. After adjusting for the £449k retrospective top up in month, the Trust’s position was c. £2.1m

favourable to budget (£1.7m favourable in Month 2) which was driven by continued reductions in pay and non-pay

costs above what was originally expected due to activity reductions, offset by an increase in costs for Covid. The

Trust will need to reset its budget from Month 5 onwards once new national financial arrangements are confirmed.

The Trust’s month 3 financial position includes revenue costs of c. £1.8m relating to COVID (£1.4m in May), of which

c. £1.3m relates to pay costs and £0.6m to non-pay costs. 164 orders have been approved by Gold Command to

date. The main increase in spend in month were in relation to pay for the additional student nurses (approx. 76

WTE), additional junior doctors (approx. 56 WTE F1’s & HO’s) and the payment of protected enhancements for

shielding staff (circa £200k for the past 3 months).

The clinical income position reported at Month 3 continues to be aligned to the national block arrangements in place

as previously set out to the Board. Activity levels across most points of delivery (POD) continue to be significantly

lower than the normal Trust average. This is shown in the table below which sets out the percentage movement in

activity for the monthly positions compared to the monthly average for 2019/20. It can be seen that some areas are

starting to show an increase in activity (especially A&E and non-elective) but are still significantly lower than activity

levels in 2019/20. Activity is expected to continue increase over the next couple of months as Division delivery plans

£000 £000

Income -34,659 -103,735

Pay

Substantive Pay 21,953 65,038

Bank 601 1,943

Agency 677 1,805

Recharges 567 1,727

Total pay 23,798 70,512

Non-Pay

Drugs 638 1,807

Non-PbR Drugs 1,406 4,099

Clinical Supplies & Services 1,643 5,375

Other Costs 6,298 19,299

Total Non-pay 9,985 30,580

Financing costs & donated assets 1,325 3,663

Deficit Position as at month 3 before retrospective top up 449 1,021

Retrospective top up -449 -1,021

Reported Position at month 3 0 0

Month 3 YTD

1. Month 3 Financial Position Highlights

for restarting urgent activity are finalised. The activity requirements from NHSI/E will also become clearer once

planning guidance is received.

Non NHS Clinical Income and Other Income was £159k behind plan in month 3 (£626k behind plan YTD). The main

drivers are due to limited Bowel Screening Activity undertaken for STH, lower RTA income and recharges. The in

month position was £94k favourable to the average of month 1 and 2 income levels due to the receipt of extra

Education income and bowel screening starting back up again in June (circa 37 spells).

The expenditure position in month, (excluding Covid), continues to be driven by reductions in costs (both pay and

non-pay) as a result of decreases in planned and emergency activity. However in month pay costs were c£0.5m

higher than the average of month 1 and 2 spend which was driven by the increase in junior doctors, student nurses

and enhancements for shielded staff as set out above. Non-Pay has continued to be favourable to plan in drugs,

clinical supplies and other non-pay costs due to lower activity levels. It is expected that expenditure will start to

increase in the following months as the Trust moves into the next phase of COVID response and activity starts to

increase. It should also be noted that the Trust is yet to receive planning guidance for financial arrangements post

July, but will update the Board as this becomes available.

Capital expenditure spend in month 3 is £0.8m. This is £0.1m ahead of the £0.7m plan. YTD capital expenditure

spend is £3.3m, including COVID-19 capital spend of £1.4m. All areas are on plan with nothing significant to bring to

the Boards attention, except that the Trust has submitted a capital plan for the next phase of the Covid response

which will be presented to the next F&P Committee.

The cash balance at the end of June was £65.2m (May: £66.5m). The decrease of cash in month is mainly as a result

of paying capital invoices in month, with cash remaining high due to the Trust receiving two months’ worth of the

block income in April.

The Board is asked to note:

The Trust’s deficit for month 3 (June 2020) was £449k before the retrospective top up. However, in line with

national guidance the Trust has accrued a central retrospective top up payment of £449k in order to report a

break even financial position at Month 3. The year to date financial position is a £1,021k deficit before the

retrospective top up. It should also be noted that the Trust is yet to receive planning guidance or updated

financial arrangements post July at the time of writing.

2. Recommendations

Title Integrated Quality & Performance Report

Report to Trust Board Date 21 July 2020

Author Rebecca Joyce, Chief Operating Officer

Tim Noble, Medical Director

David Purdue, Director of Nursing, Midwifery and AHPs


Decision

Assurance x

Information


This report highlights the key performance and quality targets required by the Trust to maintain NHSI compliance. The report focuses on the main performance area for NHSi compliance for May 2020 including:

Cancer 62 day classic, measured on average quarterly performance

4hr Access, measured on average quarterly performance

18 weeks measured on monthly performance against active waiters, performance measured on the worst performing month in the quarter

Diagnostics performance against key tests

Infection control measures, C Diff and MRSA Bacteraemia *Impact on performance from Covid 19 is clearly stated in the report. The Quality report highlights the ongoing work with Divisions and external partners to improve patient outcomes and a focus on mortality rates. The report contains a review of 7 day services against the National Standard.

D2


Key Questions for the Board are:

Is the Trust maintaining performance against agreed trajectories with our CCGs and in the context of national standards?

Is the Trust providing a quality service for the patients?

Are NEDs assured that the actions being undertaken to address underperformance and maintain current standards are robust and deliver the agreed improvements?


This report supports all elements of the strategic direction by identifying areas of good practice and areas where the Trust requires improvements to meet our expectations.


F&P6 Failure to achieve compliance with performance and delivery aspects of the Single Oversight Framework, CQC and other regulatory standards F&P15 Commissioner plans do not come to fruition and do not achieve the required levels of acute service reduction F&P5 Failing to address the effects of the agency cap


The Board is asked to consider the report.

Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust PERFORMANCE EXCEPTION REPORT – May 2020

1

(A) 4hr Access

National Target – 95%

Hospital % Achievement

Attendances No of Breaches

% Streamed from FDASS

Doncaster 94.11% 7365 434 13.44%

Bassetlaw 94.48% 3077 170 6.5%

Mexborough 100% 1048 0 0.48%

Trust 94.64% 11490 604 10.4%

Main Issues Affecting Performance Summary of Improvement Plan Expected Improvement

Timescales

Covid 19 has severely impacted both

EDs with departments split into 2 areas

to manage 2 simultaneous pathways

(yellow & blue patients).

Although lower than usual attendances

(27% reduction in May 2020 compared

to May 2019), we have seen a 40%

increase in attendances from April

2020.

both sites have seen high acuity on type

1 presentations from both Covid and

non covid pathways – we have seen a

significant increase in non‐Covid

patients attending the Emergency

Departments.

To note, performance on DRI site has

sginficiantly improved from May 2019

with a 4.27% improvement.

Earlier Senior Assessment, ‘Supertracking’

of patients by a Senior Doctor &

Emergency Assessment Unit have been

the three driving principles of the

improvement seen in performance,

particularly on the DRI site.

Senior Teams will work to support the

ongoing provision of the above principles

to ensure provision of early treatment

plans for patients.

Sustainability of improved performance is

dependent on a culture shift within the

Departments.

Work has commenced to build

relationships across Divisions with the

Senior Clinical Teams to review patient

pathways and streamline the patient

journey where possible.

Senior team presence in the department

Monday –Friday until 10pm

weekly COO led “Quality, Flow and

Performance meeting” with Divisional &

departmental leadership team

Local target achieved for

May 2020.

Targets for June 2020 are

based on qualitative

measures to support the

embedding of the three

driving principles for

improvement.


2

(B) Ambulance Handover Breaches

National Target – Within 30 Minutes – 100%

Local Target / Trajectory – Less than 15 minutes – 78.4% (tbc for 2020/21)

Between 15 – 30 minutes – 21.6% (tbc for 2020/21)

Month Hospital No of Arrivals

% less than 15 minutes

% between 15 & 30 minutes

% over 30 minutes

Longest Wait (hrs & minutes)

May 2020 Doncaster 1724 69.66% 29.87% 0.46% 53 Minutes

Bassetlaw 693 39.39% 59.16% 1.44% 58 Minutes

Trust 2417 60.98% 38.27% 0.74% N/A

Main Issues Affecting Performance Summary of Improvement Plan Expected Improvement

Timescale

During May 2020 431 more ambulances

arrived at DRI compared to the previous

month, however numbers of ambulance

arrivals are still down in comparison to the

same time last year.

Both sites continue to experience challenges

with ‘batching’ of ambulance arrivals at

numerous pinch points throughout the day.

Whilst these are pre‐alerted on the

ambulance screen within the department,

with the reduction in space and capacity

within both Emergency departments, this

often leads to delays in handover

Meetings have taken place with YAS and

EMAS to discuss challenges with ambulance

handover times. YAS agreed to review the

‘batching’ of ambulance arrivals.

The changes to the departments in July 2020

will increase the footprint for non‐covid

ambulance arrivals which will improve

handover times and flow within both EDs.

An initial scoping meeting has taken place

with the Trust and YAS to discuss the

implementation of the national ‘Talk before

you walk’ initiative which sees patients ‘pre‐

booking slots for appropriate Emergency

Department attendances, with the aim to

signpost patients to the most appropriate

health care service. This is a long term plan

– no implementation date has been agreed.

Improvements of both

department estates will take

effect from July 2020.


3

(C) Referral to Treatment (RTT) National RTT Target – 92%

Year End Waiting List Target – as of January 2020 ‐ 29935

The following table summarises the position by specialty compared to the national target of 92% and locally agreed waiting list target. Recovery plans are monitored via the Performance Assurance Framework through weekly service level performance meetings and Divisional Accountability meetings.

Specialty Waiting List RTT Percentage

BREAST SURGERY 256 93.8%

CARDIOLOGY 1431 74.3%

CLINICAL HAEMATOLOGY 95 98.9%

DERMATOLOGY 762 84.3%

DIABETIC MEDICINE 454 78.6%

ENT 2819 75.0%

GENERAL MEDICINE 1663 84.2%

GENERAL SURGERY 2174 72.5%

GERIATRIC MEDICINE 105 81.0%

GYNAECOLOGY 1424 82.8%

MEDICAL OPHTHALMOLOGY 267 79.0%

NEPHROLOGY 69 82.6%

OPHTHALMOLOGY 1899 77.1%

ORAL SURGERY 1956 56.7%

ORTHODONTICS 96 74.0%

PAEDIATRIC CARDIOLOGY 78 76.9%

PAEDIATRICS 550 86.4%

PAIN MANAGEMENT 289 91.0%

PODIATRIC SURGERY 3 33.3%

PODIATRY 167 60.5%

RESPIRATORY MEDICINE 629 77.4%

RHEUMATOLOGY 412 74.8%

TRAUMA & ORTHOPAEDICS 5085 60.1%

UPPER GASTROINTESTINAL SURGERY 107 58.9%

UROLOGY 1474 69.5%

VASCULAR SURGERY 386 79.3%

Grand Total 24784 72.3%


4

Overarching Issues Affecting

Performance

Summary of Trust Wide / Corporate

Improvement Plan

Expected Improvement

Timescales

All routine activity was stepped down in May 2020 due to the Trust’s response to COVID 19 and in line with National Guidance. This has continued to severely affect the achievement of the RTT standard and performance will continue to be affected until routine activity increases significantly. We have been particularly challenged in our ability to offer face to face consultations due to the need to ensure our staff are kept safe and to comply with national guidance in relation to patients staying at home.

The Trust continues to see a reduction

in referrals affecting the RTT position by

reducing the overall denominator of the

waiting list.

Each Division has produced a recovery

plan to outline the proposed timescales

for reintroducing routine elective activity

in line with national guidance. A full

‘project structure’ has been developed to

support the innovations required to

undertake elective activity safely and

appropriately. For example the roll out of

telephone and video consultations.

Divisions have now

submitted their recovery

plans with details of how

routine activities will be

safely reintroduced. Levels

of activity and mediums will

differ per speciality, however

with national guidance

stating patients should be

seen in order of clinical need

and not waiting times,

increased activity will not

necessarily equate to an

improvement in RTT

performance in the short‐

medium term.

(D) 52 Week Breaches

National Target – 0

Assuming no clock stops & all previously reported breaches are carried over.

Month End Breaches – May 2020

Carried over Breaches – no treatment

Predicted Breaches – June 2020

Predicted Breaches – July 2020

Predicted Breaches – August 2020

17 10 85 183 357

Incomplete Pathways May 2020 April 2020

Total (Trust) 24784 25006

% under 18 Weeks (Trust) 72.3% 82.2%

Total (Doncaster CCG) 14788 14877

% under 18 Weeks (Doncaster CCG) 73.9% 83.1%

Total (Bassetlaw CCG) 4786 4851

% under 18 Weeks (Bassetlaw CCG) 74.7% 83.6%


5

Specialty Breakdown (new breaches)

No of Breaches CCG Breakdown (new breaches)

Oral Surgery 3 3 x NHS England

Trauma & Orthopaedics 6 5 x Doncaster 1 x East Riding of Yorkshire

General Surgery 1 1 x Doncaster

ENT 2 1 x North Lincolnshire 1 x Bassetlaw

Urology 3 3 x Doncaster

Ophthalmology 2 1 x Bassetlaw 1 x NHS England

Overarching Issues

Affecting Performance

Summary of Trust Wide / Corporate Improvement Plan Expected Improvement

Timescales

All 52 week breaches

declared in May 2020

were directly impacted

by Covid 19 and the

inability to provide

routine elective care in

line with national

guidance.

Each 52 week breach continues to be reviewed and

breach reports produced to ensure any lessons learnt can

be identified from the management of the full patient

pathway – acknowledging the ultimate reason for breach

is due to Covid 19.

All long waiting patients are reviewed on a weekly basis

via a central PTL meeting with clinical reviews being

undertaken to ensure all patients waiting receive a risk

stratification review and are graded appropriately.

As per national guidance on

risk stratification & delivery,

patients will be treated in

accordance with clinical

need and not length of time

waiting, so the Trust will

expect the number of 52

week breaches to grow

exponentially over the

coming weeks.

(E) Diagnostics National Target – 99%

Exam Type <6W >=6W Total Performance Longest Wait

MRI 371 1269 1640 22.62% 24

CT 764 1194 1958 39.02% 22

Non‐Obstetric Ultrasound 1098 3189 4287 25.61% 35

DEXA 139 252 391 35.55% 20

Audiology 0 265 265 0.00% 20

Echo 255 239 494 51.62% 11

Nerve Conduction 14 118 132 10.61% 17

Sleep Study 42 28 70 60.00% 9

Urodynamic 3 90 93 3.23% 36

Colonoscopy 147 407 554 26.53% 18

Flexible Sigmoidoscopy 41 135 176 23.30% 20

Cystoscopy 90 148 238 37.82% 34

Gastroscopy 131 479 610 21.48% 21

Total 3095 7813 10908 28.37%


6

Performance for the Trust, NHS Doncaster and NHS Bassetlaw is outlined below:

Waiters <6W

Waiters >=6W

Total Performance

Trust 3095 7813 10908 28.37%

NHS Doncaster 2036 5093 7129 28.56%

NHS Bassetlaw 819 1906 2725 30.06%

Overarching Issues Affecting

Performance

Summary of Trust Wide / Corporate

Improvement Plan

Expected Improvement Timescales

All routine diagnostic work was stepped down in line with National Guidance. This continues to severely affect the achievement of the diagnostic standard and performance will continue to be affected until routine activity increases significantly. We have been particularly challenged in our ability to offer a full, pre‐COVID19, diagnostic routine service due to the need to ensure our staff are kept safe and to comply with national guidance in relation to patients staying at home.

Diagnostic services for ‘two week waits’ and urgent patients continues and we have urged primary care to continuing referring patients through these pathways. Our teams continue to vet all request cards to ensure urgent patients are seen in order of clinical priority. There is a robust process in place to ensure that no urgent patients are missed, with an internal SOP in place for clinical triage.

The Division has submitted a robust recovery plan for the recommencement of some routine diagnostic activity which has been approved at board level. Levels of routine activity should start to increase from late June 2020. Additionally, active dialogue is taking place with the Integrated Care System to ensure an equitable approach across the region and to take advantage of capacity offered from other parts of the region.

(F) Cancer Performance Cancer Performance – Trust – April 2020

Standard Target Performance

31 Day Classic 96% 98.6%

31 Day Sub – Surgery 94% 100%

31 Day Sub – Drugs 98% 100%

62 Day – IPT Scenario Split 85% 79.3%

62 Day 50/50 Split 85% 82.8%

62 Day – Local Performance (local measure only) ‐ 89.9%

62 Day – Shared Performance only 50/50 Split (local measure only)

‐ 31.6%

62 Day Screening 90% 95.7%

62 Day Consultant Upgrades (local measure only) 85% (local) 78.6%


7

Cancer Performance ‐ Specialty – April 2020

31 Day ‐ Classic

31Day Sub ‐ Surgery

31 Day Sub ‐ Drugs

62 Day – Classic 50/50 split

62 Day – Day 38 IPT split

62 Day Screening

62 Day Consultant Upgrades

Operational Standard

96% 94% 98% 85%

85% 90%

85% (locally agreed target – no national standard)

Breast 100% 100% 100% 100% 100%

Gynaecology 100% 90% 81.80%

Haematology 100% 100% 100% 100% 100%

Head & Neck 33.3% 20% 0%

Lower GI 93.3% 100% 35.7% 31.3% 80% 66.7%

Lung 100% 66.7% 50% 76.5%

Skin 100% 97.5% 97.5%

Testicular 100% 100%

Upper GI 100% 0% 0% 100%

Urological 97.4% 100% 100% 84.0% 84%

Performance 98.6% 100% 100% 82.8% 79.3% 95.7% 78.6%

Cancer Performance Exceptions – April 2020

Tumour Group Breached Standard 31 Day / 62 Day

No of Breaches

Summary of Breach Issues

Summary of Trust Wide / Corporate Improvement Plan

Breast Achieved ‐ No Issues

No Issues

Gynaecology

62 Day 1 Shared Care – Complex Diagnostic Pathway

No Issues

Haematology Achieved ‐ No Issues No Issues

Head & Neck 62 Day 3 Delays due to investigations & OP Capacity at STH

Embedding of weekly PTL meeting

Embedding of twice monthly internal divisional performance meetings

Lower GI 31 Day / 62

Day

9 Delays due to patient choice* & treatment changes due to risk stratification

New guidance released 16.6.2020 for patient triage


Embedding of twice monthly internal divisional performance meetings with Cancer Services Manager, GM & BM

Lung 62 Day 7 All shared care breaches / complex pathways

Embedding of refreshed weekly performance meetings, including Cancer performance input fortnightly


8

Skin Achieved ‐ No Issues No Issues

Upper GI 62 Day 4 Delays due to patient choice*, diagnostics & complex diagnostic pathways



Urological 62 Day 4 Delays due to diagnostics & complex diagnostic pathways

Embedding of weekly PTL meeting – patient level


Submission of business case for precision point biopsy equipment – to enable a one‐stop shop approach.

*Increased patient reluctance to attend for Endoscopic procedures due to self‐isolation requirements pre and post procedure.

Action Plan Update (as requested at Finance & Performance Committee – May 2020) Bowel Screening Nationally screening take up is at 28% for secondary test after initial remoting testing has taken place. This is having a severe impact on cancer pathway performance. Outpatients Bad news clinics continue to be held face to face in Parkhill Hospital on the DRI site. Many new referrals are undergoing a telephone assessment as their first appointment and being referred for the necessary diagnostics. Areas such as head and neck are still having a face to face appointment for first attendance as telephone is not a suitable media. As a Trust we continue to collect feedback from the telephone and video consultations to ensure these are providing a quality service for our patients. Diagnostics Suspected and confirmed cancer patients continue to undergo diagnostics during the pandemic. From week commencing 22.6.2020 Endoscopy provision increases and this will allow us to ensure patients are diagnosed in a timely manner. Due to the British Society of Gastroenterology guidance issued at the onset of the Covid 19 pandemic, Endoscopy patients were cancelled which has resulted in a backlog of both urgent and routine activity. The increase of endoscopy activity will improve the performance for Lower GI and Upper GI cancer tumour groups. Theatres Approval has been given to run an elective list at BDGH each weekday from the 29th June 2020, increasing our capacity for urgent and cancer patients.


9

(G) Stroke National Target – (Direct Admission within 4 hours) – 75% March 2020

Direct Admission within 4 Hours

Bassetlaw CCG

Doncaster CCG

Barnsley CCG

Other CCG Total

Yes 7 22 2 0 31

No 12 13 0 2 27

Total 19 35 2 2 58

Performance 36.8% 62.9% 100.0% 0.0% 53.4%

Overarching Issues Affecting Performance / Breach Reasons

No of Breaches

Summary of Trust Wide / Corporate Improvement Plan

Expected Improvement Timescales*

Stroke Unit Bed Availability 2 Review & update operational policy – include new patient pathways, protocols & SOPs

December 2020

Delay in Transfer from ED 4

Advanced Clinical Practitioner role introduced to increase specialist outreach in to ED for early identification of stroke patients

October 2019

Delay ‐ transport BDGH to DRI 0 Qii project to include all stakeholders:

ED / CT / Stroke Team / Site Management

TBC *

Delay at CT Scan 0

Patient Presentation: secondary / late diagnosis of stroke. 13

Development of intra‐cranial haemorrhage pathway to improve early stroke diagnosis

June 2020

Patient Needs 5 N/A N/A

Exclude – Hospital Stroke 2 N/A N/A

Further Investigation Required 3 N/A N/A

*All timescales delayed due to Covid 19. Timescales to be set in line with return to BAU. Longest delay for direct admission: 8 days, 9 hours 18 minutes – ‘Patient sent to AMU has had bilateral leg weakness, no stroke symptoms found in ED. Referred back to stroke following MRI days later’

For the second consecutive quarter, the Trust has achieved the highest Sentinal Stroke National Audit Programme (SSNAP) score – A. These standards are informed by the National Clinical Guidelines for Stroke.


10

(H) Cancelled Operations on the Day for Non Clinical Reasons (Theatre & Non Theatre) National Target – 1%

CCG Total Activity No of Cancellations % Achievement

Trust 1449 2 0.14%

Doncaster 1049 2 0.14%

Bassetlaw 263 0 0%

Other 137 0 0%

Overarching Issues Affecting Performance / Breach Reasons

No of Breaches

Summary of Improvement Plan

Insufficient Time (clinical reasons) 2

All cases planned through theatre planning group using individual consultants pre‐agreed nominal timing for each procedure – all captured on Bluespier & all overruns discussed at theatre strategy group.

(I) Cancelled Operations – Not Rebooked within 28 Days National Target – 0 In May 2020 there were no operations cancelled that were not rebooked within 28 days

Length of Stay Average Length of Stay


11

Summary of Main Issues Summary of Improvement Plan

The main issues with LoS continue to be related to the COVID pandemic, with an increased number remaining in acute care for an average of 7 days.

Further information to be provided next month, however during May 2020, the return to previous ways of working have assisted in reducing length of stay for non‐elective patients.

Super‐Stranded Patients

* The exclusions are as follows, based the data available on each snap shot date;

Any patient who was at Montagu Hospital

Any patient under the care of Rehabilitation

Any patient aged under the age of 18

Any patient on ward PARK, BARL, EPAU, ECL, ED WARD and DIS

Summary of Main Issues Summary of Improvement Plan

The same issues continue to apply for super‐stranded patients, however for May 2020 we have seen further fall in this cohort of patients with a count of 28 patients against a target of71.

The Trust are currently mapping the new processes put in as a result of the national guidance for a Single Point of Access. In the meantime, restarts and SPOC have reverted to the old process.

Delayed Transfers of Care (DTOC) DToCs are not being collected currently as we have KPIs against the new discharge guidance, 2hr turnaround which has not been met by any patient. This has been superseded by the necessity for swabbing all patients being discharged to Care Homes.

Local

TargetActual Variance

Local


A&E: Max wait four hours from

arrival/admission/transfer/dischargeMay-20 62% 80.6% 95% 94.64% -0.36% 95% 93.03% -1.97%

Max time of 18 weeks from point of referral to treatment-

incomplete pathwayMay-20 76% 71.0% 92% 72.32% -19.68% 92.00% 77.28% -14.72%

RTT 52 Week Breaches to date May-20 N/A N/A 0 27 27 0 27 27

Waiting list size (from 1/4/19) - 18 Weeks referral to

treatment -Incomplete PathwaysMay-20 N/A N/A 29935 24784 5151 29935 24784 5151

% waiting less than 6 weeks from referral for a diagnostics

testMay-20 43.1% 44.3% 99% 28.37% -70.63% 99% 32.67% -66.33%

Day 28 Standard (patients received diagnosis or exclusion of

cancer)Apr-20 N/A N/A - - - - -

31 day wait for diagnosis to first treatment- all cancers Apr-20 96.9% 96.3% 96% 98.64% 2.64% 96% 98.64% 2.64%

31 day wait for second or subsequent treatment: surgery Apr-20 93.1% 90.9% 94% 100.00% 6.00% 94% 100.00% 6.00%

31 day wait for second or subsequent treatment: anti cancer

drug treatmentsApr-20 100.0% 99.0% 98% 100.00% 2.00% 98% 100.00% 2.00%

31 day wait for second or subsequent treatment:

radiotherapyApr-20 94.4% 95.3% - - - - - -

62 day wait for first treatment from urgent GP referral to

treatmentApr-20 78.7% 74.3% 85% 79.27% -5.73% 85% 79.27% -5.73%

62 day wait for first treatment from consultant screening

service referralApr-20 71.4% 81.1% 90% 95.65% 5.65% 90% 95.65% 5.65%

A&E Attendances May-20 N/A N/A 0 10598 10598 0 18308 18308

Non Elective Activity - Discharges May-20 N/A N/A 0 2789 2789 0 5259 5259

Daycase Activity (Contracted levels achieved) May-20 N/A N/A 0 679 679 0 1192 1192

Other Elective Activity (Contracted levels achieved) May-20 N/A N/A 0 295 295 0 441 441

Outpatient new activity (Contracted levels achieved) May-20 N/A N/A 0 1782 1782 0 3552 3552

Outpatient Follow Up activity (Contracted levels achieved) May-20 N/A N/A 0 2941 2941 0 6514 6514

Ambulance Handovers Breaches -Number waited <= 15

MinutesMay-20 N/A N/A 78.90% 60.98% -17.92% 78.90% 61.80% -17.10%

Ambulance Handovers Breaches -Number waited >15 & <30

MinutesMay-20 N/A N/A 22.20% 38.27% -16.07% 22.20% 37.50% -15.30%

Ambulance Handovers Breaches-Number waited >30 & < 60

MinutesMay-20 N/A N/A 0% 0.74% -0.74% 0% 0.68% -0.68%

Ambulance Handovers Breaches -Number waited >60

MinutesMay-20 N/A N/A 0% 0.00% 0.00% 0% 0.02% -0.02%

Proportion of patients scanned within 1 hour of clock start

(Trust)Mar-20 N/A N/A 48% 48.28% 0.28% 48% 48.25% 0.25%

Category

Performance

(NHSI

Compliance

Framework)

CURRENT MONTH YEAR-TO-DATE Trend Graph (May-18 - stated month)

This is calculated based on rolling 24 month data with performance

below expected control limits highlighted in red and above

expected control limits in green

Peer

Benchmark

National

BenchmarkIndicator

Latest

Month

Reported

Performance

(Cancer)

Performance

(Activity)

Performance

(Ambulance

Handover

Times)

Performance

(Stroke)

Local


Local


Category

Performance

(NHSI

Compliance

Framework)





Peer

Benchmark

National

BenchmarkIndicator

Latest

Month

Reported

Proportion directly admitted to a stroke unit within 4 hours

of clock startMar-20 N/A N/A 75% 53.45% -21.55% 75% 56.22% -18.78%

Percentage of all patients given thrombolysis Mar-20 N/A N/A 90% 100.00% 10.00% 90% 100.00% 10.00%

Percentage treated by a stroke skilled Early Supported

Discharge teamMar-20 N/A N/A 24% 83.33% 59.33% 24% 79.19% 55.19%

Percentage discharged given a named person to contact

after dischargeMar-20 N/A N/A 80% 82.76% 2.76% 80% 94.75% 14.75%

Stroke Strategy - TIA Assessed & Treated within 24 Hours Mar-20 N/A N/A - - - - - -

Out Patients: DNA Rate May-20 0.0% 0.0% 8.73% 8.16% 0.57% 8.73% 8.09% 0.64%

Out Patients: Hospital Cancellation Rate May-20 N/A N/A 4.50% 32.91% -28.41% 4.50% 35.03% -30.53%

Overdue Follow Ups / Review List / Missing List (over 3

months = 25% overdue / under 3 months = 50% overdueN/A N/A 25.00% - - 25.00% - -

Typing Backlog (number / date) May-20 N/A N/A 3WD 0WD 3WD 3WD 0WD 3WD

Out Patient Booking - 2 weeks prior May-20 N/A N/A 95% 63.63% -31.37% 95% 58.94% -36.06%

Clinic Utilisation May-20 N/A N/A 95% 77.15% -17.85% 95% 74.18% -20.82%

ASIs 7 Days + May-20 N/A N/A 0 0 0 0 0 0

Missing Outcomes 14 Days + May-20 N/A N/A 0 429 -429 0 429 -429

Theatre Booking - 3 weeks prior May-20 N/A N/A - 21% - - 22% -

Theatre Booking - 4 weeks prior May-20 N/A N/A 95% 18% -76.91% 95% 18% -77.31%

Theatre Booking - 5 weeks prior May-20 N/A N/A - 17% - - 14% -

Theatre Utilisation May-20 N/A N/A 87% 55% 31.81% 87% 61% 25.83%

Cancelled Operations on the day (For non-clinical reasons) May-20 N/A N/A 1% 0.14% 1% 1% 0.46% 1%

Cancelled Operations-28 Day Standard May-20 N/A N/A 0 0 0 0 16 16

ERS Advice & Guidance Response Time May-20 N/A N/A 2WD 13WD -11 2WD 11WD -9

Infection Control Hosptial Onset C.Diff May-20 N/A N/A TBC 2 - TBC 5 -

Infection Control Community Onset C.Diff May-20 N/A N/A TBC 1 - TBC 2 -

Infection Control Combined Onset C.Diff May-20 N/A N/A TBC 3 - TBC 7 -

Patients

Performance

(Stroke)

Peformance

(Theatres &

Out Patients)

Local


Local


Category

Performance

(NHSI

Compliance

Framework)





Peer

Benchmark

National

BenchmarkIndicator

Latest

Month

Reported

Infection Control MRSA May-20 N/A N/A 0 0 0 0 0 0

HSMR (rolling 12 Months) Mar-20 N/A N/A 100 99.75 0.25 100 99.75 0.25

HSMR : Non-Elective (rolling 12 Months) Mar-20 N/A N/A 100 99.71 0.29 100 99.71 0.29

HSMR : Elective (rolling 12 Months) Mar-20 N/A N/A 100 94.91 5.09 100 94.91 5.09

Never Events May-20 N/A N/A 0 0 0 0 1 -1

Sis May-20 N/A N/A - 1 - - 3 -

VTE Jan-20 N/A N/A 95% 95.00% 0.00 95% 95.28% 0.00

Pressure Ulcers - Category 3 May-20 N/A N/A 5 4 1 10 11 -1

Pressure Ulcers - Category 2 / UNS / DTI May-20 N/A N/A 0 62 62 0 62 62

Falls with Severe Harm / Lapse in Care / SI May-20 N/A N/A 0 1 -1 0 1 -1

Falls with Moderate or Severe Harm May-20 N/A N/A 3 4 1 3 4 1

Complaints Resolution Performance (% achieved closure in

agreed timescales with complainant)May-20 N/A N/A 90% 54.55% -35.45% 90% 54.55% -35.45%

Complaints Upheld / Partially Upheld by Parliamentary

Health Service Ombudsman May-20 N/A N/A - 0 - - 0 -

Claims CNST (patients) May-20 N/A N/A TBC 5 - TBC 5 -

Claims LTPS - staff May-20 N/A N/A - 1 - - 1 -

Friends & Family Response Rates (ED) Mar-20 N/A N/A - - - - 2.56% -

Friends & Family Response Rates Mar-20 N/A N/A - - - - 21.49% -

Emergency Readmissions within 30 days (PbR Methodology) May-20 N/A N/A 7% 8.00% -1% 7% 8.57% -2%

DTOC Jan-00 N/A N/A 3% - - 3% - -

Super Stranded Patients May-20 N/A N/A 71 28 43 71 65 6

Average Length of Stay (Elective & Non-Elective) N/A N/A - 3.29 - - 3.62 -

Bed Occupancy <92% N/A N/A 92% - - 92% - -

Mixed Sex Accommodation N/A N/A 0 0 0 0 0 0

Patients

Local


Local


Category

Performance

(NHSI

Compliance

Framework)





Peer

Benchmark

National

BenchmarkIndicator

Latest

Month

Reported

Sepis Screening - % of appropriate patients screened N/A N/A 90% - - 90% - -

Sepsis Prescribing - Antibiotics within 1 Hour N/A N/A 90% - - 90% - -

Deaths Screened as part of Mortality Review Process Jan-00 N/A N/A 80% - - 80% - -

NICE Guidance Response Rate Compliance May-20 N/A N/A 90% 93.47% 3.47% 90% 93.47% 3.47%

NICE Guidance % Non & Partial Compliance N/A N/A TBC 23.83% - TBC 23.83% -

% Patients Asked for Smoking Status N/A N/A 90%

Awaiting

ability to

capture

- 90% - -

Of Patients who Smoke, % offered BAG / NRT & Referral to

Smoking CessationN/A N/A 50%Awaiting ability to capture electronically- 50% - -

Appropriate Anitbiotic Prescribing for UTI in Adults (16+) N/A N/A 60% - - 60% - -

Cirrhosis & Fibrosis Tests for Alcohol Dependent Patients N/A N/A 35% - - 35% - -

Staff Flu Vaccinations (1.9.20 - 28.2.21) N/A N/A - - - - - -

Recording of NEWS2 Scores for Unplanned Critical Care

Admissions (60%)N/A N/A 60% - - 60% - -

Screening & Treatment of Iron Deficiency Anaemia - Major

Blood Loss SurgeryN/A N/A 60% - - 60% - -

Treatment of CA Pneumonia - BTS Care Bundle N/A N/A 70% - - 70% - -

Rapid Rule Out Protocol - ED Patients with Suspected Acute

MI (60%)N/A N/A 60% - - 60% - -

Adherence to Evidence Based Interventions Clinical Criteria N/A N/A 80% - - 80% - -

People Appraisals (rolling 12 months) N/A N/A 90% - - 90% - -

Non-Medical Appraisals - in season (April - July) N/A N/A 90% - - 90% - -

Sickness N/A N/A 4% - - 4% - -

SET Training N/A N/A 90% - - 90% - -

Vacancies N/A N/A 5% - - 5% - -

Turnover (rolling 12 months) N/A N/A 10.00% - - 10% - -

Casework - number of grievances open N/A N/A - - - - - -

Casework - number of conduct cases open N/A N/A - - - - - -

Patients -

CQUINNS

Patients

Local


Local


Category

Performance

(NHSI

Compliance

Framework)





Peer

Benchmark

National

BenchmarkIndicator

Latest

Month

Reported

Number of Overpayments (rolling 12 months) N/A N/A TBC - - TBC - -

Compliance with EWTD N/A N/A YES - - YES - -

Time to Fill Vacancies (from TRAC authorisation -

unconditional offer)N/A N/A 47WD - - 47WD - -

Title Quality and Patient Experience Report

Report to Board of Directors Date 21.07.2020

Author David Purdue, Chief Nurse


Decision

Assurance x

Information


In July 2019, NHS improvement changed the definition of Patient safety to be about maximising the things that go right and minimising the things that go wrong. It is integral to the NHS' definition of quality in healthcare, alongside effectiveness and patient experience. It is essential that we listen and learn from our patients, visitors and staff to ensure we deliver our aim to be an outstanding organisation. This report highlights the key patient safety, quality and experience outcomes against the key performance indicators in June 2020.


Is the Trust Board assured that the actions being undertaken are meeting the quality objectives for the Trust


This report contributes to True North Objective One and the breakthrough objective for 2020.


F&P6 Failure to achieve compliance with performance and delivery, CQC and other regulatory standards Leading to (i) Negative patient and public reaction towards the Trust (ii) Impact on reputation


D3

That the report be noted.

Quality and Experience Report June 2020

Patient Safety

Serious Incidents There has been one serious incident for a care issue reported at the end of June. This incident is

currently being investigated. This takes the total number of serious incidents for care issues,

reported year to date, to five. This includes one never event.

All incidents are thoroughly investigated by appropriately trained investigators and progress

monitored through the serious incident panel, which has continued weekly throughout the Covid

pandemic.

Falls The total number of patients falling in quarter one is 259. There have been increases in patients

falling resulting in harm (April – 24 patients, May 23 patients, June 35 patients).

There has been one fall in June with moderate harm (head injury‐skull fracture) which has been

reported as a serious Incident. This is a total of two falls with severe harm being reported as a

serious incident, year to date.

The total number of patients in quarter 1 who have fallen, resulting in moderate or severe harm is

six. Three have sustained moderate harm (2 head injuries and a fractured wrist ‐ April and June) and

three severe harm (two fractured hips and one head injury ‐ all in May).

All falls are investigated using the Trust Multi‐disciplinary Inpatient Falls Investigation Tool (MiFIT).

The quality improvement accreditation for falls was paused for Q1 due to Covid‐19 and has now

been re‐started.

The falls strategy is currently under review to assess what are the next steps needed to reduce the

current number of falls.

Throughout 2019/20 with all surgical wards except one (B6) scored green or blue on the RAG rating.

All medical wards except one (C2/CCU) scored green or blue on the RAG for the end of the year.

Hospital Acquired Pressure Ulcers (HAPU) The total numbers of HAPU reported in Quarter 1 (including category 3, category 2 and UNS/DTI) in

June 2020, is 192 (April – 56 patients, May – 69 patients, June – 67 patients).

There have been five category 3 HAPU in June 2020. These were on the respiratory unit, ward 16,

AMU, fracture clinic and the surgical assessment Unit. This takes the total numbers of Category 3

HAPU to 17, year to date.

Reporting of HAPU Cat 3 is no longer a serious incident, in agreement with the CCG and in line with

NRLS reporting. The executive review panel has re‐started, using virtual technology to extract

learning from these cases.

The quality improvement accreditation for the Skin Integrity Team (SIT) worked well through

2019/20 with all surgical wards except two RAG green or blue. Medical wards have scope for

improvement with six out of 18 wards RAG amber or red. SIT accreditation has now re‐started after

a pause on Q1 due to covid‐19.

Infection Prevention and Control

Clostridium difficile There were six cases of Clostridium difficile in June. This is split into five cases of hospital associated,

hospital acquired (HOHA) and one case which was community onset, hospital acquired (COHA). This

takes the number of cases, year to date to 13. No lapses in care have been identified as yet, with

patients appropriately being prescribed antibiotics.

The number of CDiff cases is of concern and through the PIR process the administration and

stewardship of antibiotics has been shown to be a theme. This is partially due to the treatment of

Covid 19 antibiotics, which are the most common to cause CDiff. This practice has now changed

along with the renewed emphasis on antibiotic stewardship which will reduce the number of CDiff

cases.

e‐Coli Bacteremia

There have been four cases of eColi bacteremia which are now having a PIR in the same way as Cdiff

to establish learning. This takes the number of cases, year to date to 14.

MRSA bacteraemia There have been no cases of MRSA Bacteremia for 117 days. MRSA Colonisation There have been no cases of MRSA colonisation, leaving the total number of cases, year to date to 5. The deep clean schedule continues to progress well. 20 wards have now been deep cleaned in year, a further three are on track, two are partially completed. Two theatres have also been completed. The quality improvement accreditation for infection, prevention and control was paused for Q1 due to covid and has now re‐started.

Covid 19

Nosocomial Infections Guidance was updated on the 12th of June relating to reducing infection rates within hospital settings. These procedures are all in place across all of the sites. Any outbreaks involving for the 5 patients or staff are reported to Public Health England. Any outbreaks are closed after the last infected patient is clear for 28 days. DBTFT has had 4 outbreaks all on the DRI site and non‐involving yellow wards. The outbreaks have related to both staff and patients and have occurred generally in the ward areas with the worst environments. 2 in orthopaedic wards, 1 on a surgical ward and 1 in medicine. The learning from these outbreaks has been communicated across the Trust sites. Key messages

Social distancing

Poor compliance in wearing the PPE correctly

Hand hygiene compliance

Crowded locations on the ward with visitors to the ward therapists etc.

Multiuse items not cleaned e.g. telephone, computers

Bank staff

All of these ward areas have been deep cleaned and fogged. The deep clean plan is ahead of

schedule.

Test and Track The Trust has to complete a weekly return to NHSE/I in relation to the number of staff isolating through Test and Track. Current Hospital position 8 members of staff have needed to self‐isolate due to test and trace. Mortality Rates from Day 8 Following Admission The Trust has been identified as an outlier for patients who died following an initial negative swab and then became covid positive whilst an inpatient. This is for deaths from the 1st of May to the 28th of May. As a Trust we did not routinely swab all emergency admissions until the 27th of April, so though the patients were swabbed after admission they may have already have had the virus.

Information team identified that within this time period there were 24 deaths meeting the criteria. A

screening tool was devised in order to capture key information relevant to the request .

Each case underwent a mortality review by the medical examiner officers using the Covid‐19

mortality screening tool. The IPC Matron simultaneously completed a PIR for each patient.

A robust review has taken place by triangulating data from several sources in order to determine

whether patients were more at risk of dying as a result of hospital onset Covid‐19. The data is

consistent with NHSE reporting and does correlate with their findings of DBTH being a national

outlier.

The root cause of this was due to staff related outbreaks rather than directly associated with

patients. Immediate recommendations and actions were undertaken by the IPC team in order to

minimise future risk and it is noted that following the outbreaks, that there have been frequent visits

by IPC and practices have been noted as greatly improved.

A full report on this process will be delivered to the Quality and Effectiveness Committee on the 28th

of July.

CQC Compliance

The CQC will focus on the compliance against the IPC Board Assurance Framework, which was

launched by NHSE/I in May 2020. This document was reviewed in May 2020 by the Board. The CQC

have reviewed the document and the supporting risk assessments and are meeting with the Trust on

the 29th of July to review our compliance.

Patient Experience

45 formal complaints were received in June, higher than May’s figure of 23. The top themes from

the formal complaints were around treatment (14), COVID 19 (8) and diagnosis (6). These are

monitored through the Patient Experience and Engagement Committee (PEEC).

The COVID‐19 Dashboard is still being used and there has been 19 complaints, 7 ACQ’s and 7

concerns at the time of writing (03/07). This is an increase of 7 complaints, 1 ACQ and 1 concern

since last month’s figures. To populate the COVID‐19 dashboard, the subject of COVID‐19 for

complaints has to be listed as first, this therefore may show a higher figure for this data.

There are currently 50 complaints that are open at the time of writing (03/07), there are an

additional 52 complaints that are paused due to COVID 19. 113 complaints have been closed since 1

April 2020.

The Friends and Family Test (FFT), was due to relaunched nationally from 1st April 2020 but this has

been deferred until September 2020, in line with national guidance over Covid‐19. Work has

continued on developing a spreadsheet with all the locations on, the Divisions have been given the

opportunity to refresh this information. FFT will then on its relaunch have an alternative way of

collecting data, as patients, friends and family will be given the opportunity to provide their

feedback online via the Trust’s website. This will be in addition to the current option of completing

an FFT card. Nationally NHS E/I have launched an online tool for data comparison for the FFT.

The annual patient experience report was approved at the patient experience and engagement

committee in June 2020.

2019 CQC Adult Inpatient Survey

Respondents and response rate 505 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust inpatients responded to the survey The response rate was 42.01% Banding Your trust’s results were better than most trusts for 1 questions. How do you feel about the length of time you were on the waiting list before your admission to hospital? Your trust’s results were worse than most trusts for 1 questions. Were you given enough privacy when discussing your condition or treatment? Your trust’s results were about the same as other trusts for 61 questions. Comparisons with last year’s survey Your trust’s results were significantly higher this year for 4 questions.

How do you feel about the length of time you were on the waiting list before your admission to hospital?

Before you left hospital, were you given any written or printed information about what you should or should not do after leaving hospital?

Did a member of staff explain the purpose of the medicines you were to take at home in a way you could understand?

Did hospital staff tell you who to contact if you were worried about your condition or treatment after you left hospital?

Your trust’s results were significantly lower this year for 1 questions. Did you find someone on the hospital staff to talk to about your worries and fears? There were no statistically significant differences between last year’s and this year’s results for 56 questions. National Cancer Patient Experience Survey

The National Cancer Patient Experience Survey results have just been published and the results for

the Trust continue to demonstrate further improvement. This was the first year that Picker was used

and therefore it is difficult to directly compare quite a lot of questions with previous ones as the

wording has changed.

Headlines results

In the National League table by provider Trust DBTH ranked joint 42nd/ 145. This result is based on

the number of questions we were better than / within the expected range

DBTH have improved on this each year and have again received the best result in the SYB Cancer

Alliance

For this question we were ranked 18/141

Percentage responses are given in case Mix adjusted and case mix unadjusted, for case mix adjusted

there was just one question we were lower than the national average

Current YTD reported SI's (April-Jun 20) 6 13

Current YTD delogged SI's (April-Jun 20) 0 3

Serious Incidents - Jun 2020 (Month 3)(Data accurate as at 02/07/2020)

Overall Serious Incidents

Themes

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

Number reported SI's (Apr-Jun 19)

Number delogged SI's (Apr-Jun 19)

0.00

0.05

0.10

0.15

0.20

0.25

0.30

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

Pressure Ulcers - Cat 3 & 4 (HAPU) per 1000 occupied bed days

0.00

0.05

0.10

0.15

0.20

0.25

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/19

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

Care Issues per 1000 occupied bed days

0.00

0.01

0.02

0.03

0.04

0.05

0.06

0.07

Jun

/19

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/19

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

Serious Falls per 1000 occupied bed days

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

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

0123456789

10

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

Number Serious Incidents Reported(Trust & Divisions)

Clinical Speciality Services Medicine

Surgery & Cancer Children & Families

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

Standard Qtr 1 Apr May Jun YTD Qtr 1 Apr May Jun YTD

2020-21 Infection Control - C-diff 44 Full Year 13 4 3 6 13 HOHA 10 3 2 5 10

2019-20 Infection Control - C-diff 39 Full Year 9 1 4 4 9 COHA 3 1 1 1 3

2020-21 Trust Attributable 12 0 0 0 0 0

2019-20 Trust Attributable 12 0 0 0 0 1

Standard Qtr 1 Apr May Jun YTD

2020-21 Serious Falls (moderate/severe harm) 6 Full Year 6 2 3 1 6

2019-20 Serious Falls 10 Full Year 3 2 1 0 3

Standard Qtr 1 Apr May Jun YTD

2020-21 Pressure Ulcers 56 Full Year 192 56 69 67 192

2020-21 Pressure Ulcers

(Cat 3)17 7 5 5 17


(UNS/DTI Low Harm)26 13 4 9 26


(Cat 2)149 36 60 53 149

Infection Control C.Diff - June 2020 (Month 3)

(Data accurate as at 13/07/2020)

Pressure Ulcers & Falls that result in a serious fracture - June 2020 (Month 3)

(Data accurate as at 02/07/2020)

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 there were 5 PU's

awaiting RCA

0

10

20

30

40

50

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

C-diff

2020-21 C-diff Cumulative total 2020-21 CoHa Cumulative Total 2020-21 HoHa Cumulative Total

2019-20 C-diff Cumulative total Standard

02468

10

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

De

c

Jan

Feb

Mar

Falls that result in a serious fracture

2020-21 Falls Cumulative Total 2019-20 Falls Cumulative Total

Standard

0

5

10

15

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

Trust Attributable C-diff

2020-21 Trust Attributable Cumulative Total

2019-20 Trust Attributable Cumulative Total

Month

`

3

1

0

0

3

0

4

3

0

0

0

2

1

2

1

2020/21 0 0

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD

2020/21 2 5 3 102019/20 4 4 11 902020/21 2 1 2 5

2019/20 5 4 0 36

2019/20

7

Outstanding

Number Currently Outstanding

3

9

Parliamentary Health Service Ombusdman (PHSO)

Not Upheld

Case Withdrawn

Jun-20

Fully / Partially Upheld

Not Investigated

Number of cases referred

for investigation

Complaints & Claims - June 2020 (Month 3)Data accurate as at 02/07/2020

Complaints

Not Upheld

Outcomes

YTD

Complaints - Resolution Perfomance (% achieved resolution within timescales)

Complaints Closed - Outcome

2017/18

Number referred for

investigation

YTD

Please note: At the time of producing this report the number of claims reported are provisional and prior to validation

No further Investigation

Claims


Case Withdrawn

Outstanding

Clinical Negligence Scheme for Trusts (CNST) Not including

Disclosures

Not Investigated

2018/19

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.

Liabilities to Third Parties Scheme (LTPS)

0

Outstanding

No further Investigation

Not Upheld


Outstanding

4

June2020

Complaints ReceivedRisk Breakdown

20 Working Days

40 Working Days

90 Working Days

Year to DateComplaints Received

Risk Breakdown

0

10

20

30

40

50

60

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

Complaints Received

Complaints Mean UCL LCL

0

20

40

60

80

100

120

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

Concerns Received

Concerns Mean UCL LCL

30%40%50%60%70%80%90%

100%

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

Complaints Resolution Performance

0.00

0.20

0.40

0.60

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

Number of CNST Claims per 1000 Occupied bed days

Claims per 1000 occupied bed days Claims per 1000 occupied bed days - Previous years performance

0

5

10

15

20

25

30

Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20

Act

ual

Nu

mb

er

Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20

Complaints Upheld 6 8 4 4 8 3 5 7 3 1 2 1

Complaints Partially upheld 14 24 14 24 14 13 13 16 17 19 18 5

Complaints not upheld 2 12 10 9 7 4 12 8 9 10 13 9

Outcome not reported 0 0 0 0 0 5 5 11 13 17 10 6

Closed Complaints - Outcomes


Number of complaints received - 2020/21 0 0 2 2

Number of complaints received - 2019/20 6 1 1 8

Diagnosis 1Staff attitude & behaviour 1

Communication 0

Competence 0Treatment 0Nursing - ADL 0Diagnostic Tests 0

Admissions/transfers/discharge procedure/sleeper out 0

Medication 0

Hospital Environment 0Other 0Patient equality, diversity and safety 0Nutrition & Hydration 0Medical records 0Complaint Handling 0Nursing - Continence 0Pain Management 0


Number of Datix Incidents Reported - 2020/21 28 24 42 94

Number of Datix Incidents Reported - 2019/20 33 29 35 97


Number of Serious Incidents Reported - 2020/21(including de-logged)

0 0 0 0

Number of Serious Incidents Reported - 2019/20(including de-logged)

0 0 0 0

Datix Incidents & Serious Incidents

Complaints

There have been 3 incidents within Children and Young Persons which have triggered Duty of

Candour to be completed. Initial communication was completed in 100% of cases, Letter 1 in

33.3% of the records and Letter 2 has been completed on 50% of records.

Childrens & Young People - Quality Metrics

June 2020 (Month 3)(Data accurate as at 2/7/2020)

There were 2 complaints received in June, one related to an alleged delay in diagnosis and the other was

regarding the attitude of a doctor whereby the patient felt that the doctor was being dismissive about the

patient’s condition.

Duty Of Candour (Doc)

Please note: An incident which has caused moderate, severe or patient death requires DoC to be completed

Thematic breakdown (Apr 19 - May 2020)

Please note that a direct correlation between the number of complaints received and the subjects within thematic breakdown can not been made as most of the complaints have more

than one subject noted.

0

1

2

3

Ap

r

May Jun

Jul

Au

g

Sep

Oct

No

v

Dec Jan

Feb

Mar

Title Hospital Standardised Mortality Ratio (HSMR)

Report to Board of Directors Date 21.07.2020

Author Dr T J Noble, Medical Director


Decision

Assurance x

Information


The overall rolling HSMR has remained steady over the recent six months currently at 99.17 and within the expected range. This is reflected in both the “non‐elective” and the “elective” figures. The monthly HSMR for March which is in the early part of the Covid outbreak was at 100. The monthly HSMR is always three months behind in terms of its production by HED. The crude mortality rate increased rapidly in March 2020 at the start of the Pandemic, peaking as would be expected in April and since then there has been a consistent downward trend. This reduction in crude mortality is reflected on both sites. As expected there has been a significant change in overall Trust activity in part due to cancellation of elective work. It is recognised that the HSMR model is designed on the basis of historical deaths over a ten year period and therefore may not be fit for purpose in a situation where there is a sudden rise in deaths nationally. However, while the interpretation of the HSMR figure needs to be undertaken with caution given a number of uncertainties introduced as a result of Covid not least issues with coding variability nonetheless it would still be beneficial to monitor the standard as a way of keeping a focus on mortality within the Trust, and in time a more accurate position will emerge. During the Pandemic the Trust has succeeded in maintaining the Medical Examiner process which has been vital in ensuring oversight of the quality of care delivered. The Trust was one of two Trusts in the region who have maintained this process and this has been recognised.

D4

The further Medical Examiner appointments will no doubt enhance this process and has been fully supported in terms of allocation of the resource by the Regional Team. The Board’s commissioned report to the Quality & Effectiveness Committee will be presented on the 28th July 2020 and will include further detail.


The Trust Board can be assured that the actions being taken in respect of Mortality Governance meet the quality objectives for the Trust.


This report contributes to True North Objective One and the breakthrough objective for 2020.


F&P6 Failure to achieve compliance with performance and delivery, CQC and other regulatory standards Leading to (i) Negative patient and public reaction towards the Trust (ii) Impact on reputation



2016 2017 2018 2019 2020

January 116.80 99.21 94.86 105.78 110.43

February 99.94 97.73 105.44 98.13 92.71

March 90.54 97.37 88.42 101.87 100.60

April 105.91 88.50 98.37 100.70

May 101.15 96.60 91.20 91.36

June 80.27 93.67 89.98 98.32

July 92.56 97.73 107.07 104.77

August 100.27 87.52 94.65 112.17

September 90.26 95.34 90.09 83.64

October 90.29 88.66 96.74 100.24

November 88.98 82.30 99.04 88.64

December 82.30 93.52 80.45 103.24

Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 May-20

Trust 1.28% 1.49% 1.12% 1.49% 1.26% 1.91% 1.93% 1.44% 1.69% 5.03% 3.54% 2.14%

DRI 1.30% 1.60% 1.15% 1.32% 1.22% 2.04% 1.89% 1.26% 1.76% 4.95% 3.52% 2.37%

BDGH 1.43% 1.36% 1.20% 2.36% 1.64% 1.71% 2.42% 1.57% 1.75% 7.23% 5.05% 1.51%

HSMR Trend (monthly) Crude Mortality (monthly) - June 2020 (Month 3)(number of deaths/number of patient discharged)

Hospital Standardised Mortality Ratio (HSMR) - March 2020 (Month 12)

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

99.17

90

92

94

96

98

100

May

18

- A

pr

19

Jun

18

- M

ay 1

9

July

18

- J

un

19

Au

g 1

8 -

Ju

l 19

Sep

t 1

8 -

Au

g 1

9

Oct

18

- S

ep 1

9

No

v 1

8 -

Oct

19

Dec

18

- N

ov

19

Jan

19

- D

ec 1

9

Feb

19

- Ja

n 2

0

Mar

19

- Fe

b 2

0

Ap

r 1

9 -

Mar

20

99.27

90

92

94

96

98

100

May

18

- A

pr

19

Jun

18

- M

ay 1

9

July

18

- J

un

19

Au

g 1

8 -

Ju

l 19

Sep

t 1

8 -

Au

g 1

9

Oct

18

- S

ep 1

9

No

v 1

8 -

Oct

19

Dec

18

- N

ov

19

Jan

19

- D

ec 1

9

Feb

19

- Ja

n 2

0

Mar

19

- F

eb 2

0

Ap

r 1

9 -

Mar

20

88.64

40

50

60

70

80

90

100

110

120

May

18

- A

pr

19

Jun

18

- M

ay 1

9

July

18

- J

un

19

Au

g 1

8 -

Ju

l 19

Sep

t 1

8 -

Au

g 1

9

Oct

18

- S

ep 1

9

No

v 1

8 -

Oct

19

Dec

18

- N

ov

19

Jan

19

- D

ec 1

9

Feb

19

- Ja

n 2

0

Mar

19

- F

eb 2

0

Ap

r 1

9 -

Mar

20

1.0%1.5%2.0%2.5%3.0%3.5%4.0%4.5%5.0%5.5%

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

Crude Mortality (Trust)

0.5%

5.5%

10.5%

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

Crude Mortality (BDGH)

1.0%2.0%3.0%4.0%5.0%6.0%

Jul/

19

Au

g/1

9

Sep

/19

Oct

/19

No

v/1

9

Dec

/19

Jan

/20

Feb

/20

Mar

/20

Ap

r/2

0

May

/20

Jun

/20

Crude Mortality (DRI)

Title People & Organisational Development update

Report to Board of Directors Date July 2020

Author Karen Barnard, Director of People & OD


Decision

Assurance

Information


The report this month provides an update on the work being undertaken in relation to Equality, Diversity and Inclusion, an update from the Freedom to Speak Up Guardian and updated information related to absence and swabbing data. A verbal update will be provided to the Board in relation to the number of risk assessments completed. Members will recall receiving information regarding the risk assessment process last month. Trusts are now being required to submit this data centrally to NHSI/E with the first window of reporting closing on 17 July 2020. With regard to the engagement of BAME colleagues we intend to work with senior BAME colleagues to explore how best to involve a wider group of BAME colleagues to understand the issues affecting them within the Trust. At the heart of our leadership development programme going forward will be the development of an inclusive culture demonstrating that We Care. Two particular initiatives include reciprocal mentoring and the Moving Forward programme. We are recruiting an EDI lead to ensure that we have the lived experience to draw on in this work moving forward. The P&OD team is reviewing its offer to the organisation and this will be shared with the Executive Team for discussion shortly.

With regard to the report from the Freedom to Speak Up Guardian it is pleasing to note that we benchmark favourably in relation to the national FTSU index and the improvements we have made. The report provides the recent number of concerns raised (10 in quarter 4 2019/20 and 12 in quarter 1 2020/21).

An update is provided in terms of the absence figures up to May 2020. Data is also provided in relation to the number of staff being swabbed for Covid 19 and the number of positive cases. Numbers have reduced significantly with no positive cases being recorded since 4 July (up to 14 July when the report was run).


Do members of the Board feel assured that appropriate actions are taking place to support our staff during the pandemic period and into the recovery period?


People – As a Teaching Hospital we are committed to continuously developing the skills, innovation and leadership of our staff to provide high quality, efficient and effective care

D5


F&P 8 Inability to recruit right staff and have staff with right skills leading to: i) Increase in temporary expenditure ii) Inability to meet FYFV and Trust strategy iii) Inability to provide viable services.

Q&E 6 Failure to improve staff morale leading to:

i) Recruitment and retention issues ii) Impact on reputation iii) Increased staff sickness levels


Members are asked to receive this report.

Equality, Diversity and Inclusion Recent events have brought to the forefront of our attention the important contribution all of our colleagues make regardless of their gender, ethnicity, disability etc. Our staff survey results earlier this year continued to show disproportionate views of both BAME and disabled colleagues despite our overall improvements. Evidence during the covid 19 pandemic has indicated that there is a disproportionate impact of covid on BAME colleagues together with males. The risk assessment process developed within the Trust has as its basis the identification whether colleagues have one or more risk factors (gender, age, ethnicity, certain comorbidities and pregnancy) followed by a more detailed risk assessment to identify the level of risk for an individual (low, moderate, high) and therefore where they are safe to work and what level of PPE is required. Public Health England published a review into the surveillance data and found that the impact of Covid 19 has replicated existing health inequalities and in some cases exacerbated them. www.nhsconfed.org/resources/2020/06/phe-review-disparities-in-risk-and-outcomes-of-covid19 Based on this evidence it has been important to ensure that staff with higher risk levels undertake a risk assessment discussion with their line manager to ensure they feel protected in their ongoing work within the Trust. On occasions these risk assessments have resulted in decisions that colleagues should be shielding or undertaking different roles. NHS Improvement/England’s Chief People Officer launched a comprehensive programme to address the issue of impact of Covid 19 on our BAME colleagues with 5 streams of work – protection of staff, rehab and recovery, communications, staff networks and representation in decision making underpinned by three principles of protecting, supporting and engaging our staff. Whilst the Trust’s EDI forum has been developing and there has been particular interest to develop an LGBTQ+ staff network it has proved more difficult to instigate a BAME staff network. We therefore intend to initiate conversations using QI methodology in order to demonstrate our commitment to take action to improve the working lives of our BAME colleagues – evidence is that improving the experience of BAME colleagues will result in overall improvements to everyone’s experience. IO will also be making direct contact with our senior BAME colleagues about how they might support this work. At the heart of our approach going forward will be an Inclusive Culture demonstrating that We Care. Specific initiatives being finalised include the introduction of reciprocal mentoring, access to the Moving Forward (Stepping Up) development programme, leading for inclusivity as a bedrock of our leadership development programme and exploration of the introduction of Associate NED roles as a means of securing diverse leadership. The Workforce Race and Disability Equality Standards are due to be reported by the end of August and therefore a report will come to the August Board of Directors meeting in advance of the data being published. The next section is a reminder of our Gender Pay Gap, WRES and WDES data from last year and the planned actions.

Gender pay gap Summary

Although males make up a lower proportion of the total workforce at DBTH (18%), just under half of them (46.2%) are paid in the top earnings quartile.

There is a larger % gender pay gap between Medical and Dental staff 15.7% compared to consultants at 8.2%.

Males make up the vast majority of recipients of Clinical Excellence Awards (96 of 120 awarded). These bonuses are received by 8.3% of all males employed compared to 0.44% of women. The bonus payments will have the impact of inflating the average salaries. All the

http://www.nhsconfed.org/resources/2020/06/phe-review-disparities-in-risk-and-outcomes-of-covid19

figures are based on net salaries and so many are further depressed by salary sacrifice schemes which, particularly in the case of childcare, tend to be absorbed by females.

There has been a small narrowing of the gender pay gap between male and female average hourly rate of -0.96 when comparing March 18 to March 19.

There has been little movement in the mean and median rates between the reporting period 18 and 19.

When comparing 2018 to 2019 bonus payments in the gender pay gap is 10.45. In 2019 16 more males and 2 more females were in receipt of bonus payments compared to 2018.

GENDER PAY GAP ACTION PLAN

Through our approaches to agile/flexible working practices we wish to ensure females are encouraged and supported to apply to become Consultants and senior leaders.

Through our leadership development programmes, coaching and mentoring schemes we want to inspire and encourage females to apply and take up senior leadership roles.

We are actively participating in the national work reviewing reasons for disparity in the achievement of Clinical Excellence Awards.

We will actively review our full staff survey results and staff engagement outputs to share ideas and feedback from women employed by the Trust to shape and inform our plans, strategies and policies.

Workforce Race Equality Standard/Workforce Disability Equality Standard

Key messages for the Organisation:

There are gaps in the data we hold regarding Ethnicity of staff (4.5% unknown) and Disability

status (23% not known)

There has been a significant deterioration in the likelihood of BAME staff being appointed from

shortlisting (2.44 from 1.06)

Disabled applicants have a 44% chance of successful appointment from shortlisting (20 shortlisted

applicants in total)

The likelihood of BAME staff being in a formal disciplinary process is 0.74 as compared to white

staff – this is almost within the ‘normal’ range of 0.8-1.25

Consultant and Non Consultant career grade doctors have a much higher representation of BAME

staff than other grades of staff.

Disabled staff are 1.48 times more likely to be in formal capability process compared to non-

disabled staff

Both disabled and BAME staff experience more bullying, harassment and abuse than white and

non-disabled staff – there has been a rise since 2018

37.9% of disabled staff say that they have felt pressure from their manager to come to work,

despite not feeling well enough to perform their duties as opposed to 29.7% of non-disabled staff.

32.2% of disabled staff reported that they are satisfied with the extent to which their organisation

values their work as opposed to 45.1% non-disabled staff.

63.8% of disabled reported that their employer has made adequate adjustment(s) to enable them

to carry out their work.

The summary findings from the WRES and WDES suggest that there is further work in respect of data

capture, the recruitment of disabled and ethnically diverse staff and improving their overall

experience and inclusivity and support within our organisation. The actions identified below are

critical in our journey to a more tolerant, inclusive culture where civility and respect is the ‘way we do

business’.

Actions to address areas raised:

The Staff Equality, Diversity and Inclusion Group meets quarterly which is an inclusive staff

network to engage with all staff and address issues

Unconscious Bias training available for all staff

Educate managers in supporting staff with disabilities and making adequate adjustments

(understand what the data is telling us)

Living the DBTH values and behaviours training

Inclusive and Compassionate Leadership embedded in all leadership programmes

Staff engagement forums to listen and act on staff feedback and experiences

Implementation of actions plans in response to Staff Survey results

Visible organisational support for Doncaster Pride and have an active role in engaging with the

local community

The Rainbow Badge initiative gives healthcare staff a way to show that their place of work offers

open, non-judgemental and inclusive care for all who identify as LGBT+ (lesbian, gay, bisexual,

transgender, the + simply means inclusive of all identities, regardless of how people define

themselves). Rainbow Badge initiative to train and educate staff around appreciating diversity

and LGBT+, this will be launched in September

Project Choice is a supported internship programme for people with learning disabilities,

difficulties or autism (LDDA). NHS Health Education England, support NHS Trusts to deliver the

programme nationally. The focus is ‘work readiness’ and matching skills to employment. The

project teams ensure there are placements across the Trusts looking specifically at entry-level

jobs to make sure the right learner is allocated to this role. They also work closely with managers

to confirm that tasks are clearly understood.

Develop role models at all levels within the organisation for BAME and disabled staff

Explore how to reach out into the wider community to engage and attract people from diverse

backgrounds, cultures and with disabilities into our organisation

Explore how we ensure that we attract and recruit staff, volunteers and governors from diverse

backgrounds, cultures and groups into our organisation and how we can create opportunities for

future or potential employees to engage with our organisation with a view to proactively

generating interest when future vacancies arise

As we now move into the recovery phase bite sized training sessions are being introduced over the next few weeks: Diversity and Inclusion, Looking after yourself, Speaking Candidly and Compassionately, Looking out for your team, Creating safe spaces, Values and Behaviours, Diversity and inclusion The leadership programmes Develop, Belong and Thrive are due to recommence in September on a virtual platform. Governors recently attended an EDI briefing session as part of their development programme.

Freedom to Speak Up update In November 2019, the Board of Directors approved DBTH’s first Freedom to Speak Up strategy. This strategy brought together a partnership approach to enable widespread culture change in relation to freedom to speak up practices. The strategy focused on key themes including roles and responsibilities, education and engagement, understanding data, monitoring and performance and key priorities for action. Recently the NGO published the 2020 FTSU Index report. As previously reported to the board overall the Trust saw an increase in the FTSU Index rating, moving from 76% to 78.7%. Members of the Board will recall the report they received at the March Board of Directors meeting detailing our internal results including comparisons between Divisions and Directorates. We have now received comparator data across organisational sectors and regionally. National average 2015 2016 2017 2018 2019 75.5% 76.7% 76.8% 78.1% 78.7% As can be seen we now perform in line with the national average and are slightly above the average for NE and Yorkshire at 78.5%. Across the ICS we are the most improved acute Trust with 2 Trusts having deteriorated and at a 2.7% increase the Trust was just outside of the top ten most improved Trusts (improvements ranging from 2.8% to 5.4%). The FTSU index also ranges quite significantly by type of Trust with Community Trusts having the highest score (and the biggest improvement). The average for Acute Trusts was 77.9% against which we benchmark favourably. As we are all aware many aspects of the Freedom to Speak up strategic work have been placed on hold due to the nature and impact of the COVID-19 Pandemic. However, it is important to acknowledge that it has never been more important to uphold the principles of the FTSU ethos and ensure staff feel they have the opportunity to be heard and that they feel supported when they do speak up. The key areas affected by the pausing of some FTSU services are the implementation of the FTSU education and support plan and the Introduction and training of FTSU Champions. These areas will need to be reviewed and built into a revised plan that takes account of the wider staff needs post COVID-19. This revised plan will also need to allow for more responsive work in conjunction with the Leadership & Organisational Development team as part of the COVID-19 restorative phase. This work will include “Story telling” to enable staff to understand and appreciate the different impact that the pandemic has had on many staff regardless of their roles and responsibilities. This will also encourage confidence in holding transparent discussions. Even though some proactive measures are paused, access to the FTSU Guardian, continues to grow with ever increasing figures each month. These range from individual cases to multiple cases and cover a wide range of themes. The trend in these themes in the last few weeks is beginning to indicate a change in staff resilience. This was to be expected as the pandemic continues. Some of these cases are coming through from clusters of staff and require a different approach to resolving the issues identified. In quarter 4 of 2019/20 there were 10 cases involving 15 individuals. Within quarter 1 of 2020/21 12 cases have been raised 8 being individuals and 4 being cases involving multiple people. It is essential to continue to learn from both our internal cases and the national case reviews from the NGO. Internally we need to commit to action where key issues are raised, using the FTSU opportunities to engage with teams and leaders to explore the culture of their departments and how improvements

could be made. It is also best practice to consider the ongoing case reviews conducted by the NGO. The latest review poses 3 key matters for the Trust to consider. These are in relation to the use of the “National Integrated Speak up Policy”, feedback to and from those who speak up and capacity for FTSU services. It is important to consider using the recommendations of these reviews as an additional benchmarking guide for the completion of our annual FTSU self-assessment. Due to the impact of COVID -19 and its impact on timescales, we need to consider the potential to conduct and present the Annual Self-Assessment as part of the FTSU Annual Report to Board in November. Sickness absence

Data in relation to June will be considered at the Finance and Performance Committee meeting later in the month.

Absence

Occurrences

Days Lost % Rate Absence

Occurrences


Occurrences


Occurrences

Days Lost % Rate

Doncaster & Bassetlaw Teaching Hospitals NHS FT 848.00 4829.54 2.78% 1327.00 10727.28 6.37% 1031.00 14032.73 7.93% 2315.00 29589.56 5.70%

272 COVID-19 1.00 3.00 1.23% 5.00 49.00 1.76% 5.00 52.00 1.72%

272 Chief Executive Directorate 0.00 0.00 0.00% 1.00 12.00 2.20% 0.00 0.00 0.00% 1.00 12.00 0.70%

272 Children & Families Division 104.00 558.39 3.00% 143.00 1113.55 6.13% 80.00 1273.47 6.78% 229.00 2945.41 5.30%

272 Clinical Specialties Division 208.00 1187.00 2.63% 278.00 2319.43 5.33% 243.00 3300.52 7.35% 532.00 6806.96 5.10%

272 Directorate Of Strategy & Improvement 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00%

272 Doncaster & Bassetlaw HC Services Ltd 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00%

272 Education and Research Directorate 14.00 90.09 4.15% 16.00 149.93 7.27% 5.00 17.00 0.80% 25.00 257.03 4.04%

272 Estates & Facilities 88.00 434.97 3.09% 119.00 968.23 7.02% 102.00 1283.71 8.95% 211.00 2686.90 6.37%

272 Executive Team Board 2.00 16.00 0.47% 6.00 32.20 0.99% 6.00 61.20 1.82% 9.00 109.40 1.09%

272 Finance & Healthcare Contracting Directorate 0.00 0.00 0.00% 0.00 0.00 0.00% 2.00 34.00 0.79% 2.00 34.00 0.27%

272 IT Information & Telecoms Directorate 12.00 87.12 3.95% 6.00 38.67 1.77% 1.00 2.00 0.09% 16.00 127.79 1.92%

272 Medical Director Directorate 0.00 0.00 0.00% 0.00 0.00 0.00% 1.00 3.41 8.14% 1.00 3.41 2.74%

272 Medicine Division 256.00 1509.13 3.33% 474.00 3855.76 8.81% 311.00 4270.90 9.36% 761.00 9635.79 7.15%

272 Nursing Services Directorate 9.00 64.80 3.12% 8.00 56.25 2.76% 9.00 124.55 5.98% 19.00 245.60 3.96%

272 People & Organisational Directorate 6.00 51.05 2.74% 1.00 1.60 0.09% 1.00 3.84 0.20% 7.00 56.49 1.00%

272 Performance Directorate 25.00 124.49 2.20% 33.00 192.89 3.57% 27.00 299.56 5.36% 63.00 616.94 3.71%

272 Surgery and Cancer Division 128.00 706.49 2.53% 245.00 1983.78 7.38% 239.00 3309.57 11.93% 440.00 5999.84 7.27%

Absence

Occurrences


Occurrences


Occurrences


Occurrences

Days Lost % Rate


272 COVID-19 0.00 0.00 0.00% 2.00 15.80 0.57% 2.00 15.80 0.52%




272 Directorate Of Strategy & Improvement 1.00 2.00 0.86% 0.00 0.00 0.00% 0.00 0.00 0.00% 1.00 2.00 0.29%

272 Doncaster & Bassetlaw HC Services Ltd 1.00 19.08 8.02% 1.00 14.72 6.26% 0.00 0.00 0.00% 1.00 33.80 4.72%






272 Medical Director Directorate 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00 0.00% 0.00 0.00%






Absence

Occurrences


Occurrences


Occurrences


Occurrences

Days Lost % Rate


272 COVID-19 1.00 3.00 1.23% 7.00 64.80 2.33% 7.00 67.80 2.24%




272 Directorate Of Strategy & Improvement 1.00 2.00 0.86% 0.00 0.00 0.00% 0.00 0.00 0.00% 1.00 2.00 0.29%

272 Doncaster & Bassetlaw HC Services Ltd 1.00 19.08 8.02% 1.00 14.72 6.26% 0.00 0.00 0.00% 1.00 33.80 4.72%






272 Medical Director Directorate 0.00 0.00 0.00% 0.00 0.00 0.00% 1.00 3.41 8.14% 1.00 3.41 2.74%






Mar-20

COVID-19 COVID-19

Apr-20

COVID-19

Cumulative

COVID-19

May-20

NON COVID-19 NON COVID-19 NON COVID-19

Mar-20 Apr-20 Cumulative

NON COVID-19

May-20

All Absence All Absence All Absence

Mar-20 Apr-20 Cumulative

All Absence

May-20

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20

Absence Graph

COVID-19 Non- COVID-19 All Absence

Total number of Covid 19 swabbing tests

As can be seen there has been a significant reduction in the number of symptomatic staff requiring testing with no positive test results since the 4 July 2020.

Positive COVID 19 Swabbing Test ResultsData Extracted from Absence Management Database 14th July 2020

Count of PKAbsenceID Column Labels

Organisation Level 2020/03 2020/04 2020/05 2020/06 2020/07 Grand Total

17 22 11 2 52

272 Children & Families Division 3 5 5 1 14

272 Clinical Specialties Division 12 18 34 2 66

272 COVID-19 1 1 2

272 Education and Research Directorate 2 2 4

272 Estates & Facilities 3 12 20 5 40

272 Executive Team Board 2 3 2 1 8

272 Finance & Healthcare Contracting Directorate 1 1 2

272 IT Information & Telecoms Directorate 1 1

272 Medicine Division 14 95 47 20 2 178

272 Nursing Services Directorate 2 2

272 Performance Directorate 1 7 8

272 Surgery and Cancer Division 13 38 80 18 3 152

Grand Total 68 198 209 49 5 529

Ethnic Origin of Members of Staff with Positive COVID 19 Swabbing Test ResultsData Extracted from Absence Management Database 14th July 2020

Count of PKAbsenceID Column Labels

Ethnic Origin 2020/03 2020/04 2020/05 2020/06 2020/07 Grand Total

A White - British 32 142 169 41 5 389

18 23 14 2 57

H Asian or Asian British - Indian 6 6 9 21

SC Filipino 7 2 1 10

C White - Any other White background 2 2 1 2 7

L Asian or Asian British - Any other Asian background 2 3 5

D Mixed - White & Black Caribbean 1 2 1 4

Z Not Stated 1 1 1 1 4

LK Asian Unspecified 1 2 1 4

N Black or Black British - African 1 1 1 1 4

E Mixed - White & Black African 2 1 3

PC Black Nigerian 1 1 2

F Mixed - White & Asian 1 1 2

C3 White Unspecified 2 2

S Any Other Ethnic Group 1 1 2

J Asian or Asian British - Pakistani 1 1 2

LA Asian Mixed 1 1 2

M Black or Black British - Caribbean 1 1

CP White Polish 1 1

B White - Irish 1 1

Unspecified 1 1

SE Other Specified 1 1

P Black or Black British - Any other Black background 1 1

G Mixed - Any other mixed background 1 1

LF Asian Tamil 1 1

K Asian or Asian British - Bangladeshi 1 1

Grand Total 68 198 209 49 5 529

Title Board Assurance Framework and Corporate Risk Register Update

Report to Board of Directors Date 21 July 2020

Author Fiona Dunn, Acting Deputy Director Quality & Governance


Decision X

Assurance

Information X

Executive summary containing key messages and issues The Board Assurance Framework and risk example attached is an updated draft from the original proposal agreed at the Baard of Directors in April 2020. The Board is asked to note that whilst the review is ongoing all risks associated with the BAF continue to be reviewed on DATIX. BOARD ASSURANCE FRAMEWORK – PURPOSE The Board Assurance Framework provides the Board of Directors with a record of the strategic risks relating to the delivery of its strategic objectives and the internal controls to prevent these risks from occurring. It is a means of focusing the attention of the Board on the management of its strategic risks and a record of assurances in place. BOARD ASSURANCE FRAMEWORK - REFRESH The Board Assurance Framework refresh includes alignment to the Trust’s True North objectives, strategic risks and to formalise Board ownership. Information on the plan to refresh of the Board Assurance Framework was provided to the Board of Directors’ meeting on 29 October 2019. A Board workshop was planned for April 2020 however this was cancelled due to the current COVID19 Pandemic and vacancy of Company Secretary. This paper therefore serves to give an update as to the next steps in the BAF and CRR review process following an initial workshop identifying the strategic risks linked to the Trusts True North objectives that would stop the Trust from achieving its vision to be the safest Trust in England.

G1

Therefore a proposed outline plan has been summarised in the paper below including examples of suggested layout in the appendices.


Does the implementation plan address the future BAF & CRR reporting requirements?


The attached Board Assurance Framework template captures and reports on the Strategic Risks to the achievement of the Trust’s Strategic objectives.

Link to Board Assurance Framework

The attachment is the draft version of the proposed Board Assurance Framework & CRR

Link to Risks on Corporate Risk Register / New Risks

The report highlights all Strategic Risks to the achievement of the Trust Strategic objectives.

Recommendations

The Board is asked to review and approve the attached BAF and CRR update plan

Board Assurance Framework (BAF) Review and Refresh Update, including Corporate risk register.

The Board Assurance Framework attached is an updated draft from the original proposal agreed at the Baard of Directors in April 2020. The Board is asked to note that whilst the review is ongoing all risks associated with the BAF continue to be reviewed on DATIX. BOARD ASSURANCE FRAMEWORK – PURPOSE The Board Assurance Framework provides the Board of Directors with a record of the strategic risks relating to the delivery of its strategic objectives and the internal controls to prevent these risks from occurring. It is a means of focusing the attention of the Board on the management of its strategic risks and a record of assurances in place. BOARD ASSURANCE FRAMEWORK - REFRESH The Board Assurance Framework is currently being refreshed both in presentation and content to ensure alignment to the Trust’s True North objectives, strategic risks and to formalise Board ownership. Information on the plan to refresh of the Board Assurance Framework was provided to the Board of Directors’ meeting on 29 October 2019. A Board workshop was planned for April 2020 however this was cancelled due to the current COVID19 Pandemic and vacancy of Company Secretary. Towards the end of April 2020 this refresh was reinstated and a draft proposal of the new BAF layout and report was presented to the Board of Directors for approval of “proof of concept” and also included a draft report using the new corporate risk layout using the Trust’s strategic COVID risk management plan used as a worked example for Board discussion and approval. This was approved and an initial work shop was held with the Executive Team in July to start to identify the key strategic risks, particularly in light of changes post COVID, that would stop the Trust from achieving its vision to be the safest Trust in England. Identifying these true strategic risks for the BAF would then allow separation of many operational risks from the existing BAF which would then be included on the Corporate Risk Register (CRR) where appropriate. Ideally the BAF should not contain operational risks unless they pose a significant threat to the organisational objectives. It was recognised that a further session around gaining an understanding of the Trust’s risk appetite and tolerance would be useful to allow inclusion on to the new BAF template. Clearly the ultimate ideal aim of this BAF refresh is to utilise it as a tool to drive the future Board agenda. The Board is asked to note that this refresh is closely linked in with other work streams that are now being pursued:

Reinstatement of the Qi review of the Board processes that had stalled at the end of last year

The new pilot project of a digital Board Leadership programme current being facilitated by NHS Providers.

All work streams are closely linked and are designed to ultimately help in the drive of an effective Board. This paper therefore serves to give an update as to the next steps in the BAF and CRR review process. Therefore a proposed outline plan has been summarised below. UPDATE PLAN: An updated plan for the way forward to achieve this refresh and implementation of the new reporting and monitoring of the BAF and CRR is suggested in further section below. Step 1: BAF: Draft updated strategic risks identified New strategic risks for the Four True North strategic Aims identified.

True North 1 - Aim: o To provide outstanding care and improve patient experience

Breakthrough Objective:

Achieve measurable improvements in our quality standards & patient experience Strategic risks:

Risk of patient harm if we do not listen to feedback and fail to learn

Risk of not using available quality assurance data to best effect in order to identify areas to improve or manage patient care.

Risk to safety and poor patient experience as a result of failure to improve the estate and infrastructure.

True North 2 - Aim: o Everybody knows their role in achieving the vision

Breakthrough Objective: o Achieve a 5% improvement in our staff having a meaningful appraisal linked to our

vision Strategic risks:

o Risk of disconnect between ward and Board leading to negative impact on staff morale and patient care

o Failure of people across the Trust to meet the need for rapid innovation and change

True North 3 - Aim: o Feedback from staff and learners in top 10% in UK

Breakthrough Objective: o The Trust is within the top 25% for staff & learner feedback

Strategic risks: o Failure to provide appropriate learner environment that meets the needs of staff and

patients o Failure to enable staff in self actualization o Failure to deliver an organizational development strategy that allows implementation of

trust values of people across the Trust to meet the need for rapid innovation and change

True North 4 - Aim: o In recurrent surplus to invest in improving patient care

Breakthrough Objective: o Every team achieves their financial plan for the year

Strategic risks: o The varied degree of commercial awareness within the organization and its impact on

the effective financial business of the Trust o Uncertainty of future financial planning and business expectations (post COVID BAU

effect)

Step2: Completion of BAF template

Identify Controls and assurance (mitigation & evidence of making impact)

Understand impact of risk and rationale for rating

Agree risk appetite for this risk (further workshop to be organised for team)

Understand any operational risks that may impact and cross reference. Step 3: Completion of Front summary page and development of links to subcommittee & CRR dashboards

Front page to include high level Heat map of risk and overall movement of change for each strategic risk (risk reference only – Level 1)

Heat map of risks linked to BAF and on CRR to feed next level summary dashboard (Level 2) identifying risks at description level with risk movement. This dashboard to be used for sub Committee high level oversight.

Step 4: Completion of summary risk description dashboard (as above) & detail risk summary

Design and population of risks to new CRR template dashboard summary (level 2)

Design and population of risk detail template (level 3) to link to level 2 dashboard.

Step 5. Review of Risks on CRR.

Complete review and refresh of operational risks on Corporate risk register Step 6 Review of Risk Management Policy Further operational steps:

Complete review and rationalization of risks on DATIX post COVID impact

Implementation of a refreshed risk management training and oversight programme.

Board Level 1 Heat Map - BAF

Sub –Committee Level 2 dashboard – CRR summary

Sub –Committee Level 3 - Risk detail template

Level 4 - CRR DATIX dashboard output

Increase

in risk d

etail

Appendix 1: Updated DRAFT BAF framework with new strategic risks o Level 1 summary Page 1 o Detailed BAF Risks Pages 2-6

Appendix 2: EXAMPLE Strategic risk dash board detail (Level 2 ) Appendix 3: EXAMPLE Risk Detail template (Level 3 ) Appendix 4: CURRENT CRR DATIX dashboard output (Level 4)

Board Assurance Framework – Risks to achievement of Strategic Aims OUR VISION : To be the safest trust in England, outstanding in all that we do

True North Strategic Aim 1 True North Strategic Aim 2 True North Strategic Aim 3 True North Strategic Aim 4

To provide outstanding care and improve patient experience

Everybody knows their role in achieving the vision

Feedback from staff and learners in top 10% in UK

In recurrent surplus to invest in improving patient care.

Breakthrough Objective: Achieve measurable improvements in our quality standards & patient experience

Breakthrough Objective: Achieve a 5% improvement in our staff having a meaningful appraisal linked to our vision

Breakthrough Objective: The Trust is within the top 25% for staff & learner feedback

Breakthrough Objective: Every team achieves their financial plan for the year

Current Risk Level Summary

This is a draft example utilizing the new addition to CRR of the Trust plans to COVID19 pandemic. The entire current BAF based on the 5 P’s was last reviewed in 28/2/2020 reviewed alongside the corporate risk register. This new format has been aligned to the True North Objectives THE FOLLOWING TEXT IN ITALICS IS EXAMPLE TEXT FOR NOW & WILL GIVE A SUMMARY OF THE BAF CHANGES & ASSURANCE NEEDED.(THE DATA IN THE TABLES BELOW IS THE TRUST ACTUAL DATA………… The key risks to outstanding patient experience remains workforce, the key risk to financial sustainability is underperformance against income plan, cost improvement plan and the underlying financial deficit and the key risk to operational excellence remains RTT 18 and the 52 week breach position . Additional assurance continues to be sought internally and the evidence of this is referenced in the respective director reports to the January trust board . PLEASE NOTE THAT THIS IS THE NEW PROPSED BAF SUMARY WHICH INDICATES THE START TO ALIGN NEW STAREGIC RISKS TO THE TRUE NORTH OBJECTIVES.

F&P Dashboard QEC Dashboard

Heat Map of individual SA risks (2019 -2020 BAF)

No Harm

1 Minor

2 Moderate

3 Major

4 Catastrophic

5

Rare 1

Unlikely 2

2

Q&E8, Q&E3

1 Q&E4

2 A&R1, F&P10

2 F&P18, Q&E10

Possible 3

1

Q&E7

3 Q&E5, Q&E2,

F&P14

4 Q&E11, F&P5, F&P9, Q&E6

2 F&P11, F&P19

Likely 4

2

F&P12, F&P15

7 Q&E9, F&P1, F&P3, F&P6,

F&P13, F&P8, Q&E1,

4 F&P4,

F&P20,Q&E12, F&P12,

Certain 5

COVID 2472

Overall change per Strategic Aim (SA)

Q1 2020/21

Q2

2020/21

Q3

2020/21

Q4

2019/20

No of risks/SA

Change

SA1 new

SA2 new

SA3 new

SA4 new

COVID several

F&P1 –

Level 1 info

Extreme

risk

Hyperlink to

F&P Level 2

Dashboard

Hyperlink to

CRR Level 4

info risk

Appendix%202%20level%202.pdf

Appendix%204%20Level%204%20CRR%20June%202020.pdf

Appendix%203%20Level%203%20CRR%20June%202020.pdf

COVID19 Major incident

Risk Owner: Trust Board Committee: Q&E, F&P, COVID19 - Addition to SA1 Date last reviewed : 03 June 2020

Strategic Objective To deliver safe & effective service to patients and staff during a World-wide pandemic of Coronavirus which will infect the population of Doncaster and Bassetlaw (including staff) resulting in reduced staffing, increased workload due to COVID-19 and shortage of beds, ventilators.

Risk Appetite: The Trust has a high appetite for risks that impact on patients and staff during a worldwide pandemic.

Initial Risk Rating Current Risk Rating Target Risk Rating

5(C) x 5(L) = 25 extr 5(C) x 4(L) = 20 extr 3(C) x 3(L) = 9 low

Risks:

Impact on safety of patients

Impact on patient experience

Potential delays to treatment

Impact on patient harm

Impact on reputation

Adverse impact on Trust's financial position

Impact on staff & Inability to provide viable service

Rationale for risk current score:

Previous unknown pandemic: o Patients, staffing, resources etc

Data modelling predictions based on “best” guess principles from previous flu epidemics

Unknown timescale of outbreak

Future risks:

Unknown if second phase outbreak/pandemic

Opportunities:

Change in practices, new ways of working by

Controls / assurance (mitigation & evidence of making impact):

Pandemic incident management plan implemented.

Governance & Performance Management and Accountability Framework

Gold & Silver Command pandemic management structure (Strategic & Tactical) in place 24/7

Individual work streams identified to deliver a critical pathway analysis

Regular data modeling and analysis of trends and action to address shortfalls.

Continued liaison with leads of operational work streams to identify risks to delivery.

National reporting & monitoring eg PHE, NHSI/E, WHO etc

NEW – Summary of Post Implementation Review undertaken

Individual work streams identified to plan:

Temporary Site Reconfiguration

Reduction in Planned Care – Outpatients & Surgery

Vulnerable Patients

Emergency Pathways (Adult)

Increasing Critical Care Capacity

Consolidation of maternity and Delivery of Children’s Services

Trauma Consolidation

Diagnostics and Pharmacy

Care of Deceased Patient

People Planning, Education and Research

Ethical Decision Making

Infection Control and Prevention Support

IT and Digital, Estates, Finance & Procurement

Partnerships, Communication and Engagement

Recovery Phase

Assurance (evidence of making an impact):

See evidence of plans in link (Overall Plan)

Risk log (see link)

High Level COVID Narrative

Post implementation review

Gaps in controls / assurance (actions to achieve target risk score):

Overall delivery of work streams pandemic plans – link CRR Risk ID2472 on DATIX

OUR VISION : To be the safest trust in England, outstanding in all that we do

True North Strategic Aim 1 – To provide outstanding care & improve patient experience.

Risk Owner: Trust Board Committee: Q&E, F&P,

People, Partners, Performance, Patients, Prevention

Date last reviewed : June 2020

Strategic Objective To provide outstanding care and improve patient experience Breakthrough Objective Achieve measurable improvements in our quality standards & patient experience

Risk Appetite: The Trust has a low appetite for risks TBC



Risks:

Risk of patient harm if we do not listen to feedback and fail to learn

Risk of not using available quality assurance data to best effect in order to identify areas to improve or manage patient care.

Risk to safety and poor patient experience as a result of failure to improve the estate and infrastructure.

Rationale for risk current score: Impact:

Impact on performance

Impact on Trust reputation

Impact on safety of patients

Impact on patient experience

Potential delays to treatment

Possible Regulatory action

Future risks:

Risk references: To be defined in detail

Opportunities:

Change in practices, new ways of working


Comments:

Need to ensure Trust Values are effective Assurance (evidence of making an impact):


Level 2 info to

relevant risks

on CRR eg F&P

or QEC

Appendix%202%20level%202.pdf


True North Strategic Aim 2 – Everybody knows their role in achieving the vision

Risk Owner: Trust Board Committee: Q&E, F&P, People, Partners, Performance, Patients Date last reviewed : June 2020

Strategic Objective Everybody knows their role in achieving the vision Breakthrough Objective Achieve a 5% improvement in our staff having a meaningful appraisal linked to our vision

Risk Appetite: The Trust has a low appetite for risks TBC



Risks:

Risk of disconnect between ward and Board leading to negative impact on staff morale and patient care

Failure of people across the Trust to meet the need for rapid innovation and change




Impact on safety of patients & experience


Recruitment and retention issues

Increased staff sickness levels

Deterioration in management-staff relationships

Future risks:


Opportunities:


Increase skill set learning


Comments: Considerations – capacity & capability of workforce




True North Strategic Aim 3 – Feedback from staff and learners in top 10% in UK

Risk Owner: Trust Board Committee: Q&E, F&P, People, Partners, Performance,Patients Date last reviewed : June 2020

Strategic Objective Feedback from staff and learners in top 10% in UK Breakthrough Objective The Trust is within the top 25% for staff & learner feedback

Risk Appetite: The Trust has a low appetite for risks TBC Initial Risk Rating

Current Risk Rating Target Risk Rating


Risks:

Failure to provide appropriate learner environment that meets the needs of staff and patients

Failure to enable staff in self actualization

Failure to deliver an organizational development strategy that allows implementation of trust values





Recruitment and retention issues

Increased staff sickness levels

Deterioration in management-staff relationships

Financial impact for the Trust

Future risks:


Opportunities:


Future new build


Comments:

Requires good OD plan “fit for purpose”

Staff survey impact

Need good data

Recruitment & retention




True North Strategic Aim 4 – In recurrent surplus to invest in improving patient care

Risk Owner: Trust Board Committee: Q&E, F&P, People, Partners, Performance, Patients Date last reviewed : June 2020

Strategic Objective In recurrent surplus to invest in improving patient care Breakthrough Objective Every team achieves their financial plan for the year

Risk Appetite: The Trust has a low appetite for risks TBC Initial Risk Rating

Current Risk Rating Target Risk Rating


Risks:

The varied degree of commercial awareness within the organization and its impact on the effective financial business of the Trust

Uncertainty of future financial planning and business expectations (post COVID BAU effect)






Financial impact for the Trust

Reduction in hospital activity and subsequent income

Future risks:

F&P1


Opportunities:



Comments:

Require agreed and achievable workforce plans based on evidence

Identification of “new normal”



Appendix 2 (Level 2 detail ) Corporate Risk Register linked to BAF Summary June 2020

ID RefDivision /

Corporate(s)Title Risk Owner Risk level (current)

Rating

(current)

Risk level

(Target)Last Reviewed Review date

Movement since

last review

2472 COVID1

Directorate of

Nursing, Midwifery

and Allied Health

Professionals

COVID-19 Purdue, David Extreme Risk 25 High Risk Jun-20 01/07/2020

11 F&P1Directorate of

Finance

Failure to achieve compliance with financial performance and

achieve financial planSargeant, Jonathan Extreme Risk 16 High Risk Jun-20 01/08/2020

7 F&P6Chief Operating

Officer

Failure to achieve compliance with performance and delivery

aspects of the SOF, CQC and other regulatory stanadrdsJoyce, Rebecca Extreme Risk 16 High Risk May-20 01/06/2020

1244 F&P3Directorate of

FinanceFailure to deliver Cost Improvement Plans in this financial year Sargeant, Jonathan Extreme Risk 16

Moderate

RiskMay-20 01/06/2020

12 F&P4 Estates and FacilitiesFailure to ensure that estates infrastructure is adequately

maintained and upgraded in line with current legislationEdmondson-Jones, Kirsty Extreme Risk 20 High Risk May-20 22/06/2020

1410 F&P11Information

TechnologyFailure to protect against cyber attack Anderson, Ken Extreme Risk 15

Moderate

RiskMay-20 01/06/2020

2349 ?Chief Operating

OfficerFailure to specifically achieve RTT 92% standard Joyce, Rebecca Extreme Risk 15

Moderate

RiskMay-20 01/06/2020

16 F&P8 Directorate of P&ODInability to recruit right staff and ensure staff have the right skills to

meet operational needsBarnard, Karen Extreme Risk 16 High Risk May-20 01/06/2020

2426Information

TechnologyMultiple software systems end-of-support Linacre, David Extreme Risk 20 High Risk May-20 01/06/2020

2147 F&P21 Estates and Facilities REF 29 - Edge Protection DRI Loukes, Simon (Inactive User) Extreme Risk 15Moderate

RiskMay-20 01/06/2020

1807F&P20 /

Q&E12Estates and Facilities Risk of critical lift failure Edmondson-Jones, Kirsty Extreme Risk 20 High Risk May-20 01/06/2020

1412 F&P12 Estates and Facilities Risk of fire Edmondson-Jones, Kirsty Extreme Risk 20 High Risk May-20 25/06/2020

2144 F&P22 Estates and Facilities EFA/2018/005 - Assessment of Ligature Points Timms, Howard High Risk 12 Low Risk May-20 01/06/2020

2148 F&P23 Estates and Facilities REF 31 - Unable to Test Fire Dampers - DRI East Ward Block Timms, Howard High Risk 12Moderate

RiskMay-20 25/06/2020

F&P1 –

Hyperlink to

Level 3 risk

detail

Appendix 3 Level 3 CRR June 2020.pdf

Appendix 3 Level 3 - Risk Details

Risk ID & Title

Cons = 4 1 2 3 4 5 6 8 9 10 12 15 16 20 25

Like = 4 target current initial

Very Low Risk Low Risk Medium Risk High Risk Extreme Risk

Exec Lead : Jon Sargeant

Last reviewed : June 2020

F&P1 (11)

Failure to achieve compliance

with financial performance

and achieve financial plan

Risk Description

16

Committee reviewed at : F&P (date)

Failure to achieve compliance with financial performance and achieve financial plan leading to :

(i) Adverse impact on Trust's financial position

(ii) Adverse impact on operational performance

(iii) Impact on reputation

(iv) Regulatory action

(i) Project groups established

and cases being brought to

Board

(ii) Plan to address the

unidentified CIP and

workforce (ongoing)

(iv)Performance Assurance

Framwork.

(v) Deep Dives undertaken at

F&P

(vi) Appointment of clear

strategic lead at Executive

Level and use of Monitor

Toolkit to assess strategic

position

Controls

(i) Achievement of strategic

projects

(ii)Lack of clear clincal strategy

from the ICS

(iv) Unidentified CIP

(v) Workforce Plans

(vi) Demand and capacity

planning

(vii) Lack of clear clinical

strategy from ICS

Gaps in Assurance

(i) Exceeded control total in 2018/19

(ii) Production of 2019/20 budget

(iii) Unqualified opinion on 2017/18 accounts

(vi) Accounts submitted to NHSI by deadline

(v) Financial plans submitted to NHSI

(vi) Board approval of budgets

(vii) Budget setting approved by Finance and Performance Committee

(viii) Minutes of accountability and NHSI meetings

(ix) External Audit review of financial performance (within Annual

Accounts work)

(x) Regular finance reports to F&P

(xi) Good performance over the last quarter

(xiii) Significant assurance audit with limited number of improvements

on core financial systems

(xiv) External audit 2018/19

(xv) Efficiency Director and team recruited

(xvi) Financal performance regime implemented

(xvii) Regulator standing down fortnightly reporting

(xviii) Regulator standing down finance review meetings with Chief

Finance Officer

Assurance

i) Business and budget planning processes.

(ii) Financial governance policies and procedures.

(iii) Monthly monitoring of financial performance.

(iv) Data analysis of trends and action to address deterioration.

(v) Continued liaison with budget holders to identify risks to

delivery.

(vi) Detailed monitoring by Finance and Performance Committee.

(vii) Budgets set on recurrent outturn resulting in a more robust

financial plan.

(viii) Budgets signed off by divisions and corporate departments.

(ix) Monthly monitoring at Board and directorate level.

(x) Uncommitted general contingency reserve.

(xi) Regular finance meetings with budget holders.

(xii) Performance review meetings with NHSI.

(xiii) All directorates signed up to control total.

(xiv) Appointment of suitably quaified Efficiency Director.

(xv) Formation of Efficiency and Effectiveness Committee.

(xvi) Full Capital Monitorring Committee

(xvii) Cash Committee monthly

(xviii) Robust Cash Forecasts

Action to address gaps

& Update

Review date : 1/8/2020

July2020 FJD

Appendix 4 (Level 4 detail) Corporate Risk Register SummaryJune 2020

ID Ref Review dateDivision /

Corporate(s)Speciality(ies) Title Description Risk Owner

Risk level

(current)

Rating

(current)

Risk level

(Target)Last Reviewed

Movement

since last

review

1517 Q&E9 03/09/2020Clinical Specialist

Services

Pharmacy (Outpatient),

Pharmacy (inpatient)Availability and Supplies of Medicines

There are extraordinary stresses on the medicine supply chain which are leading to unavailability of medicines in

the hospital. This could have an impact on patient care, potentially delaying the delivery of treatment, non-

optimisation of treatment and decrease in patient satisfaction. It could also increase the chance of error and harm

occurring

The issues is causing significant disruption and increased workload of the pharmacy procurement and logistics

team which compounds the problem. Disruption of work by other professionals involved in supply and

administration of medicines is possible as well.

There a number of issues causing it:

- Manufacturing Issues

- Central rationing of supplies by CMU

- Wholesaler and supply chain issues

- Unpaid invoices

- Knock on disruption of procurement and logistics teams sometimes delaying response

Updated: 25/10/18

Further national shortages around products like epipens and the LMWH (daletparin and enoxaparin) are causing

further acute shortages of vital and established treatments. Pharmacy are mitigating the risk of the impact of

these shortages by purchasing alternative products but because of the nature of these medicines and how

frequently they are used, the risk to patients from shortages is more significant now. There is potential for delays

in treatment, treatment failure and confusion in spite of mitigation which may lead to error and harm.

Barker,

AndrewExtreme Risk 16 High Risk Jun-20

2472 COVID1 01/07/2020

Directorate of

Nursing, Midwifery

and Allied Health

Professionals

Not Applicable (Non-

clinical Directorate)COVID-19

World-wide pandemic of Coronavirus, which will infect the population of Doncaster and Bassetlaw (including staff)

resulting in reduced staffing, increased workload due to COVID-19 and shortage of beds, ventilators.

Purdue,

DavidExtreme Risk 25 High Risk Jun-20

11 F&P1 01/08/2020

Directorate of

Finance, Information

and Procurement


clinical Directorate)

Failure to achieve compliance with

financial performance and achieve

financial plan

Failure to achieve compliance with financial performance and achieve financial plan leading to :

(i) Adverse impact on Trust's financial position

(ii) Adverse impact on operational performance

(iii) Impact on reputation

(iv) Regulatory action

Sargeant,

JonathanExtreme Risk 16 High Risk Jun-20

7 F&P6 01/06/2020Chief Operating

Officer



Failure to achieve compliance with

performance and delivery aspects of the

SOF, CQC and other regulatory stanadrds

Failure to achieve compliance with performance and delivery aspects of the Single Oversight Framework, CQC and

other regulatory standards leading to:

(i) Regulatory action

(ii) Impact on reputation

Joyce,

RebeccaExtreme Risk 16 High Risk May-20

1244 F&P3 01/06/2020

Directorate of

Finance, Information

and Procurement



Failure to deliver Cost Improvement Plans

in this financial year

Failure to deliver Cost Improvement Plans in this financial year leading to :

(i) Negative impact on Turnaround

(ii) Negative impact on Trust's financial positon

(iii) Loss of STF funding

Sargeant,

JonathanExtreme Risk 16

Moderate

RiskMay-20

19 Q&E1 01/06/2020

Directorate of People

and Organisational

Development



Failure to engage and communicate with

staff and representatives in relation to

immediate challenges and strategic

development

Failure to engage and communicate with staff and representatives in relation to immediate challenges and

strategic development

Barnard,

KarenExtreme Risk 16 High Risk May-20

12 F&P4 22/06/2020 Estates and FacilitiesNot Applicable (Non-


Failure to ensure that estates

infrastructure is adequately maintained

and upgraded in line with current

legislation

Failure to ensure that estates infrastructure is adequately maintained and upgraded in line with current legislation,

standards and guidance.

Note: A number of different distinct risks are contained within this overarching entry. For further details please

consult the E&F risk register. leading to

(i) Breaches of regulatory compliance and enforcement

(ii) Claims brought against the Trust

(iii) Inability to provide safe services

(iv) Negative impact on reputation

(v) Reduced levels of business resilience

(vi) Inefficient energy use (increased cost)

(vii) Increased breakdowns leading to operational disruption

(viii) Restriction to site development

Edmondson-

Jones, KirstyExtreme Risk 20 High Risk May-20

F&P1 –

Hyperlink to

Level 3 risk

detail

Appendix 3 Level 3 CRR June 2020.pdf

Appendix 4 (Level 4 detail) Corporate Risk Register SummaryJune 2020

ID Ref Review dateDivision /

Corporate(s)Speciality(ies) Title Description Risk Owner

Risk level

(current)

Rating

(current)

Risk level

(Target)Last Reviewed

Movement

since last

review

1410 F&P11 01/06/2020Information

Technology


clinical Directorate)Failure to protect against cyber attack

Failure to protect against cyber attack - leading to:

(i) Trust becoming non-operational

(ii) Inability to provide clinical services

(ii) Negative impact on reputation

The top 3 DSP risk areas have been recognised as:

(1) Insider threat (accidental or deliberate)

(2) New / zero day vulnerability exploits

(3) Failure to wholly implement patch management

Anderson,

KenExtreme Risk 15

Moderate

RiskMay-20

2349 ? 01/06/2020Chief Operating

Officer



Failure to specifically achieve RTT 92%

standard

(i) Regulatory action

(ii) Impact on reputation

iii) Delayed access for Patients

(iv) Potential clinical risk for patients identified via NECs audit (assessed as low)

Joyce,

RebeccaExtreme Risk 15

Moderate

RiskMay-20

16 F&P8 01/06/2020

Directorate of People

and Organisational

Development



Inability to recruit right staff and ensure

staff have the right skills to meet

operational needs

Inability to recruit right staff and have staff with right skills leading to:

(i) Increase in temporary expenditure

(ii) Inability to meet FYFV and Trust strategy

(iii) Inability to provide viable services

Barnard,

KarenExtreme Risk 16 High Risk May-20

1854 Q&E13 01/06/2020 Medical ServicesEmergency Department /

A & E / Acute

Initial ED BDGH triage assessment

processes

C- Sub-optimal quality of the initial triage and clinical assessment processes and clinical oversight of the waiting

area.

E- Unwell children and adults may not be provided with the full assessments required to provide high quality care.

E- Potential of harm to patients.

Carville, Kate Extreme Risk 16Moderate

RiskMay-20

2426 01/06/2020Information

Technology


clinical Directorate)Multiple software systems end-of-support

Installed software versions have gone past the date of supplier support and there has been insufficient internal

resources to upgrade and dependencies with multiple software systems being incompatible with the supported

software, have prevented these upgrades. This leads to vulnerabilities within our infrastructure. For example,

unpatched systems are significantly more vulnerable to cyber attacks. A single compromised device threatens all

devices. There is a further vulnerability the Trust faces where we cannot draw on the expertise of the supplier to

fix faulty software in a timely manner or at all.

Linacre,

DavidExtreme Risk 20 High Risk May-20


clinical Directorate)REF 29 - Edge Protection DRI

Due to the lack of edge protection on flat roofs across the site at DRI there is an increased risk of falls from height,

which could result in death or serious injury

Loukes,

Simon

(Inactive

User)

Extreme Risk 15Moderate

RiskMay-20

1807F&P20 /

Q&E1201/06/2020 Estates and Facilities


clinical Directorate)Risk of critical lift failure

Risk of critical lift failure leading to:

(a) Reduction in vertical transportation capacity in the affected area

(b) Impact on clinical care delivery

(c) General access and egress in the affected area

Edmondson-



clinical Directorate)Risk of fire

Failure to ensure that estates infrastructure is adequately maintained and upgraded in accordance with the

Regulatory Reform (Fire Safety) Order 2005 and other current legislation standards and guidance.

Note: a number of different distinct risks are conatained within this overarching entry. For further details please

consult the EF risk register. leading to :

(i) Breaches of regulatory compliance could result in Enforcement or Prohibition notices issued by the Fire and

Rescue Services

(ii) Claims brought against the Trust

(iii) Inability to provide safe services

(iv) Negative impact on reputation

No change to risk - work ongoing.

Edmondson-


1855 Q&E14 01/06/2020 Medical ServicesEmergency Department /

A & E / Acute

Staffing for registered children’s nurses in

ED BDGH

C- Lack of paediatric nurses in ED

E- Breach in safe staffing levels

E- Patients at risk of harm. Potential staff injury/sickness

Carville, Kate Extreme Risk 16 High Risk May-20



EFA/2018/005 - Assessment of Ligature

Points

Following the death of a patient using a ligature attached to low level taps in a bathroom (not at DBTH), a

subsequent coroners regulation 28 highlighted that there was confusion nationally regarding how ligature points

should be assessed and removed.

EFA/2018/005 - advises that Trust's should review and update ligature risk assessments, anti ligature policies and

associated forms/toolkits.

Until this is work complete there is a potential risk of unidentified ligature points existing within Trust properties,

which have the potential to lead to an adverse incident occurring.

Timms,

HowardHigh Risk 12 Low Risk May-20



REF 31 - Unable to Test Fire Dampers - DRI

East Ward Block

Fire dampers on the East Ward Block ventilation ducts are connected directly from the damper to the ductwork via

a fusible link. It is not possible to test these dampers as they can not be reset once operated. As a result, it is not

possible to confirm that the dampers will operate under fire conditions. If the dampers were to fail to operate this

would compromise the fire compartmentation of the building, leading to an increased spread of fire & smoke

under fire conditions, creating a risk to life and property. Any work to test or replace the dampers is further

complicated by the potential presence of asbestos containing materials on joints between ductwork and the

dampers.

No change to risk - work ongoing.

Timms,

HowardHigh Risk 12

Moderate

RiskMay-20

BOARD OF DIRECTORS – 21 JULY 2020

CHAIR’S ASSURANCE REPORT

FINANCE AND PERFORMANCE COMMITTEE – 30 JUNE 2020

Overview

The meeting took place by teleconference owing to the Covid 19 critical incident being managed across the

Trust. All normal attendees took part and we were joined by Trust Chair Suzy Brain England. The first

session of the meeting was dedicated to an update on the management of the current emergency situation.

The following session, and principal business of the meeting was a workshop looking at revising our

approach to performance management.

Performance/operational delivery

The Board will receive a separate performance overview report and I do not want to simply summarise that

here. The focus of the committee in terms of performance this month was to receive and understand the

current performance metrics, but then to examine how we might reset our compass to guide us through a

changed ‘business as usual’ over the next few months and even possibly years. Covid precautions could

impact significantly upon the Trust’s ability to sustain its normal throughput and turnover of patients. In the

absence (at that point) of central guidance we discussed how (in conjunction with QEC) we might develop a

joined up approach to tracking what could be longer and more problematic waiting times. The ambition was

to have a thorough grasp of new entrants, length of wait and profile of exit points in order to understand the

stock and flow of patient waits and provide the best quality and most timely service we could, factoring in

clinincal urgency and our changed circumstances. In a meeting with energy and some creative tension we

explored what that could look like, particularly by trying to build on existing work and not asking

unnecessarily for novel solutions requiring additional work.

Since the committee I met with Jon Sargeant and later Head of Performance Julie Thornton. A good deal of

work was in hand and Julie is devising and developing an approach that could better profile ALL of our

waiting lists against both time and urgency of need, in line with Royal College of Surgeons guidance grades

recently adopted. This appears to be in line with the slowly emerging steer from NHSi, but it is essential we

make progress now rather than wait for the centre.

Julie will attend the next F+P to give us an update on how this work is progressing.

Finance

The meeting was primarily performance focused, however we received the normal finance report, a precis of

which will be presented to Board with any interim update information that becomes available.

G2

You will recall that we reported at the last last Trust Board the government’s top up arrangements that

enabled books to be balanced despite the inadequacy of block payments in properly funding the trust and

the consequent structural monthly gap (circa £2m). We said we would continue to monitor closely this

approach. The block contract position with presumed top up continues. The executive summary of the

Finance paper captures the position well –

“The Trust’s financial position continues to be favourable to budget as a result of continued larger than expected reductions in pay and non pay costs mainly relating to a higher than expected reduction in activity due to COVID. However the Trust still required a £119k retrospective top up (£572k YTD) in order to report a break even position. This position will come under further pressure as the Trust begins to implement Divisional delivery plans to increase activity over the coming months. At this point it is exected that the ICS/System will receive a financial envelope to work within for the rest of the financial year. The Trust’s month 2 financial position includes revenue costs of c. £1.4m relating to COVID (£1.4m in April), of which c. £0.8m relates to pay costs and £0.6m to non‐pay costs (no significant changes from Month 1). The financial governance arrangements regarding COVID expenditure continue to be in place, with 156 orders approved by Gold Command to date. The clinical income position reported at Month 2 continues to be aligned to the national block arrangements in place as previously set out to the Committee and Board. Activity levels across most points of delivery (POD) continue to be significantly lower than the normal Trust average. Some areas have shown some activity increase since Month 1 (e.g. A&E by 36%) however this is from a low base point. As set out above activity is expected to increase over the next couple of months as Division delivery plans for restarting urgent activity are finalised.”

Capital expenditure is slightly ahead of the plan agreed at the last meeting, but progressing well.

The cash position continues to be strong, with significant prepayment of block funds held in Trust accounts.

People

The workforce report again included a comprehensive update from Karen Barnard as to activity to best

profile staff skills and availability against need, and how those staff were being supported, gaining assurance

as to the efforts being made in this area. Governor observer Bev Marshall’s note to colleagues post meeting

captured it nicely –

“Once again, the main focus of the department was responding to the problems caused by the Covid outbreak. There was good news on the recruitment front, with 43 healthcare assistants, 26 support assistants, 78 newly qualified nurses, 11 midwives, 4 paediatric nurses and 2 ODPs being recruited. Absence rates rose slightly, largely due to absence relating to Covid. However, bank and agency spend is at a lower level than this time last year as a result of ward closures and staff redeployment. It is anticipated that, as activities return to normal and staff are returning to their substantive duties this item will start to rise. Analysis of the spread of Covid positive staff by division and ethnicity was provided to the committee. It was noted that the level of infection had reduced significantly overall during June. Analysts by ethnicity and staff group had been undertaken and it was noted that a greater proportion of BAME colleagues had acquired the infection. Whilst about 9.4% of the staff are BAME ,they accounted for approximately 13% of the absence. All staff have now been asked to complete a personal circumstances form, in order that those with a higher risk factor, which includes ethnicity, can have a risk assessments undertaken.”

Risk

The relevant risks were considered actively with each paper received at the meeting. Work continues to

develop a more refined approach to capturing the risk management processes in a readily digestible form.

AGENDA ITEM / ISSUE

COMMITTEE UPDATE NEXT ACTION LEAD TIMESCALE

Minutes and Actions from previous meetings

The Committee approved the minutes from the previous meeting and noted progress on actions being assured that all were appropriately tracked

None N/A N/A

Covid‐19 Operational Briefing

The Committee was assured by the personal report of the COO in relation to the management of the current emergency within the Trust and briefed as to progress across the region.

None N/A N/A

Integrated performance report and workshop session

The Committee was assured by the report and workshop session, but much work needs to be done to prepare us for the future

F+P Chair to meet with, DoF and Julie Thornton to progress a revised approach to reporting. Rebecca Joyce would ensure that there was narrative to support the achievement of local trajectories within the report.

NR RJ

July 2020 July 2020

Financial performance

The Committee was assured by the report, but noted the continuing uncertainty in relation to the block grant funding stream and ad hoc monthly top‐ups.

None N/A N/A

Capital Position The Committee noted that the Board had accepted and endorsed the revised capital plans and budget cast in line with revised government guidance.

None N/A N/A

Workforce Management

The Committee was assured by the report

None N/A N/A

Corporate Risk Register

The Committee noted continuing progress with the preparation of an updated risk register.

A workshop would be planned to align the risk to the True North Objectives.

FD July 2020

Information Items

The meeting also received and noted the minutes of a number of sub‐committees and approved the minutes of its last meeting.

The efficiency and effectiveness of the RFID wheelchair service would be incorporated into the

KEJ

July 2020

Estates and Facilities Quarterly Report. Further detail would be included in the draft Committee Annual Report on workforce matters relating to 2019/20.

FD

July 2020

No escalations were received by the Committee and there were no escalations to the Board

KEY

CLOSED

ASSURED

PARTIALLY ASSURED / SOME ACTION TO TAKE

NOT ASSURED / ACTION REQUIRED

BOARD OF DIRECTORS – 21 JULY 2020


CHARITABLE FUNDS COMMITTEE – 16 JUNE 2020

Overview: The meeting as usual follows the Board meeting and Fred and Ann Green Advisory Group meeting with non‐

executives in attendance as well as the CEO and Finance Director.

The committee followed the Fred and Ann Green Advisory Group to ensure that any business matters arising

from the Advisroy Group could be ratified or actioned at the Charitable Funds Committee where

appropriate. .

AGENDA ITEM / ISSUE

COMMITTEE UPDATE NEXT ACTION LEAD TIMESCALE


The Committee approved the minutes from the previous meeting and noted progress on actions being assured that all were appropriately tracked

None

Review of Fund Balances

A review of fund balances for the previous 12 months to March 2020 was presented for information and discussion and were noted.

None

Approval of Expenditure from F&AGLAG

There was no approval of expenditure to be made from F&AGLAG. The item approved was in relation to an expetention to the EPR which had been previously agreed by CF and it was agreed to fund that through F&AGLAG in retrospect. A late bid to the advisory group was not supported for the HSDU and it was agreed to re‐visit in light of the further attempts to secure funding elsewhere. It was not presented to CF for discussion therefore.

Furthere review of HSDU bid may be required

JS TBC

Presentation A presentation by Lois Mellor Head of Midwifery was provided following receipt of a grant for improvements to Ward 2 bathroom improvement scheme.

None

Identification of Projects

An update was provided on potential future bids which received CF in principle support.

Further updates to be provided at future meetings.

JS Sept 2021

Fundraising Strategy Update

An update on the Business Case for the Fundraiser was discussed with revised timescales agreed.

An update was provided onall the fantastic donations received through the Covid‐19 Pandemic for the Trust both in terms of cash and gifts. The update also noted the launch of the fundraising for the memorial gardens.

Update at next meeting ES Sept 2021

Review of Risk Position – Standard Life

The update on investments highlighted a loss due to fluctuations in the stock market up to March 2020 of 7.4%.

Keep under review MB Sept 2021

Review of ISA 260 workplans

An update was provided on progress against actions highlighted following the External Audit 2018/19.

To add an annual review of the reserves policy to the workplan

MB March 21

Information Items

The meeting also received and noted the minutes of its last meeting and the workplan for information.

None N/A N/A

No escalations were received by the Committee and there were no escalations to the Board

KEY

CLOSED

ASSURED



Page 1 of 3

BOARD OF DIRECTORS – July 2020


AUDIT AND RISK COMMITTEE (ARC) – Thursday 16 July 2020

Overview:

ARC was undertaken by videoconference and in addition to the 4 NED members in attendance

there was: Internal Audit (KPMG) including 2 KPMG colleagues who will take forward 2020/21

work; External Audit (EY); the Trust DoF plus snr Finance Team members,; the Local CounterFraud

Officer; our Governor observer (Bev Marshall) and the Trust Board secretary. Guests joining the

ARC meeting to present updates were: Director of HR&OD; Director of Estates; and the Chief

Information Officer

AGENDA ITEM / ISSUE

COMMITTEE UPDATE NEXT ACTION LEAD TIMECALE


The Committee approved the minutes from the previous meeting and noted progress on actions being assured that most were appropriately tracked

None N/A N/A

EY External Audit ‐ Audit Results Report – Annual Audit Letter 2019/20

An overall unqualified (clean) audit opinion. The report reviews several aspects of Trust financial performance as follows:‐ Accounts – misstatement due to Fraud or Error – no matters to report Accounts – Fraud in revenue and expenditure – no matters to report Accounts – Going Concern – Concur with managements view that the accounts should be prepared on a Going Concern basis. Accounts – Valuations – obtained assurance that the valuation of land & buildings is not materially misstated. Value for Money ‐ no matters to report about arrangements to secure economy, efficiency and effectiveness.

Present to Council of Governors

F Dunn/ J Sargeant

Sept AMM (CoG)

External Audit ‐ ISA 260 Recommendation follow‐up

ARC was given verbal assurance from the Director of HR&OD of planned improvements in documentation/ evidence retention in relation to starters and leavers to address the control recommendation

This will be followed up in 2020/21 Audit process by EY

K.Barnard Nov 2020

Counter Fraud Annual Counter Fraud report 2019/20 Quarter 1 Update 2020/21 Counter Fraud Operational Plan & risk assessment 2020/21

Reports gave assurances that Fraud activity is being managed, monitored and overseen.

N/A N/A

Page 2 of 3

AGENDA ITEM / ISSUE


Standards of Business Conduct and Employee Declaration Policy

The Policy had been amended slightly from the previous version and will be relaunched Compliance with the Policy was discussed (under Matters arising) and Arc was assured verbally that a new process will be in place to ensure appropriate medical staff complete a Declaration by October 2020

This Policy was Approved by Audit Committee and a comms plan to go alongside New process for Medical staff to be in place

F Dunn T Noble

ASAP Oct 2020

Internal Audit (KPMG)

IA Progress Report 20/21 IA Recommendation tracker update Internal Audit Plan 2020/21 ‐ updated plan which had adjustments to ensure Covid‐19 related risks would be reviewed by IA during the year

All these items were noted satisfactorily The slightly revised Internal Audit Plan for 2020/21 was approved

N/A N/A

Internal Audit Report – Discharges & Delayed Transfer of Care (DTOC)

The Audit Report concluded Significant Assurance on the systems and processes in place to collate, record and report DTOC ensuring completeness and accuracy. ARC expressed some concern regarding outstanding recommendations from a previous audit, although took some assurance that other progress was satisfactory

J Sargeant to pick up with D.Purdue on firm dates for completion of DTOC actions

J Sargeant

Internal Audit Report – Clinical Governance WHO Checklist

The Audit Report concluded Partial Assurance on the policies and practices surrounding completion of WHO Checklist in outpatients. Five recommendations were made (1 high, 3 med, 1 low) and the report is referred into QEC to ensure clinical and quality ownership and oversight of the risks.

1. Report to QEC 2. Recommendatio

ns followed up through ARC

R Wilson July 2020

Internal Audit Report – Referral to Access Data Quality

The Audit Report concluded Partial Assurance on the Trusts Referral to Access policy and the controls in place to ensure compliance. Five Recommendations were made (4 med, 1 low) which will be followed up. It was also agreed to refer into F&P Committee for oversight on the risks of RTT

1. Report to F&P 2. Recommendatio

ns followed up through ARC

R Wilson July 2020

Internal Audit Report – P&OD HR Systems Review

The Audit report was a consultancy piece of work to review efficiency, capability and capacity and effectiveness and was requested by management. Nine recommendations were made which all have agreed owners and timescales.

1. Recommendations followed through ARC

2. Tendering process underway for Payroll SBS

Corporate Risk register and BAF

ARC reviewed and noted the current risk register and risk position.

Page 3 of 3

AGENDA ITEM / ISSUE


It was noted a paper with the plan for next steps with the Risk process would be brought to the next Board. ARC requested a review of progress with Internal Audit Recommendations at its Oct meeting ARC requested an informal session on Datix for NEDs (& others) to join to understand the current use of Datix in risk management

Board ARC ARC/ NEDs

F Dunn F Dunn F Dunn

July 2020 Oct 2020 TBC

Security Management – LSMS Report

Annual Report 2019/20; Annual Workplan; 2020/21; Quarter 1 Update 2020/21 The Committee discussed Door entry control, new SABA contract performance, Lone Worker Devices and support for staff assaulted during Covid‐19 period. ARC were assured security risks are identified and being managed.

The Annual Workplan was APPROVED Next report due Oct 2020

1. Standing Orders;

2. Standing Financial Instructions;

3. Reservation of Powers to the Board

These were reviewed and subject to minor amendments were commended to the Board

To Board for APPROVAL

J Sargeant July 2020

Information Governance Assurance Framework

This was reviewed and subject to minor amendments was commended to the Board

Progress will be monitored via the IGG which reports into ARC, and the DPST which is an annual declaration.

K Anderson

Gifts and Hospitality during Covid‐19

ARC received a summary of the corporate gifts & hospitality register being maintained during the Covid‐19 period

NONE

No escalations were received by the Committee, and there were no escalations to the Board.

Kath Smart – Chair of Audit & Risk Committee: 16 July 2020

KEY

CLOSED

ASSURED



Title Review of Standing Financial Instructions, Standing Orders and Scheme of Delegation

Report to Trust Board of Directors Date 21st July 2020

Author Matthew Bancroft – Head of Financial Control


Decision X

Assurance

Information


The Standing Financial Instructions, Standing Orders and Scheme of Delegation has been reviewed and updated in line with best practice and up to date practices in the Trust. A summary of these changes include:

‐ Updating names for Committees and Corporate Structures ‐ References to Prudential Borrowing Limit removed (PBL removed April 2013) ‐ Updating legislation references to include post Brexit legislation ‐ Updating references to “Estatecode”(now “The efficient management of healthcare

estates and facilities”) ‐ Updating references to NHSLA (now “NHS Resolution”) ‐ Updating references to NHSI/NHSE

The documents were reviewed at Audit & Risk Committee on 16th July 2020.


N/A


Ensuring the Trust is appropriately governed


N/A


The Committee is asked to approve the updated documents.

G3

CORP/FIN 1 (A) v10

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Standing Orders Board of Directors

July 2020

NHS Foundation Trusts must agree Standing Orders (SOs) for the regulation of their proceedings and business. The Board of Directors are also required to adopt schedules of reservation of powers

and delegation of powers. These documents, together with Standing Financial Instructions, provide a regulatory framework for the business conduct of the Trust. They fulfil the dual role of protecting the Trust's interests and protecting staff from any possible accusation that they have

acted less than properly.

The Standing Orders, Scheme of Delegation and Standing Financial Instructions provide a comprehensive business framework. All executive and non‐executive directors, and all members of staff, should be aware of the existence of these documents and, where necessary, be familiar

with the detailed provisions.

Provisions within the Standing Orders which are not subject to suspension under SO 5.40 are indicated in italics.

Did you print this document yourself? The Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up‐to‐date version. If, for exceptional reasons, you need to print a policy off, it is only valid for 24 hours.

Name and title of author/reviewer: Jon Sargeant and Matthew Bancroft

Date written/revised: July 2020

Approved by (Committee/Group): Board of Directors

Date of approval:

Date issued:

Next review date: July 2021

Target audience: Trust‐wide

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Amendment Form

Please record brief details of the changes made alongside the next version number. If the procedural document has been reviewed without change, this information will still need to be recorded although the version number will remain the same.

Version

Date Issued

Brief Summary of Changes

Author

Version 10 July 2020 Update of legislation references to include any subsequent updates relating to the UK’s exit from EU.

Removal of all references and detail pertaining to the use of ‘Approved Lists’ in relation to Works tenders.

Removed references to Prudential Borrowing Limits.

Updated limits with relation to Charitable Funds expenditure.

Includes Appendix 1. Temporary COVID19 Business Continuity Terms of Reference Trust Board, Board Committee and Governor Meetings – Emergency powers section 6.2

Matthew Bancroft

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CONTENTS

1 Introduction 6

Delegation of Powers 6

2 Interpretation and Definitions 6

3 The Board of Directors 8

Composition of the Board of Directors 8

Non‐executive Directors 9

Joint Directors 9

4 Chair of the Board of Directors 9

Deputy Chair 9

5 Practice and Procedure of Meetings 10

Annual Members Meeting 10

Admission of the Public and Press 10

Calling Meetings 10

Notice of Meetings 11

Chair of Meeting 11

Quorum 11

Voting 12

Setting the Agenda 13

Minutes 13

Record of Attendance 13

Notices of Motion 13

Withdrawal of Motion or Amendments 13

Motion to Rescind a Resolution 14

Motions 14

Chair’s Ruling 14

Joint Directors 14

Suspension of Standing Orders 15

6 Arrangements for the Exercise of Functions by Delegation 15

Emergency Powers 15

Delegation to Committees 16

Delegation to Officers 16

7 Committees 16

Appointment of Committees 16

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Confidentiality 17

8 Declaration of Interests and Register of Interests 18

Declarations of Interests 18

Authorisation of Conflict of Interest 19

Register of Interests 19

9 Disability of Directors in Proceedings on Account of Pecuniary Interest 19

10 Standards of Business Conduct 21

Policy 21

Interest of Officers in Contracts 21

Canvassing of, and Recommendations by, Directors in Relation to

Appointments

21

Relatives of Directors or Officers 22

11 Tendering and Contract Procedure 22

Duty to comply with Standing Orders 22

EU Directives Governing Public Procurement 22

Financial Thresholds 23

Formal Competitive Tendering and Quotations 24

Where tendering or competitive quotation is not required 26

Private Finance 26

Contracts 26

Personnel and Agency or Temporary Staff Contracts 27

Healthcare Services Contracts 27

Contracts Involving Funds Held on Trust 27

Legality of Payments 27

12 Disposals 27

13 In‐House Services 28

14 Custody of Seal and Sealing of Documents 28

Custody of Seal 29

Sealing of Documents 29

Register of Sealing 29

15 Signature of Documents 29

16 Miscellaneous 29

Standing Orders to be given to Directors and Officers 29

Documents having the standing of Standing Orders 30

Review of Standing Orders 30

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17 Variation and Amendment of Standing Orders 30

ANNEX – TENDERING PROCEDURE 31

1. Invitation to tender 31

2. Receipt, safe custody and record of formal tenders 32

3. Works tenders 33

4. Lists of approved firms 33

5. Negotiated tenders 34

6. Tenders not strictly in accordance with specification 35

7. Post tender negotiation 36

8. Preservation and destruction of documents 37

9. Forms of contract 37

Appendix 1 Equality Impact Assessment Form 38

CORP/FIN 1 (A) v10

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1 INTRODUCTION 1.1 Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust is a Public Benefit

Corporation that was established by the granting of Authorisation by Monitor (now NHS Improvement).

1.2 The principal purpose of the Trust is set out in the 2012 Act, and the Trust Constitution.

1.3 The Trust is required to adopt Standing Orders (SOs) for the regulation of its proceedings

and business. 1.4 The powers of the Trust are set out in section 4 of the Constitution. 1.5 The Trust has specific powers to contract in its own name and to act as a corporate trustee.

In the latter role it is accountable to the Charity Commission for those funds deemed to be charitable as well as to NHS Improvement. The Trust also has a common law duty as a bailee for patients' property held by the Trust on behalf of patients.

1.6 Failure to comply with SFIs and SOs is a disciplinary matter which could result in dismissal.

1.7 Delegation of Powers

The Trust has resolved that certain powers and decisions may only be exercised or made by the Board of Directors in formal session. These powers and decisions are set out in the Scheme of Delegation.

1.8 Under the Standing Orders relating to the Arrangements for the Exercise of Functions (SO

6) the Board of Directors may exercise its powers to make arrangements for the exercise, on behalf of the Trust, of any of its functions by a committee or sub‐committee appointed by virtue of SO 7 or by an executive director, in each case subject to such restrictions and conditions as the Board of Directors thinks fit or as NHS Improvement may direct.

1.9 Delegated Powers are covered in the Scheme of Delegation, which has effect as if

incorporated into the Standing Orders. 2 INTERPRETATION AND DEFINITIONS 2.1 Save as permitted by law, at any meeting the Chair of the Trust, advised by the Chief

Executive, shall be the final authority on the interpretation of Standing Orders. 2.2 These Standing Orders shall only be applied in accordance with the Constitution. Where

any provision in these Standing Orders contradicts any provision in the Constitution, the Constitution shall be paramount.

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2.3 In these Standing Orders:

“the 2006 Act” means the National Health Service Act 2006 as amended from time to time;

“the 2012 Act” means the Health and Social Care Act 2012 as amended from time to time;

"Accounting Officer" means the person who from time to time discharges the functions specified in paragraph 25(5) of Schedule 7 to the 2006 Act;

“Board of Directors” means the board of directors as constituted in accordance with the Trust Constitution;

“Chair” means the Chair of the Trust appointed in accordance with the Trust Constitution;

“Chief Executive” means the Chief Executive Officer of the Trust appointed in accordance with the terms of the Trust Constitution;

“Committee” means a committee appointed by the Board of Directors;

“Committee members” means those persons formally appointed by the Board of Directors to sit on or to chair specific committees;

"Constitution" means the Trust Constitution and all annexes to it;

“Corporate Director” A non‐voting director with executive responsibilities, appointed by the Board of Directors;

“Director” means a director on the Board of Directors;

“Director of Finance” means the Chief Finance Officer of the Trust;

“Executive Director” means an executive director of the Trust appointed in accordance with the Trust Constitution;

“Funds held on Trust” means those funds which the Trust holds at its date of incorporation, receives on distribution by statutory instrument or chooses to accept under powers derived under S.90 of the 2006 Act;

“Member” means a member of the Trust;

“NHS Improvement” means the body corporate known as NHS Improvement.

“Motion” means a formal proposition to be discussed and voted on

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during the course of a meeting;

“Nominated Officer” means an officer charged with the responsibility for discharging specific tasks within the SOs and SFIs;

“Non‐Executive Director” means a non‐executive director of the Trust appointed in accordance with the Trust Constitution;

“Officer” means an employee of the Trust;

"Secretary" means the Trust Board Secretary or any other person appointed to perform the duties of the secretary of the Trust, including a joint, assistant or deputy secretary;

“SFIs” means Standing Financial Instructions;

“SOs” means Standing Orders;

“the Trust” means Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust.

3 THE BOARD OF DIRECTORS 3.1 All business of the Board of Directors shall be conducted in the name of the Trust. 3.2 All funds received in trust shall be in the name of the Trust as corporate trustee. In relation

to funds held on trust, powers exercised by the Trust as corporate trustee shall be exercised separately and distinctly from those powers exercised as a Trust.

3.3 Directors acting on behalf of the Trust as a corporate trustee are acting as quasi‐

trustees. Accountability for charitable funds held on trust is to the Charity Commission and to NHS Improvement. Accountability for non‐charitable funds held on trust is only to NHS Improvement.

3.4 Composition of the Board of Directors

In accordance with the 2006 Act, the 2012 Act, and the Constitution, the composition of the Board of Directors of the Trust shall be:

(a) The Chair of the Trust (b) 6 non‐executive directors

(c) 6 executive directors including:

the Chief Executive (the Accounting Officer)

the Director of Finance (the Chief Finance Officer)

the Medical Director

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the Director of Nursing 3.5 The Board of Directors may appoint corporate directors in addition to the six executive

directors described above. Non‐voting Corporate directors shall attend meetings of the Board of Directors but shall not have a vote (see SO 5.19).

3.6 Non‐executive Directors Non‐executive Directors are appointed by the Council of Governors. The appointment shall be in accordance with the Constitution.

3.7 The regulations governing the tenure of office of the Non‐executive Directors shall be in

accordance with the Constitution. 3.8 Joint Directors

Where more than one person is appointed jointly to a post in the Trust which qualifies the holder for executive directorship or in relation to which an executive director is to be appointed, those persons shall become appointed as an executive director jointly, and shall count for the purpose of Standing Order 3.4 as one person.

4 CHAIR OF THE BOARD OF DIRECTORS 4.1 The Chair of the Trust is the Chair of the Board of Directors. 4.2 The Chair is appointed by the Council of Governors. The appointment shall be in

accordance with the Constitution. 4.3 The regulations governing the tenure of office of the Chair shall be in accordance with the

Constitution. 4.4 At any meeting of the Board of Directors, the Chair, if present, shall preside. If the Chair is

absent from the meeting, the Deputy Chair shall preside. 4.5 If the Chair is absent from a meeting temporarily on the grounds of a declared conflict of

interest the Deputy Chair, if present, shall preside. 4.6 Deputy Chair

Where the Chair of the Trust has died or has otherwise ceased to hold office or where he has been unable to perform his duties as Chair owing to illness, absence from England and Wales or any other cause, references to the Chair in the Schedule to these Regulations shall, so long as there is no Chair able to perform his duties, be taken to include references to the Deputy Chair. In such cases the Deputy Chair shall act as Chair of the Board of Directors.

4.7 The appointment of the Deputy Chair shall be as prescribed in the Constitution.

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4.8 The regulations governing the tenure of office of the Deputy Chair shall be in accordance

with the Constitution. 5 PRACTICE AND PROCEDURE OF MEETINGS 5.1 All business at meetings of the Board of Directors shall be conducted in the name of the

Trust. 5.2 Annual Members Meeting

The Trust will publicise and hold an annual meeting of its members in accordance with the constitution and the 2012 Act.

5.3 Admission of the Public and Press

The public and representatives of the press shall be afforded facilities to attend all formal meetings of the Board of Directors but shall be required to withdraw upon the Board of Directors resolving as follows:

“That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”.

5.4 The Chair (or Deputy Chair when acting as Chair) shall give such directions as he thinks

fit in regard to the arrangements for meetings and accommodation of the public and representatives of the press such as to ensure that the Board of Directors business shall be conducted without interruption and disruption and, without prejudice to the power to exclude on the grounds of the confidential nature of the business to be transacted, the public will be required to withdraw upon the Board of Directors resolving as follows:

“That in the interests of public order the meeting adjourns for (the period to be specified) to enable the Board of Directors to complete business without the presence of the public.”

5.5 Members of the public or representatives of the press are not permitted to record

proceedings in any manner unless with the express prior agreement of the Chair (or Deputy Chair when acting as Chair). Where permission has been granted, the Chair (or Deputy Chair) retains the right to give directions to halt recording of proceedings at any point during the meeting. For the avoidance of doubt, “recording” refers to any audio or visual recording, including still photography.

5.6 Calling Meetings

Ordinary meetings of the Board of Directors shall be held at such times and places as the Board of Directors may determine.

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5.7 The Chair may call a meeting of the Board of Directors at any time. If the Chair refuses to

call a meeting after a requisition for that purpose, signed by at least one‐third of the whole number of directors, has been presented to him, or if, without so refusing, the Chair does not call a meeting within seven days after such requisition has been presented to him such one third or more directors may forthwith call a meeting. In such cases, meetings shall be held at the Trust’s designated headquarters.

5.8 Notice of Meetings

Save in the case of emergencies or the need to conduct urgent business, the Secretary shall give at least fourteen days written notice of the date and place of every meeting of the Board of Directors to all Directors.

5.9 The notice of the meeting, specifying the business proposed to be transacted at it, and

signed by the Chair or by an officer of the Trust authorised by the Chair to sign on his behalf shall be delivered to every director, or sent by post to the usual place of residence of such director, so as to be available to him at least three clear days before the meeting.

5.10 Lack of service of the notice on any director shall not affect the validity of a meeting. 5.11 In the case of a meeting called by directors in default of the Chair, the notice shall be

signed by those directors and no business shall be transacted at the meeting other than that specified in the notice.

5.12 Failure to serve such a notice on more than three directors will invalidate the meeting. A

notice shall be presumed to have been served at the time at which the notice would be delivered in the ordinary course of the post.

5.13 Chair of Meeting

At any meeting of the Board of Directors, the Chair, if present, shall preside. If the Chair is absent from the meeting the Deputy Chair, if there is one and he is present, shall preside. If the Chair and Deputy Chair are absent such non‐executive director as the directors present shall choose shall preside.

5.14 If the Chair is absent from a meeting temporarily on the grounds of a declared conflict of

interest the Deputy Chair, if present, shall preside. If the Chair and Deputy Chair are absent, or are disqualified from participating, such non‐executive director as the directors present shall choose shall preside.

5.15 Quorum

No business shall be transacted at a meeting of the Board of Directors unless at least one‐third of the whole number of the directors are present including at least one executive director and one non‐executive director.

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Directors can participate in meetings by telephone or through the use of video conferencing facilities, where such facilities are available. Participation in a meeting through any of these methods shall be deemed to constitute presence in person at the meeting.

5.16 An officer in attendance for an executive director but without formal acting up status may

not count towards the quorum. 5.17 If a director has been disqualified from participating in the discussion on any matter and/or

from voting on any resolution by reason of the declaration of a conflict of interest, he shall no longer count towards the quorum. If a quorum is then not available for the discussion and/or the passing of a resolution on any matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business i.e. lack of a quorum for specific items will not invalidate the whole meeting.

5.18 The requirement for at least one executive director to form part of the quorum shall not

apply where the executive directors are excluded from a meeting. 5.19 Voting

Each executive and non‐executive director shall be entitled to exercise one vote. Corporate directors who are not executive directors (as described in SOs 3.4 and 3.5) shall not have a vote.

5.20 Every question at a meeting shall be determined by a majority of the votes of the directors present and voting on the question and, in the case of any equality of votes, the person presiding shall have a second or casting vote.

5.21 All questions put to the vote shall, at the discretion of the Chair of the meeting, be

determined by oral expression or by a show of hands. A paper ballot may also be used if a majority of the directors present so request.

5.22 If at least one‐third of the directors present so request, the voting (other than by paper

ballot) on any question may be recorded to show how each director present voted or abstained.

5.23 If a director so requests, his vote shall be recorded by name upon any vote (other than by

paper ballot). 5.24 In no circumstances may an absent director vote by proxy. Absence is defined as being

absent at the time of the vote.

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5.25 An officer who has been appointed formally by the Board of Directors to act up for an

executive director during a period of incapacity or temporarily to fill an executive director vacancy, shall be entitled to exercise the voting rights of the executive director. An officer attending the Board of Directors to represent an executive director during a period of incapacity or temporary absence without formal acting up status may not exercise the voting rights of the executive director. An officer’s status when attending a meeting shall be recorded in the minutes.

5.26 Setting the Agenda

The Board of Directors may determine that certain matters shall appear on every agenda for a meeting of the Board of Directors and shall be addressed prior to any other business being conducted.

5.27 A director desiring a matter to be included on an agenda shall make his request in writing

to the Chair at least ten clear days before the meeting. Requests made less than ten days before a meeting may be included on the agenda at the discretion of the Chair.

5.28 Minutes

The minutes of the proceedings of a meeting shall be drawn up and submitted for agreement at the next ensuing meeting where they will be signed by the person presiding at it.

5.29 No discussion shall take place upon the minutes except upon their accuracy or where the

Chair considers discussion appropriate. Any amendment to the minutes shall be agreed and recorded at the next meeting.

5.30 Minutes shall be circulated in accordance with directors' wishes. Where providing a record

of a public meeting the minutes shall be made available to the public. 5.31 Record of Attendance

The names of the directors present at the meeting shall be recorded in the minutes. 5.32 Notices of Motion

A director of the Trust desiring to move or amend a motion shall send a written notice thereof at least ten clear days before the meeting to the Chair, who shall insert in the agenda for the meeting all notices so received subject to the notice being permissible under the appropriate regulations. This paragraph shall not prevent any motion being moved during the meeting, without notice on any business mentioned on the agenda subject to SO 5.11.

5.33 Withdrawal of Motion or Amendments

A motion or amendment once moved and seconded may be withdrawn by the proposer with the concurrence of the seconder and the consent of the Chair.

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5.34 Motion to Rescind a Resolution

Notice of motion to amend or rescind any resolution (or the general substance of any resolution) which has been passed within the preceding six calendar months shall bear the signature of the director who gives it and also the signature of four other directors. When any such motion has been disposed of by the Board of Directors, it shall not be competent for any director other than the Chair to propose a motion to the same effect within six months; however the Chair may do so if he considers it appropriate.

5.35 Motions

The mover of a motion shall have a right of reply at the close of any discussion on the motion or any amendment thereto.

5.36 When a motion is under discussion or immediately prior to discussion it shall be open to a

Director to move:

(i) An amendment to the motion. (ii) The adjournment of the discussion or the meeting.

(iii) The appointment of an ad hoc committee to deal with a specific item of business.

(iv) That the meeting proceed to the next business.*

(v) The appointment of an ad hoc committee to deal with a specific item of business.

(vi) That the motion be now put to a vote.*

In the case of sub‐paragraphs denoted by * above, to ensure objectivity motions may only be put by a Director who has not previously taken part in the debate.

5.37 No amendment to the motion shall be admitted if, in the opinion of the Chair of the

meeting, the amendment negates the substance of the motion. 5.38 Chair’s Ruling

Statements of directors made at meetings of the Board of Directors shall be relevant to the matter under discussion at the material time and the decision of the Chair of the meeting on questions of order, relevancy, regularity and any other matters shall be observed at the meeting.

5.39 Joint Directors Where a post of executive director is shared by more than one person: (a) both persons shall be entitled to attend meetings of the Trust:

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(b) either of those persons shall be eligible to vote in the case of agreement between

them: (c) in the case of disagreement between them no vote should be cast; (d) the presence of either or both of those persons shall count as one person for the

purposes of SO 5.15 (Quorum). 5.40 Suspension of Standing Orders

Any one or more of the Standing Orders may be suspended at any duly constituted meeting, provided that:

(i) at least two‐thirds of the Board of Directors are present, including one executive

director and one non‐executive director; (ii) a majority of those present vote in favour of suspension; and (iii) the variation proposed does not contravene any statutory provision or direction

made by NHS Improvement. 5.41 A decision to suspend SOs shall be recorded in the minutes of the meeting. 5.42 A separate record of matters discussed during the suspension of SOs shall be made and

shall be available to the directors. 5.43 No formal business may be transacted while SOs are suspended. 5.44 The Audit Committee shall review every decision to suspend SOs. 6 ARRANGEMENTS FOR THE EXERCISE OF FUNCTIONS BY DELEGATION 6.1 Subject to SO 1.5 and such directions as may be given by NHS Improvement, the Board of

Directors may make arrangements for the exercise, on behalf of the Trust, of any of its functions by a committee or sub‐committee, appointed by virtue of SO 1.5 or 6.3 or by a executive director of the Trust in each case subject to such restrictions and conditions as the Board of Directors thinks fit.

6.2 Emergency Powers

Those powers of the Trust which the Board of Directors has retained to itself may in urgent circumstances be exercised by the Chief Executive after having consulted the Chair. A decision is urgent where any delay would seriously prejudice the Trust’s or the public’s interests. The exercise of such powers by the Chief Executive shall be reported to the next formal meeting of the Board of Directors for ratification.

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6.3 Delegation to Committees

The Board of Directors shall agree from time to time to the delegation of executive powers to be exercised by committees or sub‐committees, which it has formally constituted. The constitution and terms of reference of these committees, or sub‐committees, and their specific executive powers shall be approved by the Board of Directors.

6.4 Delegation to Officers

Those functions of the Trust which have not been retained as reserved by the Board of Directors or delegated to an executive committee or sub‐committee shall be exercised on behalf of the Board of Directors by the Chief Executive. The Chief Executive shall determine which functions he will perform personally and shall nominate officers to undertake the remaining functions for which he will still retain accountability to the Board of Directors.

6.5 The Chief Executive shall prepare a Scheme of Delegation identifying his proposals, which

shall be considered and approved by the Board of Directors, subject to any amendment, agreed during the discussion. The Chief Executive may periodically propose amendment to the Scheme of Delegation, which shall be considered and approved by the Board of Directors as indicated above.

6.6 Nothing in the Scheme of Delegation shall impair the discharge of the direct accountability

to the Board of Directors of the Director of Finance or other executive director to provide information and advise the Board of Directors in accordance with any statutory requirements.

6.7 The arrangements made by the Board of Directors as set out in the Scheme of Delegation

shall have effect as if incorporated in these Standing Orders. 7 COMMITTEES 7.1 Appointment of Committees

Subject to SO 1.5 and such directions as may be given by NHS Improvement, the Board of Directors may and, if directed to, shall appoint committees of the Board of Directors, consisting wholly or partly of directors of the Trust or wholly of persons who are not directors of the Trust.

7.2 A committee appointed under SO 7.1 may, subject to such directions as may be given by

NHS Improvement or the Board of Directors appoint sub‐committees consisting wholly or partly of members of the committee (whether or not they include directors of the Trust or wholly of persons who are not members of the Trust committee).

7.3 The Standing Orders of the Board of Directors, as far as they are applicable, shall apply with

appropriate alteration to meetings of any committees or sub‐committee established by the Board of Directors.

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7.4 Each such committee or sub‐committee shall have such terms of reference and powers

and be subject to such conditions (as to reporting back to the Board of Directors), as the Board of Directors shall decide. Such terms of reference shall have effect as if incorporated into the Standing Orders.

7.5 Committees may not delegate their executive powers to a sub‐committee unless expressly

authorised by the Board of Directors. 7.6 The Board of Directors shall approve the appointments to each of the committees, which it

has formally constituted. Where the Board of Directors determines that persons, who are neither directors nor officers, shall be appointed to a committee, the terms of such appointment shall be determined by the Board of Directors subject to the payment of travelling and other allowances being in accordance with such sum as may be determined.

7.7 Where the Board of Directors is required to appoint persons to a committee and/or to

undertake statutory functions as required by NHS Improvement, and where such appointments are to operate independently of the Board of Directors such appointment shall be made in accordance with the regulations laid down by NHS Improvement.

7.8 The committees and sub‐committees established by the Board of Directors are:

(a) Audit and Risk (b) Quality and Effectiveness (c) Nominations and Remuneration (d) Charitable Funds (e) Finance and Performance

7.9 Confidentiality

A member of a committee shall not disclose a matter dealt with by, or brought before, the committee without its permission until the committee shall have reported to the Board of Directors or shall otherwise have concluded on that matter.

7.10 A Director of the Trust or a member of a committee shall not disclose any matter reported

to the Board of Directors or otherwise dealt with by the committee, notwithstanding that the matter has been reported or action has been concluded, if the Board of Directors or committee shall resolve that it is confidential.

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8 DECLARATION OF INTERESTS AND REGISTER OF INTERESTS 8.1 Pursuant to Section 20 of Schedule 7 of the 2006 Act, a register of Directors’ interests

must be kept by the Trust. 8.2 Pursuant to Section 152 of the 2012 Act, Directors have a duty:

a) to avoid a situation in which the director has (or can have) a direct or indirect

interest that conflicts (or possibly may conflict) with the interests of the Trust.

b) not to accept a benefit from a third party by reason of being a director or doing (or not doing) anything in that capacity.

8.3 Declaration of Interests

Directors are required to declare interests, which are relevant and material. All existing Directors should declare relevant and material interests. Any Directors appointed subsequently should do so on appointment.

8.4 Interests which should be regarded as "relevant and material" and which, for the guidance of doubt, should be included in the register, are:

a) Directorships, including non‐executive directorships held in private companies or

PLCs (with the exception of those of dormant companies). b) Ownership or part‐ownership of private companies, businesses or consultancies

likely or possibly seeking to do business with the NHS. c) Majority or controlling share holdings in organisations likely or possibly seeking to

do business with the NHS. d) A position of authority in any organisation, including charity or voluntary

organisations, in the field of health and social care. e) Any connection with a voluntary or other organisation contracting for NHS services. f) Any connection with an organisation, entity or company considering entering into

or having entered into a financial arrangement with the NHS Foundation Trust, including but not limited to, lenders or banks.

8.5 If directors have any doubt about the relevance of an interest, this should be discussed

with the Chair.

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8.6 At the time the interests are declared, they should be recorded as appropriate. Any

changes in interests should be declared at the next Board of Directors meeting as appropriate following the change occurring. It is the obligation of the Director to inform the Trust Board Secretary in writing within 7 days of becoming aware of the existence of a relevant or material interest. The Secretary will amend the Register upon receipt within 3 working days.

8.7 During the course of a Board of Directors meeting, if a conflict of interest is established, the

director concerned should withdraw from the meeting and play no part in the relevant discussion or decision. For the avoidance of doubt, this includes voting on such an issue where a conflict is established. If there is a dispute as to whether a conflict of interest does exist, majority will resolve the issue with the Chair having the casting vote.

8.8 There is no requirement for the interests of directors' spouses or partners to be declared.

8.9 Authorisation of Conflict of Interest

Where a director has a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the Trust (in contravention of the duty outlined at SO 8.2), this may be authorised if a majority of directors vote in favour of authorisation. If there is a dispute as to whether a conflict or potential conflict of interest exists, majority will resolve the issue with the Chair having the casting vote.

8.10 If a director has a direct or indirect interest that conflicts (or possibly may conflict) with the interests of the Trust that is not authorised by the Board of Directors, the director in question will be deemed to be in breach of the statutory duty outlined at SO 8.2.

8.11 Register of Interests

The details of directors’ interests recorded in the Register will be kept up to date by means of a monthly review of the Register by the Secretary, during which any changes of interests declared during the preceding month will be incorporated.

8.12 Subject to contrary regulations being passed, the Register will be available for inspection

by the public free of charge. The Chair will take reasonable steps to bring the existence of the Register to the attention of the local population and to publicise arrangements for viewing it. Copies or extracts of the Register must be provided to members of the Trust free of charge and within a reasonable time period of the request. A reasonable charge may be imposed on non‐members for copies or extracts of the Register.

9 DISABILITY OF DIRECTORS IN PROCEEDINGS ON ACCOUNT OF PECUNIARY INTEREST 9.1 If a director of the Trust has any pecuniary interest, direct or indirect, in any contract,

proposed contract or other matter and is present at a meeting of the Board of Directors at which the contract or other matter is the subject of consideration, he shall at the meeting

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and as soon as practicable after its commencement disclose the fact and shall not take part in the consideration or discussion of the contract or other matter or vote on any question with respect to it.

9.2 The Trust shall exclude a director from a meeting of the Board of Directors while any

contract, proposed contract or other matter in which he has a pecuniary interest, is under consideration.

9.3 For the purpose of this Standing Order, directors shall be treated as having indirectly a

pecuniary interest in a contract, proposed contract or other matter, if: (a) he, or a nominee of his, is a director of a company or other body, not being a public

body, with which the contract was made or is proposed to be made or which has a direct pecuniary interest in the other matter under consideration;

or (b) he is a partner of, or is in the employment of a person with whom the contract was

made or is proposed to be made or who has a direct pecuniary interest in the other matter under consideration;

and in the case of married persons, persons in a civil partnership, or unmarried persons

living together as partners, the interest of one spouse or partner shall, if known to the other, be deemed for the purposes of this Standing Order to be also an interest of the other.

9.4 A director shall not be treated as having a pecuniary interest in any contract, proposed

contract or other matter by reason only: (a) of his membership of a company or other body, if he has no beneficial interest in

any securities of that company or other body; (b) of an interest in any company, body or person with which he is connected as

mentioned in SO 9.3 above which is so remote or insignificant that it cannot reasonably be regarded as likely to influence a director in the consideration or discussion of or in voting on, any question with respect to that contract or matter.

9.5 Where a director: (a) has an indirect pecuniary interest in a contract, proposed contract or other matter

by reason only of a beneficial interest in securities of a company or other body, and (b) the total nominal value of those securities does not exceed £5,000 or one‐

hundredth of the total nominal value of the issued share capital of the company or body, whichever is the less, and

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(c) if the share capital is of more than one class, the total nominal value of shares of

any one class in which he has a beneficial interest does not exceed one‐hundredth of the total issued share capital of that class,

this Standing Order shall not prohibit him from taking part in the consideration or

discussion of the contract or other matter or from voting on any question with respect to it without prejudice however to his duty to disclose his interest.

9.6 SO 9 applies to a committee or sub‐committee of the Board of Directors as it applies to the

Board of Directors and applies to any member of any such committee or sub‐committee (whether or not he is also a director of the Trust) as it applies to a director of the Trust.

10 STANDARDS OF BUSINESS CONDUCT 10.1 Policy

Directors shall act in accordance with the Nolan Principles Governing Conduct of Public Office Holders at all times.

10.2 The Trust has adopted as good practice the national guidance contained in HSG(93)5

`Standards of Business Conduct for NHS staff' and staff must comply with this guidance. The following provisions should be read in conjunction with this document.

10.3 Interest of Officers in Contracts

If it comes to the knowledge of a director or an officer of the Trust that a contract in which he has any pecuniary interest not being a contract to which he is himself a party, has been, or is proposed to be, entered into by the Trust he shall, at once, give notice in writing to the Chief Executive of the fact that he is interested therein. In the case of married persons, or persons living together as partners, the interest of one partner shall, if known to the other, be deemed to be also the interest of that partner.

10.4 An officer must also declare to the Chief Executive any other employment or business or

other relationship of his, or of a cohabiting spouse, that conflicts, or might reasonably be predicted could conflict with the interests of the Trust.

10.5 The Trust shall require interests, employment or relationships so declared by staff to be

entered in a register of interests of staff. 10.6 Canvassing of, and Recommendations by, Directors in Relation to Appointments

Canvassing of directors of the Trust or members of any committee of the Trust directly or indirectly for any appointment under the Trust shall disqualify the candidate for such appointment. The contents of this paragraph of the Standing Order shall be included in application forms or otherwise brought to the attention of candidates.

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10.7 A director of the Trust shall not solicit for any person any appointment under the Trust or recommend any person for such appointment: but this paragraph of this Standing Order shall not preclude a director from giving written testimonial of a candidate's ability, experience or character for submission to the Trust.

10.8 Informal discussions outside appointments panels or committees, whether solicited or

unsolicited, should be declared to the panel or committee. 10.9 Relatives of Directors or Officers

Candidates for any staff appointment shall when making application disclose in writing whether they are related to any director or the holder of any office under the Trust. Failure to disclose such a relationship shall disqualify a candidate and, if appointed, render him liable to instant dismissal.

10.10 The directors and every officer of the Trust shall disclose to the Chief Executive any

relationship with a candidate of whose candidature that director or officer is aware. It shall be the duty of the Chief Executive to report to the Board of Directors any such disclosure made.

10.11 On appointment, directors (and prior to acceptance of an appointment in the case of

executive directors) should disclose to the Trust whether they are related to any other director or holder of any office under the Trust.

10.12 Where the relationship of an officer or another director to a director of the Trust is

disclosed, the Standing Order headed `Disability of directors in proceedings on account of pecuniary interest' (SO 9) shall apply.

10.13 In accordance with paragraph 1.1.2 of the Trust's Standards of Business Conduct and

Employees Declarations of Interest Policy, any Board member or member of staff who receives or is offered and declines hospitality in excess of £50.00 is required to enter the details of the hospitality in the Trust's Hospitality Register.

11 TENDERING AND CONTRACT PROCEDURES 11.1 Duty to comply with Standing Orders

The procedure for making all contracts by or on behalf of the Trust shall comply with these Standing Orders (except where SO 5.40 (Suspension of SOs) is applied).

11.2 EU Directives Governing Public Procurement

Directives by the Council of the European Union promulgated by the Department of Health (DoH) or any subsequent public procurement legislation following the UKs exit from the European Union prescribing procedures for awarding all forms of contracts shall have effect as if incorporated in these Standing Orders.

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11.3 The Trust shall comply as far as is practicable with the requirements of the Capital

Investment Manual and with guidance contained in "The Procurement and Management of Consultants within the NHS".

11.4 Financial Thresholds

The Trust shall set financial thresholds above which competitive quotations and tenders are to be invited. The value to be compared to the threshold is the estimated full amount of the goods and/or services to be paid during the life of the contract exclusive of vat.

11.5 The estimated value of the requirement is calculated with reference to the following:

a) all possible options under the contract need are included; b) where volumes and prices are known in advance, then the value of the contract is the

full amount which will be paid during the life of the contract; c) where the contract is for an indefinite period, or for a period of time which is

uncertain when the contract is entered into, or the volumes are uncertain, then the estimated amount to be paid is the estimated monthly value multiplied by 24;

d) where it is proposed to enter into two or more contracts for goods or services of a

particular type, then the estimated value of each of the contracts must be added together. This aggregate value is the one which must be applied and assessed against the threshold. Where the aggregate value is above the threshold, each contract has to be put to competition, even if the estimated value of each individual contract is below the threshold;

e) for building or engineering works this is the estimated value of the whole works

project, irrespective of whether or not it comprises a number of separate contracts for different activities. For example if the construction of a new building is divided into three phases, site clearance, construction and fitting out, the threshold must be applied to the value of all three phases, even though the activities are different and different contractors may be used.

11.6 If the estimate proves to have been flawed, for example, because bids or the eventual

contract value are significantly higher than estimated, there may be a breach of the Regulations and the competition may have to be stopped and started again. There may, for example, be unfairness to contractors who relied upon a flawed estimate in reaching a decision not to bid for a particular contract.

11.7 The current thresholds (exclusive of vat) are 3 written quotes up to £25,000, formal quotes up to £50,000; local tenders £50,000 to EU Threshold and measured term contract for works £250,000.

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11.8 Formal Competitive Tendering and Quotations

The Trust shall ensure that competitive tenders are invited for the supply of goods, materials and manufactured articles and for the rendering of services including all forms of management consultancy services (other than specialised services sought from or provided by the DoH); for the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens); where the value is expected to exceed the financial threshold (11.7)and for disposals.

11.9 Formal tendering procedures may be waived by officers to whom powers have been delegated by the Chief Executive without reference to the Chief Executive where:

(a) the estimated expenditure or income does not, or is not reasonably expected to,

exceed the financial threshold (11.7); or (b) where the supply is proposed under special arrangements negotiated by the DoH in

which event the said special arrangements must be complied with.

11.10 Formal tendering procedures are not required where:

(a) the requirement is covered by an existing contract;

(b) the requirement is covered by an existing framework

11.11 Formal tendering procedures may be waived by the Chief Executive where:

(a) where a consortium arrangement is in place and a lead organisation has been appointed to carry out tendering activity on behalf of the consortium members;

(d) the timescale genuinely precludes competitive tendering. Failure to plan the work

properly is not a justification for single tender; or (e) specialist expertise is required and is available from only one source; or (f) the task is essential to complete the project, AND arises as a consequence of a

recently completed assignment and engaging different consultants for the new task would be inappropriate; or

(g) there is a clear benefit to be gained from maintaining continuity with an earlier

project. However in such cases the benefits of such continuity must outweigh any potential financial advantage to be gained by competitive tendering; or

(h) where provided for in the Capital Investment Manual.

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Where it is decided that competitive tendering is not applicable and should be waived by virtue of (d) to (g) above the fact of the waiver and the reasons should be documented and reported by the Chief Executive to the Audit and Risk Committee in the next formal meeting.

11.12 The limited application of the single tender rules (11.9 and 11.10 above) should not be used to avoid competition or for administrative convenience or to award further work to a consultant originally appointed through a competitive procedure.

11.13 Quotations are required from at least three suppliers where formal tendering procedures are waived under SO 11.9 (a) and where the intended expenditure or income exceeds, or is reasonably expected to exceed the financial threshold (11.7).

11.14 If a framework agreement is to be used, the selection of the best supplier for the particular need is to be made on the basis of either: (a) the supplier offering the most economically advantageous offer (using the original

award criteria) for the particular need where the terms of the agreement are precise enough; or

(b) through mini competition between those suppliers on the framework capable of meeting the particular need using the terms of the original terms, supplemented or refined as necessary.

11.15 Works requirements falling below the MTC financial threshold (11.7) can be placed with

the measured term contract supplier, following the process set out in that contract.

11.16 Except where SOs 11.10 and 11.11, or a requirement under SO 11.2, applies, the Board of Directors shall ensure that invitations to tender are sent to a sufficient number of suppliers to provide fair and adequate competition as appropriate, and in no case less than three written competitive tenders must be obtained, having regard to suppliers capacity to supply the goods or materials or to undertake the services or works required.

11.17 The number of suppliers to be invited to tender for building and engineering schemes valued above the financial threshold (11.7) will be a minimum of six, of which four written competitive tenders must be obtained, unless the requirement is waived in writing by the Chief Executive or Director of Finance.

11.18 The Board of Directors shall ensure that normally the suppliers invited to tender (and where appropriate, quote) for building and engineering schemes are among those on approved lists (see Annex Section 5). Where in the opinion of the Director of Finance it is desirable to seek tenders from firms not on the approved lists, the reason shall be recorded in writing to the Chief Executive.

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11.19 Tendering procedures are set out in the Annex.

11.20 Quotations should be in writing or via the e‐tendering system for quotes above £25,000 unless the Chief Executive or his nominated officer determines that it is impractical to do so in which case quotations may be obtained by telephone. Confirmation of telephone quotation should be obtained as soon as possible and the reasons why the telephone quotation was obtained should be set out in a permanent record.

11.21 All quotations should be treated as confidential and should be retained for inspection.

11.22 The Chief Executive or his nominated officer should evaluate the quotations and select the one that is either the lowest cost or is the most economically advantages to the Trust taking into account quality. If this is not the lowest or economically advantages then this fact and the reasons why should be in a permanent record.

11.23 Where tendering or competitive quotation is not required Where tenders or quotations are not required, because expenditure is below the financial threshold (11.7), the Trust shall procure goods and services in accordance with procurement procedures approved by the Board of Directors.

11.24 The Chief Executive shall be responsible for ensuring that best value for money can be demonstrated for all services provided under contract or in‐house. The Board of Directors may also determine from time to time that in‐house services should be market tested by competitive tendering (SO 11.8).

11.25 Private Finance When the Board of Directors proposes, or is required, to use finance provided by the private sector the following should apply:

(a) The Chief Executive shall demonstrate that the use of private finance represents

value for money and genuinely transfers risk to the private sector. (b) The proposal must be specifically agreed by the Board of Directors in the light of

such professional advice as should reasonably be sought in particular with regard to vires.

(c) The selection of a private sector partner must be on the basis of competitive

tendering or quotations.

11.26 Contracts The Trust may only enter into contracts within its statutory powers and shall comply with:

(a) these Standing Orders;

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(b) the Trust's SFIs; (c) EU Directives, their subsequent replacements in UK law and other statutory

provisions. (d) any relevant directions including the Capital Investment Manual and guidance on

the Procurement and Management of Consultants; Where appropriate contracts shall be in or embody the same terms and conditions of

contract as was the basis on which tenders or quotations were invited.

11.27 In all contracts made by the Trust, the Board of Directors shall endeavour to obtain best value for money. The Chief Executive shall nominate an officer who shall oversee and manage each contract on behalf of the Trust.

11.28 Personnel and Temporary Staff Contracts The Chief Executive shall nominate officers with delegated authority to enter into contracts for the employment of other officers, to authorise regrading of staff, and enter into contracts for the employment of temporary staff.

11.29 Healthcare Services Contracts Healthcare Services Contracts made between two NHS organisations are subject to the provisions of the 2006 Act.

11.30 The Chief Executive shall nominate officers with power to negotiate for the provision of

healthcare services with commissioners of healthcare.

11.31 Contracts Involving Funds Held on Trust Contracts Involving Funds Held on Trust shall do so individually to a specific named fund. Such contracts involving charitable funds shall comply with the requirements of the Charities Acts.

11.32 Legality of Payments It is the responsibility of the Director of Finance to ensure that all payments made by the Trust fall within its powers.

12 DISPOSALS 12.1 Competitive Tendering or Quotation procedures shall not apply to the disposal of: (a) any matter in respect of which a fair price can be obtained only by negotiation or

sale by auction as determined (or pre‐determined in a reserve) by the Chief Executive or his nominated officer;

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(b) obsolete or condemned articles and stores, which may be disposed of in

accordance with the Trust’s condemnation policy; (c) items to be disposed of with an estimated sale value of less than £5,000; (d) items arising from works of construction, demolition or site clearance, which

should be dealt with in accordance with the relevant contract; (e) land or buildings concerning which DoH guidance has been issued but subject to

compliance with such guidance. 13 IN HOUSE SERVICES 13.1 In all cases where the Board of Directors determines that in‐house services should be

subject to competitive tendering the following groups shall be set up: (a) Specification group, comprising the Chief Executive or nominated officer(s) and

specialist(s). (b) In‐house tender group, comprising representatives of the in‐house team, a

nominee of the Chief Executive and technical support. (c) Evaluation group, comprising normally a specialist officer, a supplies officer and a

Director of Finance representative. For services having a likely annual expenditure exceeding £250,000, a non‐executive director should be a member of the evaluation team.

13.2 All groups should work independently of each other but individual officers may be a

member of more than one group. No member of the in‐house tender group may, however, participate in the evaluation of tenders.

13.3 The evaluation group shall make recommendations to the Board of Directors. 13.4 The Chief Executive shall nominate an officer to oversee and manage the contract. 14 CUSTODY OF SEAL AND SEALING OF DOCUMENTS 14.1 Custody of Seal

The Common Seal of the Trust shall be kept by the Company Secretary in a secure place.

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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 (or an officer nominated by him) and authorised and countersigned by the Chief Executive (or an officer nominated by him). Officers nominated to approve the use of the seal on behalf of either the Director of Finance or Chief Executive 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, description of the document, date of sealing, and the directors authorising the use of the seal).

15 SIGNATURE OF DOCUMENTS 15.1 Where the signature of any document will be a necessary step in legal proceedings

involving the Trust, it shall be signed by the Chief Executive, unless any enactment otherwise requires or authorises, or the Board of Directors shall have given the necessary authority to some other person for the purpose of such proceedings.

15.2 The Chief Executive or nominated officers shall be authorised, by resolution of the Board of

Directors, to sign on behalf of the Trust any agreement or other document (not required to be executed as a deed) the subject matter of which has been approved by the Board of Directors or committee or sub‐committee to which the Board of Directors has delegated appropriate authority.

16 MISCELLANEOUS 16.1 Standing Orders to be given to Directors and Officers

It is the duty of the Chair to ensure that existing Governors and all new Directors are notified of and understand their responsibilities within SOs and SFIs. Updated copies shall be issued to Directors designated by the Chair. New Directors shall be informed in writing and shall receive copies where appropriate of SOs.

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16.2 Documents having the standing of Standing Orders Standing Financial Instructions shall have effect as if incorporated into SOs.

16.3 Review of Standing Orders

Standing Orders shall be reviewed annually by the Board of Directors. The requirement for review extends to all documents having the effect as if incorporated in SOs.

17 VARIATION AND AMENDMENT OF STANDING ORDERS 17.1 These Standing Orders shall be amended only if:

(i) at least two‐thirds of the Board of Directors are present; and (ii) a majority of those present, including no fewer than half the total of the Trust’s

non‐executive directors, vote in favour of amendment; and

(iii) the variation proposed does not contravene any statutory provision or direction made by NHS Improvement.

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Annex ‐ TENDERING PROCEDURE 1 INVITATION TO TENDER 1.1 All invitations to submit a tender on a formal competitive basis by utilising the E‐

Tender Portal and shall include:

(a) clear instructions of documentation to complete, including pricing information, technical specifications and business continuity plans

(b) details of the closing date, time and place of receipt of submission with a named lead of who to contact should there be submission problems.

1.2 Extensions of time for the period allowed for receipt of tenders shall only be considered

where no tenders have been received or, if tenders have been received, on the basis that all parties are notified and all agreed to the proposed extension . Suppliers may re‐submit if they wish by the new deadline.

1.3 Each invitation shall include as a minimum (where appropriate) the following:

(a) Instructions to Offer (b) Terms of offer including Evaluation Criteria (c) Specification of goods/service (d) Terms and conditions of contract as appropriate. (e) Offer schedule(s) (f) Form of offer

1.4 Other than in exceptional circumstances, all preparation in relation to the specification

and the evaluation of product should be conducted prior to invitation to tender. 1.5 Other than in exceptional circumstances, all preparation in relation to the specification

and the evaluation of product should be conducted prior to invitation to tender.

1.6 There shall normally be no contact between Officers of the Trust and the candidates invited to tender in relation to the tender or the proposed contract between the issue of the tender documentation and the award of the contract other than via the use of the Electronic Portal to:‐

(a) clarify questions relating to the specification, or (b) clarify questions relating to the completion of the tender documents, or (c) offer all parties invited to tender a briefing on the Trust’s requirements with the

opportunity for the Officers of the Trust and such persons as deemed appropriate and parties invited to tender representatives to ask questions of each other at a meeting arranged by the Trust specifically for this purpose:

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where this happens an electronic record should be made and retained for future inspection, or

(d) arrange trials of supplies and/or equipment.

No clarification by Officers of the Trust shall be sought with candidates in relation to financial matters including pricing until after tenders have been opened.

2 RECEIPT, SAFE CUSTODY AND RECORD OF FORMAL TENDERS 2.1 All communicating with candidates between invitation to tender and receipt of tender

by the Trust shall be channelled through the e‐tendering portal.

2.1.1 Unsuccessful tenderers will be notified via the e‐tendering portal. 2.1.3 All tenders received and associated documents (or copies of) will be retained by

those seeking the tender and stored on the E‐Tendering Portal against the unique Contract reference number for future reference, inspection and audit where required along with the evaluation scoring and details of the evaluation team.

2.1.4 By utilising the E‐Tendering Portal procedures shall be adopted to ensure that all tenders received are retained in the secure electronic Portal and remain unopened until such time as they are officially opened which shall be as soon as is reasonably practicable following the latest date and time set for receipt of tenders.

2.2 The tenders will be opened and recorded electronically in the e‐tendering portal by two Procurement officers.

2.3 Where examination of tenders reveals errors which would affect the tender figure,

the tenderer is to be given details of such errors and afforded the opportunity of confirming or withdrawing his offer.

2.4 Where the lowest tender submitted is so much below the estimate it prompts doubts

as to whether an error has been made in tendering, especially where it differs substantially from the other tenders, confirmation of price may be sought from the tenderer via the e‐tendering portal without disclosing that it is the lowest tenderer, and an assurance that the contractual arrangements and technical documentation have been fully understood. If the tenderer has made an error, he may withdraw his tender. If he stands by his original price, it must be decided whether acceptance would carry too great a risk of subsequent failure before establishing an order of preference.

2.5 Where only one tender/quotation is received the Trust shall, as far as practicable,

ensure that the price to be paid is fair and reasonable.

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2.6 Wherever the invitation to tender does not demonstrate sufficient competition by reason of an inadequate response to the invitation, the supervising officer/project manager concerned shall set up a fresh competition, and all tenderers submitting a tender from the original invitation shall be invited to re‐tender.

3 WORKS TENDERS

3.1 Every tender for building and engineering works, except for maintenance work only

where Estmancode guidance should be followed, shall embody or be in the terms of the current edition of either the appropriate Joint Contracts Tribunal (JCT) or Department of the Environment (GC/Wks) standard forms of contract or NEC3 form of contract amended to comply with Concode. When the content of the works is primarily engineering, tenders shall embody or be in the terms of the General Conditions of Contract recommended by the Institutions of Mechanical Engineers, Electrical Engineers and the Association of Consulting Engineers (Form A) or, in the case of civil engineering work, the General Conditions of Contract recommended by the Institution of Civil Engineers. The standard documents should be amended to comply with Concode and, in minor respects, to cover special features of individual projects. Tendering based on other forms of contract may be used only after prior consultation with the DoH.

3.2 Works to a maximum value of £250,000 may alternatively be procured through an agreed Measured Term Contract, based on the provisions of the Joint Contracts Tribunal (JCT) contract form. The current Measured Term Contract award should be renewed in February 2017.

3.3 Works of value greater than £1m may be procured under an EU Public Procurement compliant Procure 22.

4 APPROVED FIRMS

(a) Building and Engineering Construction Works

(i) Invitations to tender shall be via compliant procurement routes in conjunction with the procurement team.

(ii) Suppliers that are successful in winning contracts shall ensure that when

engaging, training, promoting or dismissing employees or in any conditions of employment, shall not discriminate against any person because of colour, race, ethnic or national origins, religion or sex, and will comply with the provisions of current legislation and regulations.

(iii) All Contractors shall conform with the requirements of the Health and Safety at

Work Act etc. 1974, Management of Health & Safety at Work Regulations 1999

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and any amending and/or other related legislation concerned with the Health, Safety and Welfare of workers and other persons, and to any relevant British Standard Code of Practice issued by the British Standard Institution and the Construction (Design & Management) Regulations 2015. Contractors are legally required to provide to the appropriate Estates & Facilities manager a copy of its safety policy and evidence of the safety of plant and equipment, when requested and associated Risk Assessment & Method Statement pertinent to specific projects commensurate with standard Health & Safety methodology.

(b) Financial Standing and Technical Competence of Contractors

The Director of Finance may make or institute any enquiries he deems appropriate concerning the financial standing and financial suitability of approved contractors. The Director of Estates and Facilities will similarly make such enquiries as is felt appropriate to be satisfied as to their technical competence.

5 NEGOTIATED TENDERS 5.1 The use of a negotiated tender leading to a 'continuation' or 'run‐on' contract may be

appropriate where the need arises for additional work which, if authorised as variation on the existing contract or let to another contractor would be undesirable or unduly disruptive and expensive. This situation can arise in two circumstances:

(a) when the need is for further work of a similar nature to that already being

executed and normally on the same or a closely adjoining site; and (b) when the need is for alteration to the works executed in the original contract

which it is important should be carried out by the same contractor in order to safeguard the Trust's rights with regard to defects in the works.

5.2 The following criteria must be observed when considering the use of negotiated tender

procedure:

(a) The initial contract must have been awarded as a result of competitive tendering.

(b) The new work must not be of a disproportionately high value (i.e. as a general

rule not more than 50%) in relation to the value of the initial contract.

(c) For further work of a similar nature a high proportion (at least 60%) of the value of the new work must be covered by rates included in the initial contract that can be used as basis of negotiation of new rates.

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(d) For alteration works, the rates must be based as far as practicable on the same fundamental costing data used for rates in the initial contract.

(e) The aggregate value of contracts awarded for additional works may not exceed

50% of the value of the original contract.

(f) During the negotiations the contractor's agreement must be obtained that the addition of further work will not later be raised by him as a ground for a claim for disruption of the initial contract. (The costs of any necessary reorganisation of the initial contract so as to accommodate the further work must be raised during the negotiations and, if agreed, included in the negotiated amount).

(g) At the conclusion of the negotiations the Trust must have reasonable evidence

to show that the negotiated amount is no less favourable than a freshly obtained competitive tender would be.

(h) The procedure must not be used simply to recover time lost during the initial

contract or as a means of bringing forward a later scheme, or as a substitute for good planning.

(i) The details of the further work should be fully prepared and meet the normal

requirements of readiness to proceed to tender.

(j) The timetable for the negotiations should be linked with the planning of capital expenditure so that this does not place any additional constraint on the Trust's freedom of action.

6 TENDERS NOT STRICTLY IN ACCORDANCE WITH SPECIFICATION 6.1 Tenders not strictly in accordance with the specification may be considered if a marked

financial advantage to the Trust would otherwise be lost. A marked financial advantage is a saving in excess of £1000 or 1% of the tender price, whichever is the greater.

6.2 Provided there is no reason to doubt the bona fides of the tenderer, the lowest tenderer

to specification may be asked to revise his tender to conform to the revised specification.

6.3 If he is willing to do so but refuses to abide by his original price, his tender must be

rejected. 6.4 If he declines to revise his tender to conform with the specification then, in the case of

professional Services Contracts or Supplies Contracts, post tender negotiations may be undertaken in accordance with the procedures below. Otherwise his tender should be rejected and the second lowest (or second highest in the case of a sale) should be

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considered. 6.5 If so many of the tenderers fail to conform with the specification that the whole basis of

the competition is invalidated or post tender negotiations do not take place then consideration should be given to re‐commencing competition and inviting further tenders.

7 POST TENDER NEGOTIATION 7.1 At any time prior to acceptance of a tender by the Trust the Chief Executive or any

officer authorised by him, may authorise post tender negotiations if it appears that a marked financial advantage as defined above may accrue to the Trust, or, if subsequently there has been a bona fide change in specification which is not so significant as to warrant abandonment of the procedure and the invitation of further tenders.

7.2 Where the negotiation is carried out by officers of the Trust each tenderer shall be

notified that the Trust wishes to enter into post tender negotiations, and at least each of the three lowest (or highest in the case of a sale) tenderers, or all the tenderers if less than three submitted valid tenders, shall be invited to attend a separate meeting at the Trust's offices (unless an adverse financial report has been received from the Director of Finance in respect of any tenderer, in which case that tenderer shall be excluded from the invitation). At each such meeting the Trust shall be represented by at least two officers, one of whom shall write a minute of the meeting, which, as soon as practicable thereafter, shall be confirmed as correct by the other officer and each tenderer shall be given equal opportunity on an equal footing insofar as it is reasonably practicable to negotiate his tender, whether as to price, quality or in any other respect. Negotiations with each tenderer may continue over a series of meetings and any amendment finally negotiated shall be confirmed by the tenderer in writing to the Trust.

7.3 The time during which all negotiations shall be completed by receipt of written

confirmation of any amendments shall be specified in the invitation referred to in 8.2 above and may be extended by notice in writing from the Trust to all tenderers at any time.

7.4 Post tender negotiation in relation to Estates contracts shall only take place in

accordance with the guidance given in the current edition of the Code of Procedure Single Stage Selective Tendering issued by the National Joint Consultative Committee for Building.

7.5 Upon the expiration of the time for negotiation, or any extended period, any amended

tender shall be considered in accordance Section 4 on the Acceptance of Tenders.

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8 PRESERVATION AND DESTRUCTION OF DOCUMENTS 8.1 Estates' Tenders

Documents relating to the successful tender shall not be destroyed. Documents relating to unsuccessful tenders will be destroyed after six successive financial years following the financial year of origin.

8.2 Supply of Goods and Services

Documents relating to the successful tender shall not be destroyed. Documents relating to unsuccessful tenders will be destroyed six years after the end of the financial year of origin.

9 FORMS OF CONTRACT 9.1 Supplies contracts may be executed under hand. 9.2 An Official Order or Letter of Acceptance will be sent to the successful tenderer in

respect of contracts for estates services up to and including £250,000 in value. In the case of estates services which exceed £250,000 in value but do not exceed £500,000, contracts may be executed underhand.

9.3 Those exceeding £500,000 in value will be executed under the Common Seal of the

Trust. 9.4 Every contract for building and engineering works (except contracts for maintenance

work only, where Estmancode guidance should be followed) shall embody or be in the same terms and conditions of contract as those on the basis of which tenders were invited.

9.5 In the case of Consultants' commissioning agreements relating to building and

engineering works, to which a professional service contract for consultant design services relates, the contract shall be evidenced in writing, so far as is possible having regard to the custom and practice of the profession concerned.

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Appendix 1. Temporary COVID19 Business Continuity Terms of Reference Trust Board, Board Committee and Governor Meetings March 2020

Standing Orders: Emergency Powers The powers which the Board has reserved to itself within its Standing Orders may in emergency or for an urgent decision be exercised by the Chief Executive and the Chairman. The exercise of such powers by the Chief Executive and Chairman shall be reported to the next formal meeting of the Trust Board in public session for formal ratification as per section 6.2 of current Standing Orders. 1. The Terms of Reference and Membership, including quorum arrangements, for the Board

and its Committees will be temporarily suspended as of 17th March 2020, until further notice. All other aspects of the Trust Standing orders remains unchanged.

2. During this period, if meetings are to be held, then this will be done through the use of telephone / digital technology.

3. The primary focus of communication with the Board and sub committees will be the organisation’s response to COVID19 whilst continuing to have an overview on the safety of all DBTH patients and the wellbeing of staff. The governance assurance for this overview will be provided through the Trusts COVID19 Strategic Management plan.

4. Whilst some effort will be made to continue aspects of ‘business as usual’ activity, based upon the existing business cycles / forward agenda:

a) All matters for approval will be either:

‐ Deferred if not urgent or ‐ Circulated to Board / Committee members via email for approval, whilst

allowing sufficient time for review / response or ‐ Discussed via telephone / digital technology with the decision recorded by

Corporate Governance or ‐ Discussed between the Chief Executive or nominated Executive Director with

the Board / Committee chair for Chairs Action

b) In these circumstances the quorum will be two Executive Directors (CEO and DeputyCEO or DoF) and two Non‐Executive Directors (Chair or Vice Chair and one other).

5. It is likely that those responsible for preparing assurance papers for Committees and the

Board will not be in a position to do so. Therefore:

a) All matters for information or assurance will be either:

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‐ Put on hold until further notice or ‐ Circulated via email

6. For ad hoc items agreed by the Executive Directors as requiring a decision by the Board:

‐ Circulated to Board / Committee members via email for approval, whilst allowing sufficient time for review / response or

‐ Discussed via telephone / digital technology with the decision recorded by Corporate Governance

‐ Discussed between the Chief Executive or nominated Executive Director with the Board / Committee chair for Chairs Action

c) In these circumstances the quorum will be two Executive Directors (CEO and DeputyCEO

or DoF) and two Non‐Executive Directors (Chair or Vice Chair and one other). 7. The Business Cycles will be reviewed and updated within Corporate Governance, to

maintain an accurate record of items considered / approved or deferred.

8. Council of Governors meeting (including Governor Forum and Governor Briefing) have been put on hold until further notice. The Chair and Company Secretary will keep the Governors informed as required. For example, the Governors will be forwarded a copy of this paper after it is approved at Board on 21 April 2020. The Chair will also contact the lead and deputy lead Governors as required to keep them in the picture.

9. Council of Governor elections – In view of the pressure on the Trust due to COVID19 the

recruitment campaign has been suspended (approved at Board 21 March 2020). Social distancing 'rules' make meaningful engagement with prospective governors impossible at the moment, and for the next few weeks, possibly months. COVID19 permitting, the proposal is to pick up planning for the election in June before current governor terms end and set a schedule to run an election around October. All governors will be able to continue until the end of their current term and those who are eligible will be able to apply to be re‐elected once the timetable has been set in the autumn. This proposal will be reviewed in June in the light of COVID19 issues at that time.

10. The Chairs Appraisal will take place to meet the NHS Providers deadline of 30 June 2020. The Non‐Executive Directors appraisals will take place to meet the NHS Providers deadline of 30 September 2020.

11. These COVID19 temporary terms of reference are an addendum to the Trusts current

Standing Orders CORP/FIN1 (A) v9 and if it is silent on a matter then the Trusts Standing orders should be referred and complied with.

Date Approved: 21/4/2020 (Board of Directors) Date for Review: 21/4/2021

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APPENDIX 1 ‐ EQUALITY IMPACT ASSESSMENT PART 1 INITIAL SCREENING

Service/Function/Policy/Project/ Strategy

CSU/Executive Directorate and Department

Assessor (s) New or Existing Service or Policy?

Date of Assessment

Standing Orders Board of Directors 2020 – CORP/FIN 1 (A) v10

CE/Finance Jon Sargeant/Matthew Bancroft

Existing Policy June 2020

1) Who is responsible for this policy? Name of CSU/Directorate – Finance Department

2) Describe the purpose of the service / function / policy / project/ strategy? Who is it intended to benefit? What are the intended outcomes? To provide standing orders for the Board and a framework for the delegation of powers from the Board.

3) Are there any associated objectives? Legislation, targets national expectation, standards No

4) What factors contribute or detract from achieving intended outcomes? – Compliance with the policy

5) Does the policy have an impact in terms of age, race, disability, gender, gender reassignment, sexual orientation, marriage/civil partnership, maternity/pregnancy and religion/belief? Details: [see Equality Impact Assessment Guidance] ‐ No

If yes, please describe current or planned activities to address the impact [e.g. Monitoring, consultation] – N/A

6) Is there any scope for new measures which would promote equality? [any actions to be taken] N/A

7) Are any of the following groups adversely affected by the policy? No

Protected Characteristics Affected? Impact

a) Age No

b) Disability No

c) Gender No

d) Gender Reassignment No

e) Marriage/Civil Partnership No

f) Maternity/Pregnancy No

g) Race No

h) Religion/Belief No

i) Sexual Orientation No

8) Provide the Equality Rating of the service / function /policy / project / strategy – tick () outcome box

Outcome 1 Outcome 2 Outcome 3 Outcome 4 *If you have rated the policy as having an outcome of 2, 3 or 4, it is necessary to carry out a detailed assessment and complete a Detailed Equality Analysis form in Appendix 4

Date for next review: June 2021

Checked by: Jon Sargeant/Matthew Bancroft Date: June 2020

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Standing Financial Instructions July 2020


Name and title of author/reviewer: Jon Sargeant – Director of Finance



Date of approval:

Date issued:



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Standing Financial Instructions

Amendment Form

Please record brief details of the changes made alongside the next version number. If the procedural document has been reviewed without change, this information will still need to be recorded although the version number will remain the same.

Version

Date Issued

Brief Summary of Changes Author

Version 8 July 2020 Updated job titles throughout

Updated the NHS Logistics provider details

Updated references to NHSI/NHSE throughout.

Updated references to procurement legislation and the impact of leaving the EU

Updated references to “Estatecode”

Updated references to “NHSLA”

Matthew Bancroft

Version 7 March 2019 Updated names of structures/meetings

Updated sections relating to PBL, Data Protection, Health & Safety and budget virements.

Jon Sargeant

Version 6

30 January 2018

Updated sections on Audit, Budgets, funded/ budgeted establishment, Banking, Payment of Directors and Employees, Non Pay Expenditure, Funds Held on Trust

Procurement and Tendering Appendix added

Winston Weir

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Contents

Page No. 1. INTRODUCTION ................................................................................................................................ 6

1.1. General ................................................................................................................................ 6 1.2. Terminology ........................................................................................................................ 6 1.3. Responsibilities and Delegation .......................................................................................... 7

2. AUDIT................................................................................................................................................ 9 2.1 Audit and Risk Committee ................................................................................................... 9 2.2 Fraud and Corruption ........................................................................................................ 10 2.3 Security Management ....................................................................................................... 10 2.4 Director of Finance ............................................................................................................ 11 2.5 Role of Internal Audit ........................................................................................................ 11 2.6 External Audit .................................................................................................................... 12

3. PRUDENTIAL BORROWING REQUIREMENT CONTROL ................................................................... 12 4. BUSINESS PLANNING, BUDGETS, BUDGETARY CONTROL, AND MONITORING ............................. 12

4.1 Preparation and Approval of Business Plans and Budgets ................................................ 13 4.2 Budgetary Delegation ........................................................................................................ 13 4.3 Budgetary Control and Reporting ..................................................................................... 14 4.4 Capital Expenditure ........................................................................................................... 15 4.5 Monitoring Returns ........................................................................................................... 15

5. ANNUAL ACCOUNTS AND REPORTS ............................................................................................... 15 6. BANK AND GOVERNMENT BANKING SERVICE ACCOUNTS ............................................................ 15

6.1 General .............................................................................................................................. 16 6.2 Bank and Government Banking Service Accounts ............................................................ 16 6.3 Banking Procedures ........................................................................................................... 16 6.4 Tendering and Review ....................................................................................................... 17

7. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS .......................................................................................................... 17 7.1 Income Systems ................................................................................................................. 17 7.2 Fees and Charges ............................................................................................................... 17 7.3 Debt Recovery ................................................................................................................... 17 7.4 Security of Cash, Cheques and Other Negotiable Instruments ......................................... 18

8. CONTRACTING FOR PROVISION OF SERVICES ................................................................................ 18 9. TERMS OF SERVICE AND PAYMENT OF DIRECTORS AND EMPLOYEES ........................................... 19

9.1 Remuneration and Terms of Service ................................................................................. 19 9.2 Funded/ Budgeted Establishment ..................................................................................... 19 9.3 Staff Appointments ........................................................................................................... 20 9.4 Processing of Payroll .......................................................................................................... 20 9.5 Contracts of Employment ................................................................................................. 21 9.6 Directors and Staff Expenses ............................................................................................. 21

10. NON‐PAY EXPENDITURE ................................................................................................................. 22 10.1 Delegation of Authority ..................................................................................................... 22 10.2 Choice, Requisitioning, Ordering, Receipt and Payment for Goods and Services ............ 22 10.3 Legally Binding Agreements (e.g. leases) .......................................................................... 25 10.4 Grants to Local Authorities and Voluntary Bodies ............................................................ 26

11. EXTERNAL BORROWING AND INVESTMENTS ................................................................................ 26 11.1 External Borrowing ............................................................................................................ 26 11.2 Investments ....................................................................................................................... 26

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12. CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS ............................................................................................................................................ 27 12.1 Capital Investment ............................................................................................................ 27 12.2 Private Finance .................................................................................................................. 28 12.3 Asset Registers .................................................................................................................. 30 12.4 Security of Assets .............................................................................................................. 30

13. STORES AND RECEIPT OF GOODS ................................................................................................... 32 14. DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS ........................................ 33

14.1 Disposals and Condemnations .......................................................................................... 33 14.2 Losses and Special Payments ............................................................................................ 34

15. INFORMATION TECHNOLOGY ........................................................................................................ 35 16. PATIENTS' PROPERTY ..................................................................................................................... 36 17. FUNDS HELD ON TRUST .................................................................................................................. 37

17.1 Introduction ...................................................................................................................... 37 17.2 Existing Trusts .................................................................................................................... 37 17.3 New Trusts ......................................................................................................................... 38 17.4 Sources of New Funds ....................................................................................................... 38 17.5 Investment Management .................................................................................................. 39 17.6 Disposition Management .................................................................................................. 39 17.7 Banking Services ................................................................................................................ 40 17.8 Asset Management ........................................................................................................... 40 17.9 Reporting ........................................................................................................................... 40 17.10 Accounting and Audit ........................................................................................................ 40 17.11 Administration Costs ......................................................................................................... 41 17.12 Taxation and Excise Duty................................................................................................... 41 17.13 Authorisation Levels of Expenditure from Trust Funds .................................................... 41

18. RETENTION OF DOCUMENTS ......................................................................................................... 41 19. RISK MANAGEMENT & INSURANCE ............................................................................................... 42

19.1 Programme of Risk Management ..................................................................................... 42 19.2 Insurance: Risk Pooling Schemes Administered by NHS Resolution ................................. 42 19.3 Insurance Arrangements with Commercial Insurers ......................................................... 42 19.4 Arrangements to be Followed by The Board in Agreeing Insurance Cover ...................... 43

20. ACCEPTANCE OF GIFTS BY STAFF AND LINK TO STANDARDS OF BUSINESS CONDUCT ................. 43 APPENDIX 1 ‐ INVESTMENTS ....................................................................................................................... 44 APPENDIX 2 – SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS ........................... 45 APPENDIX 3 – BUDGETARY VIREMENT........................................................................................................ 46 APPENDIX 4 ‐ PROCUREMENT AND TENDERING ......................................................................................... 47 APPENDIX 5 ‐ Equality Impact assessment part 1 initial screening ............................................................. 52

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FOREWORD

NHS Foundation Trusts need to agree Standing Orders (SOs) for the regulation of their proceedings and business. The Board of Directors are also required to adopt schedules of reservation of powers and delegation of powers.

The documents, together with Standing Financial Instructions, provide a regulatory framework for the business conduct of the Trust. They fulfil the dual role of protecting the Trust's interests and protecting staff from any possible accusation that they have acted less than properly.

The Standing Orders, Delegated Powers and Standing Financial Instructions provide a comprehensive business framework. All executive and non‐executive directors, and all members of staff, should be aware of the existence of these documents and, where necessary, be familiar with the detailed provisions.

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1. INTRODUCTION

1.1. General

1.1.1. These Standing Financial Instructions (SFIs) detail the financial responsibilities, policies and procedures adopted by the Trust. They are designed to ensure that its financial transactions are carried out in accordance with the law and Government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. They should be used in conjunction with the Schedule of Decisions Reserved to the Board and the Scheme of Delegation adopted by the Trust. They shall have effect as if incorporated in the Standing Orders (SOs) of the Trust.

1.1.2. These SFIs identify the financial responsibilities which apply to everyone working for the Trust and its constituent organisations including Trading Units. They do not provide detailed procedural advice. These statements should therefore be read in conjunction with the detailed departmental and financial procedure notes. All financial procedures must be approved by the Director of Finance subject to review by the Finance and Performance Committee.

1.1.3. Should any difficulties arise regarding the interpretation or application of any of the SFIs

then the advice of the Director of Finance must be sought before acting.. The user of these SFIs should also be familiar with and comply with the provisions of the Trust's SOs.

1.1.4. Failure to comply with SFIs and SOs is a disciplinary matter which could result in dismissal.

1.2. Terminology

1.2.1. Any expression to which a meaning is given in Health Service Acts, or in the Financial Directions made under the Acts, shall have the same meaning in these instructions; and

“the Board” means the board of directors as constituted in accordance

with the Trust Constitution;

"Budget" means a resource, expressed in financial terms, proposed by the Board for the purpose of carrying out, for a specific period, any or all of the functions of the Trust;

"Budget Holder" means the director or employee with delegated authority to manage finances (Income and Expenditure) for a specific area of the organisation;

“Chairman” means the chairman of the Trust appointed in accordance with the Trust Constitution;

“Chief Executive” means the Chief Executive Officer of the Trust appointed in accordance with the terms of the Trust Constitution;

"Constitution" means the Trust Constitution and all annexes to it;

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“Director” means a director on the Board of Directors;

“Director of Finance” means the Chief Finance Officer of the Trust;

“Executive Director” means an executive director of the Trust appointed in accordance with the Trust Constitution;

“Funds held on Trust” means those funds which the Trust holds at its date of incorporation, receives on distribution by statutory instrument or chooses to accept under powers derived under S.90 of the 2006 Act;

“Legal Adviser" means the properly qualified person appointed by the Trust to provide legal advice;

“NHS Improvement” means the body corporate known as NHS Improvement;

“Nominated Officer” means an officer charged with the responsibility for discharging specific tasks within the SOs and SFIs;

“Officer” means an employee of the Trust;

“SOs” means Standing Orders;

“the Trust” means Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust.

1.2.2. Wherever the title Chief Executive, Director of Finance, or other nominated officer is used in

these instructions, it shall be deemed to include such other director or employees who have been duly authorised to represent them.

1.2.3. Wherever the term "employee" is used and where the context permits it shall be deemed to include employees of third parties contracted to the Trust when acting on behalf of the Trust.

1.3. Responsibilities and Delegation

1.3.1. The Board exercises financial supervision and control by:

(a) formulating the financial strategy;

(b) requiring the submission and approval of budgets within approved overall income;

(c) defining and approving essential features in respect of important procedures and financial systems (including the need to obtain value for money); and

(d) defining specific responsibilities placed on directors and employees as indicated in the Scheme of Delegation document.

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1.3.2. The Board has resolved that certain powers and decisions may only be exercised by the

Board in formal session. These are set out in the ’Reservation of Powers to the Board’ document.

1.3.3. The Board will delegate responsibility for the performance of its functions in accordance with the Scheme of Delegation document adopted by the Trust.

1.3.4. Within the SFIs, it is acknowledged that the Chief Executive is ultimately accountable to the

Board and as Accountable Officer to NHS Improvement, for ensuring that the Board meets its obligation to perform its functions within the available financial resources. The Chief Executive has overall executive responsibility for the Trust's activities, is responsible to the Board for ensuring that its financial obligations and targets are met and has overall responsibility for the Trust’s system of internal control.

1.3.5. The Chief Executive and Director of Finance will, as far as possible, delegate their detailed

responsibilities but they remain accountable for financial control.

1.3.6. It is a duty of the Chief Executive to ensure that existing directors and employees and all new appointees are notified of and understand their responsibilities within these Instructions.

1.3.7. The Director of Finance is responsible for:

(a) implementing the Trust's financial policies and for co‐ordinating any corrective action necessary to further these policies;

(b) maintaining an effective system of internal financial control including ensuring that detailed financial procedures and systems incorporating the principles of separation of duties and internal checks are prepared, documented and maintained to supplement these instructions;

(c) ensuring that sufficient records are maintained to show and explain the Trust's transactions, in order to disclose, with reasonable accuracy, the financial position of the Trust at any time;

And, without prejudice to any other functions of directors and employees to the Trust, the duties of the Director of Finance include:

(d) the provision of financial advice to the Trust and its directors and employees;

(e) the design, implementation and supervision of systems of internal financial control; and

(f) the preparation and maintenance of such accounts, certificates, estimates, records and reports as the Trust may require for the purpose of carrying out its statutory duties.

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1.3.8. All directors and employees, severally and collectively, are responsible for:

(a) the security of the property of the Trust;

(b) avoiding loss;

(c) exercising economy and efficiency in the use of resources; and (d) conforming with the requirements of Standing Orders, Standing Financial Instructions,

Financial Procedures and the Scheme of Delegation. 1.3.9 Any contractor or employee of a contractor who is empowered by the Trust to commit the

Trust to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Chief Executive to ensure that such persons are made aware of this.

1.3.10 For any and all directors and employees who carry out a financial function, the form in

which financial records are kept and the manner in which directors and employees discharge their duties must be to the satisfaction of the Director of Finance.

2. AUDIT

2.1 Audit and Risk Committee

2.1.1 In accordance with Standing Orders and the Audit Code for Foundation Trusts, the Board shall formally establish an Audit Committee, with clearly defined terms of reference and following guidance from the NHS Audit Committee Handbook.

The Board has established the Audit and Risk Committee to perform the role of the Audit

Committee along with additional responsibilities in relation to risk management and assurance. The sub‐committee will provide an independent and objective view of internal controls and risk management by:

(a) overseeing Internal and External Audit services;

(b) reviewing all internal audit reports;

(c) reviewing financial and information systems and monitoring the integrity of the financial statements and reviewing significant financial reporting judgments;

(d) monitoring compliance with Standing Orders and Standing Financial Instructions;

(e) ensuring that there are adequate arrangements in place for countering fraud and reviewing the outcomes of counter fraud work;

(f) assessing and providing assurance to the Board on the validity of the control environment within the Trust

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(g) reviewing schedules of losses and compensations and making recommendations to the Board;

(a) reviewing controls assurance systems, including disseminating relevant information to governors; and

(b) reviewing risk management arrangements.

The Board shall satisfy itself that at least one member of the committee has recent and relevant financial experience.

2.1.2 Where the committee feel there is evidence of ultra vires transactions, evidence of

improper acts, or if there are other important matters that the committee wish to raise, the chairman of the committee should raise the matter at a full meeting of the Board. Exceptionally, the matter may need to be referred to NHS Improvement. (To the Director of Finance in the first instance.)

2.1.3 It is the responsibility of the Director of Finance to ensure an adequate internal audit service

is provided and the committee shall be involved in the selection process when an internal audit service provider is changed.

2.2 Fraud and Corruption

2.2.1 In line with their responsibilities, the Chief Executive and Director of Finance shall monitor and ensure compliance with directions on fraud and corruption.

2.2.2 The Trust shall nominate a suitable person to carry out the duties of the Local Counter

Fraud Specialist (LCFS). 2.2.3 The LCFS shall report to the Director of Finance and shall work with staff in the NHS

Counter Fraud Authority.

2.2.4 The Local Counter Fraud Specialist will provide a written report to the Audit and Risk Committee, at least annually, on counter fraud work within the Trust and national context.

2.3 Security Management

2.3.1 The Chief Executive will monitor and ensure compliance with directions on NHS security

management. 2.3.2 The Board shall nominate a suitable person to carry out the duties of the Local Security

Management Specialist (LSMS). 2.3.3 The Chief Executive has overall responsibility for controlling and coordinating security.

However, key tasks are delegated by the Chief Executive to the Director responsible for Security Management (SMD) and the appointed Local Security Management Specialist (LSMS).

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2.3.4 The LSMS shall work with the staff in NHS Counter Fraud Authority. 2.3.5 The LSMS will provide a written report, at least annually, to the Audit and Risk Committee

on security management work within the Trust.

2.4 Director of Finance

2.4.1 The Director of Finance is responsible for;

(a) ensuring there are arrangements to review, evaluate and report on the effectiveness of internal financial control including the establishment of an effective internal audit function;

(b) ensuring that the internal audit is adequate and meets the mandatory audit standards;

(c) deciding at what stage to involve the police in cases of fraud, misappropriation, and other irregularities;

(d) ensuring that an annual internal audit report is prepared for the consideration of the Audit and Risk Committee and the Board. The report must cover:

(i) a clear statement on the effectiveness of internal control, (ii) major internal financial control weaknesses discovered, (iii) progress on the implementation of internal audit recommendations, (iv) progress against plan over the previous year, (v) strategic audit plan covering the coming three years, (vi) a detailed plan for the coming year. 2.4.2 The Director of Finance or designated auditors are entitled without necessarily giving prior

notice to require and receive:

(a) access to all records, documents and correspondence relating to any financial or other relevant transactions, including documents of a confidential nature;

(b) access at all reasonable times to any land, premises or employee of the Trust;

(c) the production of any cash, stores or other property of the Trust under an employee’s control; and

(d) explanations concerning any matter under investigation.

2.5 Role of Internal Audit

2.5.1 Internal audit will provide an independent and objective opinion on risk management, control and governance arrangements by measuring and evaluating their effectiveness. The Head of Internal Audit will provide an annual opinion on the whole system of internal control.

2.5.2 Internal audit will review, appraise and report upon:

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(a) the extent of compliance with, and the financial effect of, relevant established policies, plans and procedures;

(b) the adequacy and application of financial and other related management controls;

(c) the integrity, reliability and suitability of financial and other related management data;

(d) the extent to which the Trust’s assets and interests are accounted for and safeguarded from loss of any kind, arising from:

(i) fraud and other offences, (ii) waste, extravagance, inefficient administration, (iii) poor value for money or other causes. 2.5.3 Whenever any matter arises which involves, or is thought to involve, irregularities

concerning cash, stores, or other property or any suspected irregularity in the exercise of any function of a pecuniary nature, the Director of Finance must be notified immediately.

2.5.4 The Head of Internal Audit will normally attend Audit and Risk Committee meetings and has

a right of access to all committee members, the Chairman and Chief Executive of the Trust. 2.5.5 The Head of Internal Audit shall be accountable to the Audit and Risk Committee. The

reporting system for internal audit shall be agreed between the Director of Finance, the Audit and Risk Sub‐Committee and the Head of Internal Audit. The agreement shall be in writing and shall comply with the best practice guidance on reporting contained in the NHS Internal Audit Manual. The reporting system shall be reviewed at least every 3 years.

2.6 External Audit

2.6.1 The external auditor is appointed by the Council of Governors and paid for by the Trust, in

accordance with paragraph 35 of the Constitution. The auditor must be a member of one or more of the bodies referred to in paragraph 11, Annex 6 of the Constitution.

2.6.2 The Council of Governors must ensure that the auditor meets the criteria included by the Code of Audit Practice issued by the National Audit Office (NAO) on behalf of the Comptroller and Auditor General at the date of appointment and on an ongoing basis throughout the term of their appointment.

3. PRUDENTIAL BORROWING REQUIREMENT CONTROL

No longer required

4. BUSINESS PLANNING, BUDGETS, BUDGETARY CONTROL, AND MONITORING

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4.1 Preparation and Approval of Business Plans and Budgets

4.1.1 The Chief Executive will compile and submit to the Board an annual business plan which takes into account financial targets and forecast limits of available resources. The annual business plan will contain:

(a) a statement of the significant assumptions on which the plan is based;

(b) details of major changes in workload, delivery of services or resources required to achieve the plan.

4.1.2 In addition the Director of Finance will annually compile, and submit to the Board, such

financial plans as required by NHS Improvement 4.1.3 Prior to the start of the financial year the Director of Finance will, on behalf of the Chief

Executive, prepare and submit budgets for approval by the Board. Such budgets will:

be in accordance with the aims and objectives set out in the annual business plan;

accord with workload and staffing plans;

be produced following discussion with appropriate budget holders;

be prepared within the limits of available funds;

identify potential risks; and

comply with NHS Improvement requirements and other regulations 4.1.4 The Director of Finance shall monitor financial performance against budget and business

plan monthly and report to the Board and Financial Oversight Committee appropriately. 4.1.5 All budget holders must provide information in a timely manner as required by the Director

of Finance to enable budgets to be compiled. 4.1.6 All Budget Holders will sign up to their allocated Budgets at the commencement of each

financial year. 4.1.7 The Director of Finance has a responsibility to ensure that adequate training is delivered on

an on‐going basis to budget holders to help them manage successfully.

4.2 Budgetary Delegation

4.2.1 The Chief Executive may delegate the management of a budget to permit the performance of a defined range of activities. This delegation must be in writing and be accompanied by a clear definition of:

(a) the amount of the budget;

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(b) the purpose(s) of each budget heading; (c) individual and group responsibilities; (d) authority to exercise virement; (e) achievement of planned levels of service; and (f) the provision of regular reports.

4.2.2 The Chief Executive and delegated budget holders must not exceed the budgetary total or

virement limits set by the Board. 4.2.3 Any budgeted funds not required for their designated purpose(s) revert to the immediate

control of the Chief Executive, subject to any authorised use of virement. 4.2.4 Non‐recurring budgets should not be used to finance recurring expenditure without the

authority in writing of the Chief Executive, as advised by the Director of Finance. In defining what is either non‐recurring or recurring the Director of Finance will have the final decision.

4.3 Budgetary Control and Reporting

4.3.1 The Director of Finance will devise and maintain systems of budgetary control. These will include:

(a) monthly financial reports to the Board in a form approved by the Board containing:

income and expenditure to date showing trends, forecast year‐end position, and variances against budget;

balance sheet;

cashflow;

movements in working capital;

capital project spend and projected outturn against plan;

explanations of any material variances from plan; movements in reserves;

details of any corrective action where necessary and the Chief Executive's and/or Director of Finance’s view of whether such actions are sufficient to correct the situation;

(b) the issue of timely, accurate and comprehensible advice and financial reports to each

budget holder, covering the areas for which they are responsible;

(c) investigation and reporting of variances from financial, workload and staffing budgets;

(d) monitoring of management action to correct variances; and

(e) arrangements for the authorisation of budget transfers or virements. 4.3.2 Each Budget Holder is responsible for ensuring that:

(a) any likely overspending or reduction of income which cannot be met by virement is not incurred without the prior consent of the Board;

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(b) the amount provided in the approved budget is not used in whole or in part for any purpose other than that specifically authorised subject to the rules of virement; and

(c) no permanent employees are appointed without the approval of the Chief Executive other than those provided for in the budgeted establishment as approved by the Board.

4.3.3 Detailed rules relating to budgetary virement are set out in Appendix 3. 4.3.4 The Chief Executive is responsible for identifying and implementing cost improvements and

income generation initiatives in accordance with the requirements of the Annual Business Plan and a balanced budget.

4.4 Capital Expenditure

4.4.1 The general rules applying to delegation and reporting shall also apply to capital

expenditure. (The particular applications relating to capital are contained in Chapter 12.)

4.5 Monitoring Returns

4.5.1 The Chief Executive is responsible for ensuring that the appropriate monitoring forms are submitted to NHS Improvement and other parties as required.

5. ANNUAL ACCOUNTS AND REPORTS

5.1 The Director of Finance, on behalf of the Trust, will:

(a) prepare financial returns in accordance with the accounting policies and guidance given by NHS Improvement, the Trust's accounting policies, Government Accounting Manual and international financial reporting standards (IFRS);

(b) prepare and submit annual financial reports in accordance with current guidelines; and

(c) submit financial returns for each financial year in accordance with the guidance and timetable prescribed by NHS Improvement.

5.2 The Trust's audited annual accounts and auditor’s report and Quality Accounts must be

presented to the Board of Directors for approval or to Audit and Risk Committee by delegation from the Board and to a general meeting of the Council of Governors.

5.3 The Trust will publish an annual report, in accordance with guidelines on local

accountability, and present it at the Annual Members’ Meeting. The document will comply with NHS Improvement’s Annual Reporting Manual (ARM).

6. BANK AND GOVERNMENT BANKING SERVICE ACCOUNTS

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6.1 General

6.1.1 The Director of Finance is responsible for managing the Trust's banking arrangements and for advising the Trust on the provision of banking services and operation of accounts. This advice will take into account guidance/Directions issued from time to time by NHS Improvement.

6.1.2 The Board shall approve the banking arrangements.

6.2 Bank and Government Banking Service Accounts

6.2.1 The Director of Finance is responsible for:

(a) Setting arrangements in place that NHS Shared Business Service compiles with its contract with the organisation for bank and banking services

(b) Commercial bank accounts and accounts operated through the Government Banking

Service (GBS);

(c) establishing separate bank accounts for the Trust's non‐exchequer funds;

(d) ensuring payments made from commercial banks or GBS accounts do not exceed the amount credited to the account except where arrangements have been made; and

(e) reporting to the Board all arrangements made with the Trust's bankers for accounts to

be overdrawn.

6.3 Banking Procedures

6.3.1 The Director of Finance will prepare detailed instructions (agreed with NHS Shared Business

Services) on the operation of commercial bank and GBS accounts which must include:

(a) the conditions under which each commercial bank and GBS account is to be operated;

(b) the limit to be applied to any overdraft; and

(c) those authorised to sign cheques or other orders drawn on the Trust's accounts. 6.3.2 The Director of Finance must advise the Trust's bankers in writing of the conditions under

which each account will be operated. 6.3.3 Payments over £10,000 shall be supported by more than one authorised signature on the

cheque or authority to pay as appropriate. 6.3.4 The Director of Finance shall nominate members of his staff who are authorised to act as

signatories in respect of commercial bank and GBS accounts.

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6.4 Tendering and Review

6.4.1 The Director of Finance will review the banking arrangements of the Trust at regular intervals to ensure they reflect best practice and represent best value for money by periodically seeking competitive tenders for the Trust's banking business.

6.4.2 Competitive tenders should be sought at least every 5 years. The results of the tendering

exercise should be reported to the Board. This review is not necessary for GBS accounts.

7. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS

7.1 Income Systems

7.1.1 The Director of Finance is responsible for designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, collection and coding of all monies due.

7.1.2 The Director of Finance is also responsible for the prompt banking of all monies received.

7.2 Fees and Charges

7.2.1 The Director of Finance is responsible for approving and regularly reviewing the level of all fees and charges other than those determined by the Department of Health or by Statute. Independent professional advice on matters of valuation shall be taken as necessary.

7.2.2 All employees must inform the Director of Finance promptly of money due arising from

transactions which they initiate/deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.

7.2.3 The Director of Finance shall be responsible for implementing any such guidance issued by NHS Improvement in relation to the costing and pricing of services, and in particular services provided to NHS Commissioning bodies.

7.3 Debt Recovery

7.3.1 The Director of Finance is responsible for the appropriate recovery action on all outstanding debts.

7.3.2 Income not received should be dealt with in accordance with losses procedures. 7.3.3 Overpayments should be detected (or preferably prevented) and recovery initiated.

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7.4 Security of Cash, Cheques and Other Negotiable Instruments

7.4.1 The Director of Finance is responsible for:

(a) approving the form of all receipt books, agreement forms, or other means of officially acknowledging or recording monies received or receivable;

(b) ordering and securely controlling any such stationery;

(c) the provision of adequate facilities and systems for employees whose duties include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys, and for coin operated machines; and

(d) prescribing systems and procedures for handling cash and negotiable securities on behalf of the Trust.

7.4.2 Official money shall not under any circumstances be used for the encashment of private

cheques. 7.4.3 All cheques, postal orders, cash etc., shall be banked intact. Disbursements shall not be

made from cash received. 7.4.4 The holders of safe keys shall not accept unofficial funds for depositing in their safes unless

such deposits are in special sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss, and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss. Where receipt of such indemnities is problematic or unclear no such items shall be held in Trust safes.

7.4.5 A cheque and payable order register shall be kept in which all cheque and payable order

stocks ordered, received and issued shall be recorded and signed for by nominated officers.

8. CONTRACTING FOR PROVISION OF SERVICES

8.1 The Chief Executive is responsible for negotiating contracts for the provision of services to patients in accordance with the Business Plan, and for establishing the arrangements for providing extra‐contractual services. In carrying out these functions, the Chief Executive should take into account the advice of the Director of Finance regarding:

(a) costing and pricing of services;

(b) payment terms and conditions; and

(c) amendments to contracts and extra‐contractual arrangements. 8.2 Contracts should be so devised as to minimise risk whilst maximising the Trust's opportunity

to generate income. 8.3 The Director of Finance shall produce regular reports detailing actual and forecast contract

income (linked to contract activity) with a detailed assessment of the impact of the variable elements of income and an assessment of any significant risks faced.

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8.4 This also includes both partnership and provision of facilities arrangements to private

healthcare providers in their provision of health care and diagnostic services to patients.

9. TERMS OF SERVICE AND PAYMENT OF DIRECTORS AND EMPLOYEES

9.1 Remuneration and Terms of Service

9.1.1 In accordance with Standing Orders, the Board shall establish a Nominations and

Remuneration Committee, with clearly defined terms of reference, specifying which posts fall within its area of responsibility, its composition, and the arrangements for reporting.

9.1.2 The Committee will:

(i) Identify and appoint candidates to fill Executive Director positions when they arise.

(ii) Identify and nominate a candidate, for approval by the Council of Governors, to fill the position of Chief Executive.

(iii) Decide any matter relating to the disciplining or the continuation in office of any Executive Director at any time including the suspension or termination of service of an individual as an employee of the Trust.

(iv) Monitor and evaluate the performance of individual Executive Directors on an annual basis.

(v) Decide and review the terms and conditions of office of Executive Directors and senior managers on locally‐determined pay in accordance with relevant Trust policies, including:

a. Salary, including any performance‐related pay or bonus; b. Provisions for other benefits, including pensions and cars; and c. Other allowances.

(vi) Decide all contractual arrangements for Executive Directors, including, but not limited to, termination payments.

9.1.3 The Committee shall report to the Board regarding its recommendations.

9.1.4 The Trust will remunerate the Chairman and Non‐executive Directors in accordance

with instructions issued by the Council of Governors.

9.2 Funded/Budgeted Establishment

9.2.1 The staffing plans incorporated within the annual budget will form the funded / budgeted establishment. The funded/ budgeted establishment will list out the grade, amount, whole time equivalent for the relevant department(s) and must be set out and agreed each

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financial year. 9.2.2 The funded/budgeted establishment of any department may not be varied without the

approval of the Chief Executive and Director of People & OD. 9.2.3 The funded/budgeted establishment of any clinical department will take account of the

required safe levels of clinical staff as necessary for the running of those services.

9.3 Staff Appointments

9.3.1 No director or employee may engage, re‐engage, or regrade employees, either on a permanent or temporary nature, or hire agency staff, or agree to changes in any aspect of remuneration;

(a) unless authorised to do so by the Chief Executive; and

(b) within the limit of his approved budget and funded establishment. 9.3.2 The Board will approve procedures presented by the Chief Executive for the determination

of commencing pay rates, condition of service, etc, for employees.

9.4 Processing of Payroll

9.4.1 The Director of People and Organisational Development is responsible for:

(a) ensuring that arrangements in place so that NHS Shared Business Services provide an effective and efficient payroll service

(b) specifying timetables for submission of properly authorised time records and other notifications;

(c) the final determination of pay;

(c) making payment on agreed dates; and

(d) agreeing method of payment. 9.4.2 The Director of People and Organisational Development will issue instructions regarding:

(a) verification and documentation of data;

(b) the timetable for receipt and preparation of payroll data and the payment of employees;

(c) maintenance of subsidiary records for pension, income tax, social security and other authorised deductions from pay;

(d) security and confidentiality of payroll information;

(e) checks to be applied to completed payroll before and after payment;

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(f) authority to release payroll data under the provisions of the Data Protection Act;

(g) methods of payment available to various categories of employee;

(h) procedures for payments to employees;

(i) procedures for the recall of bank credits

(j) pay advances and their recovery;

(k) maintenance of regular and independent reconciliation of pay control accounts;

(l) system to ensure the recovery from leavers of sums of money and property due by them to the Trust.

9.4.3 Appropriately nominated managers have delegated responsibility for:

(a) submitting time records, and other notifications in accordance with agreed timetables;

(b) completing time records and other notifications in accordance with the Director of People and Organisational Development's instructions and in the form prescribed by the Director of People and Organisational Development.

(c) submitting termination forms in the prescribed form immediately upon knowing the effective date of an employee's resignation, termination or retirement. Where an employee fails to report for duty in circumstances that suggest they have left without notice, the Director of People and Organisational Development must be informed immediately.

9.4.4 Where the Director of People and Organisational Development has contracted with another

body to administer the Trust’s payroll service responsibility for compliance with the above requirements remain with the Director of People and Organisational Development.

9.4.5 Regardless of the arrangements for providing the payroll service, the Director of Finance

shall ensure that the chosen method is supported by appropriate (contracted) terms and conditions, adequate internal controls and audit review procedures and that suitable arrangements are made for the collection of payroll deductions and payment of these to appropriate bodies.

9.5 Contracts of Employment

9.5.1 The Board shall delegate responsibility to a manager for:

(a) ensuring that all employees are issued with a Contract of Employment in a form approved by the Board and which complies with employment legislation; and

(b) dealing with variations to, or termination of, contracts of employment.

9.6 Directors and Staff Expenses

9.6.1 Claims for expenses should be submitted in accordance with the Director of People and

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Organisational Development's instructions and in the form prescribed by the Director of People and Organisational Development.

9.6.2 All claims should be submitted for authorisation, along with any accompanying receipts, as

soon as possible after the end of the month concerned. However, all claims must be submitted within three months of the month in which the claim arose. Any claim periods in excess of this deadline will not usually be paid.

9.6.3 Once authorised, claims will be paid in accordance with current guidelines and regulations. 9.6.4 Claimants must not make duplicate claims for expenses from any other body in addition to

that from the Trust.

10. NON‐PAY EXPENDITURE

10.1 Delegation of Authority

10.1.1 The Board will approve the level of non‐pay expenditure on an annual basis and the Chief

Executive will determine the level of delegation to budget managers. 10.1.2 The Chief Executive will set out:

(a) the list of managers who are authorised to place requisitions for the supply of goods and services; and

(b) the maximum level of each requisition and the system for authorisation above that level.

10.1.3 The Chief Executive shall set out procedures on the seeking of professional advice regarding

the supply of goods and services.

10.2 Choice, Requisitioning, Ordering, Receipt and Payment for Goods and Services

10.2.1 The requisitioner, in choosing the item to be supplied (or the service to be performed) shall

always obtain the best value for money for the Trust. In so doing, the advice of the Trust’s Head of Procurement shall be sought. Wherever appropriate, the supply of goods and services shall be covered by a contract following a competitive exercise.

10.2.2 The Trust’s Head of Procurement shall be responsible for ensuring that the Trust complies

with all applicable laws in relation to choice, requisitioning, ordering and receipt for goods and services. The Director of Finance shall be responsible for the prompt payment of accounts and claims. Payment of contract invoices shall be in accordance with contract terms.

10.2.3 The Director of Finance will:

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(a) advise the Board regarding the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds (whole life costs) should be incorporated in standing orders and regularly reviewed (see Appendix 4);

(b) prepare procedural instructions where not already provided in the Scheme of

Delegation or procedure notes for budget holders on the obtaining of goods, works and services incorporating the thresholds;

(c) be responsible for the prompt payment of all properly authorised accounts and claims;

(d) be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable. The system shall provide for:

(i) A list of directors/employees (including specimens of their signatures) authorised to certify invoices.

(ii) Certification that:

‐ goods have been duly received, examined and are in accordance with specification and the prices are correct;

‐ work done or services rendered have been satisfactorily carried out in accordance with the order, and, where applicable, the materials used are of the requisite standard and the charges are correct;

‐ in the case of contracts based on the measurement of time, materials or expenses, the time charged is in accordance with the time sheets, the rates of labour are in accordance with the appropriate rates, the materials have been checked as regards quantity, quality, and price and the charges for the use of vehicles, plant and machinery have been examined;

‐ where appropriate, the expenditure is in accordance with regulations and all necessary authorisations have been obtained;

‐ the account is arithmetically correct;

‐ the account is in order for payment.

(iii) A timetable and system for submission to the Director of Finance of accounts for payment; provision shall be made for the early submission of accounts subject to cash discounts or otherwise requiring early payment.

(iv) Instructions to employees regarding the handling and payment of accounts within the Finance Department.

(e) be responsible for ensuring that payment for goods and services is only made once the

goods and services are received, (except as below).

(f) be responsible for ensuring that all payments made by the Trust fall within its powers.

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10.2.4 Prepayments are only permitted where exceptional circumstances apply. In such instances:

(a) Prepayments are only permitted where the financial advantages outweigh the disadvantages (i.e. cash flows must be discounted to NPV) and the intention is not to circumvent cash limits;

(b) the appropriate Director must provide, in the form of a written report, a case setting out all relevant circumstances of the purchase. The report must set out the effects on the Trust if the supplier is at some time during the course of the prepayment agreement unable to meet his commitments;

(c) the Director of Finance will need to be satisfied with the proposed arrangements before contractual arrangements proceed; and

(d) the budget holder is responsible for ensuring that all items due under a prepayment contract are received and he/she must immediately inform the appropriate Director or Chief Executive if problems are encountered.

10.2.5 Official Orders must:

(a) be consecutively numbered, even where electronically generated;

(b) be in a form approved by the Director of Finance;

(c) state the Trust's terms and conditions of trade; and

(d) only be issued to, and used by, those duly authorised by the Chief Executive. 10.2.6 Managers must ensure that they comply fully with the guidance and limits specified by the

Director of Finance and that:

(a) all contracts (other than for a simple purchase permitted within the Scheme of Delegation or delegated budget), leases, tenancy agreements and other commitments which may result in a liability are notified to the Director of Finance in advance of any commitment being made;

(b) contracts above specified thresholds are advertised and awarded in accordance with public procurement regulations);

(c) where consultancy advice is being obtained, the procurement of such advice must be in accordance with guidance issued by the Department of Health and NHS England/NHS Improvement;

(d) no order shall be issued for any item or items to any firm which has made an offer of gifts, reward or benefit to directors or employees, other than:

(i) isolated gifts of a trivial character or inexpensive seasonal gifts, such as calendars;

(ii) conventional hospitality, such as lunches in the course of working visits;

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(e) no requisition/order is placed for any item or items for which there is no budget provision unless authorised by the Director of Finance on behalf of the Chief Executive;

(f) all goods, services, or works are ordered in advance on an official order as outlined in the Procurement Policy. All invoices received where an order is not already in place will be returned;

(g) verbal orders must only be issued very exceptionally ‐ by an employee designated by the Chief Executive and only in cases of emergency or urgent necessity. All such instances shall be reported to the Director of Finance and followed up with an official purchase order;

(h) No orders shall be issued retrospectively of the items being received or the service being delivered;

(i) orders are not split or otherwise placed in a manner devised so as to avoid the financial thresholds;

(j) goods are not taken on trial or loan in circumstances that could commit the Trust to a future uncompetitive purchase;

(k) changes to the list of directors/employees authorised to certify invoices are notified to the Director of Finance;

(l) purchases from petty cash are restricted in value and by type of purchase in accordance with instructions issued by the Director of Finance; and

(m) petty cash records are maintained in a form as determined by the Director of Finance. 10.2.7 The Director of Finance shall ensure that the arrangements for financial control and financial

audit of building and engineering contracts and property transactions comply with the good practice guidance. The technical audit of these contracts shall be the responsibility of the relevant Director.

10.3 Legally Binding Agreements (e.g. leases)

10.3.1 Any leases or rental agreements must be vetted by the Director of Finance prior to final

agreement, to enable insurance issues and technical accounting treatment to be determined. In addition, all leases entered into on behalf of the Trust should represent value for money.

10.3.2 All lease agreements must be signed on behalf of the Trust by the Director of Finance (or his

deputy) in addition to being accompanied by the usual order and duly authorised in accordance with these SFIs.

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10.4 Grants to Local Authorities and Voluntary Bodies

10.4.1 Grants to local authorities and voluntary organisations made under the powers of section 28A of the NHS Act 2006 or section 64 of the Health Service and Public Health Act 1968 shall comply with procedures laid down by the Director of Finance which shall be in accordance with these Acts.

10.4.2 The financial limits for officers’ approval of grants are set out in the Scheme of Delegation.

11. EXTERNAL BORROWING AND INVESTMENTS

11.1 External Borrowing

11.1.1 The Director of Finance will advise the Board concerning the Trust's ability to pay interest

on, and repay, both the originating capital debt and any proposed new borrowing, within the limits set by NHS Improvement for NHS Foundation Trusts. The Director of Finance is also responsible for reporting periodically to the Board concerning Public Dividend Capital debt and all loans and overdrafts.

11.1.2 Any application for PDC, a loan or overdraft will only be made by the Director of Finance or

by an employee so delegated by him. Also such applications must however first be authorised by the Board.

11.1.3 The Director of Finance must prepare detailed procedural instructions concerning

applications for PDC, loans and overdrafts. 11.1.4 All borrowings should be kept to the minimum period of time possible, consistent with the

overall cash flow position. Any short term borrowing requirement in excess of one month must be authorised by the Director of Finance.

11.1.5 All long term borrowing must be consistent with the plans outlined in the current Business

Plan. Where there is a need to vary from this principle due to unforeseen in year events a revised business plan will be prepared and provided to the Board to support its deliberations when considering the need to borrow.

11.2 Investments

11.2.1 Temporary cash surpluses must be held only in such public or private sector investments as authorised by the Board and within such government guidance as may be in place from time to time. The need to prudently manage public funds from unnecessary risk will be a key factor in any decision making regarding what bodies to deposit such funds with.

11.2.2 The Director of Finance is responsible for advising the Board on investments and shall report

periodically to the Board concerning the performance of investments held.

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11.2.3 The Director of Finance will prepare detailed procedural instructions on the operation of investment accounts and on the records to be maintained.

12. CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS

12.1 Capital Investment

12.1.1 The Chief Executive:

(a) shall ensure that there is an adequate appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon business plans;

(b) is responsible for the management of all stages of capital schemes and for ensuring that schemes are delivered on time and to cost; and

(c) shall ensure that the capital investment is not undertaken without the availability of resources to finance all revenue consequences, including capital charges.

(d) shall ensure that processes and procedures are in place to monitor, record and report

spend against each element of the Capital programme. 12.1.2 For every capital expenditure proposal the Chief Executive shall ensure:

(a) that a business case (in line with the guidance contained within the Capital Investment Manual) is produced setting out:

(i) an option appraisal of potential benefits compared with known costs to determine the option with the highest ratio of benefits to costs; and

(ii) appropriate project management and control arrangements; and (b) that the Director of Finance has certified professionally to the costs and revenue

consequences detailed in the business case. 12.1.3 For capital schemes where the contracts stipulate stage payments, the Chief Executive will

issue procedures for their management, incorporating the recommendations of "The efficient management of healthcare estates and facilities” (previously “Estatecode") and other official guidance that may become available from time to time.

The Director of Finance shall assess on an annual basis the requirement for the operation

of the construction industry tax deduction scheme in accordance with Inland Revenue guidance.

The Director of Finance shall issue procedures for the regular reporting of expenditure and commitment against authorised expenditure.

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12.1.4 The approval of a capital programme shall not constitute approval for expenditure on any scheme.

The Chief Executive shall issue to the manager responsible for any scheme:

(a) specific authority to commit expenditure;

(b) authority to proceed to tender;

(c) approval to accept a successful tender.

The Chief Executive will issue a scheme of delegation for capital investment management in accordance with ""The efficient management of healthcare estates and facilities” guidance and the Trust's Standing Orders.

12.1.5 The Director of Finance shall issue procedures governing the financial management,

including variations to contract, of capital investment projects and valuation for accounting purposes.

12.2 Private Finance

12.2.1 Where appropriate the possibility of attracting private finance will be investigated for capital expenditure proposals.

12.2.2 The Chief Executive will consider such proposals along with all other bids received, in line

with the Trust's priorities. 12.2.3 Where the proposal is approved the private sector will be invited to submit their bids based

upon clear, high level, service based objectives. 12.2.4 Once the private sector bids have been received the Director of Finance will provide or

commission any specialist assistance to allow the bids to be appraised on a like for like basis. 12.2.5 The Chief Executive shall be responsible for deciding upon the preferred shape of the

proposed contract and inviting the bidders to tender. 12.2.6 The Director of Finance shall ensure that all privately financed proposals represent value for

money and genuinely transfer risk to the private sector. 12.2.7 Proposals which include the lease of equipment and/or buildings will be tested for Value for

Money and the Transfer of Risk by the Capital Accountant. 12.2.8 To allow this appraisal of the lease to take place the following financial details shall be

obtained:

(a) Capital value of asset(s) supplied;

(b) Minimum lease period;

(c) Minimum lease payment;

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(d) Frequency of lease payment, including details as to whether required in arrears or advance;

(e) Premium for payment by non‐direct debit method if applicable;

(f) Interest rate implicit in the lease (if available). 12.2.9 Figures shall be requested for a number of different lease periods, to identify the option,

which gives the best returns for the Trust, and be exclusive of VAT. 12.2.10 For comparative purposes the capital value of the asset supplied will be the value at the

start of the contract plus the discounted value of any enhancements during the minimum lease term less the discounted value of any disposal proceeds at the end of the lease term.

12.2.11 The fundamental requirements of a PFI proposal with regards risk are that it is allocated to

the party which is best able to manage it and that it is genuinely transferred to the private sector.

12.2.12 By achieving optimum risk transfer between the parties to the PFI proposal there is a

greater likelihood that value for money will also be achieved. 12.2.13 The risks associated with a project typically fall under the following headings:

(a) Design and Construction Risks;

(b) Commissioning and Operating Risks;

(c) Demand, Volume or Usage Risks;

(d) Technology and Obsolescence Risks;

(e) Regulation and Other Risks;

(f) Project Financing Risks. 12.2.14 The Value for Money attributable to a project is tested by comparing the net present value

(or cost) of the estimated annual cash flows over an appraisal period equivalent to the PFI contract term.

12.2.15 In addition the PFI proposal shall be assessed for its affordability. This will show whether the

proposal is affordable to the Trust and that the impact on prices can be afforded by the Trust's main commissioner.

12.2.16 The Director of Finance will be notified in advance of all lease and PFI agreements before

any commitment is made. 12.2.17 The Chief Executive will ensure that all proposed agreements are scrutinised by either in‐

house experts or the Trust's Solicitors to ensure that the agreements are comprehensive and are not disadvantageous to the Trust.

12.2.18 The Board must specifically agree all PFI proposals before any contracts are signed.

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12.2.19 When comparing the financials of the various options VAT shall be included within the

calculation in so far as it is irrecoverable. The Director of Finance shall engage professional VAT advisers to facilitate this where it is felt necessary.

12.3 Asset Registers

12.3.1 The Chief Executive is responsible for the maintenance of registers of assets, taking account of the advice of the Director of Finance concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year. Where systems are in place to monitor these on an ongoing basis a rolling programme of checks and/or sampling will be acceptable.

12.3.2 The Trust shall maintain an asset register recording fixed assets. The minimum data set to

be held within these registers shall be based on good accounting practice. 12.3.3 Additions to the fixed asset register must be clearly identified to an appropriate budget

holder and be validated by reference to: (a) properly authorised and approved agreements, architect's certificates, supplier's

invoices and other documentary evidence in respect of purchases from third parties; (b) stores, requisitions and wages records for own materials and labour including

appropriate overheads; and (c) lease agreements in respect of assets held under a finance lease and capitalised. 12.3.4 Where capital assets are sold, scrapped, lost or otherwise disposed of, their value must be

removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where appropriate).

12.3.5 The Director of Finance shall approve procedures for reconciling balances on fixed assets

accounts in ledgers against balances on fixed asset registers. 12.3.6 The value of each asset shall be indexed to current values in accordance with good

accounting practice and NHS Improvement guidelines. A periodic revaluation of land and buildings will be undertaken, by an independent professional valuer, as required by accounting guidelines.

12.3.7 The value of each asset shall be depreciated using methods and rates as specified in

accounting standards. 12.3.8 The Director of Finance shall calculate capital charges.

12.4 Security of Assets

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12.4.1 The overall control of fixed assets is the responsibility of the Chief Executive. 12.4.2 Asset control procedures (including fixed assets, cash, cheques and negotiable instruments,

and also including donated assets) must be approved by the Director of Finance. This procedure shall make provision for:

(a) recording managerial responsibility for each asset;

(b) identification of additions and disposals;

(c) identification of all repairs and maintenance expenses;

(d) physical security of assets;

(e) periodic verification of the existence of, condition of, and title to, assets recorded;

(f) identification and reporting of all costs associated with the retention of an asset; and

(g) reporting, recording and safekeeping of cash, cheques, and negotiable instruments. 12.4.3 All discrepancies revealed by verification of physical assets to fixed asset register shall be

notified to the Director of Finance. 12.4.4 Whilst each employee has a responsibility for the security of property of the Trust, it is the

responsibility of directors and senior employees in all disciplines to apply such appropriate routine security practices in relation to property as may be determined by the Board. Any breach of agreed security practices must be reported in accordance with instructions.

12.4.5 Any damage to the Trust's premises, vehicles and equipment, or any loss of equipment,

stores or supplies must be reported by directors and employees in accordance with the procedure for reporting losses.

12.4.6 Where practical, assets should be marked as Trust property.

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13. STORES AND RECEIPT OF GOODS

13.1 Stores, defined in terms of controlled stores and departmental stores (for immediate use) should be:

(a) kept to a minimum;

(b) subjected to annual stock take;

(c) valued at the lower of cost and net realisable value. 13.2 Subject to the responsibility of the Director of Finance for the systems of control, overall

responsibility for the control of stores shall be delegated to an employee by the Chief Executive. The day‐to‐day responsibility may be delegated by him/her to departmental employees and stores managers/keepers, subject to such delegation being entered in a record available to the Director of Finance. The control of Pharmaceutical stocks shall be the responsibility of a designated Pharmaceutical Officer; the control of fuel oil and similar items of a designated estates manager.

13.3 The responsibility for security arrangements and the custody of keys for all stores and

locations shall be clearly defined in writing by the designated manager/Pharmaceutical Officer. Wherever practicable, stocks should be marked as health service property.

13.4 The Director of Finance shall set out procedures and systems to regulate the stores including

records for receipt of goods, issues, and returns to stores, and losses. 13.5 Stocktaking arrangements shall be agreed with the Director of Finance and there shall be a

physical check covering all items in store at least once a year. Where stock control systems allow this may be undertaken on a rolling or sample basis as is felt best to ensure the accurate control and recording of stock.

13.6 Where a complete system of stores control is not justified, alternative arrangements shall

require the approval of the Director of Finance. 13.7 The designated Manager/Pharmaceutical Officer shall be responsible for a system approved

by the Director of Finance for a review of slow moving and obsolete items and for condemnation, disposal, and replacement of all unserviceable articles. The designated Officer shall report to the Director of Finance any evidence of significant overstocking and of any negligence or malpractice (see also Chapter 14, Disposals and Condemnations, Losses and Special Payments). Procedures for the disposal of obsolete stock shall follow the procedures set out for disposal of all surplus and obsolete goods.

13.8 For goods supplied via the NHS Supply Chain Coordination Limited (SCCL) central

warehouses, the Chief Executive shall identify those authorised to requisition and accept goods from the store. The authorised person shall check receipt against the delivery note before forwarding this to the Director of Finance who shall satisfy himself that the goods have been received before accepting the recharge.

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13.9 All goods received shall be checked as regards quantity and/or weight and inspected as to

quality and specification. 13.10 The issue of stores shall be supported by an authorised requisition note and a receipt for the

stores issued shall be returned to the Procurement Department, Issuing Department, or Director of Finance.

13.11 Where a 'topping up' system is used a record shall be maintained as approved by the

Director of Finance. Regular comparisons shall be made of the quantities issued to wards/departments etc. and explanations recorded of significant variances.

13.12 All transfers and returns shall be recorded on forms provided for the purpose and approved

by the Director of Finance. 13.13 Breakages and other losses of goods in stores shall be recorded as they occur and a

summary shall be presented to the Director of Finance at regular intervals. Tolerance limits shall be established for all stores subject to unavoidable loss, e.g. shrinkage in the case of certain food stuffs and natural deterioration of certain goods.

14. DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS

14.1 Disposals and Condemnations

14.1.1 The Director of Finance must prepare detailed procedures for the disposal of assets including condemnations, and ensure that these are notified to managers.

The Trust may not dispose of any protected property without the approval of NHS Improvement.

14.1.2 When it is decided to dispose of a Trust asset, the head of department or authorised deputy

will determine and advise the Director of Finance of the estimated market value of the item, taking account of professional advice where appropriate.

14.1.3 All unserviceable articles shall be:

(a) condemned or otherwise disposed of by an employee authorised for that purpose by the Director of Finance;

(b) recorded by the Condemning Officer in a form approved by the Director of Finance which will indicate whether the articles are to be converted, destroyed or otherwise disposed of. All entries shall be confirmed by the countersignature of a second employee authorised for the purpose by the Director of Finance.

14.1.4 The Condemning Officer shall satisfy himself as to whether or not there is evidence of

negligence in use and shall report any such evidence to the Director of Finance who will take the appropriate action.

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14.2 Losses and Special Payments

14.2.1 The Director of Finance must prepare procedural instructions on the recording of and accounting for condemnations, losses, and special payments. The Director of Finance must also prepare a ‘fraud response plan’ that sets out the action to be taken both by persons detecting a suspected fraud and those persons responsible for investigating it.

14.2.2 Any employee discovering or suspecting a loss of any kind must either immediately inform

their head of department, who must immediately inform the Chief Executive and the Director of Finance or inform an officer charged with responsibility for responding to concerns involving loss or fraud confidentially. This officer will then appropriately inform the Director of Finance and/or Chief Executive. Where a criminal offence is suspected, the Director of Finance must immediately inform the police if theft or arson is involved. In cases of fraud and corruption or of anomalies which may indicate fraud or corruption, the Director of Finance must inform the relevant LCFS, who will then inform NHS Counter Fraud Authority in accordance with Secretary of State for Health’s Directions.

The Director of Finance must ensure that NHS Counter Fraud Authority and the External Auditor are notified of all frauds.

14.2.3 For losses apparently caused by theft, fraud, arson, neglect of duty or gross carelessness,

except if trivial and where fraud is not suspected, the Director of Finance must immediately notify:

(a) the Board, and

(b) the External Auditor. 14.2.4 The Board shall approve the writing‐off of losses. The level of delegation to Senior Officers

of the Trust are set out in the Reservation of Powers to the Board and Delegation of Powers section 5, paragraph 11.

14.2.5 The Director of Finance shall be authorised to take any necessary steps to safeguard the

Trust's interests in bankruptcies and company liquidations. 14.2.6 For any loss, the Director of Finance should consider whether any insurance claim can be

made. 14.2.7 The Director of Finance shall maintain a Losses and Special Payments Register in which

write‐off action is recorded. 14.2.8 All losses and special payments must be reported to the Audit and Risk Committee at

every meeting although the identities of individuals should not be reported unless requested.

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15. INFORMATION TECHNOLOGY

15.1 The Director of Finance, who is responsible for the accuracy and security of the computerised financial data of the Trust, shall:

(a) devise and implement any necessary procedures to ensure adequate (reasonable) protection of the Trust's data, programs and computer hardware for which he/she is responsible from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998;

(b) ensure that adequate (reasonable) controls exist over data entry, processing, storage, transmission and output to ensure security, privacy, accuracy, completeness, and timeliness of the data, as well as the efficient and effective operation of the system;

(c) ensure that adequate controls exist such that the computer operation is separated from development, maintenance and amendment;

(d) ensure that an adequate management (audit) trail exists through the computerised system and that such computer audit reviews as he may consider necessary are being carried out.

15.2 The Director of Finance shall satisfy himself that new financial systems and amendments to

current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy will be obtained from them prior to implementation.

15.3 In the case of computer systems which are proposed General Applications, all responsible

directors and employees will send to the Director of Finance: (a) details of the outline design of the system;

(b) in the case of packages acquired either from a commercial organisation, from the NHS, or from another public sector organisation, the operational requirement.

15.4 The Director of Finance shall ensure that contracts for computer services for financial

applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness, and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.

15.5 Where another health organisation or any other agency provides a computer service for

financial applications, the Director of Finance shall periodically seek assurances that adequate controls are in operation.

15.6 Where computer systems have an impact on corporate financial systems the Director of

Finance shall satisfy himself that:

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(a) systems acquisition, development and maintenance are in line with corporate policies such as an Information Technology Strategy;

(b) data produced for use with financial systems is adequate, accurate, complete and timely, and that a management (audit) trail exists;

(c) Director of Finance staff have access to such data; and

(d) such computer audit reviews as are considered necessary are being carried out. 15.7 The Director of People and Organisational Development shall publish and maintain a

Freedom of Information (FOI) Publication Scheme, or adopt a model Publication Scheme approved by the information Commissioner. A Publication Scheme is a complete guide to the information routinely published by a public authority. It describes the classes or types of information about the Trust that is made publicly available.

16. PATIENTS' PROPERTY

16.1 The Trust has a responsibility to provide safe custody for money and other personal property (hereafter referred to as "property") handed in by patients, in the possession of unconscious or confused patients, or found in the possession of patients dying in hospital or dead on arrival.

16.2 The Chief Executive is responsible for ensuring that patients or their guardians, as

appropriate, are informed before or at admission by:

‐ notices and information booklets, ‐ hospital admission documentation and property records, ‐ the verbal advice of administrative and nursing staff responsible for admissions,

that the Trust will not accept responsibility or liability for patients' property brought into Health Service premises, unless it is handed in for safe custody and a copy of an official patients' property record is obtained as a receipt.

16.3 The Director of Finance must provide detailed written instructions on the collection,

custody, investment, recording, safekeeping, and disposal of patients' property (including instructions on the disposal of the property of deceased patients and of patients transferred to other premises) for all staff whose duty is to administer, in any way, the property of patients. Due care should be exercised in the management of a patient's money in order to maximise the benefits to the patient.

16.4 Where it is a requirement for the opening of separate accounts for patients' moneys, these

shall be opened and operated under arrangements agreed by the Director of Finance. 16.5 In all cases where property of a deceased patient is of a total value in excess of £5,000 (or

such other amount as may be prescribed by any amendment to the Administration of Estates, Small Payments, Act 1965) or other statue, the production of Probate or Letters of Administration shall be required before any of the property is released. Where the total value of property is £5,000 or less, forms of indemnity shall be obtained.

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16.6 Staff should be informed, on appointment, by the appropriate departmental or senior

manager of their responsibilities and duties for the administration of the property of patients.

16.7 Where patients' property or income is received for specific purposes and held for

safekeeping the property or income shall be used only for that purpose, unless any variation is approved by the donor or patient in writing.

17. FUNDS HELD ON TRUST

17.1 Introduction

17.1.1 Standing Orders (SOs) identify the Trust's responsibilities as a corporate trustee for the management of funds it holds on trust and define how those responsibilities are to be discharged. They explain that although the management processes may overlap with those of the organisation of the Trust, the trustee responsibilities must be discharged separately and full recognition given to the duel accountabilities to the Charity Commission for charitable funds held on trust and to NHS Improvement for all funds held on trust.

17.1.2 The reserved powers of the Board and the Scheme of Delegation make clear where

decisions regarding the exercise of dispositive discretion are to be taken and by whom. Directors and officers must take account of that guidance before taking action. SFIs are intended to provide guidance to persons who have been delegated to act on behalf of the corporate trustee.

17.1.3 As management processes overlap most of the sections of these SFIs will apply to the

management of funds held on trust. This section covers those instructions which are specific to the management of funds held on trust. Any further guidance is set out in the Charitable Funds Policy (approved by Board of Directors in 2019).

17.1.4 The over‐riding principle is that the integrity of each trust must be maintained and statutory

and trust obligations met. Materiality must be assessed separately from Exchequer activities and funds.

17.1.5 The Director of Finance shall maintain such accounts and records, including an investment

register, as may be necessary to record and protect all transactions and funds of the Trust as trustees of funds held on trust.

17.2 Existing Trusts

17.2.1 The Director of Finance shall make arrangements for the administration of all existing funds held on trust and shall produce instructions covering every aspect of the financial management of the funds.

17.2.2 The Director of Finance shall periodically review the funds in existence and shall make

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recommendations to the Board regarding the potential for rationalisation, within statutory guidelines.

17.3 New Trusts

17.3.1 The Director of Finance shall arrange for the creation of a new trust where funds and/or other assets are received and cannot be adequately managed as part of an existing trust.

17.3.2 When making such as assessment as outlined in 17.3.1 above the needs for simplicity of

administration and therefore downward pressure on costs shall also be considered.

17.4 Sources of New Funds

17.4.1 In respect of donations, the Director of Finance shall:

(a) provide guidelines to officers of this Body as to how to proceed when offered funds. These to include:

(i) the identification of the donor’s intentions; (ii) where possible, the avoidance of new trusts; (iii) the avoidance of impossible, undesirable or administratively difficult objects; (iv) sources of immediate further advice; and (v) treatment of offers for personal gifts; and (b) provide secure and appropriate receipting arrangements which will indicate that funds

have been accepted directly into this Body's trust funds and that the donor's intentions have been noted and accepted.

17.4.2 The Director of Finance shall deal with all Legacies and Bequests. 17.4.3 In respect of Fundraising, the Director of Finance shall:

(a) deal with all arrangements for fund‐raising by and/or on behalf of this Body and ensure compliance with all statutes and regulations;

(b) be empowered to liaise with other organisations/persons raising funds for this Body and provide them with an adequate discharge. The Director of Finance shall be the only officer empowered to give approval for such fund‐raising subject to the overriding direction of the Board;

(c) for alerting the Board to any irregularities regarding the use of this Body's name or its registration numbers; and

(d) be responsible for the appropriate treatment of all funds received from this source. 17.4.4 In respect of Trading Income, the Director of Finance shall:

(a) be primarily responsible with other designated officers, for any trading undertaken by this Body as corporate trustee; and

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(b) be primarily responsible for the appropriate treatment of all funds received from this source.

17.4.5 In respect of Investment Income, the Director of Finance shall be responsible for the appropriate treatment of all dividends, interest and other receipts from this source (see below).

17.5 Investment Management

17.5.1 The Director of Finance shall be responsible for all aspects of the management of the investment of funds held on trust. The issues on which he shall be required to provide advice to the Board shall include:‐

(a) the formulation of investment policy within the powers of this Body under statute and within governing instruments to meet its requirements with regard to income generation and the enhancement of capital value;

(b) the appointment of advisers, brokers, and, where appropriate, fund managers and:

(i) the Director of Finance shall agree the terms of such appointments; and for which

(ii) written agreements shall be signed by the Chief Executive;

(c) pooling of investment resources and the preparation of a submission to the Charity Commission for them to approve;

(d) the participation by this Body in common investment funds and the agreement of terms of entry and withdrawal from such funds;

(e) that the use of Trust assets shall be appropriately authorised in writing and charges raised within policy guidelines;

(f) the review of the performance of brokers and fund managers;

(g) the reporting of investment performance.

17.6 Disposition Management

17.6.1 The exercise of this Body's dispositive discretion shall be managed by the Director of Finance in conjunction with the Board. In so doing he shall be aware of the following:

(a) The objects of various funds and the designated objectives;

(b) the availability of liquid funds within each trust;

(c) the powers of delegation available to commit resources;

(d) the avoidance of the use of exchequer funds to discharge trust fund liabilities (except where administratively unavoidable), and to ensure that any indebtedness to the Exchequer shall be discharged by trust funds at the earliest possible time;

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(e) that funds are to be spent rather than preserved, subject to the wishes of the donor and the needs of this Body; and

(f) the definitions of "charitable purposes" as agreed by the Charity Commission.

17.7 Banking Services

17.7.1 The Director of Finance shall advise the Board and, with its approval, shall ensure that appropriate banking services are available to this Body as corporate trustee. These bank accounts should permit the separate identification of liquid funds to each trust where this is deemed necessary by the Charity Commission.

17.8 Asset Management

17.8.1 Assets in the ownership of or used by this Body as corporate trustee, shall be maintained along with the general estate and inventory of assets of the Body. The Director of Finance shall ensure:

(a) that appropriate records of all assets owned by this Body as corporate trustee are maintained, and that all assets, at agreed valuations, are brought to account;

(b) that appropriate measures are taken to protect and/or to replace assets. These to include decisions regarding insurance, inventory control, and the reporting of losses;

(c) that donated assets received on trust are accounted for appropriately;

(d) that all assets acquired from funds held on trust which are intended to be retained within the trust funds are appropriately accounted for;

(e) all share and stock certificates and property deeds shall be deposited either with the Trust's bankers or, where this is not practicable, held securely at trust premises.

17.9 Reporting

17.9.1 The Director of Finance shall ensure that regular reports are made to the Board with regard to, inter alia, the receipt of funds, investments, and the disposition of resources.

17.9.2 The Director of Finance shall prepare annual accounts in the required manner which shall be

submitted to the Board within agreed timescales. 17.9.3 The Director of Finance shall prepare an annual trustees' report and the required returns to

the Charity Commission for adoption by the Board.

17.10 Accounting and Audit

17.10.1 The Director of Finance shall maintain all financial records to enable the production of reports as above and to the satisfaction of internal and external audit.

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17.10.2 The Director of Finance shall ensure that the records, accounts and returns receive

adequate scrutiny by internal audit during the year. He will liaise with external audit and provide them with all necessary information.

17.10.3 The Board shall be advised by the Director of Finance on the outcome of the annual audit.

The Chief Executive shall submit the Management Letter to the Board.

17.11 Administration Costs

17.11.1 The Director of Finance shall identify all costs directly incurred in the administration of funds held on trust and, in agreement with the Board, shall charge such costs to the appropriate trust accounts.

17.12 Taxation and Excise Duty

17.12.1 The Director of Finance shall ensure that this Body's liability to taxation, duties and other such charges is managed appropriately, taking full advantage of available concessions, through the maintenance of appropriate records, the preparation and submission of the required returns and the recovery of deductions at source.

17.13 Authorisation Levels of Expenditure from Trust Funds

17.13.1 The Board has established levels of authorisation necessary for expenditure from the funds held on trust, these are set out in the Reservation of Powers to the Board and Delegation of Powers section 5, paragraph 8.

These will be reviewed on a regular basis to ensure that they remain at an appropriate

financial level.

18. RETENTION OF DOCUMENTS

18.1 The Chief Executive shall be responsible for maintaining archives for all documents required

to be retained following good practice under the direction contained in Department of Health guidelines.

18.2 The documents held in archives shall be capable of retrieval by authorised persons. 18.3 Documents held in accordance with the latest Department of Health guidance shall only be

destroyed at the express instigation of the Chief Executive, records shall be maintained of documents so destroyed.

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19. RISK MANAGEMENT & INSURANCE

19.1 Programme of Risk Management

19.1.1 The Chief Executive shall ensure that the Trust has a programme of risk management which

will be approved and monitored by the Board. 19.1.2 The programme of risk management shall include:

(a) a process for identifying and quantifying risks and potential liabilities;

(b) engendering among all levels of staff a positive attitude towards the control of risk;

(c) management processes to ensure all significant risks and potential liabilities are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk;

(d) contingency plans to offset the impact of adverse events;

(e) audit arrangements including; internal audit, clinical audit, health and safety review;

(f) a clear indication of which risks shall be insured;

(g) arrangements to review the risk management programme.

The existence, integration and evaluation of the above elements will provide a basis to complete the annual governance statement within the Annual Report and Accounts.

19.1.3 The Director of Finance shall ensure that insurance arrangements exist in accordance with

the risk management programme.

19.2 Insurance: Risk Pooling Schemes Administered by NHS Resolution

19.2.1 The Board shall decide if the Trust will insure through the risk pooling schemes administered by the NHS Resolution (previously NHS Litigation Authority) or self‐insure for some or all of the risks covered by the risk pooling schemes. If the Board decides not to use the risk pooling schemes for any of the risk areas (clinical, property and employers/third party liability) covered by the scheme this decision shall be reviewed annually.

19.3 Insurance Arrangements with Commercial Insurers

19.3.1 The Board shall decide if the Trust will insure with commercial insurers to supplement or replace the cover available through the risk pooling schemes. If the Board decides to use commercial insurers this decision shall be reviewed annually.

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19.4 Arrangements to be followed by The Board in Agreeing Insurance Cover

19.4.1 Where the Board decides to use the risk pooling schemes administered by the NHS Litigation Authority the Director of Finance shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme. The Director of Finance shall ensure that documented procedures cover these arrangements.

19.4.2 Where the Board decides not to use the risk pooling schemes administered by the NHS

Litigation Authority for one or other of the risks covered by the schemes, the Director of Finance shall ensure that the Board is informed of the nature and extent of the risks that are self‐insured as a result of this decision.

19.4.3 The Director of Finance will draw up formal documented procedures for the management

of any claims arising from third parties and payments in respect of losses which will not be reimbursed.

19.4.4 All the risk pooling schemes require Scheme members to make some contribution to the

settlement of claims (the ‘deductible’). The Director of Finance should ensure documented procedures also cover the management of claims and payments below the deductible in each case.

20. ACCEPTANCE OF GIFTS BY STAFF AND LINK TO STANDARDS OF BUSINESS CONDUCT

20.1 The Board Company Secretary shall ensure that all staff are made aware of the Trust

Policy on acceptance of gifts and other benefits in kind by staff. This policy follows the guidance contained in the department of health standards of business conduct for NHS staff set out in “Code of Conduct for Directors and employees”.

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APPENDIX 1 ‐ INVESTMENTS

INVESTMENTS 1. The Director of Finance shall ensure that all funds are invested in the name of the Trust. No

officer other than the Director of Finance shall open accounts to invest funds on behalf of the Trust.

2. The Director of Finance shall advise bankers and other approved deposit facilities in writing

of the conditions under which each account shall be operated. 3. Transfers of funds from bank and GBS accounts to investment accounts must be authorised

by two signatories.

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APPENDIX 2 – SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS

SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS 1. All cash, cheques postal orders and other forms of payments received by an officer other

than a cashier shall be entered immediately on an approved form. All cheques and postal orders shall be crossed immediately "Not negotiable ‐A/c Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust". The remittances shall be passed to the cashier from whom a signature shall be obtained.

2. The opening of coin operated machines and the counting and recording of the takings shall

be undertaken by two officers together, except as may be authorised in writing by the Director of Finance and the coin box keys shall be held by a nominated officer.

3. Where amounts of cash have to be transported, special arrangements shall be made by the

Director of Finance with a specialist security firm. Under no circumstances shall cash in excess of (£500) be transported by only one officer and the route travelled and times of collection shall be varied as far as practicable.

4. During the absence (e.g. on holiday) of the holder of a safe or cash box key, the officer who

acts in his place shall be subject to the same controls as the normal holder of the key. There shall be written discharge for the safe/or cash box contents on the transfer of responsibilities and the discharge document must be retained for inspection.

5. All unused cheques and other orders shall be subject to the same security precautions as are

applied to cash. 6. Staff shall be informed on appointment, by the appropriate departmental or senior officers,

of their responsibilities and duties for the collection, handling or disbursement or cash, cheques, etc, in line with appropriate financial procedures. This must be in writing, acknowledged, and acknowledgement retained.

7. Any loss or shortfall of cash, cheques, or other negotiable instruments, however occasioned

shall be reported immediately to the Director of Finance

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APPENDIX 3 – BUDGETARY VIREMENT

BUDGETARY VIREMENT 1. Virement is the term used to define the movement of funds from one budget heading to

another. 2. Virement within Individual Budgets:

2.1 Where a budget holder is expected to be under spent at the year‐end, the budget holder may be allowed to offset this under spending against overspendings elsewhere in his/her budget, subject to the criteria itemised below.

2.2 Budget holders are not allowed to use non‐recurrent savings for recurrent commitments,

for example, savings on equipment purchased cannot be used to appoint new permanent staff.

2.3 Subject to the overall financial position of the individual Division and the Trust, virement will

be allowed using the following criteria:

(a) Efficiency/CIP targets are being achieved; (b) The predicted year end expenditure will be within budget; (c) The predicted year end income will at least achieve the target; (d) The proposed expenditure is within overall policy, i.e. virement cannot be used to

initiate a development of a new / existing service, which is not policy; (e) All other targets are being achieved; (f) Approval has been obtained from the Director of Finance.

2.4 Virement between Divisions:

Expected underspendings can be transferred to another Division subject to the agreement of both budget holders and the same constraints as above.

2.5 Virement between Revenue and Capital:

This can only be done in exceptional circumstances when approved in advance by the Director of Finance.

2.6 Budgetary and Virement Limits of the Chief Executive:

Budgetary or virement limits of the Chief Executive delegated by the Board are outlined in the Scheme of Delegation

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APPENDIX 4 ‐ PROCUREMENT AND TENDERING

1.0 INTRODUCTION 1.1 The Trust’s Standing Financial Instructions (SFI’s) set out procedures to be adopted in

obtaining goods and services. 1.2 This supplementary procedure note deals with the setting of thresholds above which

quotations (competitive or otherwise) or formal tenders must be obtained and detailed procedures in relation to procurement and tendering.

1.3 The Director of Finance (or Deputy in his absence) must personally authorise any order or

contract which commits the Trust to expenditure from £5,000 up to £250,000 as determined by the scheme of delegation. The Chief Executive (or Director of Finance in his absence) must authorise all expenditure from £250,000 to £1,000,000.

1.4 Any commitment on behalf of the Trust in respect of all capital projects and financial

commitments, including leases, costing between £0.5m and £1.5m, in their entirety if included in the Trust’s Annual Plan or Capital Plan must be approved by the Trust’s Corporate Investment Group (CIG). Any proposals above £0.5m and below £1.5m which have not already been approved in the Trust’s Annual Plan or Capital Plan must be submitted to CIG for review and recommendation to the Board. These costs are whole life costs. All expenditure in excess of £1.5m requires approval of the Board.

1.5 In addition to the Trust delegated tendering limits, attention must be paid to the UK

procurement regulations, any regulations governing procurement within the European Union and any subsequent procurement legislation that become statutes following the UKs exit from the European Union in all cases advice should be sought from the Head of Procurement Head of Procurement to ensure compliance with appropriate thresholds.

2.0 COMPETITIVE TENDERING (Over £50,000) 2.1 The Trust must ensure that goods and services are procured in an efficient manner and are

purchased at the most competitive price. The standard method of procurement will be by competitive tender for goods or services expected to cost in excess of £50,000; this may be waived under the following circumstances:

‐ Where the requirements are ordered under existing contracts or where in the

opinion of the Finance Director: ‐ there is only one supplier and no reasonably satisfactory alternative product/service; ‐ competition would be impractical, impossible or not beneficial;

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‐ the requirement is to be ordered under existing contracts;

‐ the work for practical reasons must be of the same manufacture, for instance repairs/spare parts for existing equipment;

‐ where it is known that a marked financial advantage will accrue to the Trust from

making a spot purchase of products subject to quickly changing market conditions. 2.2 In any of these circumstances the detail should be documented and the authorisation

counter‐signed by the Head of Procurement in confirmation of such circumstances. 3.0 COMPETITIVE AND NON‐COMPETITIVE QUOTATIONS (£50,000 and under) 3.1 Three competitive quotations must be obtained for all contracts and services where the

value is not expected to exceed £50,000 but is above £5,000. 3.2 Non‐competitive quotations in writing, or electronically via the e‐tendering portal if the

value is expected to exceed £25,000, may be obtained for the following purposes:

(a) where the supply of goods (or related goods) is of a special character and does not exceed £5,000;

or where in the opinion of the Finance Director:

(b) there being only one supplier and no reasonably satisfactory alternative product/service;

(c) competition would be impractical, impossible or not beneficial; (d) the requirement is to be ordered under existing contracts;

(e) the work for practical reasons must be of the same manufacture, for instance, repairs/spare parts for existing equipment;

(f) where it is known that a marked financial advantage will accrue to the Trust

from making a spot purchase of products subject to quickly changing market conditions.

In any of these circumstances the detail should be documented and the authorisation counter‐signed by the Head of Procurement in confirmation of such circumstances.

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3.3 Officers should involve the Head of Procurement in choice of supplier, price negotiation and in the procurement process for all goods and services.

3.4 Where the supplier being used is nationally or regionally approved, and/or they are

providing a continuous supply in operational terms, it may be appropriate to use annual orders duly authorised as appropriate. Annual orders must include a clear schedule of the items being ordered, their agreed individual prices, an estimate of the volumes required of each item for the period of the order and hence an agreed total cost which must not be exceeded. The advice of the Head of Procurement should be sought when establishing such annual orders to ensure that the correct format is applied and that value for money is obtained.

3.5 No single supplier or single annual order should be used for a period in excess of 12

months. The advice of Head of Procurement should be sought. Where this advice is not sought or not acted upon the requisitioner must advise the Chief Executive in writing seeking waiver of this rule.

4.0 TENDERING PROCEDURES 4.1 The basic procedures to be followed in relation to competitive tenders are set out below. 4.2 In all cases the tender that provides the best value for money must be accepted using a

defined combination of cost and quality. Any proposal to waive this rule would need the approval of:

‐ goods/services in excess of Director of Finance £5,000 and up to £250,000 ‐ goods/services in excess of Chief Executive £250,000 and up to £1m

‐ goods/services in excess of £1m Board

4.3 Officers with any doubts concerning the appropriateness of competitive tendering in

particular circumstances must seek formal clarification from the Director of Finance. The Trust will not be responsible for officers committing costs other than in accordance with the above procedures.

4.4 Tenders shall be advertised, issued and submitted on the Trust’s e‐tendering system. 4.5 Every tender for building and engineering works, except any tender for maintenance work

only, where “The efficient management of healthcare estates and facilities” guidance should be followed, shall embody or be in the terms of the current Edition of the Standard Form of Building Contract Local Authorities Edition with (or, where appropriate, without) quantities or the Agreement for Minor Building Works issued by the Joint Contract Tribunal as

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appropriate or (when the contents of the works is primarily engineering) the General Conditions of Contracts recommended by the Institute of Mechanical and Electrical Engineers and the Association of Consulting Engineers (Form A), or (in the case of civil engineering work) the General Conditions of Contract recommended by the Institution of Civil Engineers, the Association of Consulting Engineers and the Federation of Civil Engineering Contractors. These base documents should be modified and amplified to accord with current Departmental guidance forms of contract may be used after prior consultation with the Department.

4.6 Tenders submitted via e‐tendering will be electronically date and time stamped. 4.7 Tenders submitted via e‐tendering will remain electronically locked to all Trust staff until the

end time for receipt of tenders has passed. 4.8 Alterations to tenders submitted via e‐tendering will be electronically marked. 4.9 Tenders received after the due time and date may be considered only if the Chief Executive

decides that there are exceptional circumstances, e.g. where marked financial, technical or delivery advantages would accrue, and is satisfied that there is no reason to doubt the bona fides of the tenderers concerned. The Chief Executive shall decide whether such tenders are admissible and where re‐tendering is desirable.

4.10 Technically late tenders (i.e. those uploaded in good time but delayed through no fault of

the tenderer) may be regarded as having arrived in due time. 4.11 Incomplete tenders (i.e. those from which information necessary for the adjudication of the

tender is missing) and amended tenders (i.e. those amended by the tenderer upon his own initiative either orally or in writing after the due time for receipt) should be dealt with in the same way as late tenders.

4.12 Necessary discussion with a tenderer of the contents of his tender, in order to elucidate

technical, etc, points before the award of a contract, need not disqualify the tender. 4.13 While decisions as to the admissibility of late, incomplete, or amended tenders are under

consideration and while re‐tenders are being obtained, the tenders will remain electronically unopened.

4.14 Where only one tender/quotation is sought and/or received, the Trust shall, as far as is

practicable, ensure that the price to be paid is fair and reasonable. 4.15 Every contract for building and engineering works, except measured term contracts where

Estmancode guidance should be followed, should be embodied in a formal contract document which should conform to these Standing Financial Instructions. These formal contract documents should reflect any change in the terms and conditions of contract agreed following receipt of tenders.

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4.16 No goods, services or works other than works and services, executed in accordance with a contract and purchases from petty cash shall be ordered except on an official order, which may be in hard copy or electronic media. Contractors shall be notified that they should not accept orders unless in an official format. Verbal orders shall be issued only in specific instances, the first being by an officer designated by the Chief Executive in cases of emergency or urgent necessity. These must be confirmed by an official order and clearly marked "Confirmation Order". The second being by the use of official purchasing cards, by those designated to do so by the Chief Executive, and in accordance with the detailed guidance and limitations for the use of such cards as issued by the Director of Finance.

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Service/Function/Policy/Project/ Strategy CSU/Executive Directorate and Department


Date of Assessment

Standing Financial instructions –June 2020 ‐ CORP/FIN 1 (B) v.8

CE/Finance Jon Sargeant/Matthew Bancroft


1) Who is responsible for this policy? Name of CSU/Directorate – Finance Department

2) Describe the purpose of the service / function / policy / project/ strategy? Who is it intended to benefit? What are the intended outcomes? To provide a framework within which the Trust can properly conduct its financial affairs and transactions.

3) Are there any associated objectives? Legislation, targets national expectation, standards No

4) What factors contribute or detract from achieving intended outcomes? – Compliance with the policy

5) Does the policy have an impact in terms of age, race, disability, gender, gender reassignment, sexual orientation, marriage/civil partnership, maternity/pregnancy and religion/belief? Details: [see Equality Impact Assessment Guidance] ‐ No

If yes, please describe current or planned activities to address the impact [e.g. Monitoring, consultation] – N/A

6) Is there any scope for new measures which would promote equality? [any actions to be taken] N/A

7) Are any of the following groups adversely affected by the policy? No

Protected Characteristics Affected? Impact a) Age No

b) Disability No

c) Gender No

d) Gender Reassignment No

e) Marriage/Civil Partnership No

f) Maternity/Pregnancy No

g) Race No

h) Religion/Belief No

i) Sexual Orientation No



Date for next review: June 2021

Checked by: Jon Sargeant/Matthew Bancroft Date: June 2020

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Reservation of Powers to the Board

and Delegation of Powers

July 2020


Name and title of author/reviewer: Jon Sargeant, Director of Finance



Date of approval:

Date issued:



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Reservation of Powers to the Board and Delegation of Powers

Amendment Form Please record brief details of the changes made alongside the next version number. If the procedural document has been reviewed without change, this information will still need to be recorded although the version number will remain the same.

Version

Date Brief Summary of Changes Author

Version 9 July 2020 Renaming names of structures/meetings Matthew Bancroft

Version 8

November 2018

Renaming names of structures/meetings Jon Sargeant

Version 7

September 2017

Various Jon Sargeant and Matthew Kane

Version 6

September 2016

Update to ensure consistency with the SFIs Update for consistency with new committee

structure Various changes

Maria Dixon / Andrew Thomas

Version 5

March 2015

Updated to reflect changes to Standing Orders

relating to e‐tendering and Working Together Group thresholds

Andrea Smith

Version 4

November 2013

References throughout to Director of Finance, Information and Procurement / DoFIP amended to Director of Finance and Infrastructure / DoFI;

References throughout to Director of Human Resources amended to Director of People and Organisational Development;

Updated references and amendments for consistency to revised Standing Orders section 11 and tendering annex;

Clarification added to the posts included in role of ‘Senior Officer’.

Robert Paskell

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CONTENTS INTRODUCTION 4 1. RESERVATION OF POWERS TO THE BOARD 6 2. DELEGATION OF POWERS 9 3. SCHEME OF AUTHORISATION TO OFFICERS 9 4. SCHEME OF DELEGATION IMPLIED BY • STANDING ORDERS 10 AND • STANDING FINANCIAL INSTRUCTIONS 12 5. DETAILED SCHEME OF DELEGATION 15 6. ROLES AND RESPONSIBILITIES OF GOVERNORS 25 Appendix 1 – Equality Impact Assessment Form 26

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INTRODUCTION

SO 6.1 of the Standing Orders provides that "subject to such directions as may be given by NHS Improvement, the Trust may make arrangements for the exercise, on behalf of the Trust, of any of its functions by a committee or sub‐committee of directors or by an executive director of the Trust, in each case subject to such restrictions and conditions as the Board thinks fit." The Code of Accountability also requires that there should be a formal schedule of matters specifically reserved to the Trust. The purpose of this document is to provide details of those powers reserved to the Board ‐ generally matters for which it is held accountable to the NHS Improvement, while at the same time delegating to the appropriate level the detailed application of Trust policies and procedures. However, the Board remains accountable for all of its functions; even those delegated and would therefore expect to receive information about the exercise of delegated functions to enable it to maintain a monitoring role. A. Role of the Chief Executive All powers of the Trust which have not been retained as reserved by the Board or

delegated to an executive committee or sub‐committee shall be exercised on behalf of the Board by the Chief Executive. The Chief Executive shall prepare a Scheme of Delegation identifying which functions he shall perform personally and which functions have been delegated.

All powers delegated by the Chief Executive can be re‐assumed by him/her should the

need arise. As Accounting Officer the Chief Executive is accountable to NHS Improvement for the funds entrusted to the Trust.

B. Caution over the Use of Delegated Powers Powers are delegated to directors on the understanding that they would not exercise

delegated powers in a matter which in their judgement was likely to be a cause for public concern.

C. Directors' Ability to Delegate their own Delegated Powers The Scheme of Delegation shows only the "top level" of delegation within the Trust.

The Scheme is to be used in conjunction with the system of budgetary control and other established procedures within the Trust.

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D. Absence of Directors or Officer to Whom Powers have been Delegated In the absence of a director to whom powers have been delegated those powers shall

be exercised by that director's superior unless alternative arrangements have been approved by the Board. If the Chief Executive is absent, powers delegated to him may be exercised by the Deputy Chief Executive after taking appropriate advice from the Director of Finance.

The Chief Executive, following consultation with the Chair, may authorise any person

to act on his behalf and exercise such delegated powers across the full range of duties carried out by the Chief Executive.

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1. RESERVATION OF POWERS TO THE BOARD

1.1 The Code of Accountability which has been adopted by the Trust requires the Board to

determine those matters on which decisions are reserved unto itself. These reserved matters are set out in paragraphs 1.2 to 1.9 below:

1.2 General Enabling Provision The Board may determine any matter it wishes in full session within its statutory

powers. 1.3 Regulation and Control 1.3.1 Approval of Standing Orders (SOs), a schedule of matters reserved to the Board

and Standing Financial Instructions for the regulation of its proceedings and business.

1.3.2 Approval of a scheme of delegation of powers from the Board to officers. 1.3.3 Suspension of Standing Orders.

1.3.4 Variation or amendment of Standing Orders. 1.3.5 Requiring and receiving the declaration of directors' interests which may

conflict with those of the Trust and determining the extent to which that director may remain involved with the matter under consideration.

1.3.6 Requiring and receiving the declaration of interests from officers which may

conflict with those of the Trust. 1.3.7 Disciplining directors who are in breach of statutory requirements or SOs. 1.3.8 Approval of the disciplinary procedure for officers of the Trust. 1.3.9 Approval of arrangements for dealing with complaints. 1.3.10 Adoption of the organisational structures, processes and procedures to

facilitate the discharge of business by the Trust and to agree modifications there to.

1.3.11 To receive reports from committees including those which the Trust is required

to establish and to take appropriate action thereon. 1.3.12 To confirm the recommendations of the Trust's committees where the

committees do not have executive powers. To establish terms of reference and reporting arrangements of all board committees (and other committees if required).

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1.3.13 Ratification of any urgent decisions taken in accordance with SO 6.2. 1.3.14 Approval of arrangements relating to the discharge of the Trust's

responsibilities as a corporate trustee for funds held on trust. 1.3.15 Approval of arrangements relating to the discharge of the Trust's

responsibilities as a bailee for patients' property. 1.4 Appointments 1.4.1 The appointment and disestablishment of committees. 1.4.2 The appointment and dismissal of executive directors (subject to SO 3.4). 1.4.3 The appointment of members of any committee of the Trust. 1.5 Policy Determination 1.5.1 To approve management policies including personnel policies incorporating

the arrangements for the appointment, removal and remuneration of staff. Policies so received shall be listed.

1.6 Strategy and Business Plans and Budgets 1.6.1 Definition of the strategic aims and objectives of the Trust, including approval

of underpinning strategies that support its delivery. 1.6.2 Approval annually of plans, including the NHS Improvement’s annual plan in

respect of:‐ • Service delivery strategy. • The application of available financial resources. 1.6.3 Overall approval of programmes of investment to guide the letting of

contracts for the supply of clinical services. 1.6.4 Approval and monitoring of the Trust's policies and procedures for the

management of risk, through the Audit and Risk Committee. 1.7 Direct Operational Decisions 1.7.1 Acquisition, disposal or change of use of land and/or buildings. 1.7.2 The introduction or discontinuance of any significant activity or operation. An

activity or operation shall be regarded as significant if it has a gross annual income or expenditure (that is before any set off) in excess of £250,000.

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1.7.3 Approval of individual contracts (other than NHS contracts) of a capital or revenue nature amounting to, or likely to amount to over £500,000 over a 2 year period or the period of the contract if longer.

1.7.4 Approval of individual compensation payments over £100,000. 1.7.5 To agree action on litigation against or on behalf of the Trust. 1.8 Financial and Performance Reporting Arrangements 1.8.1 Continuous appraisal of the affairs of the Trust by means of the receipt of

reports as it sees fit from directors, committees, associate directors and officers of the Trust as set out in management policy statements. All monitoring returns required by NHS Improvement and the Charity Commission shall be reported, at least in summary, to the Board of Directors.

1.8.2 Approval of the opening or closing of any bank or investment accounts. 1.8.3 Receipt and approval of a schedule of NHS contracts signed in accordance with

arrangements approved by the Chief Executive. 1.8.4 Consideration and approval of the Trust's Annual Report including the annual

accounts. 1.8.5 Receipt and approval of the Annual Report(s) for funds held on trust. 1.9 Audit Arrangements 1.9.1 To approve audit arrangements (including arrangements for the separate

audit of funds held on trust) and to receive reports of the Audit and Risk Committee meetings and take appropriate action.

1.9.2 The receipt of the annual management letter received from the external

auditor and agreement of action on the recommendation where appropriate of the Audit and Risk Committee.

1.9.3 The receipt of the annual report received from the internal auditor and the

agreement of action on the recommendation where appropriate of the Audit and Risk Committee.

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2. DELEGATION OF POWERS

2.1 Delegation to Committees The Board may determine that certain of its powers shall be exercised by committees.

The composition and terms of reference of such committees shall be that determined by the Board from time to time taking into account where necessary the requirements of NHS Improvement and or the Charity Commissioners (including the need to appoint an Audit Committee and a Remuneration and Terms of Service Committee). The Board shall determine the reporting requirements in respect of these committees. In accordance with SO 7.5 committees may not delegate executive powers to sub‐committees unless expressly authorised by the Board.

3. SCHEME OF AUTHORISATION TO OFFICERS

3.1 Standing Orders and model Standing Financial Instructions set out in some detail the

financial responsibilities of the Chief Executive (CE), the Director of Finance (DoF) and other directors. These responsibilities are summarised below.

[NOTE It should be noted that the SFIs generally specify

officers responsible for various matters whereas SOs only do this occasionally].

Certain matters needing to be covered in the scheme of delegation are not covered by

SFIs or SOs or they do not specify the responsible officer. These are:

Area of responsibility Overall responsibility

Data Protection Act Requirements Chief Executive – with operational responsibility delegated to the Chief Information Officer

Health and Safety Arrangements Chief Executive – with operational responsibility delegated to the Director of Estates & Facilities

This scheme of delegation covers only matters delegated by the Board to directors and

certain other specific matters referred to in SFIs. Each director is responsible for the delegation within his area of responsibility. S/he should produce a scheme of authorisation for matters. In particular the scheme of authorisation should include how budget management and procedures for approval of expenditure are delegated.

A more detailed scheme of delegation including financial limits is given in Section 5.

CORP/FIN 1 (C) v.9

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CORP/FIN 1 (C) v.9

Page 11

SECTION 4 – SCHEME OF DELEGATION IMPLIED BY STANDING ORDERS

SCHEME OF DELEGATION IMPLIED BY STANDING ORDERS

SO REF

DELEGATED TO

DUTIES DELEGATED

2.1 CHAIR Final authority in interpretation of SOs.

4.1 CHAIR Chair all board meetings and associated responsibilities.

5.6 CHAIR Calling meetings.

8.8 CE Register(s) of interests.

11.18 CE Demonstrate that the use of private finance represents best value for money and transfers risk to the private sector.

11.20 CE Best value for money is demonstrated for all services provided under contract or in‐house.

11.20 CE Nominate an officer to oversee and manage the contract on behalf of the Trust.

11.21 CE Nominate officers to enter into contracts of employment, regrading staff, agency staff or consultancy service contracts.

11.23 CE Nominate officers with power to negotiate commissioning contracts with providers of healthcare and other authorities.

12.1(a) CE OR

NOMINATED OFFICER

Determining any items to be sold by sale or negotiation.

14.1 CE Keep seal in safe place and maintain a register of sealing.

14.4 CE/DOF OR NOMINATED

OFFICERS Approve and sign all building, engineering, property or capital documents.

15.1 CE Approve and sign all documents which will be necessary in legal proceedings

15.2 CE OR NOMINATED

OFFICERS Sign on behalf of the Trust any agreement or document not requested to be executed as a deed.

16.1 CHAIR Existing Directors, Governors and employees and all new appointees are notified of and understand their responsibilities within Standing Orders and SFIs.

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SCHEME OF DELEGATION IMPLIED BY STANDING ORDERS

SO REF

DELEGATED TO

DUTIES DELEGATED

Annex s2 CE Designate an officer responsible for receipt and custody of tenders before opening.

Annex s3 TWO SENIOR OFFICERS Open tenders.

Annex s4 DOF Decide whether any late tenders should be considered.

Annex s5 CE OR DOF Keep lists of approved firms for tenders.

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SECTION 4 – SCHEME OF DELEGATION IMPLIED BY STANDING FINANCIAL INSTRUCTIONS

SCHEME OF DELEGATION IMPLIED BY STANDING FINANCIAL INSTRUCTIONS

SFI REF

DELEGATED TO

DUTIES DELEGATED

1.3.6 CHIEF EXECUTIVE (CE) To ensure all employees and directors, present and future, are notified of and understand Standing Financial Instructions.

1.3.7 DIRECTOR OF FINANCE (DOF) Responsible for implementing the Trust's financial policies and coordinating corrective action and ensuring detailed financial procedures and systems are prepared and documented.

1.3.8 DIRECTORS Responsible for security of the Trust's property, avoiding loss, exercising economy and efficiency in using resources and conforming to Standing Orders, Financial Instructions and financial procedures.

1.3.10 DOF Form and adequacy of financial records of all departments.

2.1.1 AUDIT AND RISK COMMITTEE Provide independent and objective view on internal control and probity.

2.2 DOF Monitor and ensure compliance with directions on fraud and corruption.

2.5 HEAD OF INTERNAL AUDIT Review, appraise and report in accordance with NHS Internal Audit Manual and best practice.

2.6 COUNCIL OF GOVERNORS Appoint external auditors.

3 DOF Ensuring compliance with NHS Improvement’s requirements, ensure loans drawn are for approved expenditure only at time of need, and ensuring adequate system of monitoring.

4 DOF DOF CE

Submit budgets. Monitor performance against budget; submit to Board financial estimates and forecasts. Delegate budget to budget holders and submit monitoring returns.

4.3 DOF Devise and maintain systems of budgetary control.

5 DOF Annual accounts and reports.

6 DOF Banking arrangements.

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SFI REF

DELEGATED TO

DUTIES DELEGATED

7 DOF Income systems.

8 CE

DOF

Negotiating contracts for provision of patient services. Regular reports of actual and forecast contract expenditure.

9.1 NOM. & REMUN. COMMITTEE Remuneration & Terms of Service Committee

9.2 CE Variation to funded establishment of any department.

9.3 CE Staff, including agency staff, appointments.

9.4 DIRECTOR OF PEOPLE AND ORGANISATIONAL DEVELOPMENT

Payroll

10.1 CE / DOF Determine, and set out, level of delegation of non‐pay expenditure to budget managers.

10.2.2 DOF Prompt payment of accounts.

10.2.5 CE Authorise the use of official orders.

10.2.7 DOF Ensure that arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with the good practice guidance.

10.3 CE Grants for provision of patient services.

11 DOF Advise Board on borrowing and investment needs and prepare procedural instructions.

12 CE Capital investment programme

12.3 CE Maintenance of asset registers.

12.3.8 DOF Calculate and pay capital charges in accordance with NHS Improvement requirements.

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SFI REF

DELEGATED TO

DUTIES DELEGATED

12.4.1 CE Overall responsibility for fixed assets.

12.4.4 DIRECTORS Responsibility for security of Trust assets including notifying discrepancies to DoF, and reporting losses in accordance with Trust procedure.

13 DOF Responsible for systems of control over stores and receipt of goods.

13.8 CE Identify persons authorised to requisition and accept goods from NHS Supply Chain Warehouses.

14.2 DOF Prepare procedures for recording and accounting for losses and special payments and informing NHS Counter Fraud Authority and the External Auditor of all frauds and informing police in cases of suspected arson or theft.

15 DOF Responsible for accuracy and security of computerised financial data.

16 CE Responsible for ensuring patients and guardians are informed about patients' money and property procedures on admission.

17 DOF Shall ensure each fund held on trust is managed appropriately (subject to the discretion and approval of the Charitable Funds Committee if any).

18 CE Retention of document procedures

19.1 CE

DOF

Risk management programme

Insurance arrangements

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SECTION 5 ‐ DETAILED SCHEME OF DELEGATION & AUTHORISATION

Delegated matters in respect of decisions which may have a far reaching effect must be reported to the Chief Executive. The delegation and authorisation shown below is the lowest level to which authority is given. Delegation and authorisation to lower levels is only permitted with written approval of the Chief Executive who will, before authorising, consult with other Directors as appropriate. All items concerning Finance must be carried out in accordance with Standing Financial Instructions and Standing Orders. Key: CE ‐ Chief Executive, MD ‐ Medical Director, DoN ‐ Director of Nursing, Midwifery & AHPs, DoF ‐ Director of Finance, DoPOD – Director of People and Organisational Development, COO ‐ Chief Operating Officer,

HoCM Head of Communications and Engagement Directors for the purpose of SO/SFI and Scheme of Delegation are Executive Directors. Senior officers are staff employed in the post of Divisional Director, General Manager, Deputy Director or Head of a department.

Delegated Matter Authority Delegated To Reference Document

1. Management of Budgets SFIs Section 4

Responsibility of keeping expenditure within budgets

a) At individual budget level (Pay and Non Pay) Budget Holder

b) At service level Divisional Director or Executive Director

c) For the totality of services covered by Functional Director Executive Director or CE

d) For all other areas: DoF or Appropriate Delegated Manager

Budgetary or virement limits

a) Up to £250,000 per request Executive Director

b) Up to £500,000 per request DOF

c) Over £500,000 per request Executive Committee

Approval for the carry forward of funds into a different budgetary period, after discussion with the DoF CE

Approval of revenue business cases

a) Cases up to £250,000 Capital Investment Group

b) Cases over £250,000 Board of Directors

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2. Maintenance / Operation of Bank Accounts SFIs Section 6

Maintenance / Operation of Bank Accounts DoF

3. Quotation, Tendering & Contract Procedures SFIs Section 10

Authority to obtain at least:

a) To obtain best Value for goods/services under £5,000 Buyers & Senior Officers (Procurement and Estates)

b) 3 written quotations for goods/services from £5,000 to £25,000 Senior Officers (Procurement and Estates) & SOs Section 11

c) 3 quotations via e‐tendering portal from £25,000 to £50,000 c) 4 Tenders for goods/services (non works) via e‐tendering portal from £50,000

Senior Officer (Procurement) Senior Officer (Procurement)

& Annex

e) Competitive tenders via e‐tendering portal for works goods/services from £50,000 (after seeking responses from a minimum of 6 suppliers)

Senior Officers (Estates) or Executive Director

f) Single quotation approval up to £50,000 subject to SFIs Head of Procurementg) Single tender approval over £50,000 subject to SFIs CE or DoF 4. Non Pay Expenditure/Requisitioning/Ordering/ Payment of Goods & Services SFIs Section 10 & SOs Section 11 & Annex

Authorisation of requisitions:a) Requisitions to £2,000 Authorised Signatory for Budgetb) Requisitions to £25,000 Head of Dept. General Manager or Divisional

Director c) Requisitions to £50,000d) Requisitions to £100,000

Executive DirectorChief Operating Officer

e) Requisitions to £250,000 CE and DOFf) Requisitions over £250,000 CE and DOF, after approval by the Board Authorisation of contracts for goods & services and subsequent variations to contractsa) Contracts up to £250,000 Senior Officers (Estates, Procurement,

Pharmacy) b) Contracts over £250,000 to £500,000 DoFc) Contracts over £500,000 to £1,000,000 DoF or CE d) Contracts over £1,000,000

DoF or CE, after approval by the Board

Authorisation of call off contracts for goods and services covered by a pre‐tendered Framework

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a) Contracts up to £250,000 Senior Officers (Estates, Procurement, Pharmacy)

b) Contracts over £250,000 to £1,000,000 DoFc) Contracts over £1,000,000 to £2,000,000 DoF or CEd) Contracts over £2,000,000 DoF or CE, after approval by the board

5. Capital Schemes Business Cases SFIs Section 12 a) Production of case of need for every capital expenditure proposal

DoF & SOs Section 11

b) Certification of costs and revenue consequences DoF

c) Approval of business cases to £1,000,000 and not linked to new service development and part of agreed capital plan

Capital Investment Group

d) Approval of business cases over £1,000,000 or linked to new service development Board of Directors Capital Programmea) Production of draft capital programme DoFb) Confirmation of capital funds available DoFc) Approval of capital programme Board of Directors Capital Expenditurea) Issue authority to commit expenditure and proceed to tender up to budget approved in capital programme

DoF or CE

b) Responsibility of keeping expenditure within scheme budget Scheme Managerc) Responsibility of keeping expenditure within total capital budget DoFd) Approval of variations to scheme budgets from plan: i) To 10% of original scheme budget, a maximum of £50,000 DoF ii) To 20% of original scheme budget, a maximum of £250,000 CE iii) Above £250,000 or 20% of original scheme budget Board of Directorse) Selection of architects, quantity surveyors, consultant engineer and other professional advisors within EU regulations

DoF

f) Financial reporting on all capital scheme expenditure DoFg) Financial monitoring of all capital scheme expenditure DoFh) Granting and termination of leases with annual rent <£100k DoFi) Granting and termination of leases of >£100k CE

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6. Setting of Fees and Charges

a) Private Patient, Overseas Visitors, Income Generation and other patient related services DoF SFIs Section 7 b) Price of all NHS Contracts DoF SFIs Section 8 7. Engagement of Staff Not On the Establishment (Within NHSI price caps) SFIs Section 9 a) Management Consultancy Executive Directorb) Engagement of Trust's Solicitors DoPOD, MD and DoFc) Booking of Bank or Agency Staff i) Medical Locums General Manager or Divisional Director ii) Nursing General Manager iii) Clerical

General / Department Manager or Divisional /Executive Director

Outside NHSI price caps Executive Director 8. Expenditure on Charitable and Endowment Funds SFIs Section 17 Up to £25,000 per requestOver £25,000 per request

DoF or CECEO or DoF after authorisation from the Charitable Funds Committee.

9. Agreements/Licencesa) Preparation and signature of all tenancy agreements/licences for all staff subject to Trust Policy on accommodation for staff

DoF and DoPOD

b) Extensions to existing leases DoFc) Letting of premises to outside organisations DoFd) Approval of rent based on professional assessment DoF 10. Condemning & Disposal SFIs Section 14 a) Items obsolete, obsolescent, redundant, irreparable or cannot be repaired cost effectively General/Department Manager and

Condemning Officer b) disposal of x‐ray films Superintendent Radiographerc) disposal of controlled drugs Chief Pharmacist 11. Losses, Write‐off & Compensation SFIs Section 14 a) Losses and Cash due to theft, fraud, overpayment & others Up to £50,000 CE or Nominated Director and DoFb) Fruitless Payments (including abandoned Capital Schemes) Up to £100,000 CE or Nominated Director and DoF

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c) Bad Debts and Claims Abandoned. Private Patients, Overseas Visitors & Other Up to £50,000 CE or Nominated Director and DoFd) Damage to buildings, fittings, furniture and equipment and loss of equipment and property in stores and in use due to: Culpable causes (e.g. fraud, theft, arson) or other Up to £50,000 CE or Nominated Director and DoFe) Compensation payments made under legal obligation CE or Nominated Director and DoFf) Extra Contractual payments to contractors Up to £50,000 CE or Nominated Director and DoF Ex‐Gratia Paymentsg) Patients and staff for loss of personal effects Up to £50,000 CE or Nominated Director and DoFh) For clinical negligence up to £1,000,000 (negotiated settlements) i) Negotiate settlement up to £50,000 MD

ii) £50,000 to £100,000 CEi) over £100,000 Board of Directors

iv) Authorise payment (up to £1,000,000) CE or Nominated Director and DoFi) For personal injury claims involving negligence where legal advice has been obtained and guidance applied i) Negotiate settlement up to £25,000 DoPOD ii) £25,000 to £100,000 CE iii) over £100,000 Board of Directors iv) Authorise payment (up to £1,000,000) CE or Nominated Director and DoFj) Other, except cases of maladministration where there was no financial loss by claimant £50,000 CE or Nominated Director and DoF Losses, Write‐Off & Compensation above delegated limits Finance & Performance Committee12. Reporting of Incidents to the Police SFIs Sections 2 a) Where a criminal offence is suspected (other than theft or fraud) Director with managerial responsibility for the

area & 14

b) Where a theft is involved DoF or DoPODc) Where a fraud is involved DoF 13. Petty Cash Disbursements (not applicable to central Cashiers Office) SFIs Section 10 a) Expenditure up to £25 per item Petty Cash Holder 14. Receiving Hospitality

CORP/FIN 1 (C) v.9

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Applies to both individual and collective items of hospitality received or offered and declined, in excess of £50.00.

Declaration required in Trust's Hospitality Register

15. Implementation of Internal and External Audit Recommendations DoF SFIs Section 2 16. Maintenance & Update on Trust Financial Procedures DoF SFIs Section 1 17. Investment of Funds (including Charitable & Endowment Funds)

DoF SFIs Section 17

18. Personnel & Paya) Authority to fill funded post on the establishment with permanent staff. Budget holder (after vacancy control approval

or Management Board approval for Consultant posts)

b) Authority to appoint staff to post not on the formal establishment. CE and DoFc) Additional Increments The granting of additional increments to staff within budget DoPODd) Upgrading & Regrading All requests for upgrading/regrading shall be dealt with in accordance with Trust procedure DoPODe) Establishments

i) Additional staff to the agreed establishment with specifically allocated finance Budget holder(after vacancy control approval or Management Board approval for Consultant posts)

ii) Additional staff to the agreed establishment without specifically allocated finance CE and DoFf) Pay i) Authority to complete standing data forms affecting pay, new starters, variations and leavers Senior Officer or Executive Director ii) Authority to authorise overtime Senior Officer or Executive Director iii) Authority to complete and authorise positive reporting forms Senior Officer or Executive Director iv) Authority to authorise travel & subsistence expenses Senior Officer or Executive Director v) Approval of Performance Related Pay Assessment Remuneration Committee/CEg) Leave i) Approval of annual leave Senior Officer or Executive Director ii) Annual leave ‐ approval of carry forward (up to maximum of 5 days). Senior Officer or Executive Director iii) Annual leave ‐ approval of carry over in excess of 5 days but less than 10 days. Executive Director iv) Compassionate leave up to 3 days Senior Officer or Executive Director v) Compassionate leave up to 6 days Executive Director vi) Special leave arrangements Executive Director paternity leave Senior Officer or Executive Director

CORP/FIN 1 (C) v.9

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vii) Leave without pay Executive Director viii) Medical Staff Leave of Absence MD and CE paid and unpaid General Manager or Divisional Director ix) Time off in lieu Automatic approval with guidance x) Maternity Leave ‐ paid and unpaid Automatic approval with guidanceh) Sick Leave i) Extension of sick leave on half pay up to three months Executive Director in conjunction with DoPOD ii) Return to work part‐time on full pay to assist recovery Executive Director in conjunction with DoPOD iii) Extension of sick leave on full pay DoPOD or CEi) Study Leave i) Study leave outside the UK DoPOD or MD ii) Medical staff study leave (UK) Divisional Director iii) All other study leave (UK) Senior Officer or Executive Directorj) Removal Expenses, Excess Rent and House Purchases Authorisation of payment of removal expenses incurred by Directors taking up new appointments (providing consideration was promised at interview)

DoPOD

k) Grievance Procedure DoPOD All grievances cases must be dealt with strictly in accordance with the Grievance Procedure and the advice of a the Director of People and Organisational Development must be sought when the grievance reaches the level of Associate/Dept. Manager l) Authorised Car & Mobile Phone Users Requests for new posts to be authorised as car users DoPOD Requests for new posts to be authorised as mobile telephone users DoPODm) Renewal of Fixed Term Contract Senior Officer or Executive Directorn) Redundancy DoPODo) Ill Health Retirement Decision to pursue retirement on the grounds of ill‐health DoPODp) Dismissal Appointing Officersq) Development of personnel, industrial relations & training strategies and procedures Executive Directorsr) Authorisation of expenditure on recruitment advertising DoPODs) Day to day management of Consultants' contracts MD Divisional Directors t) Excellence Awards to Medical staff. CE 19. Authorisation of New Drugs SFIs Section 10 Estimated total yearly cost up to £25,000 Medicines Management Group Estimated total yearly cost above £25,000 CE (Subject to consultation with the above) 20. Authorisation of Sponsorship deals CE

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21. Authorisation of Research Projects CE or MD or DoN 22. Authorisation of Clinical Trials CE and MD 23. Insurance Policies and Risk Management DoF SFIs Section 19 24. Patients & Relatives Complaints a) Overall responsibility for ensuring that all complaints are dealt with effectively under regulations. CEb) Responsibility for ensuring complaints relating to a directorate are investigated thoroughly Senior Officer and PALS Rep.c) Medico ‐ Legal Complaints Co‐ordination of their management. MD 25. Relationships with Pressa) Non‐Urgent General Enquiries Within Hours HoCM Outside Hours Executive Director on callb) Urgent Within Hours HoCM Outside Hours Executive Director on call 26. Infectious Diseases & Notifiable Outbreaks MD or Consultant Microbiologist or Control of

Infection Nurse 27. Extended Role Activities Approval of any professions to undertake duties / procedures which can properly be described as beyond the normal scope of practice.

Clinical Governance Committee

28. Patient Services a) Variation of operating and clinic sessions within existing numbers COO with General Manager or Divisional

Director Outpatients COO with General Manager or Divisional

Director Theatres COO with General Manager or Divisional

Director Other COO with General Manager or Divisional

Director b) All proposed changes in bed allocation and use (excluding critical care)

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Temporary Change Bed Manager with advice from COO & DoN Permanent Change CE with advice from COO & DoN Contract monitoring & reporting DoF c) Critical Care CE or Executive Director on call 29. Facilities for staff not employed by the Trust to gain practical experience Professional Recognition, Honorary Contracts, & Insurance of Medical Staff, Work experience students DoPOD 30. Review of fire precautions CE 31. Review of all statutory compliance legislation and Health and Safety requirements including control of Substances Hazardous to Health Regulations

CE

32. Review of Medicines Inspectorate Regulations Chief Pharmacist 33. Review of compliance with environmental regulations, for example those relating to clean air and waste disposal

CE

34. Review of Trust's compliance with the Data Protection Act, including GDPR CE 35. Monitor proposals for contractual arrangements between the Trust andoutside bodies a) Monitor proposals for contractual arrangements between the Trust and other healthcare bodies DoFb) Monitor proposals for contractual arrangements between the Trust and non‐healthcare bodies DoF 36. Review the Trust's compliance with the Access to Records Act MD 37. Review of the Trust's compliance code of Practice for handling confidential information in the contracting environment and the compliance with "safe haven" per EL 92/60

MD

38. The keeping of a Declaration of Interests Register Secretary to the Board 39. Attestation of sealings in accordance with Standing Orders CE and DoF 40. The keeping of a register of Sealings CE 41. The keeping of the Hospitality Register DoF

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42. Retention of Records COO 43. Clinical Audit MD 44. Nominated Fire Director Within Hours CE Outside Hours Executive Director on call 45. Agreement of Policiesa) To recommend the adoption of new policies to the Board of Directors b) To approve policies where authorised to do so by the Board of Directors

The appropriate sub‐committee of the Board e.g. Finance and Performance for finance related policies

46. Working Together Partnership Committee in Common

All functions agreed to be delegated by the Board and listed in the DBTH Committee in Common terms of reference.

Committee in common consisting of CEO and Chair or nominated deputies

DTH CiC TORs

47. Intellectual Property The disposal of intellectual property rights

Executive Committee

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6. ROLES AND RESPONSIBILITIES OF GOVERNORS

The Constitution states that at general meetings, the Council of Governors shall discharge the following responsibilities:

6.1 The appointment or removal of the Chair and the other Non‐Executive Directors

(section 26). 6.2 Approve an appointment (made by the Non‐Executive Directors) of the Chief

Executive (section 26).

6.3 The appointment or removal of the Trust’s auditors (section 35).

6.4 Decide the remuneration and allowances, and the other terms and conditions of office, of the Chair and the other Non‐Executive Directors (section 31).

6.5 Approve any significant transaction, as defined in the constitution (section 42).

6.6 Approve any merger, acquisition, separation or dissolution proposed (section

42).

CORP/FIN 1 (C) v.9

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Service/Function/Policy/Project/ Strategy

CSU/Executive Directorate and Department


Date of Assessment

Reservation of Powers to the Board and Delegation of Powers – CORP/FIN 1 (C) v.9

CE/Finance Jon Sargeant /Matthew Bancroft


1) Who is responsible for this policy? Name of CSU/Directorate – Finance Department/Secretariat2) Describe the purpose of the service / function / policy / project/ strategy? Who is it intended to benefit? What are the intended outcomes? To

provide standing orders for the Board and a framework for the delegation of powers from the Board. 3) Are there any associated objectives? Legislation, targets national expectation, standards No4) What factors contribute or detract from achieving intended outcomes? – Compliance with the policy5) Does the policy have an impact in terms of age, race, disability, gender, gender reassignment, sexual orientation, marriage/civil partnership,

maternity/pregnancy and religion/belief? Details: [see Equality Impact Assessment Guidance] ‐ No

If yes, please describe current or planned activities to address the impact [e.g. Monitoring, consultation] – N/A 6) Is there any scope for new measures which would promote equality? [any actions to be taken] N/A7) Are any of the following groups adversely affected by the policy? NoProtected Characteristics Affected? Impacta) Age Nob) Disability Noc) Gender Nod) Gender Reassignment Noe) Marriage/Civil Partnership Nof) Maternity/Pregnancy Nog) Race Noh) Religion/Belief Noi) Sexual Orientation No



Date for next review: June 2021 Checked by: Jon Sargeant/ Matthew Bancroft Date: June 2020



(IGAF)

Roy G Underwood GCHQ Certified GDPR Practitioner and Data Protection Officer (DPO) & Head of Information Governance

Ken Anderson Chief Information Officer (CIO) & Senior Information Risk Owner (SIRO)

Version 8 dated 1st June 2020


CONTENTS

1. Introduction

2. Policy Statement

3. Scope

4. Aim

5. Objectives

6. Roles and responsibilities

6.1 Chief Executive 6.2 Senior Information Risk Owner (SIRO) 6.3 Caldicott Guardian 6.4 Deputy Caldicott Guardian/SIRO 6.5 Data Protection Officer (DPO) 6.6 Information Asset Owners 6.7 The Information Governance Group 6.8 Managers 6.9 Staff

7. Information asset and information risk management

7.1 Information assets 7.2 Information risk management

8. Governance Structure

9. Information Governance Policies and Procedures

10. Information governance training and awareness

10.1 Information governance Training 10.2 Current approach to awareness training 10.3 Monitoring of training compliance 10.4 Information governance awareness strategy

11. Information governance adverse incident reporting and management

12. Managing third party access to information

12.1 Third party supplier agreements and contracts 12.2 Information sharing with other organisations

13. IT, Cyber Security, Business Continuity and Disaster Recovery

13.1 The key responsibilities of the data security and protection function 13.2 Information security plan for Business Continuity and Disaster Recovery 13.3 The NHS Data Security and Protection Toolkit (DSPT) 13.4 Smartcard management and monitoring

14. Monitoring and review

Appendices:

Appendix A – The IGAF Wheel

Appendix B - IGAF Action Logs

Appendix C - ICT Policies

Appendix D - NCSC: Ten Steps to Cyber Security

Appendix E - Responsibilities for the registration and management of Information Assets

Information Governance Assurance Framework (IGAF)

1. Introduction

The Information Governance Framework sets out the standards to be applied across the Trust for managing information governance; including the organisational arrangements, activities, roles, responsibilities and policies that ensure the standards are met. Information governance covers the framework of law and best practice to ensure information is managed in a confidential, secure and consistent way. Particular focus is placed on the management of personal data and other confidential information to ensure it is handled legally, securely and efficiently to provide the best possible service to our patients.

2. Policy Statement

The Trust is committed to managing its information securely, legally and effectively in order to provide the best possible services to our patients. This framework provides clear guidance to staff around how information should be managed and outlines the accountability structures, governance processes, documented policies and procedures, staff training and resources required to undertake this task. Good information governance ensures that the Trust is able to provide the right service, at the right time for the right people in an inclusive, open and accountable way that upholds the rights of individuals.

3. Scope

This framework applies to all Trust staff and the following groups of people who work for or on behalf of the Trust: agency workers, locums and contractors, secondees, students and volunteers. It applies to management and governance of all information across the Trust, with a particular emphasis on personal and confidential information. It applies to information held in both electronic and paper format and their associated systems.

4. Aim

The aim of the Information Governance Framework is to ensure there is a clear structure in place for managing information governance across the Trust and this is communicated to our staff and stakeholders. It will ensure that the Trust is managing all information in an effective and efficient way and is meeting its legal and ethical requirements, including to safeguard the confidentiality and privacy of patients, staff and service users.

5. Objectives

These objectives ensure the Trust is making the best use of the information it holds, to provide the best possible service and care to patients.

The Trust is organising and protecting personal information, to ensure that the confidentiality and privacy rights of individuals are upheld.

The confidentiality, integrity and availability of information held by the Trust will be monitored and maintained to ensure data is of the appropriate quality and reliably accessible to those that need it.

Patient information held by the Trust will be shared appropriately with health and social care organisations to support the needs of direct patient care

The Trust is meeting its legal and statutory duties including in relation to the Data Protection Act 2018, the General Data Protection Regulations 2016, or any subsequent legislation to the same effect, the Freedom of Information Act, the Human Rights Act and in upholding the common law duty of confidentiality.

All staff will be given and maintain appropriate training and support to ensure they understand their responsibilities in respect of accessing and using information held by the Trust

https://en.wikipedia.org/wiki/Breach_of_confidence_in_English_law

There is a strong senior oversight of information governance within the Trust with a clear reporting structure to the Board.

All Trust staff understand the required standards for managing information and are clear about their individual responsibilities in this area.

There are adequate policies, procedures and processes in place to meet the aims of the Information Governance Framework and these are applied consistently across the organisation.

There is a clear structure for managing information risk across the organisation, with clear individual and collective accountability for the Trust’s information assets and the identification and mitigation of associated risks.

6. Roles and responsibilities

6.1 Chief Executive

Ultimate responsibility for information governance resides with the Trust Board. The Chief Executive has overall responsibility for information governance and provides assurance through the Annual Governance Statement that risks relating to information are effectively managed. Serious Untoward Incidents (SUI’s) involving data loss or confidentiality breaches must also be acknowledged in the Trust’s Annual Report.

6.2 Senior Information Risk Owner (SIRO)

The Chief Information Officer is the Trust’s SIRO, and reports to the Director of Finance. The Director of Finance reports directly to the Trust Board. The SIRO;

Leads and fosters a culture of good information governance across the Trust.

Acts as advocate for information risk and cyber security on the Board.

Ensures information governance compliance with legislation and Trust policies. Has overall responsibility for managing information risk, including cyber security.

Co-Chairs the Information Governance Group.

6.3 Caldicott Guardian

The Medical Director acts as the Caldicott Guardian for the Trust. The Caldicott Guardian is responsible for protecting the confidentiality of patient and service user information and enabling appropriate information sharing to promote high quality care. The Caldicott Guardian:

Leads and fosters a culture of good information governance across the Trust with a focus on managing patient information.

Provides a focal point for patient confidentiality and information sharing issues.

Advises on the options for lawful and ethical processing of information.

Upholds the standards around the safe and ethical use of patient information. Ensures that the Trust is meeting its statutory requirements in relation to the management of patient

information.

Acts as the ‘conscience’ of the organisation and actively supports work to enable appropriate information sharing and, advises staff on the options for lawful and ethical use of information.

6.4 Data Protection Officer (DPO)

The DPO facilitates the Trust’s compliance with its legal and ethical obligations in relation to the management of personal information by providing expert advice to the organisation around its duties and responsibilities. The individual who will undertake the role of the DPO is currently being reviewed by the organisation. The DPO:

Advises the organisation of its requirements in relation to the Data Protection Act /General Data Protection Regulations 2016 or any subsequent legislation to the same effect.

Monitors the organisation’s compliance with meeting the above and the organisation’s policies and procedures including the assignment of responsibilities and training of staff and related audits.

Collects information to identify what processing the organisation is undertaking.

Provides advice in relation to Data Protection Impact Assessments (DPIA) and monitors their performance.

Cooperates with the ICO and acts as the contact point including ensuring that the ICO is consulted in the event that a DPIA shows there is a high risk in a processing activity being undertaken (or proposed to be undertaken).

Has regard for and provides advice around risks associated with the processing of personal data.

Provides advice, information and issues recommendations to the organisation or any organisation processing information on behalf of the Trust.

Acts as deputy and assistant to the Trusts SIRO and Caldicott Guardian

Co-Chairs the Information Governance Group.

6.5 Information Asset Owners (IAO’s)

Each service area and major system that contains personal information is owned by a named Information Asset Owner. These individuals are accountable to the SIRO for the effective management of information held within their service area, and must understand in detail how the information is held, used and shared. They work with the DPO, the SIRO and the Information Governance Group to effectively manage information risk within their service area. The Information Asset Owners promote a culture of good information governance within their service areas and disseminate information and key messages to their managers and staff. Specifically, the IAO’s will ensure that:

Information Asset Administrators are appointed where necessary, to operationally manage and support the information assets owned.

Information risks within their service area are identified, recorded and have adequate mitigation controls in place.

New modules and processes (or changes to existing) do not generate unacceptable risks (this is to be achieved through DPIA’s).

The transfer and sharing of information is secure and lawful.

Regular risk assessments are undertaken and reviewed. The information system asset and data flows registers are complete and kept up-to-date for the

information assets owned.

IG incidents are reported through Datix and investigated in a timely manner.

Periodic confidentiality audits are undertaken.

Business Continuity Plans are developed and linked information risks. Plans should be tested on a regular basis.

The SIRO is kept up-to-date and aware of information risks for the information assets owned.

6.7 The Information Governance Group (IGG)

The IGG is responsible for providing expert advice and assistance to the organisation and for putting the requirements of the Information Governance Framework into practice. The IGG work with the SIRO, the Caldicott Guardian, the DPO, Information Asset Owners/Administrators and key staff across the Health Board to put in place all of requirements needed to ensure good information governance is in place across the Trust. The IGG has the following responsibilities:

Periodically reviews the Trust’s ICT strategies, policies and auditable governance reports, covering all aspects of the Data Security & Protection (DSP) agenda (so that staff understand both the spirit and the detail of what they are expected and indeed mandated to do). This is primarily to ensure that the Trust achieves - as a minimum – a ‘Fully Met’ level of compliance with the requirements of the (DSP)

Toolkit Standards. The Trust will work towards achievement and maintenance of the Cyber Essentials Plus certification by June 2021 as recommended by the NCSC and the National Data Guardian and Smart reviews, and in support of lessons learned from the “WannaCry” ransomware attack and other cyber incidents. The certification satisfies multiple elements of the DSPT; prepopulating many of the associated compliance ‘assertions’ and reducing the time and cost of demonstrating DSPT compliance.

Approving all related documentation and policies to ensure formal evidence of ownership and accountability for Information Assets, Data Flows and all of the associated Information Governance Reports and Action Plans

Reports to the Trust’s Audit & Risk Committee (ARC), who in turn report to the Trust’s Board of Directors.

Managing all Information Security Incidents in line with Trust policies.

Ensuring compliance with the Caldicott Principles.

Developing and implementing Data Protection, Confidentiality and other related policies.

Developing appropriate Information Sharing Agreements (ISAs). Developing Data Processing Agreements (DPAs) and reviewing contract arrangements with third

party organisations and suppliers.

Advising on:

o corporate subject access requests o access to medical records requests o freedom of information requests

Developing the Trust’s information and cyber security compliance. The terms of reference for the IG Group are reviewed annually, and minuted for approval by the

Audit & Risk Committee.

6.8 Managers

Managers and supervisors have the following responsibilities:

Ensuring information governance policies, procedures and guidance notes are read and understood by their staff.

Ensure staff have completed their mandatory information governance training on employment, and annually thereafter via the Trust Statutory & Essential Training (SET) booklet.

Ensure staff understand their responsibilities in terms of patient confidentiality, in particular the fact that staff should never access a patient record or information unless they have a legal basis.

Encourage the safe handling of information by their staff and report any concerns about practice to their Information Asset Owner or to the IGG.

Report any information security incidents they are made aware of to the Information Governance Group immediately through the Trusts DatixWeb application. In exceptional cases requiring immediate attention this might be preceded by a personal call via the switchboard to the Trust DPO or their deputy, or to the hospital manager on call.

Seek further guidance from the Information Governance Group in relation to any requests for information sharing that fall outside of providing direct patient care or an agreed information sharing process (unless in emergency situations).

6.9 Staff

All staff have the following responsibilities:

Read and understand the Trust’s information governance policies, procedures and guidance notes and contact their manager if they require any clarification, advice and guidance.

Complete their mandatory information governance training every two years via the ESR portal.

Ensure they are handling personal information in-line with the Trust’s policies and procedures and report any concerns about practice to their line manager or the Information Governance Team.

Report any information security incidents immediately to their line manager or to the Information Governance Team.

Seek further advice from their line manager if they receive any requests to share information unless the request is part of a process already agreed with their line manager.

Never access patient information or records unless they have a valid work reason for doing so and uphold patient confidentiality at all times. They should not access their own records or those of close family and friends, unless they have a legal and legitimate basis; this would include patient administration tasks where their line manager would need to be informed and advised.

7. Information assets and information risk management

7.1 Information assets

An information asset is a body of information, defined and managed as a single unit so it can be understood, shared, protected and exploited effectively. Information assets have recognisable and manageable value, risk, content and lifecycles. An information asset is usually a set of information that can be identified as it is used for a specific purpose or function within the Trust. Assets are held on many media types both paper-based and digital format.

Some examples of information assets:

Patient and Staff database applications

On-line social media recordings

Any Digital and/or Audio recordings of a personal or confidential nature

Trust Financial records Trust Procurement/Contract Information

Paper-based and/or Digital Medical Records

Patient complaint files

Staff personal files

Child safeguarding files Patient identifiable data held for a specific clinical audit or for research purposes

Contact databases

The Trust retains an information asset register for each service area. The asset register lists all personal and sensitive information held, and further details such as how it is stored, who it is shared with, the legal basis for processing and how long it is stored for as per the Information Commissioner’s (ICO) guidance and instruction.

In addition to the asset register, the Trust holds detailed asset risk information for its major systems that hold patient information. The Trust maintains a Corporate Risk register – on DatixWeb - which identifies significant information risks.

Information Asset Owners are responsible for agreeing any actions to mitigate risk linked to their information assets and ensuring the actions are completed. Information Asset Owners can transfer any significant information risk onto their service risk registers. Any significant information risk that affects the Trust is added to the information governance risk register and is monitored through the IGG.

7.2 Information risk management

Through this policy, the Trust will maintain clear lines of accountability for information risk management and ensure the maintenance of an Information Asset Register.

Since the implementation of the GDPR, each Information Management System (IMS) registration attracts a Data Privacy Impact Assessment (DPIA), consideration of any Data Flow mapping, and a Risk Rating and Assessment profile. Individual Systems Risk Scores must be under 6 before they can be implemented.

https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/accountability-and-governance/documentation/

https://ico.org.uk/for-organisations/guide-to-data-protection/guide-to-the-general-data-protection-regulation-gdpr/accountability-and-governance/documentation/

Risk Logs:

IAO’s ensure that information risks within their service area are identified, recorded and have adequate mitigation controls in place, and that regular risk assessments are undertaken and reviewed.

Internal Audit work with the IG & IT Operations Teams to review and expand – where necessary – the Trust ICT/Datix Risk Log. The ICT Risk Log is reviewed annually as a minimum, and is presented to the IG Group and therefore to ARC.

Critical considerations:

- Risk Analysis - Data Protection Impact Assessments - Risk Treatment/Controls - Information Governance Risk Policy - Corporate Risk Policy - Data Flows, including 3rd Party Systems/Data Access

Corporate Risk Log: The Head of Patient Safety & Quality acts as the tie between the IG and Corporate Risk Management Programme, Risk Policies – including Serious Incidents (SIs) and SIRI (DSPT) reporting - and Risk Escalation/Awareness (as Risk Scores increase they may need to be considered for the Corporate Risk Log until they reduce) at Board level.

8. Governance structure

The Trust has a clear governance structure to provide assurance to the Board that the organisation is complying with its statutory requirements and guidance and best practice in relation to information governance practice.

Organisational chart

Audit & Risk Committee Board of Directors

Board Oversight

Senior Information Risk Owner (SIRO)

IT Security &

Continuity

Manager

Data Protection Officer (DPO) & Head of

Information Governance

Head of IT Operations

Information Governance Group

IT Technical

Ops

Manager

Senior

Systems

Manager

Information

AssIentfoOrwmnaetrios n AssIentfoOrwmnaetriosn

AssIentfoOrwmnaetrios n Asset Owners

Information Asset

AIndfmoirnmisattriaotnorAssset AIdnmfoirnmisatrtiaotnorAssset

AIdnmfoirnmisatrtiaotnorAssset Administrators

Information Asset Owners/Administrators

9. Information governance policies and procedures

The IG Group has responsibility for recommending policies and procedures relating to information governance to the Trust Approved Policies and Documents (APD) Group

The policies and procedures outlined in Appendix C form part of the information governance framework.

10. Information Governance Training and Awareness

10.1 Information Governance Training

The Trust is has adopted the following approach to staff information governance training:

All IG training is recorded on ESR, to identify not only who has a compliance, but also – and more importantly - who hasn’t. The DSP Toolkit now permits a more rational use of face-to-face lectures as well as eLearning, so long as they comply with the DSP Toolkit guidance; Training is based on an agreed Training Needs Assessment which is an iterative process. The DBTH IG Training compliance is mainly achieved through the Trust Statutory & Essential Training (SET) process. The Corporate Welcome Session DOES now include Information Governance

All new employees, volunteers, locums and bank staff (except NHS Professionals who complete their own training) MUST complete a corporate SET on-line IG session. Compliance is recorded on staffs ESR record. There are additional ‘lecture theatre’ type learning sessions to provide more in-depth training for relevant staff groups, senior staff and Trust governors based on the ‘training needs’ analysis.

10.2 Information Governance Training and Awareness Strategy

The Trust is developing an Information Governance Training and Awareness Strategy which will be implemented from October 2020. This strategy will be accompanied by a dedicated action plan to develop a strategic approach to improving information governance training and awareness within the current resources available. The strategy will look at the following key areas:

Improving the completion rate for mandatory information governance training.

Undertaking further training needs analysis to ensure that resources are concentrated in the right areas.

Developing an on-line resource of easy read guides for managers and staff that cover key information governance areas.

Improving the information provided to new staff at induction.

Identifying areas where training is already taking place with key staff groups and putting information governance onto the agenda.

Annual IG Refreshers - All employees – with IT access and skills – will then complete relevant IGT SET and indeed IG Toolkit eLearning modules annually commensurate with their Trust Role. Other staff, who are have difficulty accessing eLearning modules, may attend a ‘tested’ manual IG brief which is consistent with the tone and content of the eLearning training. Some departments (Hotel Services staff etc) will receive a bespoke session appropriate to their de minimus level of involvement with ‘personal data’ and ‘confidentiality’. Where possible all staff are helped and encouraged to do the Trust SET training with the aid of the SET booklet.

Bespoke IG Sessions - Held on all sites (and via MS Teams – by arrangement). These sessions are mainly for those staff who have a more in depth and intimate relationship with ‘personal data’ records and processing1.

1 DPA 2018/GDPR

10.3 Current approach to advertising and awareness raising

The IG Group undertake a number of awareness raising activities. Some examples of activities are provided below:

Producing and disseminating information through BUZZ and the official staff Facebook group.

Running bespoke Information Governance sessions for individuals or small groups by arrangement.

Running a Data Protection/Information Governance Awareness Week.

Using other Trust-sponsored social media platforms to help promote an embedded information governance culture throughout the Trust

10.4 Monitoring of training compliance

Information Governance mandatory training compliance is reported on and monitored through the IG Group on a monthly basis.

11. Information Governance Adverse Incident Reporting and Management

The Trust has an Information Governance Incident Procedure that provides clear guidance to staff about what to do if they become aware of an information security incident.

IG Adverse Incident Reporting is through DATIX as detailed in the Corporate IG & Risk Policies, and then through the DSP Toolkit/Serious Incidents Requiring Investigation (SIRI) process. Where appropriate this reporting necessarily ties into the Trust Serious Incident Reporting Policy, including reporting to the Information Commissioner (ICO) and STEIS.

12. Managing third party access to information

12.1 Third party supplier agreements and contracts

The Trust has GDPR compliant Third Party Supplier Data Processing Agreements in place where necessary which outlines the process that must be followed before information is shared as part of any agreement or contract with an outside organisation. The policy is linked to the Trust’s procurement process and ensures that full assurance is provided to the Trust that a third party supplier has the appropriate security and technical measures in place to protect the Trust’s personal information. The Trust ensures that any contract or agreement entered into with a third party supplier has the appropriate contract or data processing agreement in place that outlines the information governance requirements prior to any information being shared.

12.2 Information sharing with other organisations

Information sharing is managed in accordance with the Trust’s data sharing protocols to ensure information sharing is managed in line with the organisation’s legal duties and is carried out in a safe and secure way. Information is shared on a legal basis with only the minimum amount of information required being shared.

The Trust’s DPO assumes responsibility for identifying all organisations with which personal information is routinely and regularly reviewed. The Trust has developed a Tier 1 agreement with local partners (Team Doncaster). Tier 2 sharing protocols tend to be bespoke to suit specific inter-organisational tasks although post-GDPR the legal basis for most personal data sharing is based around DPA 2018 Schedule 1/GDPR Article 9 2(h) and Article 6 1(a-f).

CORP/ICT 22 relates to sharing Core Systems Network Access – where possible and in line with a legal basis (GDPR Art 9 2(h)), and Caldicott Principle 7 (to share or not to share) - with Trusted third party organisations. This is now an automated system with monitoring being facilitated by periodic audits of all relevant third parties DSPT compliance.

13. IT, Cyber Security, Business Continuity and Disaster Recovery

In line with the DSPT, the Trust applies a comprehensive set of 116 controls to ensure resilience and disaster recovery in the event of a temporary or total loss of the network and/or key IT systems. Business continuity plans are in place for key electronic systems and a programme of development is being implemented through the Information Asset Owners Group. The DSPT supports GDPT evidence items; incorporates the requirements of the Cyber Essentials (CE) and Minimum Cyber Security Standard (MCSS) for larger NHS organisations; and key elements of the NIS Regulations (2018_ Cyber Assessment Framework (CAF), as advised by the NCSC. The Trust is also currently working towards Cyber Essentials Plus certification, and a fully resourced action plan will be available from July 2020 following a mapping and gap identification exercise that is currently being undertaken.

13.1 The key responsibilities of the Data Security & Protection function

Draft and/or maintain the currency of relevant ICT Security & Data Protection Policies, and indeed any other ICT related policies.

Ensure security accreditation of information systems in line with the organisation’s approved definitions of risk and relevant NHS Digital/National Cyber Security Centre (NCSC) standards.

Ensure compliance with the information security assertions as defined in the Data Security & Protection Toolkit (DSPT), contributing to the annual Internal Audit and DSPT assessments.

Ensure all arrangements for managing Information and Cyber Security are effective and aligned with the Trusts and therefore NHS Digital’s Information Security and Risk Policies.

Provide reports to senior members of management (Trust Caldicott Guardian & SIRO) who have responsibility for all aspects of Information Governance.

Co-ordinate the work of other staff with information security responsibilities in IT Services.

Co-ordinate the necessary response and resolution activities following a suspected or actual security incident or breach. Keeping the information risk lead (SIRO) and information asset owners/administrators (IAO/A’s) informed of security incidents, impacts and causes, resulting actions and learning outcomes.

Assist in the drafting of System Specific Security Policies (SSSPs)

Assist in the development of Business Continuity Management and Disaster Recovery arrangements for key information assets.

Advise in the development of the Trust Network Security policy statements and controls for the secure operation of ICT networks, including remote/teleworking facilities.

Provide advice and guidance regarding the implementation of the DSPT security standards and controls to mitigate against malicious or unauthorised mobile code.

Focus diligently on the continuing and ever expanding Cyber Security Threat

Assist in designing and configuring access controls for key systems.

Assist in developing the organisation’s Information Asset and Data Flow Register.

13.3 The NHS Digital Data Security & Protection Toolkit (DSPT)

The DSPT is an online system which allows organisations to assess themselves or be assessed against Data Security & Protection / Information Governance policies and standards. It also allows members of the public to view participating organisations' DSP Toolkit assessments.

A baseline assessment is generally published by the 31st October. The final report is due by the 31st March each year. The Trust hopes to achieve a satisfactory (Fully Met) level of compliance for all assertions for its DSPT report to NHS Digital on the 31st March 2020 (extended to 30th September 2020 for the reporting year 2019/20).

13.4 Smartcard Management & Monitoring

All Smartcard users have to sign – electronically - as having read the T&C as previously described in RA01 Short Form Conditions and which is now facilitated by an automatic on-line ‘signature’ through the Users Smartcard logon process.

The Trust’s monitoring plan includes:

Formal monitoring of active and indeed inactive account usage

The Care ID System (CIS) is now a fully automated ‘paperless’ management system.

There are clearly defined enforcement procedures which are linked with Human Resources processes for dealing with breaches in the use of Smartcards.

Monitoring - at a personal level - will only take place when there is reasonable suspicion against an individual or individuals, and the case is ongoing with HR.

Monitoring of appropriate access to patient’s Summary Care (GP) Records is carried out periodically by the Trust Privacy Office and the Head of Pharmacy Services.

o IG Lectures, Information Bulletins (through BUZZ) and Core Brief reinforces the associated safeguards and penalties

o Supporting RA WebPages are resident on the Trust Intranet

Identity Agent

o IT Services are responsible for deploying the latest NHS Digital Identity Agent (IA) across the Network, and will routinely upgrade this as new versions are issued.

RA/CIS Training

o RA Training is available for all Agents through the Trust Intranet Webpages

o Smartcards are available through the IT Service desk and the Trusts Divisional RA Agents

14. Monitoring and review

The key areas of information governance and their related action plans are monitored through regular reporting to the IG Group. These action plans form the basis of the annual work plan for the IG Group. Regular audits are undertaken by the shared services audit team with actions identified and agreed by the service lead.

Progress against these actions are monitored through the IG Group who report to the Trust Audit and Risk Assurance Committee (ARC), which reports directly to the Board.

https://www.dsptoolkit.nhs.uk/

http://intranet/Corporate-Directorates/Medical-Director/RA_Documents_and_Help.aspx

Appendix A - The IGAF Wheel

IG Wheel Component Responsible Officer

The IG Group Agenda Trust DPO

Digital Transformation Governance

Trust SIRO

IG Training (SET) Trust DPO

Project Management IT Business Manager

Cyber Essentials Plus IT Technical Ops Manager

Data Quality Assurance Head of Applied Information

DSPT 2019/20 - Ongoing Actions Trust DPO

ICT Risks IT Technical Ops Manager

Registration Authority IT Service Desk Manager

Records Management Medical Records Manager

CNR Compliance Medical Records Manager

Development Team Trust SIRO

Switchboard Telecoms Manager

FOI Compliance FOI/IG Officer

Policy Management Trust DPO

Holistic Governance Reporting

to the Trust SIRO and the Trust Audit & Risk

Committee


IG Group Agenda and Minutes: The IG Group meeting will act as the focal point for all of Digital Transformation, and Data Security & Protection ‘Governance Assurance’ reporting as detailed in the IGAF Wheel. That reporting will be made using a defined template, and will include:

- the IGAF Wheel component - the report date - the responsible person, and - all key actions, progress, and outcomes – in brief – on an ongoing basis.

Appendix B: Information Governance Assurance Framework Action Logs

Information Governance Group Matters Arising Actions

Business as Usual, Issues and Progress Actions, Responsibility & Timescales

DSP Toolkit Return

SET/IG Training

DATIX Incidents and Learning Opportunities

Registration Authority (RA) – Smartcards (IT Ops)

FOI Compliance (Communications & Engagement)

Casenote Release Compliance (Med Recs)

GDPR & The DPA 2018 (including Staff SARs)

Information Governance Webpage’s

National Data Opt-Out Programme

ICT Policy Management

Additional Information Governance Assurance Framework Reporting IT Governance Group Brief report to IGG/SIRO from the topic lead

Digital Transformation Governance Group Brief report to IGG/SIRO from the topic lead

Project Management Lead Brief report to IGG/SIRO from the topic lead

Cyber Essentials Plus Brief report to IGG/SIRO from the topic lead

Cyber Essentials Plus Accreditation

ICT Risk Management, including Cyber Security Risks

Development Team Brief report to IGG/SIRO from the topic lead

Switchboard Management Brief report to IGG/SIRO from the topic lead

Appendix C: ICT Policies – managed by the Trust APD Coordinator

Policy name Policy ID Owner/s Approving Committee

To be developed

Disposal of Information/IT Assets Policy tbn IGG/IT Ops/Procurement

Consumer Device (Smartphone/Tablets) tbn IGG/IT Ops

Information Classification Policy tbn IGG/Corporate Services

Mobile Working Policy tbn IGG/IT Ops

Third Party Supplier Security Policy tbn IGG/IT Ops/Procurement

Current and In-Use

Information Management and Technology (IM&T) Security Policy CORP/ICT 02 v.5 IGG/IT Ops IG Group

Information Management Systems (Registration) Policy CORP/ICT 03 v.5 IGG/IT Ops IG Group

Data Protection Policy CORP/ICT 07 v.5 IGG IG Group Safe Haven Guidelines CORP/ICT 08 v.5 IGG IG Group

Information Governance Policy CORP/ICT 09 v.5 IGG IG Group

Confidentiality – Code of Conduct CORP/ICT 10 v.4 IGG IG Group

Information & Communications Technology (ICT) Business Continuity Policy CORP/ICT 11 v.3 IGG/IT Ops/Corporate Services IG Group

Information Records Management - Code of Practice CORP/ICT 14 v.5 IGG/Medical Records IG Group

Freedom of Information (FOI) Policy CORP/ICT 15 v.4 Communications & Engagement IG Group

Registration Authority Strategy CORP/ICT 18 v.3 IGG IG Group

Registration Authority Policy for the Management and Issue of Smartcards CORP/ICT 19 v.3 IGG IG Group

Bulk Data Transfer Guidelines CORP/ICT 20 v.3 IGG IG Group

Information Risk Management Policy CORP/ICT 21 v.3 IGG/IT Ops IG Group

3rd Party Access to the DBTH Network and Core Patient Systems CORP/ICT 22 v.3 IGG/IT Ops IG Group

Data Quality Policy CORP/ICT 23 v.4 Information Services IG Group

Email and Internal Communications Policy CORP/ICT 27 v.2 IGG/IT Ops IG Group

Internet Usage Policy CORP/ICT 28 v.1 IGG/IT Ops IG Group

Audio/Digital Recording on Trust Premises and in Trust Meetings Policy CORP/COMM 23 v.1 IGG/IT Ops/Corporate Services APD Approval Group

To be Retired

Police Requests for Information and Evidence CORP/ICT 13 v.4

Information Governance Strategy CORP/ICT 16 v.4

Appendix D: Ten Steps to Cyber Security

Appendix E - Responsibility for the Introduction and Management of Information Assets

Process Responsibility Task

1 Notify Digital Transformation of Asset intentions

Information Asset Owner (IAO)

Notify Digital Transformation of Asset intentions as soon as possible and certainly before purchase or use

2 Asset Registration IAO Register the intention to use the Asset as per Trust Policy CORP/ICT 3

3

Data Protection Impact Assessment (DPIA)

IAO/IT Ops/DPO Complete the Trust DPIA as necessary. Complete either the full DPIA or the simpler COVID version; writeable versions for both are available on the Trust Policy webpage under CORP/ICT 3

4 Decision made to proceed IAO/IT Ops/DPO YES; Go to step 5, NO; Inform IT Ops & DPO

5 Information Sharing Agreements (ISAs) & Data Sharing Agreements (DSAs)

IAO/IT Ops/DPO Develop as and when it is appropriate do so, unless there is already a legal basis under GDPR and The Data Protection Act 2018

6 Data Flow Mapping IAO/DPO Catalogue all of the major Information flows associated with the Asset

7 Master File Actions IT OP/DPO Complete the ‘Master Asset’ File entry

8 Asset Sign Off DPO Record in IGG Minutes

9 IGG Minutes to Audit & Risk Committee IG Group / Corporate Services

Business as Usual

H1

Title Chair and NEDs’ Report

Report to Board of Directors Date 21 July 2020

Author Suzy Brain England, Chair of the Board


Decision

Assurance

Information x


The report covers the Chair and NEDs’ work since the last report presented at Board of Directors in March 2020.


N/A


The report relates to all of the strategic objectives.


N/A



Chair’s and NEDs’ Report – July 2020 Since my last report the nature of my work and the manner in which this has been delivered has changed significantly, impacted like many things by Covid-19. During the very early weeks of lockdown there was an enormous amount of planning and preparation to be undertaken by key personnel in the trust, so it was vital that these colleagues were afforded the time to focus their efforts to ensure we were in the best possible position to face the pandemic. As a result my focus centred on providing support and keeping up to date with trust developments, challenges and opportunities. Via twice weekly updates with Richard, I was kept informed of trust business, which in turn I was able to share with my NED colleagues and the Lead and Deputy Lead governors. Like many others, I have adjusted to a different way of working and now embrace the wide variety of virtual meetings available - one of the positives which has arisen from the crisis. I would like to express my sincere gratitude to each and every member of staff for the hard work, outstanding care and determination you have shown over the last four months, in supporting the running of the hospital. These certainly have been unprecedented and challenging times and I appreciate this has been a difficult time for staff, both professionally and personally; yet despite this you have continued to work together as a team and I am very proud of all you have achieved. In closing my introduction I would also like to express my sincere condolences for the loss of our well respected colleagues, Kevin Smith and Dr Medhat Atalla who sadly lost their lives to the virus. South Yorkshire & Bassetlaw ICS I continue to chair the bi-monthly SY&B ICS Committees in Common meetings which have taken place virtually since lockdown. The Chairs and Chief Executives have committed to undertake a review of lessons learned from Covid-19, which is scheduled to take place at the beginning of August 2020. Governor Briefings A refreshed governor briefing and development programme has been launched during lockdown. Sessions to date have been very well received, with good levels of governor and NED attendance. Governors have adapted well to the virtual events, which have provided an excellent opportunity to engage with governors, keeping them well informed whilst they are unable to attend our hospital sites. The following sessions have taken place to date:

Covid-19 Update – delivered by Richard Parker, Chief Executive

Confidentiality – delivered by Matthew Kane, Associate Director, Corporate Affairs at Sheffield Children’s Hospital.

Doncaster & Bassetlaw Healthcare Services Limited – co-delivered by Mark Olliver, Managing Director, Jon Sargeant and Neil Rhodes, in his capacity of Chair of the DBHS Board

Equality & Diversity – delivered by Jayne Collingwood, Head of Leadership & Organisational Development

NHS Providers My work as a trustee on NHS Providers’ Board continues; in a similar manner to the trust, NHS Providers have held condensed, lighter touch meetings via Zoom. These have allowed a good balance between Covid-19 work and routine business. You may be aware that my first term of office as a Board trustee was due to end on 30 June 2020, however, a mutual decision to extend my tenure until 30 September has been made, whilst the necessary arrangements can be made to complete an election process. My role on the Board provides a great insight to NHS Providers plans and ambitions and I have recently been consulted on arrangements for their virtual Annual Conference & Exhibition 2020 which will take place 6-8 October 2020. NHS Providers host a wide range of network and briefing sessions. This month they ran their first pilot of the NHS Providers Chair and Chief Executive Network, where fellow Chairs and Chief Executives received strategic and policy updates from Chris Hopson, NHS Providers Chief Executive and his deputy, Saffron Cordery. This was followed by dialogue from Amanda Pritchard, Chief Operating Officer on priorities going forward. You will be aware from the press and NHS publications of the heightened risk to Black, Asian and minority ethnic (BAME) individuals from Covid-19. Earlier this month NHS Providers organised a members roundtable with Baroness Doreen Lawrence, the British Jamaican campaigner and mother of Stephen Lawrence, a black British teenager who was murdered in a racist attack in South East London in 1993. The session was to assist her work leading the Labour Party’s inquiry into the impact of Covid-19. I have also attended a safe space NHS Providers meeting on race inequality and supporting BAME colleagues. Sub-committees of Board Each year I commit to observe the sub-committees of Board. This provides the opportunity to meet with wider committee members (outside of the Board), enables me to hear first-hand the business of the meeting and provides an opportunity for me to reflect on governor and NED challenge and meeting management. On 30 June I observed the Finance & Performance Committee and I plan to join the Quality & Effectiveness Committee at the end of this month.

Chair & NED Appraisals My appraisal was conducted last month by Senior Independent Director, Pat Drake. In November 2019 revised guidance was published by NHSI/E relating to the completion of Chairs’ appraisals, an action arising from the interim NHS People Plan. The principal aim was to ensure that the annual appraisal was a valuable and valued undertaking, providing an honest and objective assessment of a chair’s impact and effectiveness, while enabling potential support and development needs to be recognised. The framework provides a standardised approach, based on self-evaluation and multiple stakeholder assessment and is aligned with the five competency domains; strategic, people, professional acumen, customer focus and partnerships. In accordance with the new framework the output has been shared with Richard Barker, Regional Director and the Chair and Chief Operating Officer of NHSI. NED appraisals are already underway and are scheduled for completion by the end of July. The process has consisted of reflection and review of the previous year’s performance, supported by governor and director assessment. Individual NED’s aims will be agreed in line with our True North objectives. Company Secretary Interviews Following the postponement of the Company Secretary interviews in March I am pleased to report that we were able to reinstate the process and on 24 June seven candidates were interviewed by three panels consisting of the Chair, Chief Executive, Executive and Non- executive Directors, governors and an external assessor. In addition to the interviews each candidate was required to complete a pre-interview written submission in the form of a Board of Directors cover sheet. Following this rigorous process I am pleased to confirm that Fiona Dunn, interim Company Secretary and Acting Deputy Director of Quality & Governance was successfully appointed. I am very much looking forward to working with Fiona, please join me in offering her your support as she takes on this new role.

Other Meetings In more recent weeks, as activity has reduced, I have taken the opportunity to hold virtual meetings with the Divisional Directors. It has been good to touch base with them, hear about the challenges they have faced and their plans for the months ahead. As I mentioned earlier in my report virtual sessions have certainly created some new opportunities and has made attendance at briefings/meetings so much more accessible. At the end of last month the Yorkshire and Humber Chairs met to consider the Covid-19 response, learning, and strategy/planning going forward. We heard from Peter Wyman, Chair of the Care Quality Commission, Richard Barker, our Regional Director of NHS England/Improvement and Chris Hopson, Chief Executive of NHS Providers NED Report Kath Smart Kath’s work with her nominated sub-committees of Board, and Board itself have all continued remotely during lockdown. As Chair of the Audit and Risk Committee she has held planning meetings ahead of the year end meeting in June and also July’s routine meeting. Kath has also attended this month’s Health & Safety Committee. Since the last Chair/NED report Kath has been able to undertake non-committee activities such as the review of switchboard processes and the opening of the maternity discharge lounge with our Head of Midwifery, Lois Mellor. She has had a 1:1 discussion with our Local Counter Fraud Specialist, Mark Bishop, to review the self review tool (SRT) before sign off. The SRT provides a summary of the counter fraud work undertaken in the previous financial year. Kath also joined the panel for Radiology consultant interviews. Kath has met with Fiona Dunn and discussed risk and committee evaluation, and attended the KPMG internal audit meeting. Just last week Kath has had her appraisal, in which she has been able to reflect the previous year’s performance, receive feedback from governors and directors and agree her objectives. Pat Drake Since the last report in March Pat has attended all the Board Meetings, Finance and Performance Committee meetings as well as chairing the Quality and Effectiveness Committee (QEC) on two occasions. As part of her QEC role she has observed the Patient Experience and Engagement Committee and the Equality and Diversity Group. During this period Pat has chaired two confidential Council of Governors meetings and attended two Governor briefing sessions, chairing one other on equality and diversity, as well as making initial contact with her Governor “buddies”.

In her capacity as Senior Independent Director (SID) Pat has completed the Chair’s Appraisal as per the new NHSI requirements. As the NED for Learning from Deaths Pat chaired an interview panel to successfully appoint further Medical Examiners and attended a Mortality Group meeting. She also participated in the NED and Executive panel to appoint the Company Secretary and chaired the Clinical Excellence Awards Committee on two occasions. As Chair of the Organ Donation Committee Pat has participated in a regional meeting regarding new legislation. Finally, Pat has participated in regular meetings with the Chair and NEDs which included a session from Mark Bailey on his quality experience at Rolls Royce. Sheena McDonnell Over the last month Sheena has helped shape and develop the Governor Development Programme which includes a governor/NED buddying scheme and a schedule of briefing sessions due to run over the coming months. Sheena has attended two of these sessions on confidentiality and the pharmacy wholly owned subsidiary. A special Council of Governors meeting was held which Sheena along with other NED colleagues attended. Sheena has participated in a seminar on the new era for digital, focusing on what boards might need to consider in their approach to their digital strategies moving forward. She also attended a session hosted by fellow NED Mark Bailey on the lessons to be learned from the approach to transformation in other industries. Sheena has continued to attend board and last month this was followed by chairing the Fred and Ann Green committee and the Charitable Funds committee. Along with other NED colleagues Sheena has participated in fortnightly catch ups hosted by the Chair to keep abreast of the fast moving responses to Covid. Sheena participated in a workshop with Aberdeen Standard exploring the appetite to risk for the investment portfolio for the Charitable fund and as Freedom to Speak Up (FTSU) NED Sheena has been keeping abreast of any emerging issues through regular contact with colleagues and the FTSU guardian. Finally, Sheena has attended Audit and Risk and Ethics Committees.

Mark Bailey Since joining the Trust in February Mark has quickly brought himself up to speed on the strategic development of the Trust’s future digital capabilities and enablement of existing programmes, including patient records, remote care and e-observations with a series of familiarisation and ‘go look see’ events with the Executive and team members. He has fully engaged with the assurance and improvement work of the Quality & Effectiveness, Audit and Risk and Charitable Funds / Fred & Anne Green Committees and continues to develop his knowledge of the strategy and performance of the Trust via ‘virtual’ sessions with his fellow Non-Executives and members of the Executive team. He has attended two sessions of the Finance and Performance Committee to assist in this. Last month Mark was a member of the advisory panel for the appointment of the new Company Secretary. He also chaired the interviewing panel for the recruitment of a new consultant to our Obstetrics and Gynaecology service. He has provided ongoing support to all Governor briefing and development events and the new buddying scheme. Mark has also delivered a presentation to his non-executive and executive colleagues, where he was able to share experiences of what was involved in putting customers at the heart in the transformation of customer care at Rolls-Royce plc. Finally, as Mark’s corporate induction was postponed, due to Covid-19, he has undertaken his statutory and essential training via the e-learning portal to ensure his compliance is 100% ahead of his appraisal later in the month. Neil Rhodes Neil has continued to work virtually since the last report, attending Board, Audit & Risk Committee, Council of Governors and fulfilling his role as Chair of the Finance & Performance Committee. He sat on the executive/NED panel for the recruitment of the Company Secretary and joined fellow NEDs and executives for the presentation by Mark Bailey on his experience of service transformation within Rolls Royce plc. He co-presented to the governors on the topic of Doncaster & Bassetlaw Healthcare Services Limited, in his capacity as Chair. Governors were briefed on how the wholly owned subsidiary, came to be, it’s mission and values, it’s ambitions over the next three years, performance and financial summary at 2019/20 year end.

Chief Executive’s Report July 2020

An update on the Trust’s response to Covid-19

The Trust is continuing to see a steady decline in both new admissions related to Covid-19, and

inpatients. Currently we have around 20 Covid-19 positive inpatients and many non-consecutive

days without admitted any further positive individuals. Intensive care support for Covid 19 patients

is also falling to very low levels with several days passing with no Covid related admissions.

Due to this reduction in Covid activity we have scaled back some of our operational response but will

continue to review our position daily.

With the considerations of Personal Protective Equipment (PPE) in mind, as well as the safety of

those in our care, we are bringing back certain services and as referrals begin to increase we are

currently working to expand our outpatient and diagnostic capacity.

Since March, we have had to work differently, and in that time we have undertaken over 30,000

virtual outpatient appointments, either by phone or using video calling software. This follows a huge

increase in the number of colleagues using digital solutions to undertake Trust business, and I want

to share my thanks with the team for their perseverance during this time.

Early on in the pandemic, we committed to offering our staff free meals, as well as free parking on-

site, and this is continuing for the time being. We are exploring bringing back more catering options

within our hospitals which will require the free meal service to end, and we will ensure we

communicate this with colleagues well ahead of time so they can make the necessary preparations.

While things look a little more promising, we continue to urge our communities to stay alert and act

responsibly when out and about. As we have seen in Leicester and cities across the world, outbreaks

can occur and spread very quickly and we must remain vigilant and take every precaution to ensure

infection rates remain low in Doncaster, Worksop and the surrounding areas.

Celebrating 72 years of the NHS

Since March, the NHS has been at the vanguard of an extraordinary and unprecedented health crisis.

Across the country, hospitals and social care have dealt with this extraordinary challenge, caring for

people when they need it most. For this we shared our unending gratitude and thank them as we

marked the NHS’s 72nd birthday.

Given the unprecedented times we have, and continue, to live through, I think it is beyond doubt

that the NHS is the jewel in the crown and absolutely essential, and we depend upon all of the staff

who work so hard to provide these great services. I have always been extremely proud to work in

the NHS and over the past four months I have been even more proud due to the way in which I have

witnessed Team DBTH rise to the extraordinary challenges presented by Covid 19.

Although it is hard not to dwell on recent history, I believe it is important to reflect on the profound

effect every member of Team DBTH has on our local communities 365 days a year. Regardless of

role, service or grade, we are all here to ensure we deliver the highest quality of care for our

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patients. This requires a huge number of interlocking services and professions to play their part and

through our collective efforts we continue to show what can be achieved.

For all those working with the NHS and Social Care I share my deep thanks and appreciation,

particularly all those who have worked throughout the past number of months during the

extraordinary challenges we have faced.

Updated visiting restrictions

Following the outbreak of Covid-19 we took the difficult decision to restrict visiting with the aim of

reducing the further spread of the disease.

As we have seen a steady decline in cases of the illness throughout the past number of the weeks,

and following a review by colleagues, we have been able to ease certain restrictions, across a range

of services.

The full list and guidance can be viewed here, which came into effect from 4 July 2020:

https://www.dbth.nhs.uk/news/local-hospitals-update-visiting-restrictions/

Governor elections

Elections will soon begin to appoint seven public representatives to our Council of Governors and, as

such, we are asking local people to stand for these positions.

Public Governors play a vital role in representing the public and influencing how their local hospitals

make plans to improve and develop services. Anyone interested in becoming a public governor is

asked to submit their nomination before 5pm on Monday 20 July.

You need to be aged 16 or over and a member of Doncaster and Bassetlaw Teaching Hospitals NHS

Foundation Trust to stand for election but if you are not already a member you can join for free

online at http://www.dbth.nhs.uk

Our Rainbow Garden appeal

In late March, colleagues from across the Trust suggested that gardens be created in memory of all the local people who have sadly lost their lives to the virus, including our colleagues Kevin Smith and Dr Medhat Atalla. To help us remember these colleagues, friends and loved ones, we have launched our ‘Rainbow

Garden’ appeal, asking the people of Doncaster and Bassetlaw to help us raise a total of £35k:

£25k to create a garden at Doncaster Royal Infirmary and Bassetlaw Hospital sites. £30k to commission the materials to create a memorial at DRI for lost colleagues. £35k to purchase additional tables and benches to be located across all sites for patients and

staff to enjoy.

To-date, we have raised just over £25,000, with kind donations coming from a number of local

businesses and individuals, most notably a cheque for £10,000 from Anpario plc, as well £5,000 from

Polypipe. We want to thank everyone who has given generously for this worthwhile project.

To support the Rainbow Garden’s appeal you can donate on the Just Giving

Page: https://www.justgiving.com/crowdfunding/doncaster-bassetlaw or contact the fundraising

team on 01302 644244.

https://www.dbth.nhs.uk/news/local-hospitals-update-visiting-restrictions/

https://www.justgiving.com/crowdfunding/doncaster-bassetlaw

A huge thank you

Throughout the challenges presented by Covid-19 we have been truly humbled by the support

shown to us by our local communities. From donations of food to well-wishes shared via social

media, the public sentiment has been truly overwhelming.

I believe it is incredibly important that we thank colleagues and ensure they know that their efforts

and labours have not gone unnoticed. Currently, planning is underway to organise a number of

‘thank you’ events for our staff, and we intend to share our plans when this has been finalised, to

take place, hopefully, sometime in late summer.

Our Charity has received a substantial sum of money during the challenges presented by Covid-19,

some of which will go towards our Rainbow Appeal, staff events as well as other health and

wellbeing initiatives. Any funds donated will be used for the benefit of our colleagues and patients

alike, and we cannot thank those kind souls who have donated to us enough.

Prime Minister’s Questions

On 8 July 2020, Nick Fletcher MP for Don Valley raised a question with Prime Minister, Boris Johnson

regarding the possibility of a new hospital in Doncaster. In his answer, the Prime Minister said that

Matt Hancock, Secretary of State for Health and Social Care, would be visiting the town in the near

future to discuss investment.

As an organisation, and personally, we welcome the sentiment put forward by Nick, and we look

forward to working with the Government on any potential opportunities and investment in health

locally, and we look forward to hosting Matt Hancock at our Trust once again.

It has long been our ambition to secure funding for a new hospital in Doncaster and hopefully, once

the current challenges are behind us, this will become a possibility.

Internal appointments At the Trust, we’ve made the following appointments in the past month:

Abigail Trainer was appointed Deputy Director of Nursing, Midwifery and Allied Health

Professionals and begins in post in September.

Fiona Dunn was appointed substantive Head of Corporate Governance and has begun in

post immediately following an interim period in the role.

External appointments

Michelle Veitch was appointed Chief Operating Officer at Rotherham Doncaster and South

Humber NHS Foundation Trust (RDaSH).

Award nominations

We been nominated for the Health Service Journal’s (HSJ) ‘Patient Safety Innovation of the

Year’ accolade, in recognition of our Sharing How We Care (SHWC) initiative. Since its

inception around 18 months ago, this ambitious scheme has overseen a number of

improvements at our Trust, including a simple yet effect system for monitoring hydration,

new rules for ensuring that inpatients get a good night’s sleep, and protected mealtimes to

support better nutrition. In conjunction with the ‘World Health Organisation’s ‘No Tobacco

Day’, the organisation also went smoke free in 2019.

FINANCE AND PERFORMANCE COMMITTEE

Minutes of the meeting of the Finance and Performance Committee

Held on Tuesday 26 May 2020 via StarLeaf Videoconferencing

Present:

Neil Rhodes, Non-Executive Director (Chair) Karen Barnard, Director of People & Organisational Development Pat Drake, Non-Executive Director Rebecca Joyce, Chief Operating Officer Jon Sargeant, Director of Finance Kath Smart, Non-Executive Director

In attendance: Mark Bailey, Non-Executive Director Fiona Dunn, Acting Deputy Director of Quality and Governance/Company Secretary Laura Fawcett, General Manager for Cancer and Surgery (FP20/05/B3 and FP20/05/B4) Sheena McDonnell, Non-Executive Director Stacey Nutt, Lead Cancer Nurse (FP20/05/B3 and FP20/05/B4) Mr Olumuyiwa Olubowale, Cancer Lead for DBTH (FP20/05/B3 and FP20/05/B4) Marie Purdue, Director of Strategy and Transformation Katie Shepherd, Corporate Governance Officer (Minutes) (KAS)

To Observe: Bev Marshall, Governor

Apologies: None

ACTION

FP20/05/A1

Welcome and Apologies for Absence (Verbal)

Neil Rhodes welcomed the Members and attendees. No apologies for absence were noted.

FP20/05/A2 Conflict of Interest

No conflicts of interest were declared.

FP20/05/A3 Action Notes from Previous Meeting (Enclosure A3) The following updates were provided; Action 1 and 2 – These actions were not due until July 2020; Action 3, 4 and 5 – On the basis that these items were on the agenda, these actions would be closed; Action 7 – This action would be included in Item FP20/05/C2.

FINAL FP20/05/A1– FP20/05/G4ii

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The Committee:

- Noted the updates and agreed, as above, which actions would be closed.

Action: Katie Shepherd would update the Action Log.

KAS

FP20/05/A4 Request for Any Other Business (Verbal) Jon Sargeant advised that he had an item of other business to provide a brief update on Accounts and External Auditors which he would address during Item FP20/05/C2.

FP20/05/B1 Operational Briefing – Covid-19 (Verbal) Rebecca Joyce provided an Operational Update on Covid-19:

- At the end of April 2020, the Trust was in receipt of a letter from NHSI/E which asked that within six-weeks that all Trust’s return all pre-COVID urgent activity and to undertake some level of routine activity where able. There is lots of planning taking place to coordinate this;

- Stabilisation and Recovery Meetings were coordinating the recovery process

which included the post implementation review. Marie Purdue and Jon Sargeant were leading on this;

- Correspondence was received ten-days ago about the need to advise all elective surgical patients to shield 14 days before surgery and swab all elective patients 72 hours before surgery for Covid19, along with non-elective patients;

- There is emerging research data regarding surgery mortality rates if patients contract COVID pre or post-surgery and therefore implementing a robust process for swabbing and shielding patients was a priority.

Pat Drake asked if there was guidance on what the gap should be between a patient having Covid19 and having elective surgery. Rebecca Joyce advised that she was not aware of any guidance however there was advice that patients should undertake shielding in their household for 14-days, with a swab for Covid19 being taken three-days prior to elective surgery.

- The antibody test would be available for staff later that week and it was expected that there was a high-volume that would wish to undertake this. It wasn’t clear when the point of care testing for Covid19 would be available;

- The stocks of PPE was not as critical as it had been several weeks ago, however

it was noted that the Trust may see some areas of shortage over the coming weeks. Jon Sargeant was the Executive Lead for PPE;

- The Silver Cell was still manned between the hours of 08:00 – 20:00, however as of today the intensity of the leadership had been reduced so that the time can be reinvested back into Divisions;

Neil Rhodes asked about the challenge to increase routine surgery because of the lack of sterile gowns, and if it was still an issue. Jon Sargeant advised that presently the Trust

was stable with PPE at the current running rate, however this was an issue several weeks ago. At last check there were 10-days’ supply of the sterile gowns. Within the ICS region there was a good level of mutual aid, with Sheffield Teaching Hospitals utilising Sheffield Area until December to hold stock of PPE. As the Trust approaches the recovery phase, the run rate would change and therefore there would be careful monitoring of stock levels. The area of concern was the forecasted shortage of gloves. There was enough stock for several months, however as gloves haven’t been made, the Trust was planning for a shortage. Richard Parker was the lead for PPE within the ICS. Pat Drake asked for further information of people shielding at home for 14-days prior to elective surgery and what the consenting process was in advising patients the risks related to Covid19 and anaesthesia and pneumonia and if there was any national guidance. The figures that were previously discussed were an early site of the data as colleagues in the region had taken part in the study and therefore no further guidance had been received. Work was taking place with Surgeons regarding the consenting process which included the additional risks related to the risks of contracting COVID ore or post-surgery. Rebecca advised that she could not specifically answer the question on anaesthetic and pneumonia risks for patients who had suffered from COVID in the weeks/ months before surgery and how this would be communicated to patients however would communicate this after the meeting. It was noted that this information should be clearly communicated to patients. Rebecca Joyce advised that currently only urgent elective (cat 1 and 2) and non-elective surgery was taking place. As activity starts to increase to category 3 and 4, there will be a more finely balanced set of risks patients’ needs to consider in light of this emerging data on increased risks and the wider current COVID context. Kath Smart advised that within the Finance Paper there was a comparative table showing data in relation to this time last year and advised it would be helpful to see this type of report against activity. Rebecca Joyce advised that Divisions were reviewing the level of activity that could be started again whilst ensuring that patients and staff would remain safe. This includes an assurance process including how waiting patients are reviewed. The Stabilisation and Recovery meeting that was chaired by Jon Sargeant was required to support decisions relating to stepping up of activity, in which all Executive Directors to be in agreement. Kath Smart asked what level of oversight should be given to the Board and Committees. Neil Rhodes advised that a paper setting out the stages of return to normal along with a report of progress would be helpful. It was noted that the Stabilisation and Recovery Plan would ultimately become the annual plan. Returning to normal levels of activity would be a challenge due to the complications of social distancing and the donning and doffing of PPE. Marie Purdue advised that indicators linked to the work streams and post implementation review would be added to the framework to assure the Committee of progress. Neil Rhodes asked if prior to the next meeting members of the Committee could meet to identify a clear approach for the Committee to be in receipt of an update of progress of returning to business as usual in a project managed fashion, and to assist in shaping the annual plan. Pat Drake asked if Primary Care had received similar guidance in relation to the increase of referrals. Rebecca Joyce advised that there was some specific guidance outlining primary care should now be submitting routine referrals (part of Simon Stevens/ Amanda Pritchard letter) – and the Trust had advised both CCGs of their support for this process..

It was agreed a level of understanding was required on the expected numbers of referrals.

Action: Information would be sent to Pat Drake following the meeting of how the risk of having previously having Covid19 and anaesthesia can lead to issues would be communicated to patients prior to elective surgery.

RJ

Action: The Stabilisation and Recovery Plan would be provided at future Committee meetings outlining the expected approach to returning to normal business with an update on progress. The Committee would meet prior to the next meeting to identify a clear approach for this.

NR / MP / RJ / JS

The Committee:

- Noted the verbal Operational Briefing on Covid-19.

FP20/05/B2 Integrated Performance Report – April 2020 (Enclosure B2) Neil Rhodes highlighted that peer and national benchmarking had been removed from the IPR. Rebecca Joyce apologised for this and advised she would pick this up with the Information team. Rebecca Joyce provided the highlights of the report including:

- The Trust achieved 90.78% against a target of 95% and a local recovery trajectory of 90% in month for four-hour access, which was an improvement on the previous month;

- In March 2020 the Trust delivered 82.2% performance within 18-weeks which

was a significant reduction on the previous month, however was in line with peer

organisations. National guidance on performance monitoring was expected in

June 2020;

- The Trust had reported 10 x 52 week breach in April 2020 (9 x new + 1 x reported

in March 2020) All breaches due to Covid19 delays;

- In April 2020 the Trust achieved 36.93% against a target of 99% from Diagnostics.

This was a significant reduction from March 2020 & was expected due to the

Trust’s response to Covid19 which included ceasing routine diagnostic work;

- All 31 and 62 day nationally reported measures were achieved in Cancer

performance for March 2020 with the exception of 31 Day Surgery Standard

which achieved 92.9% against a target of 94%. This related to one breach due to

Covid19.

4 Hour Access The performance reported was encouraging, however there was 30% less attendance at ED than usual. It was noted that attendance was steadily increasing. A rota had been established in ED that puts in place leadership until 10pm each day, and significant agreements had been made between ED and Acute Medicine regarding EAU pathways which improved experience for patients and supported 4 hour performance. . There was an improved grip on performance management and Rebecca Joyce was holding weekly

meetings with the ED and Divisional leadership team. Progress was being made with the wide spread development of leadership. It was noted that David Purdue was leading on the short stay and emergency care areas to ensure the effective flow-through of patients, which would offer a benefit for longer term change. It would be important this focus continued as numbers of attendance start to increase. Pat Drake asked if the plan for funding to increase staffing in ED had been fully implemented, and how relevant it was during this period. Rebecca Joyce noted it was still very relevant and added that the Consultant interviews were taking place in early June 2020 for two posts which would be a really positive step. Recruitment of Band 6 nurses had taken place which were a good set of appointments for the department. Marie Purdue added that the Trust had been successful in the Emergency and Urgent Care tender and therefore would require the development of a model for the department to continue to change. RTT The position reported to the Committee was expected due to the lack of activity taking place due to the pandemic, however it was noted that patients were being reviewed on a regular basis. It was expected that poor performance would be reported until the Trust returns to normal levels of activity. Kath Smart advised that it had previously been stated that any 52-week breaches would undergo a full investigation and reporting. If the numbers are increasing, was there a plan in place or national guidance on this and were there predicted numbers. Rebecca Joyce advised that normal reporting of 52-week breaches was expected and it was important to investigate why the breach took place and to identify any lessons to be learned, even though the cancellations of appointments were due to Covid19. This root cause analysis process was in place. Rebecca would report the projected numbers of breaches to future Committee meetings, along with a view on the waiting list profile so the Committee could get a forward look of look waiters (for example beyond 40-weeks). Kath Smart asked what the messaging was to patients regarding cancelled appointments in light of Covid19, because the public perception may change over time. Rebecca advised that the Trust was keeping in touch with patients and maintaining communicating regular updates. Neil Rhodes noted that the Stroke information in the IPR wasn’t descriptive in line with the other sections of the report and asked if there was any worries in that department. Rebecca advised that the Stroke Team have put together an action plan to deal with key issues relating to direct admission within 4 hours. Pre-Covid19, a lot of work was taking place to address the key issues however it had been delayed due to Covid19. Further improvement were required. It was noted that the Head of Performance should ensure that the write up was consistent with the follow up of data. Pat Drake advised the Committee that she would address the Covid19 discharge solution at the Quality and Effectiveness Committee that afternoon. Pat Drake asked about the public confidence in our services during COVID and how this had impacted on the DNA rate. Rebecca advised that the DNA rate were higher in the

run up to COVID but much lower for telephone appointments. There were also higher rates of DNA in phlebotomy on site, which was concerning for patients that require that their blood is monitored as part of their care plan (i.e. INR patients). A drive in service had been set up at the Keepmoat Stadium in Doncaster and it had been reported that the attendance rates had increased with positive patients’ feedback regarding how this allayed fears about attending on site during COVID. Urgent patients presenting in ED had increased over recent weeks, however there was still a public confidence issue but campaigns have been undertaken to advise patients that the hospital was open for business.

Action: Expected 52-week breaches would be included in the Integrated Performance

to report on waiting list profile so the Committee could get a forward look of look waiters (for example beyond 40-weeks).

RJ

The Committee:

- Noted the Integrated Performance Report – April 2020.

FP20/05/B3 Deep Dive – Change to Cancer Services during Covid19 and the impact on Activity and Performance (Enclosure B3) Laura Fawcett, Stacey Nutt and Mr Olumuyiwa Olubowale were welcomed to the meeting. Becky Joyce advised that the paper presented a summary of principals introduced in the Cancer Services Team which highlighted:

- All referrals into hospital during the Covid19 pandemic had been triaged by Consultants and following this are given a face-to-face consultation;

- All cancer services activity had been relocated to Park Hill Hospital which was

working very well;

- The use of videoconferencing technology was being utilised to ensure that MDT meetings take place and these were working very well;

- There had been a significant drop in the number of referrals from a monthly average of 1129, down to 321, and therefore work had been undertaken to encourage people to go to their GP’s;

- Cancer patients were being operated on as normal, however there had been 15 cancellations – five of which were due to Theatre overrun and seven due to a pack of PPE. It was noted that the issue with theatres overrunning had been dispelled;

- No endoscopies had been undertaken since 16 March 2020 due to national

guidance and therefore it would present a challenge with the backlog. A paper would be submitted to the Gold Command regarding the reintroduction of scoping;

- Although the use of telephone and videoconferencing had been greatly received by some patients, it was noted that this was not the best source of contact with cancer patients, in particular when breaking bad news;

- It was noted that there had been feedback presented from patients as they weren’t allowed to bring another person with them to clinic, which had proved difficult in certain groups of patients, particularly elderly patients who haven’t been able to retain the information given to them at their appointments;

- It was noted that Park Hill staff had been fantastic through this period;

- Social distancing rules would limit the number of activity that could be undertaken going forward, however the team were looking into seven-day working and longer days to maintain the safety of patients;

- Some patient pathways had to be changed due to the pandemic which caused anxieties with some patients in ensuring that the change of treatment would not affect their outcome;

- It was expected that due the reduction in referrals, more patients would present in ED in the later stages of cancer, which may result in poorer outcomes.

Neil Rhodes encouraged the Cancer Services Team to work creatively with the issue of patients attending clinics on their own, and in particular when receiving complex information or diagnoses. Kath Smart asked if there was no scope to work in partnership with Park Hill for the longer term, passed September 2020. It was advised that discussions had taken place about the potential to keep one hospital site clean and if there was no scope to host cancer services within Park Hill Hospital post September 2020, that regional discussions would take place. Pat Drake thanked the Cancer Services Team for the way they have cared for end of life patients and their relatives, and advised that this was something that can be learned from. Pat Drake asked if the report could detail more information around cancer and practicalities and how the service would be delivered going forward. Pat asked if there were still issues with histology. Rebecca Joyce advised that the Integrated Performance Report was still being presented as business as usual report, however it should have more specific reports which reference Covid19 planning and response, which would include a long term view of how services are delivered. Pat Drake asked if there were likely to be changes in primary care. Laura Fawcett advised that referrals are slowly increasing, however a process was in place for consultants to contact GPs for more information if there wasn’t enough within the referral, which was something that had been noted as important going forward.

Action: The Integrated Performance Report should include cancer service planning and response, which would include a long term view of how services are delivered.

RJ

The Committee:

- Noted the Deep Dive – Change to Cancer Services during Covid19 and the impact on Activity and Performance

FP20/05/B4 Urology Exception Report (Enclosure B4)

Laura presented the exception report for Urology as concerns previous meeting with 62 day standard: In February 2020, 62% against a target of 85% was reported for the 62-week wait, which included 11 breaches, six of which were local and 5 shared care. These were due to the delays in MRI over the Christmas period, which was planned for however it was noted that this was difficult to get in line with radiology and urology. Laura advised that one action that had been taken was that Laura was in regular contact with manager to ensure that this doesn’t happen going forward. A deep dive had been undertaken to understand the communication and sharing of information to track patients appropriately and actions had been taken to introduce a weekly tracking PTL meeting. Other actions taken included a fortnightly meetings with business managers and cancer leads and a full breach report would be produced for every patient that encounters a breach which would include a risk assessment and recommendations to stop this from happening again. Neil Rhodes noted the comprehensive report but questioned if there was a grip on the issues in urology. Becky advised that the team were much clear in what processes needed to be implemented to have better grip on the pathways of patients, and Laura Fawcett had assured her that these changes would be fully implemented. Kath Smart thanked the Cancer Services Team for their presentation; and asked if the business case related to the one-stop-prostrate would be from capital or revenue. Laura advised that it was both a capital and revenue purchase, as it was a type of chair that patients can use during treatment as a replace of using a bed. Stacey Nutt advised that she had funds to pay for the chair and that it just needed ordering. Kath Smart asked if an update on how the plan was progressing could be added into the Integrated Performance Report going forward. This was agreed. Laura Fawcett, Stacey Nutt and Mr Olumuyiwa Olubowale left the meeting.

Action: A brief update would be added the Integrated Performance Report to outline the progress of the Cancer Services plan.

RJ

FP20/05/C1 Financial Impact – Covid-19 (verbal) Jon Sargeant provided a detailed update on the financial impact that Covid-19 had on the Trust, which highlighted:

- Further guidance had been received on the Covid19 Capital and Revenue;

- The update on financial arrangements for the return to business as usual from NHSI/E for the rest of the financial year had not yet been received;

- Since the last Finance and Performance Committee meeting, the Trust had

escalated the financial gap to the block contract arrangements. This had been

done through writing to and being in conversations with both the Director of

Finance for the ICS and the Regional Finance Lead for NHS I/E in Yorkshire and

the Humber;

- Capital Covid19 claims under £250k, which could previously be approved by

Trusts and retrospectively submitted to NHSI/E now have to be approved

nationally by NHSI/E.

Update on Accounts and External Auditors

Jon Sargeant advised the Committee that the date of the Year-End Audit and Risk Committee had been pushed back from 22ns May 2020 to 4th June 2020 due to issues that meant that the external auditors couldn’t make their opinions as required relating to Covid19. In relation to the Going Concern paper that had been approved by the Committee previously, whilst the Trust had met the targets and had a good cash balance, as there was no secured level of income for the next 12-months with a signed contract with the CCG, it couldn’t be signed off. A discussion would take place centrally with the Treasury and NHSI/E in how this would be dealt with in the account setting process. A response had not been received, but it was noted that every Trust were in the same predicament. The second reason was that our valuation of property and land was undertaken on 31 December 2019, which was pre-Covid19, however it was noted that the Chartered Surveyors had previously undertaken the valuation on that date, it had been questioned if it was valid due to the timings. The valuations are usually carried out on 31 March 202 which was during the Covid19 pandemic, and the Trust was awaiting guidance on this national issue. There were no other significant questions raised by the External Auditors. Neil Rhodes advised that the valuation taken on the 31 December 2019 was an accurate representation at the time it was undertaken and therefore couldn’t understand the delay in the sign off of that. Kath Smart agreed with the comment and advised her thoughts were to add a caveat to the report.

The Committee:

- Noted the Financial Impact – Covid-19 Update.

FP20/05/C2 Financial Performance – April 2020 (Enclosure C2) Jon Sargeant provided the Financial Performance update for April 2020, which highlighted:

- The report was slightly different to normal as there were no cost improvement programme (CIP) targets with in the current position;

- The Trust’s deficit for month 1 was reported as £453k before the retrospective top up; however in line with national guidance the Trust had accrued a central retrospective top up payment of £453k in order to report a break even financial position for month 1. This figure was different to the figure reported to the Board of Directors meeting on 19 May 2020 by £8k due to the position being updated to reflect additional Covid19 costs that were payable under A4C as part of the silver command arrangements;

- The Trust’s position was £1.6m favourable to budget which was driven by reductions in pay and non-pay costs;

- Capital expenditure spend in Month 1 was reported as £1.6m, including Covid19 spend of £1m;

- The cash balance at the end of April was £62.4m. The increase of cash was as a result of the Trust receiving two-month’ worth of the block income in April 2020;

Pat Drake noted that although CIPs were not taking place at present, if the Trust was looking at opportunities to help us going forward with revenue if we had money we could be saving as we move forward to a different way of working. Jon Sargenat confirmed that work was still being undertaken so that a focus would not be lost on cost improvement, however this was being undertaken as part of the stabilisation and recovery phase, so although it isn’t formally identified as CIP’s the work was still take place in a different format. Neil Rhodes asked for a better understanding of agency costs, as most work was being significantly reduced whereas agency spend was still high. It was noted that although there had been a reduction in work in some areas, ward were rostered in accordance with an expected sickness absence rate of 20%. Agency staff spend had been increased within Estates and Facilities, because although there were more service assistants appointed during the Covid19 pandemic, there was some reluctance to start working due to the pandemic and therefore agency staff had been called upon. Kath Smart asked of the process of attracting agency workers into substantive roles in the organisation, and what positive learning can be taken. Karen Barnard advised that she was working with NHS Professionals to see if the majority of temporary workers can get onto NHS Professionals books, however it was noted that some long servicing nurses work through agencies and an understanding was needed as to why this is, whether it be the flexibility or money aspect of it, however it was expected that it was a combination of both. A work steam was in place to minimise the movement of temporary workers to minimise the risk of infection. Pat Drake noted the challenge in ensuring that we get staff working in the right areas, and advised that the recruitment of 79 newly quality nurses was a higher rate than we have recruited before. Pat advised further that a focus would need to be taken on ensuring the medical staff that are recruited have the right skill mix, in ensuring the right recruitment was in place to reduce the use of agency staff. Jon Sargeant advised that there had been a 33% reduction in agency spend and this was due to the pause on annual leave during April 2020.

Jon Sargeant advised of the key issues in the withdrawal of some of the Covid19 revenue costs in the return to normal, as some won’t be as straight forward when considering social distancing. A discussion took place about the aged debtors trend and aged creditors trend and Jon Sargeant confirmed that the Trust had started to monitor performance of paying invoices in line with national guidance stating that they must be paid within 7-days. Invoices were being paid on average within 14 days for April 2020, which was an improvement on the month before, however it had been identified that significant improvements are still required in this area. Kath Smart asked if it was identified within the SBS contract, times that the Trust must be in receipt of invoices received by them. Jon Sargeant advised that due to the pandemic they had issues with their service provision as they have two centres in India that were not operational at present. SBS wrote to ask if they could be released of the duties to delivery against the KPI’s, which was declined. Kath Smart queried the timing of the data received to the Finance and Performance Committee, as the data had been received at Board beforehand, and wondered if this was accurate as agreed prior to the meeting schedule for 2020. Jon Sargeant advised that due to the timings of the meetings, the reports were available in time for the Board and advised that professionally he would always submit the most up to date data to the Board and Committees. It was agreed that this would be reviewed for 2021.

The Committee:

- Noted the Financial Performance for April 2020.

FP20/05/C3 Capital Position (Enclosure C3) Jon presented the Capital Position and highlighted:

- The paper laid out the capital plan submitted to the ICS as of last week. The ICS

would manage all local capital schemes within this limit. The total budget

allocation for the ICS was set at 95% of the expected budget in the ICS annual

plan submission before funding of emergency capital schemes. The Trust had

received any feedback from the submission to date;

- It was noted that our capital programme was a substantial proposal, and there

was a table in the paper that outlined the robust process that had been

undertaken by each of the capital sub-committees;

- Departments had been challenged to ensure that they would allow for access to

Estates workers to undertake any capital work. The ED Front Door work and the

Women and Children Hospital Fire Works would be undertaken;

- Capital works would be undertaken in the following few months, to ensure that

they are completed in readiness for a potential second surge of Covid19 and the

flu season;

- The Theatres work would be put largely on hold, until the Trust had clarity over

the timelines for the new build and would be revisited at that time.

Neil Rhodes noted it would be really encouraging if the HSDU Ward was delivered as it was an important part of the recovery phase and winter period. Surge capacity was essential. Jon Sargeant advised that the cost of the HSDU Unit had been included in the capital bid, however if this wasn’t approved, it was believed that it would be funded by the organisation. Pat Drake appreciated the granularity of the report, however noted her concerns about the exposure of the fireworks in the Women and Children’s Hospital, particular with the added pressure of the interim centralisation of maternity services to DRI. Jon Sargeant advised that the plans had been agreed and the key issue identified was that there would need to be two lifts in use at any one time, however this issue had been rectified. Most of the work would be undertaken on the ground floor and in the coffee shop. The work would be undertaken soon to avoid the winter period. Cosmetically to patients, the work would not be exposed. Kath Smart noted that the Capital Sub-Committee had made the recommendation and the content was based on the risk and need and it had been matched to the Corporate Risk Register. The risk scores weren’t included in the report. Jon Sargeant advised that the Chairs of each of the Committee’s had advised that the risk scores were accurate. Kath Smart asked what schemes did not make it onto the approved list, and how these schemes were managed as they may have been rejected at the Above and Beyond Committee because the risk score wasn’t high enough. Jon Sargeant advised that schemes would be reviewed by the Above and Beyond Committee next year. Jon Sargeant noted that the charitable fund had reduced by 10% at the last statement date due to the current climate.

The Committee:

- Approved and recommend to the Board of Directors the Capital Plan; - Note the submission of the plan to the ICS within the national timeline as

discussed at the May 2020 Trust Board; - Noted the Capital Plan 2020/21.

FP20/05/D1 Workforce Report – April 2020 (Enclosure D1) Karen Barnard presented the Workforce Report for April 2020, which highlighted: Recruitment

- The ‘Bring Back Staff’ campaign had been disappointing as not many people were offered to the Trust and of those that were there were many that were not appropriate as required significant training or return to practice;

- It had been agreed that locally the Trust would use NHS Professionals however

there had been a delay in the indemnity between the ICS, NHS Professionals and the Trust because the NHS Professional rate of pay was lower than the national

requirement and therefore required a signed indemnity. Sheffield Teaching Hospitals had taken the lead on this, however it had taken a significant amount of time to put this in place;

- A plan for a second phase of the ‘bring back staff’ campaign, however this would take a focus on care homes;

- The third-year students commenced which had been successful. Some of which were due to start as newly-qualified in September 2020, with others that live locally but had been at universities not local to them;

- The Trust had not planned to invite second-year students as employees as the demand was not high enough, however a national decision had been made that they must be employed in their placement;

- Funding for Physician Associates had not been paid through the central Covid19 budget, and therefore it was agreed that the Trust could not justify taking them on, however this programme had been reconfigured so that they could be funded through the central Covid19 budget, however it was too late as the Physicians Associates would need to start back on their studies;

- The first cohort of FY1 doctors had started, that were previously due to start in August 2020. The Trust agreed to take on additional placements as there were Trust’s in London that were unable to take them, however they would only be able to stay in the Trust for several weeks due to tenancy in local accommodation, and it was therefore considered that this would consist of a lot of work inducting the staff and would therefore be considered for future phases;

- The rotation of junior doctors had been paused during the Covid19 pandemic, however this would start again in August however there might be changes in the rota as the plan was to keep people as local as possible, as some may have previously moved elsewhere;

- There were a number of staff that were due to start in the Trust as part of general recruitment that were anxious about starting during the pandemic and therefore withdrew from post, therefore the team were progressing with trying to get as many started in post as possible;

Neil Rhodes asked for clarification of what a ‘Proning Team’ was. It was confirmed that patients in intensive care are required to be turned at regular intervals due to respiratory issues. It was the Proning Team that undertake this task. Neil Rhodes asked if the Trust was taking stock of the initiatives that have been undertaken and an analysis of what had worked well and what hasn’t. Karen advised that as part of the post implementation review, that reviews of all implemented processes were being reviewed. Karen advised that Testing Staff

- As of the 14th May there had been 337 staff tested positive for Covid19, and since then a further 81 had also tested positive. These figures include those of household members living with staff;

- A table was presented in the paper highlighting the numbers of positive Covid19

staff in ‘hot spot’ areas, where outbreak reviews had been undertaken; Neil Rhodes asked what the Trust strategy was on antibody testing. Karen advised that the antibody test would be available that week, however it was not clear how it will be moved forward. There would be a required of phlebotomists to take the blood samples. Pat Drake advised that this would be discussed that afternoon at the Quality and Effectiveness Committee. The Committee commended the Trust on its ability to develop its own destining and developing capabilities. Neil Rhodes noted that some of the quality had been lost in the usual reports due to the Covid19 pandemic, and therefore advised that it should be agreed what was required in the reports going forward. Neil Rhodes would liaise with Becky Joyce, Karen Barnard and Jon Sargeant prior to the next meeting to decipher what format the business as usual reports would contain in relation to information and data. Absence

- Karen Barnard advised the Committee that there had been 2000 members of

staff off from work due to Covid19 in total, and not at any one point in time.

Covid19 absence for April 2020 was much higher than in mark;

- A new system had been introduced for the reporting of sickness absence.

Previously a system had been introduced by which each manager had to

complete a daily return, however the data was been submitted differently and

therefore a new system was introduced in which members of staff are required

to contact their manager as normal to report that they are sick, followed by

contacting a sickness absence reporting line which had been in place for three-

weeks. The new system was being reviewed in conjunction with a new

database. The system also includes whether those staff on sick leave are able to

work from home or not;

- There were 25% gaps in midwifery which included a combination of sickness

leave, vacancies, maternity leave and medical exclusion;

- The HR Team had paused their ‘normal’ business of work at the start of the

pandemic to assist in the coordination of swabbing bookings and pastoral care,

however this involvement would be reviewed to see what ‘normal’ business

can start to take place;

- It had been suggested previously that there had been 50% sickness in medical

staff, but it was confirmed that this level of sickness was only in specific areas.

Overall the medical and dental sickness absence rate was not high, however it

should be noted that there are medical staff that are employed by other Trusts

but are hosted at ours and therefore this information isn’t always received.

Action: Neil Rhodes would liaise with Becky Joyce, Karen Barnard and Jon Sargeant prior to the next meeting to decipher what format the business as usual reports would contain in relation to information and data.

NR

The Committee:

- Noted the Workforce Report for April 2020.

FP20/05/E1 Corporate Risk Register (Verbal) Fiona Dunn advised that the revised Corporate Risk Register would be presented to the Committee in June 2020 as agreed at the last Board of Directors meeting on 21 April 2020. Fiona Dunn highlighted an addition to the Risk 2472 linked to the shortage of sterile gowns for performing non-urgent surgical procedures. See Risk ID 2489.

The Committee:

- Noted the verbal update on the Corporate Risk Register

FP20/05/F1 Escalation (Verbal) No issues were identified for escalation to/from:

- F1.1 F&P Sub-Committees; - F1.2 Board Sub-Committees; - F1.3 Board of Directors.

FP20/05/G1 Sub-Committee Meetings (Enclosure F1): The Committee:

- Noted the minute of the Cash Committee – 14 February 2020.

FP20/05/G2 Minutes of the meeting held on 28 April 2020 (Enclosure G2)

The Committee:

- Noted and approved the minutes from the meeting held on 28 April 2020.

FP20/05/G3 Committee Work Plan (Enclosure G3)

The Committee:

- Noted the Committee Work Plan.

FP20/05/G4i Any Other Business (Verbal) None.

FP20/05/G4ii

Date and time of next meeting (Verbal)

Date: Time: Venue:

Tuesday 30 June 2020 TBC Video-Conference

Charitable Funds – 17 March 2020 Page 1 of 5

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CHARITABLE FUNDS COMMITTEE

Minutes of the meeting of the Charitable Funds Committee Held on Tuesday 17 March 2020 in the Fred and Ann Green Boardroom, Montagu

Present:

Mark Bailey – Non Executive Director Suzy Brain England – Chair of the Board Pat Drake – Non Executive Director Sheena McDonnell – Non Executive Director (Chair) Richard Parker – Chief Executive Neil Rhodes - Non Executive Director Emma Shaheen – Head of Communications and Engagement Jon Sargeant – Director of Finance Kath Smart – Non Executive Director

In attendance: Katie Shepherd – Corporate Governance Officer (Minutes) (KAS)

To Observe: None

Apologies: Matthew Bancroft – Head of Financial Control David Purdue – Director of Nursing, Midwifery and Allied Health Professionals Phil Beavers – Public Governor

ACTION

CFC20/03/A1 Welcome and Apologies for Absence (Verbal)

Sheena McDonnell welcomed the Members and attendees. The apologies for absence were noted. It was agreed to move swiftly through the business in light of the current pressures facing the trust due to Covid 19.

CFC20/03/A2 Conflicts of Interest


The Committee:

- Noted the minutes of the meeting dated 17 December 2019.

CFC20/03/A3 Actions from previous meeting (Enclosure A3) Action 1 – A new date of June was agreed for Emma Shaheen to consider opportunities for match Funding; Action 2 and 3 – On this basis that these items were on the agenda, these actions would be closed;

CFC20/03/A1– CFC20/03/E5

FINAL

H4


Action 4 – On the basis that an update would be provided during item CFC20/03/C1, this action would be closed.

The Committee:

- Noted the updates and agreed, as above, which actions would be closed.

Action: Katie Shepherd would update the Action Log.

KAS

CFC20/03/B1 Review of Fund Balances (Enclosure B1)

All present were content to note the information presented within the Review of Fund Balances paper.

The Committee:

- Noted the information within the Review of Fund Balances paper.

CFC20/03/B2 Fundraising Strategy Update (Enclosure B2)

Emma Shaheen presented a business case for a Corporate Fundraiser, who would, if approved, be a dedicated support to the Communications & Engagement Team in driving forward the charitable funds strategy, setting up processes and identifying how to concentrate the functions resources on corporate fundraising, whilst also supporting the community fundraising and raising the awareness of the charity brand. Richard Parker advised that he would support the role, as the aim would be to attract more income into charitable funds. There were three options listed within the business case, with all present agreeing that the second option of employing the Corporate Fundraiser through Doncaster and Bassetlaw Healthcare Services being the best option. This would allow for the salary to be set at £30k per annum, with the option to earn up to £45k per annum based on performance. It was noted that appropriate sponsors could be linked to relevant causes, and that clear fundraising messages communicated to all. Neil Rhodes noted that Mark Oliver, Managing Director of Doncaster and Bassetlaw Healthcare Services may have some valuable input into this as he had previously worked with the Royal Voluntary Services. A discussion took place regarding the different work streams that could be undertaken to raise funds by the Corporate Fundraiser. Birth Appeal Update Emma Shaheen provided an update on the birth appeal. The Communication and Engagement Team tested the approach to up the social media posts related to the Birth Appeal over a period of two weeks. From this, 35,000 people viewed the posts, with 4,000+ clicking into the JustGiving page, however from those numbers, it created an


additional £120, and therefore highlighted that this approach did not result in an increase in extra donations, which supports the need for a specialised role to push fundraising. Mike Condon, a Bassetlaw resident had donated proceeds from the sale of his book to the DBTH Charity.

The Committee:

- Agreed to support the business case to employ a Corporate Fundraiser through Doncaster and Bassetlaw Healthcare Services for the DBTH Charity.

CFC20/03/B3 Approval of Expenditure (Verbal)

Jon Sargeant advised the Committee that the Nerve Centre work had been approved which involved the enhancement of the bed management system to assist clinical colleagues in the management of patients. This had been approved by exception outside of the meeting by Suzy Brain England, Sheena McDonnell, Richard Parker and Jon Sargeant. The cost was £405k and would include the training and development of clinical outcomes.

The Committee:

- Noted the update on the approval of expenditure.

Action: Jon Sargeant would circulate the paperwork of the bed management system bid so that all members of the Committee had been sited on the approved scheme.

JS

CFC20/03/B4 Above and Beyond Committee Report (Verbal)

David Purdue was not present at the meeting and therefore no update was provided on the Above and Beyond Committee.

The Committee:

- Agreed to defer this item.

CFC20/03/C1 Review of Charitable Funds Policy (including Reserves Investment policy and Committee Terms of Reference) (Enclosure C1)

Jon Sargeant provided an update on the changes to the Charitable Funds Policy which included:

- Improved guidance surrounding fundraising approval and cash‐based

fundraising events, such as tombola’s;

- Improved guidance that cash should be deposited into the Charitable Funds

bank account and should not be kept with staff;

- Reference to the “Above and Beyond” Committee, including application form

to request funding;


- Reference to donation envelopes, with instructions as to how to complete

them with donors;

- Charitable Funds expenditure policy (brought within this policy, but approved

previously).

Kath Smart queried the requirements under "Reserves" (page 16-17) and in particular the statement of minimum level of unrestricted reserves, which is required to be recalculated annually based on the financial position at the end of March. It was agreed this would be calculated annually, presented to the Committee and was required to be added to the work plan to ensure compliance with The Charity's reserve policy as per the last paragraph on Page 17.

Action: Monitoring Compliance with the Reserves Policy would be added to the Committee Work Plan for an annual review.

KAS

The Committee:

- Approved the changes to the Charitable Funds Policy, including the Reserves Investment policy and Committee Terms of Reference.

CFC20/03/D1 Review of Risk Position – Standard Life (Enclosure D1)

Jon Sargeant provided an update of correspondence received from Aberdeen Standard Capital, in relation to the investments that it manages on behalf of the DBTH Charity which highlighted:

- The portfolio was valued at £8,012,708 as of 10 March 2020, which reflected a reduction of 8.9% since the end of 2019, as equity markets have weakened;

- A recent market volatility, caused by an increase in Covid-19 cases outside of China coincided with the ramifications of a lower oil price, had caused a material impact on global stick markets, resulting in a fall in investor sentiment.

The Committee:

- Noted the update from the Investment Manager.

CFC20/03/E1 Above and Beyond Committee Minutes (Enclosure E1)

The Committee:

- Noted the Above and Beyond Committee minutes for 06 December 2019.

CFC20/03/E2 Minutes of the Meeting held on 17 December 2019 (Enclosure E2)

The Committee:

- Approved the minutes of the meeting held on 17 December 2019.

CFC20/03/E3 Committee Work Plan (Enclosure E3)


The Committee: Noted the Charitable Funds Committee Work Plan and agreed to add the item:

- Monitoring Compliance with the Reserves Policy

CFC20/03/E4 Any Other Business (Verbal)

No items of other business were raised.

CFC20/03/E5 Date and time of next meeting (Verbal)

Date: Time: Venue:

16 June 2020 TBC The Fred and Ann Green Boardroom, Montagu Hospital.

Management Board Held on Monday 8 June 2020 Page 1 of 6

Management Board

Minutes of the meeting of the Management Board held in on Monday 8 June 2020, 2.00pm in the Board Room Doncaster Royal Infirmary via Starleaf

Conferencing

Present Via Starleaf: In Attendance:

David Purdue, Deputy CE and D of N&AHP (Chair) Jon Sargeant – Director of Finance Karen Barnard – Director People, Organisational Development Eki Emovon, Divisional Director Dr Tim Noble, Medical Director Marie Purdue, Director of Transformation and Strategy Rebecca Joyce, Chief Operating Officer Fiona Dunn, Acting Deputy Director of Quality and Governance Nick Mallaband, Divisional Director, Medicine Antonia Durham – Hall, Divisional Director, Surgery & Cancer Division Jochen Seidel, Divisional Director, Clinical Specialties Division Ken Anderson – Acting Chief Information Officer Emma Shaheen – Head of Communications and Engagement Alasdair Strachan – Director of Education and Research Kirsty Edmondson Jones, Director of Estates and Facilities Rosalyn Wilson, Corporate Governance Officer (Minutes)

Apologies: Richard Parker, OBE – Chief Executive MB08/06/A1

David Purdue confirmed that Divisional Senior Management teams and Deputy Medical Directors had been invited to this interactive session from 14:30 to support the further development on Stabilise, Recover & Reset for the Trusts Future. See appendix 1 for attendees. Apologies for absence The Management Board:

- Noted the apologies for absence.

ACTION

MB08/06/A2 Matters Arising / Action Log Action 1 – No further update, Suspended during COVID-19 Action 2 – Not due until July 2020 Action 3 – Agreed to put on hold until August for an update, this cannot be moved forward until Emergencies are moved back to main theatres.

MB08/06/A – MB08/06/G

H5


Action 4 to 6 – Agreed that these can be closed as PPE is discussed at Silver Cell daily and updates on the use and requirements of PPE are managed operationally and raised to Gold Cell when required. Action 7 & 8 – Agreed to be closed. Action 9 – Agreed to be closed. Action 10 – Agreed to be closed. Management Board Noted the actions and confirmed that during COVID-19 updates were suspended to be picked up when the Trust returns to business as usual.

MB08/06/B1 Divisional Issues

There were no Divisional issues to raise at today’s meeting.

MB08/06/C1&2

Information Items to Note (To be taken as read) Due to COVID-19 there were no Elective Care Steering Group notes or CIG minutes to review this month.

MB08/06/D1

Items to Approve Joint Local Negotiating Committee Constitution Karen Barnard discussed the proposal in detail and advised that the revised constitution had been developed with Dr Tim Noble, Neelam Dugar LNC Chair and the BMA IRO. The main changes to the constitution is the addition of Divisional Directors to Trust management, clarity of what would happen if a joint decision cannot be reached. ` Karen Barnard has requested Management Board to agree the new proposal. Nick Mallaband discussed that this was a very positive move and the additional of more Divisional Directors to join the JLNC and that there is more scope for the committee “Where this is not possible to achieve a joint position or agreement, the failure to agree will be recorded in the minutes. Any disputes resulting from a failure to achieve a joint position, whether individual or collective, will be handled by the Trust’s grievance and disputes procedure, or nationally laid down job-planning procedure (for job-plan related disputes).”


MB08/06/D2

David Purdue asked if Management Board was the right route for approval when it relates to safety. Tim Noble advised this was safe and appropriate to sign off here at Management Board. Management Board Management Board agreed that they would be happy to sign of the constitution. Minutes of the Meeting Minutes of the Meeting – 11 May 2020 Management Board Minutes from 11 May 2020, Noted as a true record.

MB08/06/E1 Any other business David Purdue advised Management Board that the National Mandate for patient visiting within the Hospital has been reviewed and that visiting policies can be reviewed locally David Purdue asked how the patient visiting should be reviewed, do we need to do this locally and make our own decision or as part of the ICS? Tim Noble – suggested the Trust make our own changes and then review against ICS. Jochen Seidel – The Trust needs to be clear that some areas will have different rules and requirements so visiting will be different such as the difference between blue and yellow areas. Antonia Durham - Hall – due to current practice and socially distancing for patients and staff, some of the wards are overcrowded without patients having visitors. Eki Emovon – Suggested any Trust changes need to be reviewed and in line with the agreed changes made by the ICS. Management Board Agreed that a new proposal for the Trust will be developed and then taken to the ICS for review prior to implementation.


MB08/06/E2 Items for escalation to the Board of Directors (Verbal)

There were no items for escalation.

MB08/06/E3 Items for escalation from Sub‐Committees (Verbal)

There were no items for escalation.

MB08/06/F1 Corporate and Divisional Interactive Session Marie Purdue, Jon Sargeant and Paul Mapley went through the presentation titled Stabilise, Recover and Reset with Management Board and the additional attendees. Marie advised the attendees what the aim of the interactive session is. Paul Mapley asked each divisional group to discuss the 3 areas of focus in response to the proposed site plans detailed in the presentation.

Clinical model for each site

Ethical Framework

IPC, Policies and testing strategy. Within the presentation under each area on pages 26, 27 and 28 there are a number of question that the teams have been asked to review and respond to feedback to Management Board. There is a clear plan in place for recovery sign off by 3 July 2020 at Gold Command.

The Divisional Directors received feedback on the key points from their discussion.


Jon Sargeant went through the Governance of the plan and discussed how the decisions will be made. Cases will be discussed at the Stabilisation Group that meets every Monday and dependent on the impact agreed where possible at the Exec Team on the following Wednesday. If required than raised through the Board sub committees and the Board of Directors. Jon Sargeant advised that due to COVID-19 CIG is not currently meeting, the plan to extend the Monday morning meeting so this allows any decisions or escalations can be taken to the Executive Team (Gold) on the Wednesday.

MB08/06/G1 Date and Time of Next Meeting (Verbal)

The Management Board:

- Noted the date and time of the next meeting:

Monday 13 July 2020

StarLeaf Videoconferencing - The Boardroom – Doncaster Royal Infirmary.

MB08/06/G

Close of meeting (Verbal)

The meeting closed at 17:03


Appendix 1

Stabilise, Recover & Reset Interactive Session Attendees Lois Mellor – Head of Midwifery Clare Ainsley – Service Development Manager Richard Somerset – Head of Procurement Mandy Espey – Chief Allied Health Professional Julie Thornton – Head of Performance Jayne Collingwood – Head of Leadership & Organisational Development Laura Fawcett – General Manager – Surgery and Cancer Paul Mapley – Efficiency Director Tracy Crookes – Head off Information Ken Agwuh – Director of Infection & Control Gill Payne – Deputy Medical Director (Efficiency and Effectiveness) Lesley Barnett – Deputy Director of Quality and Governance Rob Mason – Head of Quality Improvement Ray Cuschieri – Deputy Medical Director (Clinical Standards) Lesley Hammond – General Manager, Emergency Medicine Alex Crickmar – Deputy Director of Finance Willy Pillay – Deputy Medical Director (Workforce and Productivity) Julie Butler – General Manager, Specialised Medicine Claire Jenkinson – Deputy Chief Operating Officer (Elective) Anthony Jones – Deputy Director People, Organisational Development Kirsty Clarke – Associate Director of Nursing - Surgery and Cancer Simon Brown – Associate Director of Nursing – Clinical Specialties Lauren Ackroyd – General Manager (O&G) – Children and Families

Update on COVID-19 from Andrew Cash, Chief

Executive Lead of South Yorkshire and

Bassetlaw Integrated Care System

Friday 3 July 2020

This update goes to the wider partners in health and care in SYB to keep everyone

informed. Please do forward to colleagues on your stakeholder distribution list.

Dear Richard

This week, as the Prime Minister announced plans to significantly invest in the national

Covid-19 recovery plan, we had news closer to home with South Yorkshire’s devolution deal

finally agreed and brought to the House of Commons. This is a significant step forward for

South Yorkshire’s economy and our congratulations go to Dan Jarvis, Mayor of the Sheffield

City Region, and his team on this fantastic achievement. Once passed into law, an

additional £30million pounds will be allocated to Sheffield City Region for regeneration

projects supporting local growth and transformation. With the dedicated support of local

council leaders from Barnsley, Doncaster, Rotherham and Sheffield, it’s a great example of

partnership working and its long-term impact is likely to shape the lives of our health and

care population for years to come.

Together with the seminal devolution deal, Sheffield MPs have written to the Government to

outline their support for a new world class research and innovation facility in Sheffield. The

Sheffield Children’s Hospital sponsored Centre for Child Health Technology (CCHT) at the

Sheffield Olympic Legacy Park would be a multi-million transformational project supported

by regional partners and international businesses including IBM Watson Health, Cannon

Medical, Phillips and the South Yorkshire and Bassetlaw Integrated Care System. The site

would span over 51,000 square metres, delivering world-class clinical and technical

H6

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innovations to support children’s health and wellbeing in SYB and beyond. I will, of course,

keep you posted on any developments, but it is highly exciting prospect for the region.

Meanwhile, modelling for influenza infections in the UK is now starting to take place as

preparations for winter get underway, with a recognition that this could occur alongside a

further Covid-19 peak. This is firmly on the radar of SYB’s testing cell which has started to

devise a winter testing strategy to support the system level planning. Supporting this work

will be a system level flu strategy, which will be made up of five Place plans and a SYB Flu

Board.

SYB NEWS ON COVID

New cases and deaths caused by Covid-19 across SYB continue to decrease and the

numbers of overall deaths are now in-line with SYB’s seasonal expectation (up to 12 June).

As an update on testing, the daily figure for 29th June saw 1,211 polymerase chain reaction

(PCR) tests for symptomatic staff/patients (around 33% capacity) and 918 antibody tests.

In terms of test and trace, we’re starting to see a more enhanced dashboard made

available; with data at postcode level, and later down the line, at street level. Local

Outbreak Control Plans continue to be developed and enacted by Local Authorities and

Directors of Public Health across SYB.

With the lockdown measures set to further ease this weekend, partners are putting plans in

place to support any increase in demand, particularly in relation to urgent and emergency

services. To further support the efforts of all health and care partners, please do continue to

push the latest communications campaigns regarding social distancing and personal

responsibilities.

SYSTEM RESET AND RESTORATION

This week’s Health and Care Management Team (HCMT) meeting focused on the System

Plan for the coming year. Now well in development, the Plan will move the System forward

and it will be ready by the end of July. It will take into account constraints such as

workforce, estates management, infection control and PPE while also incorporating

examples of best practice in SYB and nationally.

Cancer care continues to be one of the main priorities in SYB’s system recovery plans.

Partners are working to review and reprioritise patients who have previously been on

waiting lists. Those patients who have waited for a long time already and are a priority

clinically are very much at the forefront of efforts to receive fast-track diagnostic and

treatment services. Special thanks to SYBs Integrated Care System Cancer Alliance for their

work on this.

It was also pleasing to hear of SYB’s performance in the recently published National Cancer

Patient Experience Survey. The results of the NHS England and Improvement commissioned

survey saw SYB 2% above the national average in the areas of patients thinking they were

seen ‘as soon as necessary’ (86%) and the length of time ‘waiting for tests to be done

being about right’ (90%). The survey monitors national progress on the patient’s

experience of cancer care and acts as a driver to improve quality at local level. This is

strong evidence of the excellent work taking place and further vindication of what has

already been achieved in cancer care across SYB.

Meanwhile, the NHS Confederation’s ICS Network published the findings of its ‘Time to be

Radical? The view from system leaders on the future’ report (June 2020), whereby 40

system leaders convened to discuss the direction of travel for the future of health and care

delivery. This coincides with a new report from the coalition of health and social care

charities in England, National Voices; ‘Nothing about us, without us: Five principles for the

next phase of the Covid-19 response’. This puts forward some valuable advice to support

policy makers reviewing people’s rights to services especially clinically extremely vulnerable

groups.

The NHS Parliamentary Awards 2020 are now open for nominations entries and I would

encourage health and care partners to work with their MPs on nominations of individuals

and teams for these. There is more detail on the Awards below.

Finally, please do join the tributes taking place on Sunday 5th July at 5pm to mark the NHS’

72nd birthday and please share and encourage colleagues to use the social media hashtag

#ThankYouTogether.

Thank you

Andrew

__________________________________________________________

The next update will be Thursday 9th July 2020.

Situation report

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The latest Sitrep data is now available.

This data is from 01/07/20

The latest from South Yorkshire and Bassetlaw

Doncaster East Primary Care Network to host first ‘virtual’ forum – Doncaster Clinical

Commissioning Group

Update 11 – South Yorkshire Police and Crime Commissioner

Latest figures (infographic) for Covid-19 response - Rotherham Doncaster and South

Humber (RDaSH)

The Maltby District Nursing Team receives special letter of recognition from a local MP –

The Rotherham NHS Foundation Trust

How ICSs can harness the power of tech with Cindy Fedell – webinar registration now open

– Yorkshire and Humber Care Record

Smart thinking aids work in beating COVID-19 says Chief Executive – Yorkshire & Humber

Academic Health Science Network

The latest from Yorkshire and the Humber Region

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Updates up to and including 01/07/20

Upcoming items of note:

Wednesday 1 July – NHSX turns one

Thursday 2 July – NHS Parliamentary Awards launch

Thursday 2 July - CQC to publish the 2019 Adult Inpatient Survey

Weekend of July 4 & 5 – events marking the NHS 72nd anniversary

A brief look further ahead:

7 July - Adult smoking habits in the UK: 2019 published (ONS)

9 July – NHS monthly operational stats to be published

9 July - 2020 GP Patient Survey will be published

Children and Young People – End of Life Care

The NHS has now published a Standard Operating Procedure for children and young people

with palliative and end of life care needs. This applies to those who are cared for in a

community setting (home and hospice) during the COVID-19 pandemic. This publication is

intended to support staff who are providing care or supporting children and young people

(and their families) who have palliative and/or end of life care needs in the community

(including home and hospice care).

NHS COVID-19 convalescent plasma programme - staff donation appeal

NHS Blood and Transplant has now made more than 10,000 appointments for people to

donate COVID-19 convalescent plasma and is collaborating with more than 100 hospitals,

through the REMAP-CAP and RECOVERY platform trials. The programme is particularly

seeking donations from NHS colleagues. Anyone who works for the NHS and has recovered

from COVID-19 who wishes to donate convalescent plasma can call 0300 123 23 23 and

they will be prioritised for donation. People can also offer to donate by supplying their

details via the NHS Blood and Transplant website.

Support for pregnant BAME women

A press notice was issued on Saturday on the additional support for pregnant Black, Asian

and Ethnic Minority (BAME) women, as new research shows heightened risks facing women

from minority groups. Research from Oxford University shows that 55% of the pregnant

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women admitted to hospital with Covid-19 are from a BAME background, even though they

only make up a quarter of the births in England and Wales.

Chief Midwifery Officer, Jacqueline Dunkley-Bent, will be writing to all maternity units in the

country calling on them to take four specific actions which will minimise the additional risk

of Covid-19 for BAME women and their babies.

Rankin – photography

A press noticed issued on Monday about the portrait series by photographer Rankin which

has been dedicated to frontline staff to mark the birthday of the NHS.

Adult Inpatient Survey & GP Patient Survey

It’s now confirmed that the CQC will publish the 2019 Adult Inpatient Survey at 9.30am on

Thursday 2 July.

The 2020 GP Patient Survey (GPPS) will be published by NHS England at 9.30am on

Thursday 9 July 2020. The findings are published at www.gp-patient.co.uk by Ipsos MORI.

Couch to 5K press notice

A press notice has been issued on the huge increase in the number of downloads of PHE’s

Couch to 5K app in the past three months. Recent studies have shown that there is a clear

link between covid and obesity with overweight and obese people making up six in 10

Covid-19 deaths in the UK.

Recent data from EE also found that other fitness apps had surges during lockdown with

MapMyRun usage doubling and three times as many people using Strava, while over one

million people in the UK bought a bike during lockdown.

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NHS Parliamentary Awards 2020: Call to action for Local MP(s)

The NHS Parliamentary Awards provides an excellent opportunity for health and

care organisations to engage with their local MPs, tell them about the work they

do, and build or strengthen ongoing relationships.

The nomination window to put forward individuals or teams in organisation across SYB has

started.

MPs are encouraged to reach out to their local health and care organisations, as well as

members of the public, to seek nominations.

Partner organisations may benefit from working together with others across SYBs health

and care system to identify potential nominees and plan related activity in a co-ordinated

way.

As well as submitting nominations, local MP(s) may consider visits and photo opportunities

to support the process via local media, and/or a venue for the MP to announce their

nominations.

Categories

The Excellence in Healthcare:

Recognises individuals or teams who go over and above usual duties improving the

outcomes and experiences for patients living with, and beyond, major health

conditions - or working to prevent those conditions.

The Excellence in Mental Health Care Award:

To the individual or team that has worked across organisational boundaries to

develop new and effective services to help people living with mental health

problems in their community.

The Excellence in Urgent and Emergency Care Award:

To the individual or team that has made improvements to how the NHS treats

people in life or death situations.

The Excellence in Primary Care Award:

For the primary care practitioner or team who is working with patients to help them

stay healthy in their own homes - for as long as possible.

http://server.smartmailer.tractivity.co.uk/link.aspx?q=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

NHS Rising Star [New for 2020]:

To celebrate young volunteers and members of staff (under 30) who have helped to

shape, improve or deliver better services in their area.

The Future NHS Award:

To a person or team that has successfully trialed and embedded change to make

better use of data and digital technology, provide more convenient access to

services and information.

The Health Equalities Award:

An individual or team that helps ensure equality throughout our lives in the care we

receive. From being born in a safe environment through to dying with dignity.

The Care and Compassion Award:

For any Nurse, Midwife, Allied Health Professional or care staff member of any

discipline and in any setting, that has used their skills to ensure that patients

experience care and compassion.

The Wellbeing at Work Award:

For the person or team that has successfully trialed and embedded change(s) -

making the NHS a better place to work.

The Lifetime Achievement Award:

For an individual who has worked within a health or care setting for 40 years - or

more - who has left a legacy.

Key Dates

Relaunch: w/c 29 June– with nominations reopening

Nominations Open - 5 July – 1 September

Commons summer recess starts: 21 July

Nominations period closes: 1 September

Regional / Locality Shortlisting to start: 2 September – 15 September (10 Working

Days)

Commons back from Summer recess: 8 September

Regional Executive Shortlisting: 16 September – 29 September (10 Working Days)

Commons conference recess: 17 September – 13 October

National checking 30 September – 6 October (5 working days)

Shortlist sent to National Judging panel for review: 8 October

Comms teams briefed on regional champions: - 16 November (5 working days prior

to announcement)

Regional Champions announced 23 November (Mary Seacole’s date of birth)

National judging day (tbc)

NHS Awards Ceremony: 5 July 2021

For more information please contact: Ethan Tanda, 07800645145, [email protected].

mailto:[email protected]

H7

ContentsMessage from our Chair 3

About Us 4

Our Vision 5

Highlights from our year 6

What were our priorities in 2019-20? 7

Asking local people about the NHS Long Term Plan 8

Sharing our learning at the National Healthwatch England Conference 9

People tell us about their access to GP services 11

Helping improve Urgent and Emergency Care provision 12

Hearing how local people look after their emotional health 14

Healthwatch Doncaster’s Micro-Grants 15

Young Healthwatch Champions 16 & 17

Michael Smith’s story 18

Covid-19 19

Facing A Pandemic 20

Our Volunteers 21

Volunteers’ influence 22

Enter and View 23

Patient Stories 24

Thank You 25

Signposting and Information 26

Social Media 27

Choice for All Doncaster 28

Doncaster Keeping Safe Forum 29

Patient Participation Network 30

Health Ambassadors 31

Our Finances 32

Priorities for 2020-21 34

Message from our Chief Operating Officer 35

Thanking our partners 36

Contact Us 37

Annual Report 2019-20 | Healthwatch Doncaster 2

Message from our Chair

It is impossible to write anything about our last year at

Healthwatch Doncaster without mentioning the ongoing

effect of the Covid-19 virus on the whole world. My

thoughts and sympathies go out to everyone who has

been affected by this insidious disease and to the

families and friends of the many who have lost their

lives.

Because of our place in the public life of the Borough,

Healthwatch Doncaster has seen at first hand the incredible

efforts of our local hospitals, GPs and other medical and care

services in treating citizens. We add our heartfelt thanks to

those of everyone else. I would also like to acknowledge the

sterling work of Doncaster Council as personified by the

Director of Public Health, Dr Rupert Suckling.

We were quick to react to the situation by moving our staff to

home working in March and adapted with team discussions and

interaction with stakeholders through online meetings.

There is plenty about our efforts during 2019-20 in this report

and I would like to thank staff, volunteers and Board members,

who have helped us become more successful in our

endeavours.

Linda Crundell left her position on the Board and I’d like to

thank her for her contribution, including being involved in our

Enter and View Planning Group.

At the time of publication, our Vice-Chair Debbie Hilditch left

her role and I would like to thank her for her help and support.

Her part in the organisation’s move to a independent

Community Interest Company was crucial, alongside her

strategic and project leadership.

Steve Shore

Healthwatch Doncaster Chair


My thoughts and sympathies go out to everyone who has been affected by this Covid-19 disease

About us

Here to make care betterThe network’s collaborative effort around the NHS Long Term Plan shows the power of the Healthwatch network in giving people that find it hardest to be heard a chance to speak up. The #WhatWouldYouDo campaign saw national movement, engaging with people all over the country to see how the Long Term Plan should be implemented locally. Thanks to the thousands of views shared with Healthwatch we were also able to highlight the issue of patient transport not being included in the NHS Long Term Plan review – sparking a national review of patient transport from NHS England.

We simply could not do this without the dedicated work and efforts from our staff and volunteers and, of course, we couldn’t have done it without you. Whether it’s working with your local Healthwatch to raise awareness of local issues, or sharing your views and experiences, I’d like to thank you all. It’s important that services continue to listen, so please do keep talking to your local Healthwatch. Let’s strive to make the NHS and social care services the best that they can be.


I’ve now been Chair of Healthwatch England for over a year and I’m extremely proud to see it go from strength to strength, highlighting the importance of listening to people’s views to decision makers at a national and local level.

Sir Robert Francis, Healthwatch England Chair

Our vision is simple Engage

Healthwatch Doncaster will engage you in conversations about your experiences of local health and care services.

Inform

You will inform us about what is important to you and what changes and improvements you want to see in Doncaster.

InfluenceWe will use your stories, experiences, voices and opinions

that have been shared with us to influence change and improvement in local health and care services in Doncaster.


Photograph Credit: John Burke

Photograph Credit: Irene

29 volunteershelped to carry out our work, contributing over 745 hours of their time

20 studentsundertook a placement to support their studies and develop their career pathways

£10,200 sharedwith local community groups as part of the Micro-Grants scheme


Highlights of our year

5,405 commentsreceived about health and social care through our online feedback centre, or through a survey focusing on a specific topic

294 people contacted Healthwatch Doncaster for advice and information or questions about local support

12 reports publishedincluding our projects on the NHS Long Term Plan, emotional health, access to GP services and outcomes from Enter and View visits

What were our priorities in 2019-20?


NHS Long Term Plan

The views of local people were shared with the South

Yorkshire and Bassetlaw Integrated Care System and

helped shape their system-wide response to the NHS

Long Term Plan

What’s YOUR story?

We were aware that a lot of people had stories about how

they managed their own emotional health needs or

helped others with their emotional health needs. We

listened and shared their voices with local services so that

improvements can be made

Access to GP services

When we are out and about talking and listening to people,

access to GP services is often a topic of conversation. We

talked to over 1500 people with a focus on the working

age population. The outcomes and recommendations from

this report have been shared with our local CCG

Urgent and Emergency Care

The Healthwatch Doncaster volunteers wanted to spend

24 hours in Urgent and Emergency Care. Our strong

working relationship with our local Acute Trust enabled us to

get access across the Urgent and Emergency Care system

and to talk to people at various stages of their

care and treatment

Micro-Grants

We have continued to support the development of

community groups and organisations through our

innovative Micro-Grant programme. Developing

networks of support was a focus for us this year.

Young People

Healthwatch Doncaster loves to support and develop

the skills of students and young people. We have

continued to develop Young Healthwatch

and student placement opportunities

Asking local people about the NHS Long Term Plan

Healthwatch Doncaster were the co-

ordinating Healthwatch for analysing

the feedback, surveys and focus group

responses from across the South

Yorkshire and Bassetlaw Integrated

Care System (ICS) – Barnsley,

Bassetlaw, Doncaster, Rotherham and

Sheffield – about the NHS Long Term

Plan.

Over 1,300 people shared their views and

told us what they would do to improve the

NHS as part of the Long Term Plan and there

were 15 local focus groups that had more in-

depth conversations with people about their

thoughts and feelings about the NHS.

The report findings showed:

• 88% of people who completed the survey

told us they agreed with the Plan’s

commitment towards ‘prevention, choice

and control and promoting independence

and self-care’

• A third of survey respondents said they or

someone they cared for had used local

services and support to manage their

mental wellbeing and emotional health

• People told us that digital proposals were

important, including having access to

services using a phone or computer;

making appointments online; having

results communicated quickly and talking

to their doctor when they can.

Healthwatch Doncaster analysed all the data

and information, leading to a detailed report

shared with the ICS and presented to the

collaborative partnership of strategic leaders.

The report was used by the ICS to develop

and write their local response to the NHS

Long Term Plan based on what they have

heard from local people.

Healthwatch Doncaster were invited to help

facilitate workshop discussions at the NHS

Expo in September 2019 along with other co-

ordinating Healthwatch organisations. The

discussions were helpful and formed part of

the NHS Assembly’s engagement and

response to the NHS Long Term Plan.

At the Healthwatch National Awards in

Birmingham in October 2019, local

Healthwatch from South Yorkshire and

Bassetlaw were announced as the winners of

the Outstanding Achievement Award for their

collective work on the NHS Long Term Plan.

There was particular mention of the work

that had been done to engage with a wide

range of people and the focus groups that

had engaged groups of people whose voices

are not often heard or listened to.


Picture: from left to right - Healthwatch Doncaster Chief Operating Officer Andrew Goodall and Sir Robert Francis, Healthwatch England Chair alongside colleagues from Healthwatch Nottingham and Nottinghamshire

http://bit.ly/NHSLTPRpt

Sharing our learning at the National Healthwatch England conferenceSandie Hodson – Volunteer Co-

ordinator and Engagement Officer – and

Andrew Goodall – Chief Operating

Officer – developed a workshop

presentation in two parts. Sandie

shared her knowledge about recruiting

and supporting volunteers and Andrew

talked about supporting student

placements in Healthwatch Doncaster.

“I had an extremely positive response from

attendees especially local Healthwatch who

do not have the structures and processes in

place to fully support a robust volunteer

programme.”

“It was very gratifying to be able to share

knowledge gained through many years

working with volunteers and, more recently,

from my volunteer management studies to

make a contribution to the development of

the wider network,” said Sandie (pictured

below).

Healthwatch Doncaster has supported a

number of students on placements over the

last three years with great success. Young

people have learned and developed and the

organisation has benefited from their skills

and enthusiasm.

Healthwatch Doncaster are clear that when

students come in to the organisation that

they are treated like a member of the team

and supported to complete work that will

benefit local people.


10

Hampole, Doncaster Photo Credit: Healthwatch volunteer

People tell us about their access to GP services

Access to GP services has been a common theme from patient feedback to Healthwatch Doncaster and we have heard many stories from patients about their experiences.

In the summer of 2019, we engaged with over 1500 local people to gather their experiences with findings shared with service providers and published in a report.

The findings show there is a variation in the services that people of Doncaster experience in relation to accessing GP services. 55% of respondents were not satisfied with the service they received for a number of reasons.

Difficulty in telephone access, patients waiting a long period to get an appointment and lack of awareness of other health care services were common themes.

The following recommendations were proposed to help improve experiences:

• Make patients aware of other healthcare provision• Inform patients about signposting to appropriate clinicians or services• Encourage the use of digital and online services to book appointments/request prescriptions

Service providers including the Local Medical Council, NHS Doncaster Clinical Commissioning Group (CCG) and Primary Care Doncaster were receptive to the findings and recommendations and

recognised that “there is more to be done to continue to improve access and experiences of care received”.

In October 2019, NHS Doncaster CCG launched a campaign, which aims to raise awareness of the wide range of services that exist in Primary Care and encourage the use of IT to access services in order to enhance the experience of accessing GP services for local people.


Over two months, Healthwatch Doncaster gathered feedback and comments by talking to local people


Helping improve Urgent and Emergency Care provision

In September 2019, Healthwatch Doncaster undertook a project to gather people’s experiences of Urgent and Emergency Care services in Doncaster.

The services that were involved in this were:

• The Emergency Department at Doncaster Royal Infirmary: staff and volunteers visited the department during a busy night shift and spoke to patients, relatives and staff• Minor Injury Departments at Doncaster Royal Infirmary and Mexborough Montagu Hospital

• Urgent Treatment Centre at Doncaster Royal Infirmary

• Same Day Health Centre

As a result of our involvement in the 24 Hours in Urgent and Emergency Care project, our Volunteer Co-ordinator and two of our volunteers have been involved in the following:

• Sitting on a grants panel to consider bids to the South Yorkshire and Bassetlaw Integrated Care System Innovation Fund for Urgent and Emergency Care Services• Bringing the patient perspective to the commissioning process for Same Day Health Centre services in Doncaster

This has ensured that the patient voice is heard in the commissioning process.

The project report can be viewed at: www.healthwatchdoncaster.org.uk/urgentandemergencycarereport

Sue, Healthwatch Doncaster volunteer, shares her experience

of the Emergency Department at Doncaster Royal Infirmary

”When I went to A&E at 9pm, I was humbled by what I saw. The professionalism and the care given by the staff was wonderful. It didn’t matter what their job title was, the Sister fetching a bed, changing a bed; everyone just got on with it. They were all pleasant and introduced themselves to the patient, I thought they did a wonderful job”

Healthwatch Doncaster staff and volunteers visited urgent and emergency care services in the Borough

http://www.healthwatchdoncaster.org.uk/urgentandemergencycarereport


Hearing how local people look after their emotional health

In August 2019, we attended the Recovery Games and the Doncaster Pride event to gain views on how people support others to stay emotionally well. The project focussed on our qualitative themed approach “What’s YOUR Story” to gather extended narratives via audio recordings.

Our aim was to identify the main themes and gaps in support for people with emotional difficulties, particularly those in recovery and the LGBTQ+ community, to influence local services.

The receptiveness of 13 people who were willing to tell their own stories or stories of how they supported others was inspiring.

The importance of the support that family and friends provide was a key theme.However, it was recognised that they themselves need support to fulfil this role.

Talking to others who have been through similar experiences, hobbies and physical and practical help were also key findings.

Barriers included social stigma and individuals themselves accepting that they

need help.

The need for appropriate and timely referrals from GPs and timely appointments from specialist services was a feature of views received and some people reported accessing private therapies due to long waiting times.

A number of individuals told us about the lack of mental health resources, the need for a holistic approach where an individual has physical and emotional difficulties and the need for integrated working particular between health and social care services.

There was a gap identified for Youth Gender Identity Services locally.

A number of recommendations for organisations across Doncaster were made within the report and shared with services.

From left to right: Natalie, Sophie, Elle and Jill at the Doncaster Pride celebration event

The team at the Recovery Games


Healthwatch Doncaster’s Micro-Grants

We’ve been able to support 21

community groups in 2019-20 and

we have allocated £27,000 in Micro-

Grant funding over the past three

years.

A launch event was held to help generate

new and recurring interest, which

featured some of our previous recipients,

such as Doncaster Alcohol Services and

Doncaster Central Learning Centre. It

offered the opportunity for questions to

be answered prior to the funding round

being opened for applications.

Our annual celebration event, delivered at

the newly renovated Doncaster Wool

Market (pictured above), had the pleasure

of hearing from some of the projects,

which were funded as part of the 2018

programme.

Attendees were able enjoy some

spellbinding stage magic from Magi-Cal.

We have invited every organisation who

has worked with us throughout the

duration of our micro-grant programme to

reconnect with us and explore the

possibilities of bringing organisations

together to create a mutually beneficially

network of Voluntary, Community and

Faith Sector organisations.

It will also provide an opportunity for

organisations to skill share, help support

each other through crucial times and

celebrate each other’s successes.

Our vision for this network is what

grassroots organisations are all about:

people helping people. As we move

into the next phase of establishing this

network, we invite any community

organisation who believes they can bring

additional value and benefit to get in

touch with us and get involved.


Young Healthwatch Champions

At Healthwatch Doncaster, we want

young people to have their voices heard

and to gain insight on how the Health

and Social Care sector works. We want

to support young people who will be the

leaders of tomorrow.

With this in mind, we developed our Young

Healthwatch programme to help health and

social care students who required a provider

placement to complete their educational

qualifications. They also gain awareness and

skills needed to develop their careers. Our

programme developed into the ‘Young

Healthwatch Champions’.

This opportunity enabled us to build on

existing connections with Doncaster College to

create a strong partnership of directing

students to apply for our placement

opportunities. Once we had interviewed and

selected students for placements, sessions

were delivered in two 4-hour weekly

segments. Young people were mentored and

supported throughout their placement.

Sessions included: visits to organisations

within our existing networks so that students

were able to see how services were delivered.

For example, community space ‘Sober Social’,

delivered by Doncaster Alcohol Services, gave

the students opportunity to meet people in

recovery from substance misuse whilst also

speaking with the community professionals.

In addition to this, a representative from a

local learning disability peer support group

delivered a presentation to help raise the

young people’s awareness of the learning

disability community. Furthermore, the

students were able to access in-house

safeguarding awareness training to help boost

their understanding of safeguarding and how

to identify people at risk.

Alongside our student placement

opportunities, we also launched our monthly

meet up sessions which offer a safe space for

young people to meet and discuss relevant

issues. Topics included mental health support

for young people, where do I go for sexual

health issues, gender identity, visible vs

invisible health conditions and many more.

Future plans will see Young Healthwatch have

a stronger digital presence utilising social

media platforms and video calling will be used

as a way of supporting more young people

through the peaks and pitfalls of everyday life.

Activities during the meet-ups always involve creativity!

A huge thank you to students Amber C, Amber M, Beth, Bethany, Caitlin, Chloe, Cameron, Elisha, Holly, Janine, Jessica D, Jessica W, Jenani, Kacey, Kacie-Lea, Lauren, Leah, Mara, Melissa, Natalia, Sharni for their contribution to the work of Healthwatch Doncaster during vocational placements.

Read how Natalia, Mara, and Holly found their placement experience..


What did you enjoy the most?

Mara: I enjoyed all the activities I took part in and the support I have been given. I

appreciated the way I have been treated by the Healthwatch Doncaster team

Natalia: I really have enjoy the fact that I got to take part in the Micro-Grant project and I

got to directly take part in what it means to work for them

Holly: I enjoyed learning about Clinical Commissioning Groups and completing the suicide

awareness course.

Did the placement enhance your learning?

Mara: I feel more than confident to say that Healthwatch Doncaster provided me with the

opportunity of improving my knowledge and skills

Natalia: The placement definitely enhanced my learning as I got to listen to a lot of people

with much more knowledge than I have and I picked up interesting things and facts

Holly: I learnt a wide range of things to do with health and social care which will be useful

for my course

Did you feel the team supported you appropriately?

Mara: The team provided me with the best support. They asked me to get involved in their

project, which made me feel worthy and helpful

Natalia: Always listened to what I had to say and made sure I was pleased and comfortable

with the environment and with the tasks.

Holly: No one was impatient with me when I had questions or when I did not fully

understood the task.


Michael Smith’s storyJoining us originally on a student placement in 2018, Michael shares his reflections on creating videos, films and animations Healthwatch Doncaster as he embarks on his new college course in 2020

Michael holding the trophy for Healthwatch Doncaster’s input at a video editing course

What is the piece of work you are most

proud of?

“The introduction video because it gave

me new skills as I hadn’t tried a first

person perspective before. The more I did

it the more I felt comfortable. I felt so

proud of the video.”

How would you describe your personal

development from when you joined us in

February 2018 to February 2020?

“It has been positive as I’ve grown in

confidence due to the people I’ve met

during projects. When I started my new

course, it helped me to deal with new

surroundings and adapt quicker.”

How would you describe the support you

received from our staff team, our

volunteers and our Board?

“They would always ask me how things

were going. As time went on, I asked for

more support when I needed it. For

example with Sandie, I did a video for the

homecare and support project and she

was very helpful, giving me ideas on how

she wanted it.”

Is there any training you’ve enjoyed?

I learnt about software to create videos

using my phone at training I attended

with Akhlaq in Leeds. Plus, we came home

with a trophy for our group work!

What would you say to prospective

students considering a placement with

Healthwatch Doncaster?

“I highly recommend it to anyone looking

for experience, it’s a good work

environment. The people are nice and

made me feel welcome.”

Michael did some video workinvolving the volunteer group.

He was very professional.

He put interviewees at theirease which minimised theiranxiety about being on camera.

A testimonial from Healthwatch Doncaster’s volunteers on Michael

Covid-19

Our Chief Operating Officer Andrew

Goodall explains how Healthwatch

Doncaster reacted to the Covid-19

pandemic..

Covid-19 did not take us by surprise –

there were lots of reports from Italy and

Spain about the impact and scale of

changes need to defeat it – but national

changes did happen very quickly.

I am proud to say that Healthwatch

Doncaster, as a team and an organisation,

were able to react quickly and effectively

in response to the pandemic and the

national ‘lockdown’.

The Healthwatch Doncaster team were up

and running on Zoom and using remote

working immediately and we were able to

provide accurate and up to date

information through our website and

through our social media channels.

Home working and engagement through

digital channels is now part of the new

normal. The team have developed new

services and ways of engagement through

the Reaching Out project and the Daily

Dose of Healthwatch Doncaster.

All of our meeting and support

conversations take place through Zoom or

Facebook Live and it has given us all the

opportunity to become more efficient and

streamlined in our approach to agile and

remote working.

Our journey through the Covid-19

pandemic and into recovery and renewal

will be a steady one and one that we will

use to maintain our presence in

communities and our support for local

people and groups through digital tools.

Healthwatch Doncaster will still be

listening to local people about their

experiences of health and care and we

will still be championing the voice of local

people to improve the quality of health

and care services.


Healthwatch Doncaster – Facing A Pandemicwritten by Jill Telford

A dedicated team where do I start,Each one passionate about playing their part.Covid-19 came our way,And in our house we had to stay!

Not to be beat,We took our seat!Engagement with others remained in our heart,But in a Pandemic where do we start?

Talking to people from our room,Using a new platform known as Zoom.Passing on information, keeping people up to date,For sharing with others, not forgetting your mate.

Reaching Out became a must,We had to get the situation sussed.Tell us what you think, talk to usREGISTER online, don’t get the bus

When we have your details, we’ll pick up the phone,Whilst you sit on the couch in your own home.So to pass the timeand have a chat,Complete the registrationit’s as easy as that

Another addition Daily Dose, Monday to Friday,Download Zoom, Call at 11.00 I’d sayYou’ll need a code to enter the meeting,Find it on Facebook or Twitter then get comfy seating.

Make a Difference Monday starts the week,On Tuesday people talking, is what we seek.On Wednesday stories of health and social care we want to hear,Whilst Thursday we offer “Tech” support - no fear.

Reaching Out and Daily Dose, what we offer to aid,To all of you who in your homes you have stayed.Covid-19 how has it been for you?Talk to us, tell us your view.

Our Volunteers


Volunteers’ influence

Some of the work that the Healthwatch

Doncaster Volunteers have been

involved in during the period covered by

this report are:

• Regularly attending volunteer meetings

where we discuss issues relating to health and

social care both locally and nationally: These

enable us to identify areas of work that our

Healthwatch may want to develop.

• Planning and implementation of our Enter

and View programme: Our Enter and View

Planning Group have been instrumental in

helping to develop our Enter and View

programme and supporting our Authorised

Representatives.

• Representing the patient’s voice in focus

groups, grants panels and as part of the

commissioning process. One example is the

Urgent and Emergency Care project, here’s

what one of our volunteers had to say about

being involved in the tendering process for a

local service: “Our role was to score and

moderate parts of the bids from a service

user’s perspective. It’s wonderful to know that

the patient’s view is taken into account

alongside the financial and clinical parts of the

process.”

• Taking part in engagement activities to

promote Healthwatch Doncaster

“Being part of the Healthwatch

Doncaster team on the day of the

Recovery Games was great fun even

though it was rather wet. We spoke

to loads of people about how to

maintain good emotional health and

gathered feedback on services.”

Words from Healthwatch Doncaster

Volunteer Sue

Healthwatch Doncaster team at the Recovery Games in August 2019

Want to volunteer with Healthwatch Doncaster?

If you want to join our enthusiastic volunteer team, then contact us today!

Website: www.healthwatchdoncaster.org.uk/getinvolved

Telephone: 01302 965450

Email: [email protected]

Enter and View

During the period covered in this report our Authorised Representatives have

undertaken the following visits to local care homes (scheduled visits for March 2020

were postponed due to the Covid-19 pandemic):

The reports from these visits can be found here:

https://www.healthwatchdoncaster.org.uk/reports/

We carry out follow up visits 3-6 months after our original visit to see which, if any, of our

recommendations have been taken on board by the providers. This enables us to measure the

impact of our Enter and View programme in terms of improved experience for the recipients of

the service, to date this has been mostly positive.

The services that we visit appreciate our input and tell us that it is useful to have an independent

opinion on where service delivery can be improved.


It is great to see things through fresh eyes, we are here every day caring for people and sometimes it’s hard to see the bigger picture. We appreciate your input because if we can improve things even further we are happy to do it

Care Home Date Reason for visit Recommendations

Woodlea, Doncaster 17.4.19 Proactive Yes - minor

Stenson Court, Balby 15.5.19 Proactive Yes - minor

Roman Court, Mexborough

23.5.19 Proactive Yes - minor

The Old Rectory, Armthorpe


Headingly Court, Edlington


Headingly Park, Edlington


Thorndene,Doncaster


A quote from a Care Home manager aboutHealthwatch Doncaster Enter and View visits

https://www.healthwatchdoncaster.org.uk/reports/

Patient Stories

NHS Doncaster Clinical Commissioning Group

have monthly Governing Body meetings.

Patient stories are scheduled at each meeting

for members of the public to share their

experiences of local health and care services.

Since June 2019, Healthwatch Doncaster have facilitated the patient stories for the Governing

Body and we have supported local people to share their experiences of health and care services.

It was agreed that use of the Life Stages – Starting Well, Living Well and Ageing Well – would be

a good approach for the focus of each meeting.

This initiative has been very successful and feedback from the Governing

Body members and participants has been very positive. The Governing

Body have assured those attending that the information they have

received will be used to influence future service delivery.


Stories so far have included:

Lower back pain management

Work of the Young Advisors

Frailty services

Support for young people with Autism

Mental Health services

Life in a care home

Support for Children and Young People with additional health needs

Primary care services

Signposting and Information

This year we helped 294 people get the advice and information they need by: • Providing advice and information articles on our website• Answering people’s queries about services through a variety of different ways• Talking to people at community events• Promoting services and information that can help people on our social media channels


35%

16%

34%

8%

6%

Telephone Email Website Social Media Office

How did people contact Healthwatch Doncaster?


Twitter Facebook Instagram

1,974 Number of posts

739,398Total reach

1,850Video views

4,206Post engagements

Our Facebook post sharing information about the NHS Long Term Plan reached over 25,000

people across April and May

Choice for All Doncaster (ChAD)


ChAD were contacted by Joanne Blockley (Patient Advice and Liaison Team leader) from the local AcuteTrust to see if they could give their opinions on proposed feedback forms for the Friends and Family Test. Many simplified amendments were proposed and fed back to Joanne, who thanked ChAD for their prompt, detailed and constructive response.

In December, ChAD and RossingtonSMILE members took part in a photo shoot and filming at Diamond Activity and Therapeutic Services (formally The Solar Centre). All involved will feature in a short film and brochure to promote the service and activities available.

Find out more about us and the work we do

Telephone: 07834 686858

Email: [email protected]

Facebook: www.facebook.com/chadoncaster

Website: www.chadindoncaster.com

ChAD and Rossington SMILE were successful in receiving a micro-grant from Healthwatch Doncaster to put together a package about scams/social media. This enabled us to visit Lifewiseto find out more information to create three short video clips on different scenarios and write a song working with Mark Coley, from Rotherham Doncaster and South Humber NHS Foundation Trust

Following the work which ChAD had been involved in on the All Age Learning Disability and Autism Strategy, they were invited to attend the Scrutiny Panel at the Civic building where Doncaster Councillors and commissioners asked questions about difficulties people with a Learning Disability encounter.


http://www.facebook.com/chadoncaster

http://www.chadindoncaster.com/

The Forum’s main purpose

is to help

keep

people in

Doncaster safe

and well.

We achieve this in multiple ways, which

include hosting a bi-monthly Forum,

developing social media platforms and an

annual event highlighting the great

achievements of keeping people safe and

well throughout the year.

Our Forum has grown with membership

extended to people and professionals who

have an active interest in safeguarding

children, because we felt there was a

crossover of relevant issues and a need

for greater awareness.

Naturally, this influenced the variety of

guest speakers who attended the Forum.

We received information from South

Yorkshire Fire and Rescue, Voiceability,

Victim Support and Doncaster Culture and

Leisure Trust, to name a few.

Special thanks goes to Ian Walker –

Gamblers Anonymous – who shared his

personal journey about struggling with a

gambling addiction. He also shared how

gambling can affect anyone at any age

from school children to older people.

The Forum has identified a representative

to attend the local Keeping Safe sub-

group of Joint Safeguarding Boards to

share insight and ideas on local

campaigns and development of greater

partnership working between

organisations who work with adults and

children.

Our annual Keeping Safe event (pictured

below) was a festive feast. It was opened

by John Woodhouse, Chair of the Joint

Adults and Children Safeguarding Board.

Dr Alan Billings, South Yorkshire Police

Commissioner, then shared details of the

newly established Violence Reduction

Unit.

Highlights also included Jodie Keegans’

Survivors Story about domestic violence

and a showcase of how local groups are

helping to contribute to a safer Doncaster.

A local Primary School choir, who joined

us midway through the event, sang

modern Christmas songs which added a

special sparkle and festive feel to an

informative and enjoyable day.


Doncaster Keeping Safe Forum

Patient Participation Group Network


Our Patient Participation Group

Network (PPG) supports local PPG

members to come together from

across the localities and

communities in Doncaster and share

knowledge and insight.

The PPG Network enables Healthwatch

Doncaster to act as a conduit between

local patients and the local Clinical

Commissioning Group. This enhances

communication channels and helps

influence service development at a

strategic level.

Our PPG network have seen a range of

developments in Primary Care. A series of

Primary Care networks have developed

across the localities within the local area

of Doncaster with a Locality Co-ordinator

supporting community participation.

Patient Participation Groups have been

invited to be actively involved within their

own localities.

This includes bringing the Primary Care

Network representatives together with

our Patient Participation Group

representatives to discuss and support a

way forward for positive community

change.

The NHS Digital app was been trialled

and tested with a small number of

practices during the autumn and winter

months, which then saw a Borough wide

roll out of digital services enabling

patients to book appointments and order

repeat prescriptions through the NHS

App. The PPG Network were shown how

the new mobile application could benefit

patients during the trial phase so they

were able to share this information with

their own patient groups prior to the

Borough wide release.

Over the previous year, network speakers

have included: Tina Hope and Liz Leggott

from Primary Care Doncaster who shared

relevant updates on the extended access

service, which is now branded ‘More

Choice, More Appointments’; Clinical

Director Ben Scott shared his vision about

how his locality will be moving forward

and Julie Magee, the Neighbourhood Co-

ordinator for the South locality. The PPG

Network’s own carer representative

shared new information on carers and the

new ‘jointly’ app that connects everyone

who is involved with an individual’s care.

Finally, ‘Sharing Best Practice’ has been

reintroduced and consolidated into an

informative resource to help support the

on-going development of Patient

Participation Groups.

Showcasing the Network at an outreach event in Doncaster with this informative display board

Health Ambassadors


People with seldom heard voices are

not often listened to but our Health

Ambassadors initiative helps the

more marginalised communities

within Doncaster have an

opportunity to speak up and have

their say on local health and social

care services.

We have representatives from the

following communities:

• Transgender

• BAME

• Deaf

• LGBTQ+

• Asylum seekers

Every meeting, each Ambassador offers

an update on their community with

regards to what struggles they are

currently facing and any positive changes

that are happening. This provides a

supportive space where Ambassadors can

offer to help each other.

Topics of discussions throughout the year

have highlighted: video relay service – is

it being utilised enough in health settings

such as GP or hospital appointments?,

barriers faced by asylum seekers when

they wish to access GP and dental

appointments, concerns around access

and communication to and from the local

sensory team and issues regarding

prescribing medication for transgender

individuals.

All issues raised have been appropriately

addressed with the local Clinical

Commissioning Group and discussions are

ongoing to find solutions where possible.

This year we have recruited

representatives from the veteran’s

community, the deaf community, the

mental health community and young

people with autism. Moving forward,

future plans include recruiting a

Dementia representative and a young

carers representative.

Meetings have seen guest speakers from

Doncaster Council’s Equality and Diversity

team, the Voluntary, Community and

Faith Sector support team, a

representative from Healthwatch

Sheffield and colleagues from NHS

Doncaster Clinical Commissioning Group.

Trans Mission - representatives of the transgender community - at Doncaster Pride 2019

Our Finances

We are funded by our Local Authority under the Health and Social Care Act (2012).

Our core contract value is £216,360. We also received income from other services

that we delivered.


72%

9%

19%

Staffing costs

Premisescosts

Running costs £276,745

78%

7%

10%

5%

83% funding receivedfrom Doncaster Council

8% funding received fromNHS Doncaster CCG

10% additional incomefrom other work

5% income from ourreserves

£276,745

Hooton Pagnell

Photo Credit: Healthwatch volunteerPhoto Credit: Irene

Lound Hill

Photo Credit: Healthwatch volunteerPhoto Credit: John Burke

Hill Farm

Photo Credit: Healthwatch volunteer

Our Doncaster

Our priorities for 2020-21


Missed Appointments: Revisiting the project that we completed in 2017 to evaluate the impact of the changes to hospital appointments, based on our recommendations from our original report

Re-imaging engagement and involvement: We want to continue to deliver creative and innovative ways of engagement, involving local people and service providers to co-produce projects using online tools during the Covid-19 Pandemic.

Covid-19: How will people access health and social care services? What will be their experience of how services operate in the ‘new normal’.

Healthwatch Doncaster’s priorities and projects are influenced by what

we hear from local people and partners from across the Borough.

Cancer: The lived experience of people going through the cancer pathway in Doncaster.

Care and Support at Home: Talking to people about their experiences of care and support at home in the local community. Have things changed and improved since our last report in 2018?

Mental Health services: How do people access Mental Health support services in Doncaster, in light of the increase in demand relating to the Covid-19 pandemic?


Message from our Chief Operating Officer

The year started off with active

engagement in local communities across

a number of key projects and then

finished off with the Covid-19 pandemic.

The pandemic did not knock us off our

stride – it enabled us to finish the year

off by engaging with people over Zoom

and Facebook Live.

In 2019-20, Healthwatch Doncaster reinforced

our commitment to Engage, Inform and

Influence.

Engage: Healthwatch Doncaster set up and

delivered another successful Micro-Grants

programme and we supported all the

organisations that we have funded over the

last 3 years to come together as a network.

We led on a key piece of work across South

Yorkshire and Bassetlaw talking to people

about the NHS Long Term Plan and we

received national recognition for our work

locally and regionally.

Inform: Healthwatch Doncaster have

continued to provide high quality and

signposting information and support to local

people. We have developed the ‘What’s Your

Story’ approach to engagement in community

events and used this to listen to people’s

experience of emotional and mental health

support services in Doncaster. Healthwatch

Doncaster have worked closely with local

partners to deliver a key piece of work finding

out about people’s experience of accessing GP

services locally.

Influence: Healthwatch Doncaster continue to

be a loud voice for the views of local people

at the Health and Wellbeing Board,

Safeguarding Boards, Governing Bodies and

Committees. Not only are we a loud voice but

the voices of local people come through in the

reports that we write and the

recommendations that we make. We continue

to work with partners to influence an

improvement in the quality of local health and

care services

Andrew Goodall

Chief Operating Officer

Healthwatch Doncaster

The Healthwatch Doncaster team with the trophy as a result of the work around the Long Term Plan

Thanking our partners

Healthwatch Doncaster has really positive strategic and operational partnerships and relationships across health and social care in Doncaster. It is through these networks and relationships that we can overcome barriers and support local people’s voices to continue to shape and influence local services.

Healthwatch Doncaster focussed on a number of key projects in 2019-20 and we were able to deliver these to our usual high standards by working closely with all of our partners. Without these strong, local relationships we would not be able talk to as many people receiving care and support from the great services in Doncaster.

Healthwatch Doncaster are only as successful and effective as the partnerships that we have forged locally and for us these partnerships are strong and long-standing.

We would like to thank our key local partners for all their help, support and challenge over the last 12 months: • NHS Doncaster CCG• Doncaster Council• Doncaster and Bassetlaw Teaching

Hospitals NHS Foundation Trust (DBTH)• Rotherham, Doncaster and South Humber

NHS Foundation Trust (RDaSH)• Primary Care Doncaster• Local Medical Committee• Local Pharmaceutical Committee• South Yorkshire and Bassetlaw Integrated

Care System

Our local networks and relationships enable local people’s voices and opinions to make a difference and improve local services.

We have only been able to deliver the high quality reports and recommendations by working in partnership with local groups and

community organisations – without your support we would not have been able to hear as many voices and listen to as many stories and experiences of local health and care services.

Healthwatch Doncaster supports some specific networks and groups. You will have heard about the work of these groups and the voices of group members throughout this report.

Thank you to Choice for All Doncaster for speaking up on behalf of people with a Learning Disability.

Thank you to the Keeping Safe Forum for sharing messages and information to keep local people safe.

Thank you to the Health Ambassadors for supporting people, whose voices are not often heard, to speak up and speak out.

Thank you to the Healthwatch Doncaster Volunteers for getting involved in our engagement work, for leading on Enter and View and for coming up with new ideas for projects and pieces of work.

Finally, thank you to the Patient Participation Group (PPG) Network for speaking up on behalf of your individual PPG and patients so that we can support continued improvement in Primary Care. Norma Carr – Chair of the PPG Network – is stepping down as Chair from June 2020 onward. Thank you for your passion, motivation and contributions Norma. You have supported the PPG Network to grow and develop through challenge, learning and reflection. The PPG Network will continue to grow and maintain the support for local PPGs.


Contact usHealthwatch Doncaster

Cavendish CourtSouth Parade

DoncasterDN1 2DJ

01302 965450

[email protected]

www.healthwatchdoncaster.org.uk

@hwdoncaster/hwdoncaster

/healthwatchdoncaster


We confirm that we are using the Healthwatch Trademark (which covers the logo and Healthwatch brand) when undertaking work on our statutory activities as

covered by the licence agreement.

If you need this in an alternative format please contact us.

Company Number: 10158147© Copyright Healthwatch Doncaster 2020


http://www.healthwatchdoncaster.org.uk/

DONCASTER AND BASSETLAW TEACHING HOSPITALS NHS FOUNDATION TRUST

AGENDA ITEM LEAD FREQUENCY NEXT DUE

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Chair's Welcome and Apologies for Absence Suzy Brain England Each Meeting Next MeetingDeclaration of Interests Company Secretary Each Meeting Next MeetingConflict of Interests Register Company Secretary Annually Sep-20Action Log - Update on Actions from Previous Meetings Company Secretary Each Meeting Next Meeting

Various - As Agreed by Chair Various Each Meeting Next Meeting

ICS Update Richard Parker Each Meeting Next MeetingStabilisation and Recovery/Covid19 Recovery Jon Sargeant/Marie Purdue Each Meeting Next MeetingExecutive Team Objectives - Setting Richard Parker Annually Consider Nxt MtgExecutive Team Objectives - Quartely Updates Richard Parker Quarterly Oct-20 Q1 / Q2NHS Long Term Plan Richard Parker As Required Consider Nxt MtgCQC David Purdue As Required Consider Nxt MtgBudget Setting/Business Planning/Annual Plan Jon Sargeant/Marie Purdue Annually Consider Nxt MtgNHSI Plan Jon Sargeant/Marie Purdue Annually Consider Nxt MtgCommittees in Common Company Secretary As Required Consider Nxt MtgSY&B Pathology Programme Richard Parker As Required Consider Nxt MtgTrue North/Breakthrough Objectives Marie Purdue Annually Apr-21

Finance Report Jon Sargeant Each Meeting Next Meeting Jun Aug Sept Oct NovQuality and Performance Report Becky Joyce Each Meeting Next Meeting May Jul Aug Sept OctNursing, Midwifery and Allied Health Professionals Update David Purdue Each Meeting Next Meeting Jun Aug Sept Oct NovMedical Director Update Dr Tim Noble Each Meeting Next Meeting Jun Aug Sept Oct NovP&OD Report Karen Barnard Each Meeting Next MeetingReport from Guardian for Safe Working Jayuant Dugar Quarterly Feb-21Maternity CNST David Purdue (Lois Mellor) Annually Jul-20The NHS Patient Strategy Sewa Singh (Cindy Storer) Annually Jul-20Winter Plan Becky Joyce Annually Oct-20

Workforce and Recruitment Plan Karen Barnard Annually Jul-20Workforce Race Equality Standards Karen Barnard Annually Jul-20Workforce Disability Equality Standards Karen Barnard Annually Jul-20ERIC Return Kirsty Edmondson-Jones Annually Jul-20Staff Survey Results Karen Barnard Annually Feb/Mar-21Staff Survey Action Plan Karen Barnard Annually Apr-21Mixed Sex Accommodation Kirsty Edmondson-Jones Annually TBCEU Exit Becky Joyce As Required Consider Nxt Mtg

MEETING DATES

ANNUAL BOARD CYCLE OF BUSINESS

COMMITTEE BUSINESS

PUBLIC SESSION

STRATEGY

PRESENTATIONS

QUALITY PERFORMANCE AND SAFETY

CAPACITY AND CAPABILITY

H8

Control Total Jon Sargeant Annually Jan-21Use of Trust Seal Richard Parker/Company Secretary As Required Consider Nxt MtgCCG Contracts Jon Sargeant Annually Private?Reference Costs Jon Sargeant Annually Sep-20Going Concern Jon Sargeant Annually Apr-21

NHS Providers Licence Self-Assessment / Certification Company Secretary Annually Jun-21SO's SFIs, Standards of Business Conduct, Board Powers Jon Sargeant/Company Secretary Annually Jul-20

Trust Annual Report and Accounts including the Annual Governance StatementRichard Parker/Jon Sargeante/Company Secretary Annually Jun-21

ISA 260 Jon Sargeant/Company Secretary Annually Jun-21Board Assurance Framework Company Secretary Quarterly Jul-20Corporate Risk Register Company Secretary Each Meeting Jul-20Chair's Assurance Log for Finance and Performance Cttee Neil Rhodes Each Meeting Next Meeting Jun Jul Sept Oct NovChair's Assurance Log for Quality Effectiveness Cttee Pat Drake Bi-Monthly Next Meeting Jul Sept NovChair's Assurance Log for Audit and Risk Cttee Kath Smart Quarterly Next Meeting Jul NovChair's Assurance Log for Charitable Funds Cttee Sheena McDonnell Quarterly Next Meeting Jun SeptTerms of Reference for Finance and Performance Cttee Neil Rhodes Annually Mar-21Terms of Reference for Quality and Effectiveness Cttee Pat Drake Annually Mar-21Terms of Reference for Audit and Risk Cttee Kath Smart Annually Mar-21Terms of Reference for Charitable Funds Cttee Sheena McDonnell Annually Next MeetingBoard Effectivess Review Company Secretary Annually Sep-20Annual Report of the Finance and Performance Cttee (inc Effectiveness Review) Neil Rhodes Annually Sep-20Annual Report of the Quality Effectiveness Cttee (inc Effectiveness Review) Pat Drake Annually Sep-20Annual Report of the Audit and Risk Cttee (inc Effectiveness Review) Kath Smart Annually Jun-21Annual Report of the Chaitable Funds Cttee (inc Effectiveness Review) Sheena McDonnell Annually Sep-20Information Governance Assurance Framework Ken Anderson As Required Jul-20

Chair and NEDs' Report Angela O'Mara Each Meeting Next MeetingChief Executive's Report Company Secretary Each Meeting Next MeetingMinutes of the Finance and Performance Committee Company Secretary Each Meeting Next Meeting May Jun, Jul Aug Sept OctMinutes of the Quality and Effectiveness Committee Company Secretary Bi-Monthly Next Meeting May NovMinutes of the Audit and Risk Committee Company Secretary Quarterly Jul-20 May JulMinutes of the Charitable Funds Committee Company Secretary Quarterly Next Meeting Mar Jun SeptMinutes of the Management Board Company Secretary Each Meeting Next Meeting June July Aug/Sept Oct NovMinutes of the Council of Governors Company Secretary Each Meeting Next Meeting May JulyBassetlaw Integrated Care Partnership Bulletin Company Secretary As Required Consider Nxt Mtg Bulletin Bulletin Bulletin Bulletin Bulletin

Minutes of the Previous Meeting Company Secretary Each Meeting Next Meeting Jun July Sept Oct NovAny Other Business Suzy Brain England Each Meeting Next MeetingGovernor Questions Suzy Brain England Each Meeting Next MeetingDate and Time of Next Meeting Company Secretary Each Meeting Next Meeting Sept Oct Nov Dec JanWithdrawal of Press and Public Suzy Brain England Each Meeting Next Meeting

Planned for Future Meeting(s)Items Added to Individual Meetings as Required

OTHER ITEMS

Not Considered as Planned

GOVERNANCE AND RISK

FINANCE AND CONTRACT MATTERS

Presented as Planned

ITEMS FOR INFORMATION

Audit and Risk Committee

Minutes of the meeting of the Year End Audit and Risk Committee

Held on Thursday 4 June 2020 via StarLeaf Videoconferencing

Present:

Kath Smart, Non-Executive Director (Chair) Sheena McDonnell, Non-Executive Director Neil Rhodes, Non-Executive Director Mark Bailey, Non-Executive Director (MCB)

In attendance: Richard Parker, Chief Executive Jon Sargeant, Director of Finance Matthew Bancroft, Head of Financial Services (MB) Alex Crickmar, Deputy Director of Finance Clare Partridge, Internal Audit Manager, KPMG Dan Spiller – External Audit Manager, EY Steven Clarke, External Audit Account Manager, EY Fiona Dunn, Acting Deputy Director of Quality and Governance/Company Secretary Roz Wilson, Corporate Governance Officer (Minutes)

To Observe: Apologies:

Bev Marshall, Public Governor None Action

ARC04/06/A1

Kath Smart held the year end annual private meeting between Audit and Risk Committee members and the Internal and External Auditors between 14:00 – 14:30. Present, Kath Smart, Sheena McDonnell, Mark Bailey, Neil Rhodes, Clare Partridge, Steven Clarke and Dan Spiller. The meeting was positive in nature with External Auditors complementing the final accounts process under difficult circumstances and remotely. There were no matters from the private meeting that required reporting to Audit Committee or Board.

ARC04/06/B1

Welcome and Apologies for Absence (Verbal)

Kath Smart welcomed the members and attendees. No apologies for absence were noted.

ARC04/06/B2 Conflict of Interest


ARC04/06/B3 Request for any other business There were no request for other business.

ARC04/06A1 – ARC04/06G4

H9

ARC04/06/B4 Action Notes from Previous Meeting (Enclosure B4) The following updates were provided; Action 1 – Update for July’s meeting is required Action 2 – Not due yet, agreed to be on Julys agenda. Action 3 – Action closed as now complete. Action 4 – Not due yet, agreed to be on July’s agenda. Action 5 – Not due yet, agreed to be on July’s agenda. Action 6 – CP agreed to follow up with R. Fenton for the final report Action 7 – Action closed as now complete Action 8 – Agreed to be on July’s agenda. Action 9 – Overdue, JS to circulate Action 10 -Overdue, JS to circulate Action 11 – Not due yet, agreed to be on July’s agenda.

The Committee:

- Noted the updates and agreed, as above, which actions would be closed (Action 3 and Action 7)

Action: Roz Wilson would update the Action Log.

RW

ARC04/06/C1 Annual Report and Head of Internal Audit Opinion

Clare Partridge, Internal Audit (IA), presented the Annual Report and Head of Internal Audit Opinion to the committee which summarised:

The role of Internal Audit and Management;

Findings in relation to the planned internal audit coverage and output;

Recommendations;

Internal audit performance as measured against the agreed suite of performance targets.

The Internal Audit Plan originally allocated 190 days in relation to 12 reviews including the follow-up of prior recommendations, attendance at Audit Committee and associated contract management over the year. Seven audits and activities laid out in the plan for the year have been finalised as at 15 May 2020 with 167 days of audit work being delivered. These are Core Financial Controls and Financial Management, Risk Management and Board Assurance Framework, Corporate Governance, IT contract management, Safeguarding, CNST Maternity Incentive Scheme Spot Check and Information Governance. The ratings for three reviews have been agreed with management, Referral to Hospital Access, Clinical Governance (WHO Checklist) and Delayed Transfer of Care) however final management responses have yet to be provided.

In addition, management and KPMG are in the process of agreeing the findings and recommendations for one final review (P&OD effectiveness), however as this is an advisory review no rating will be provided. One review has been deferred to 2020/21 as a result of Covid-19 outbreak relating to Capacity Planning. KPMG’s reviews were undertaken by team members from our Public Sector Assurance department and appropriate specialists from across KPMG, including IT and People Consulting. 51 recommendations have been raised by internal audit during year. 38 of these recommendations have been accepted by management, the P&OD advisory review is currently in the process of being agreed. Clare Partridge advised the committee that the Head of Internal Audit’s overall opinion is that the Trust has been given “Significant Assurance with minor improvements required” which has been given on the overall adequacy and effectiveness of the organisation’s framework of governance, risk management and control. Throughout the year three reviews resulted in a partial assurance opinion and no reviews resulted in ‘No Assurance’ opinions. Kath Smart asked about the outstanding management agreements to the recommendations (Who Checklist and Referral to Access). Clare Partridge advised that Rob Fenton had discussions with the management SRO, but had to escalate the lack of responses. Jon Sargeant confirmed this has been escalated and he would chase the management responses for finalisation of the outstanding audits (WHO Checklist, Referral to Access and P&OD) Action: Jon Sargeant to chase the management responses for the WHO Checklist, Referral to Access and P&OD audits. Kath Smart asked about the days that had been deferred by KMPG and the cost implications on the expected fee for the days not delivered. Jon Sargeant advised that the days not provided would come off the fee and would be delivered in the next financial year. Sheena McDonnell queried how close to the wire the conclusion was, Clare Partridge confirmed KPMG were much more comfortable this year with the overall conclusion. Overall Kath Smart felt that the KPMG report was positive showing significant assurance with minor amendments P&OD effectiveness review will be picked up in the 2020/21 audit plan.

JS

ARC04/06/D1 DBH Annual Report

Richard Parker presented the DBH Annual Report in a slight reduced format due to COVID-19. The Executive Team had agreed to present the annual report in the reduced format due to the current constraints during COVID-19. Richard Parker explained the wording changes within the remuneration section of the report as there was a dual process that was completed through the Remuneration on nominations committee that aligned his salary in line with other Chief Executives within the other local Trusts this was guidance from NHS Providers. Also adjustments were made regarding pensions provisions. The committee noted and accepted the report, and Richard Parker asked if any of the Committee had any questions. Kath Smart thanked the team for the hard work that has gone into producing this report, but has noted a number of detail changes that are required. Action: Kath Smart to send amendments to Fiona Dunn for correction. Mark Bailey asked, point of clarification. Following the production of the CQC statement, it states requires improvement on safety and that some actions need to be completed to define services as good, Mark explained that the key message can be misconstrued. Action: Richard Parker to ask the communications team to look at the key message. Neil Rhodes pointed out that on page 63 of 168 the graphic shows top and bottom scores this looks a confusing message on working v’s unpaid hours. Richard Parker explained that the wording is from the NHS National Survey and a negative is a positive, we just need to explain this to staff when giving feedback. Sheena McDonnell asked about the final page of the annual report is discusses off payroll engagement. Richard Parker advised that this is classified and Board Members or Directors. Richard Parker clarified that the Trust has two nomination and remuneration committees, one is for Council of Governor Business and one is for Non-Executive Directors business. Due to COVID-19 it was agree that the Quality Accounts are not required to be audited this year due to the Pandemic. Although the Quality Accounts are working to the current accounts and they are to be produced by December. Work is currently underway to develop and agreed the Quality Accounts. The national deadline for submission is December 2020 although the Trust is

KS RP

currently working to produce these in time for the Annual Members Meeting in September 2020. Kath Smart requested that the plan for Quality Accounts sign off and governance process was clear. It was advised these may go straight to Board due to the deadline for AMM and Fiona Dunn was co-ordinating Action: Fiona Dunn to confirm the plan for production, sign off and governance around the Quality Accounts.

FD

The Committee:

- Noted and accepted the Annual Report pending agreed amendments to be made.

ARC04/06/D2 Draft - Annual Governance Statement 2019/2020

Richard Parker presented the Draft Annual Governance Statement which formed the Trust’s statement of internal controls. The report set out how the Trust had ensured that it had implemented processes appropriate to its circumstances covering:-

Scope of responsibility

The purpose of the system of internal control

Capacity to handle risk

The risk & control framework

Review of the economy, efficient and effectiveness of the use of resources

Information governance

CQC Review

Review of Effectiveness

4 Hour Wait

Referral to Treatment – RTT

Diagnostics

Cancer One of the Trusts great achievements throughout this year has been the CQC rating, the Unannounced and announced inspections by the CQC took place across Trust sites in September and October 2019 and the Trust received an overall rating of ‘Good’, improving on the previous years’ rating of ‘Requires Improvement’. With an improving rating on the previous year, the Board have been able to take assurance from the outcome and areas that were rated as requires improvement have robust plans in place to bring those standards up. Richard Parker concluded that following his review, his opinion is that Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust has a sound system of internal control that supports the achievement of its policies, aims and objectives. No significant internal control issues have been identified.

Sheena McDonnell asked Richard Parker if there was a reason why Charitable Funds and Fred & Ann Green were not included in the statement. Richard Parker explained that he didn’t think it was a requirement as these reports are on a separate reporting pathway and are reported differently. Jon Sargeant explained that the Annual report for Charitable Funds accounts are due before January 2021. Sheena McDonnell also suggested that there needs to be a paragraph in the statement that there is a positive the Board of Directors is held in public and Governors enabled to ask questions at the Meeting. Action: Wording to be amended to include Board held in public and Governors can ask questions and also that committee meetings have a Governor Observer. Clare Partridge from KPMG suggested that the Trust also includes a short statement reflecting on the current COVID-19 specific governance and risk assessments that have been put in place. Action: Inclusion in the AGS of a paragraph to ensure current Covd-19 governance was captured and reported. The Committee Agreed and accepted the Annual Governance statement to include the agreed changes.

RP/ FD RP/ FD

ARC04/06/D3 Draft 2019/2020 Annual Accounts & Financial Statements

Jon Sargeant presented the Annual accounts for the financial year ending 31 March 2020. These annual accounts had previously been submitted to the Finance & Performance Committee on 26 May 2020. Once approved the annual accounts would be submitted to NHSI by the 25 June 2020 deadline. The report included a Letter of Representation from the Trust to the external auditors Jon Sargeant noted that the delay on the annual accounts to the ARC committee was due to the guidance from NHSi being delayed. Jon also noted that the accounts have been produced on time and worked with Auditors to ensure deadlines were me, due to COVID-19 this had to be changed to be done remotely causing additional pressure to both DBTH and EY.

Jon Sargeant and Kath Smart thanked Alex Crickmar (DBTH), Matthew Bancroft (DBTH) and Dan Spiller from EY for their commitment to producing the annual accounts. Neil Rhodes, who is the Chair for Finance and Performance is happy to accept the accounts, and asked for the significant achievement and work during COVID-19 to e recognised. Kath Smart queried that although PDC remained stable couple of years, following the recent government conversion of loans to PDC, whether the interest payable would increase during 2021? JS confirmed it would and he had made provision to in the budgets of the Trust for this. Kath Smart asked about the provisions and estimates (Page 3 note 34). How are they spent and how accurate they are? Matthew Bancroft advised that this information isn’t routinely reported but can be produced on a 6 month basis. Action: Matthew Bancroft to review if actual expenditure against provisions varies and whether this is significant to warrant periodic reporting to F&P. It is to be noted that it is the first time, Doncaster and Bassetlaw Healthcare Services has been reported in the consolidated accounts. Kath Smart asked about the bad debt provision and write offs and that future write offs were planned to be reported through Finance & Performance Committee. Jon Sargeant advised this was also reported and discussed at the CASH committee. Jon Sargeant asked for these audited accounts to be accepted. The Committee: Approved the annual accounts for submission to Board.

MB

ARC04/06/D4 ARC Annual Report 2019/2020

The ARC annual report has been written by Kath Smart and is a factual report in collation with KPMG’s final opinion, and needs to include the revised ISA260 conclusion. Sheena McDonnell commented that this is a true reflection on work going through committee and well done for the work that has been carried out over the last 12 months. The Committee: Agreed and approved the ARC Annual Report.

Governor Observations Bev Marshall Public Governor, commented that the annual report has been well produced considering the difficulties during COVID-19. Bev asked for the annual report to go to Governors and AMM. Bev Marshall commented that on behalf of Governors, echoed Neil Rhodes Comments and the Committee and Trust must indulge on CQC outcome.

ARC04/06/E1 Final ISA 260 Report

Stephen Clarke and Dan Spiller from EY, presented the audit results report that summarised EYs preliminary audit conclusion in relation to Doncaster & Bassetlaw Teaching Hospitals NHS Foundation Trust’s financial position and results of operations for 2019/20. Steve Clarke echoed the comments made by Jon Sargeant and he commended the Trust’s finance team for their hard work to improve the quality of working papers from the Trust over the previous few years; this year the accounts would be ready for sign off a week ahead of deadline and this was a reflection of the continued improvement. Steve Clark discussed the key areas in terms of opinion, the Executive Summary, and changes in summary. Audit Differences - it was to be noted that no amendments have been required that alter the Net Surplus of the Trust (or Deficit of the Group) or the Net Asset Position of the Trust or Group. Opinion - On the basis of the work performed to date, and subject to completion of a few outstanding audit procedures, EY anticipate issuing an unqualified auditor’s report in respect of the Trust accounts. However, until all of the outstanding procedures were completed, it was possible that further matters requiring amendment may arise. Steve Clark advised that EY considered whether circumstances arising from COVID-19 resulted in a change to the overall control environment of effectiveness of internal controls, for example due to significant staff absence or limitations as a result of working remotely. We identified no issues which we wish to bring to your attention. Neil Rhodes, praised the team for their continued hard work and Kath Smart commended the Finance team for accounts position. Kath Smart queried the internal control issue of documentation relating to starters and leavers, and asked that Karen Barnard and team are Invited to discuss relevant aspects of HR section in ISA260. Action: to add ISA 260 Recommendation - P&OD from ISA260 to July Agenda.

RW

Kath Smart queried the increase in fee, and Jon Sargeant discussed the COVID-19 fees section of the report with the additional £8000 costs, is made up from 2 processes that wouldn’t typically have to do and also going concern piece of work during COVID-19 which made concluding year end more complex. Jon Sargeant has had prior discussions with EY and agreed that more work has gone into this and supported the fee increase. It was agreed that underspend on the audit programme and no audit on quality accounts and no charge for this. Bev Marshall asked about the audit fee for charitable funds, as the audit is not noted in the report. Jon Sargeant advised that the Charitable Funds accounts should be audited in later in the year and submitted by January 2021 as the Charity commission have different deadlines for accounts to Department of Health. Steve Clarke concluded that from 4 years ago, the Trust is now in a remarkable place and the team should be proud of what they have done and achieved.

ARC04/06/F1 Issues for escalation to Board of Directors, QEC or F&P Cttee

The Committee: There was nothing to escalate to Board, F&P and QEC. Action: Kath Smart will produce the Chairs report for Board.

ARC04/06/F2 ARC Sub Committees

There was nothing to raise from sub committees as they are not currently meeting in current format due to COVID-19.

ARC04/06/G1 Minutes of the meeting held on 23 March 2020 The committee: Noted the minutes form the 23 March 2020 with one amendment to the word loan, this needs to be lone.

ARC04/06/G2 Gifts and Hospitality Update During COVID-19

The Committee Noted the spreadsheet, and that the policy currently under review.

ARC04/06/G3 Information Governance Group Minutes The Committee: Noted that the Information Governance Group had not met since the last minutes received at the March meeting.

ARC04/06/G4 Date and time of next meeting (Verbal)

Date: Time: Venue:

Thursday 16 July 2020 09:30 The Board Room, Doncaster Royal Infirmary/ Video-Conference

Board of Directors – Public Meeting – 16 June 2020 Page 1 of 16

BOARD OF DIRECTORS – PUBLIC MEETING

Minutes of the meeting of the Trust’s Board of Directors held in Public on Tuesday 16 June 2020 at 11:30 in the Board Room, Doncaster Royal Infirmary via StarLeaf Video

Conferencing

Present:

Suzy Brain England OBE - Chair of the Board (In the Chair) Mark Bailey – Non-Executive Director Karen Barnard - Director of People and Organisational Development Pat Drake - Non-Executive Director Rebecca Joyce – Chief Operating Officer Sheena McDonnell – Non-Executive Director Richard Parker OBE – Chief Executive David Purdue – Deputy CE and Director of Nursing and Allied Clinical Health Professionals Neil Rhodes – Non-Executive Director and Deputy Chair Jon Sargeant – Director of Finance Kath Smart – Non-Executive Director Dr T J Noble - Medical Director

In attendance: Fiona Dunn – Acting Deputy Director Quality & Governance/Company Secretary Marie Purdue – Director of Strategy and Transformation Katie Shepherd – Corporate Governance Officer (Minutes) Emma Shaheen – Head of Communications and Engagement Rosalyn Wilson – Corporate Governance Officer

Public in attendance:

Peter Abell – Public Governor – Bassetlaw David Goodhead – Public Governor – Doncaster Dr Mark Bright – Public Governor - Doncaster Hazel Brand – Public Governor – Bassetlaw Lynne Logan – Public Governor – Doncaster Steve Marsh – Public Governor – Bassetlaw

Apologies: None

The Chair of the Board welcomed all in attendance at the virtual Board of Directors meeting, and extended the welcome to the Governors in attendance via the audience functionality.

ACTION

P20/06/A1 Apologies for absence (Verbal)

No apologies for absence were noted.

P20/06/A2 Declaration of Interests (Verbal)

No declarations of interest were declared.

The Board:

P20/06/A2 – P20/06/J FINAL

I1


- Noted the Declaration of Interests pursuant to Section 30 of the Standing Orders.

P20/06/A3 Actions from Previous Meetings (Enclosure A3)

The following updates were provided: Action 1 – Council Motion on Climate and Biodiversity Emergency – This action was not due until July 2020 however it was noted that new information would be received during August 2020 and therefore it was suggested that the Action be postponed until September 2020. The Board were in agreement that this action would be postponed until September 2020. Action 2 – Covid19 Recovery Plan – This item was added to the work plan to be delivered in July 2020 and would therefore be closed; Action 3 – Strategic Director Review Workshop – This item was not due until July 2020 however an Update would be provided as part of Item C2 – Stabilisation and Recovery. Action 4 – Deep Dive on Complaints – On the basis that this item had been added to the Quality and Effectiveness Committee work plan for July 2020 this action would be closed.

The Board:

- Agreed to postpone the due date of Action 1 – Council Motion on Climate and Biodiversity to September 2020;

- Noted the updates and agreed which actions would be closed.

P20/06/C1 ICS Update (Enclosure C1)

Richard Parker presented the points highlighted in the paper relating: Richard Parker highlighted the key points that would be of focus over the coming months, including the impact of Test and Trace, PPE and the financial envelope. Pat Drake asked if there had been any discussions of the clinical governance of the process to be outlined in relation to undertaking appointments virtually or via telephone. Richard Parker advised that there were two pieces of work being undertaken, and one of those was locally through the Stabilisation and Recovery Programme within the Trust and one through the ICS, and this was to ensure that there was a consistent message to patients, as there were many patients that have pathways that involve more than one Trust. Information sheets will be used for patients undergoing surgical procedures which will include the risks and potential complications relating to undergoing surgery. Dr Tim Noble advised that a patient safety information leaflet had been produced which includes the notification of the higher risks associated with surgery for patients testing positive for Covid19. Sheena McDonnell noted that it was encouraging to see the support given to Care Homes and the Voluntary Sector. Sheena asked what the Trusts ask was in the capital plan submitted within the financial envelope that the ICS had received of £84.7m for 2020/21. It was confirmed that the Trust had submitted the capital plan following the review of it at the Finance and Performance Committee, and it included all the required capital for this year including the fire works, theatre upgrade and emergency capital bid. Prior to Covid19


there was a planned expenditure, and last month discussions took place with each Division to review the plans with a view to check what work could be undertaken over summer, factoring social distancing, in preparation for the winter period. Areas of work had been agreed that were guaranteed to be complete prior to the winter period and would commence soon. The Trust had submitted a reduced capital plan, which was aligned to meet the expectation of the organisation in what was feasible and deliverable this year. The exception to this was the upgrade to the HSDU which was a scheme that was put forward previously to the ICS that was initially rejected, and had now been submitted as part of the national bidding process. All Phase 3 Covid19 bids need to be submitted by the 19 June 2020 and the process would be organised on a priority basis within the ICS. It was unknown what the criteria was for the priority. Kath Smart noted that £84.7m didn’t sound a lot of capital for the region, particularly as ours was £16m. Jon advised that prior to Covid19, all Trusts put their draft annual plans into the ICS, and these have been used to minus a 15% reduction for each Trust. Neil Rhodes noted his support to the HSDU work and welcomed the Chief Executive’s view on the Executive’s commitment to it as it was essential for bed management. Richard Parker advised that the initial plan was put into place at the start of the Covid19 response and the Executive were in agreement that it was an essential element to the Trust’s response to Covid19 and now in readiness for the potential second phase of Covid19 and winter pressures as it would allow for significant resilience and would be a good use of public money as it would have the flexibility of use as an enhanced recovery service or intensive care unit for many years. All Executives support and recommend this additional service to the Board of Directors and the Council of Governors. Sheena McDonnell asked what the longer term plans were for PPE. Richard Parker advised that that the initial PPE challenges previously noted were mitigated by the Heads of Procurements in South Yorkshire who did a fantastic job with their normal supply chains and although there were pressure points at times, the Trust had not had any period of time where they weren’t in some supply of a key product. As the Trust moves into Phase 2 a focus would be made to ensure that as Covid19 demand reduces, stocks are not completely depleted in preparation for a potential second surge of Covid19, winter pressures and Brexit on 31 December 2020, in which disruption to supply chain was already expected. A lot of work was being undertaken national to procure long-term contracts to mitigate this. Pat Drake noted that a number of ICS regions had appointed an Independent Chair and asked if this had been considered by the South Yorkshire and Bassetlaw ICS. Richard Parker advised that the CEO had given the commitment to develop this model. Jon Sargeant noted that the next part of the financial regime will include a revenue total share between all organisations which would support the need for an Independent Chair to ensure transparency and the management of finances.

The Board:

- Noted the update from the ICS.

P20/06/D2 Stabilisation and Recovery (Enclosure C2)

Marie Purdue presented the Stabilisation and Recovery paper which outlined the Trust’s approach to planning for stabilisation, recovery and reset following the Covid19 pandemic. Marie Purdue highlighted that the aim was to protect patients and staff throughout this


challenging time. The planning had been undertaken to accommodate either an underlying level of Covid19 or a potential second surge of Covid19, in line with regional guidance on modelling. The Trust was awaiting further national guidance. The process had been managed using a number of work streams, each led by a Senior Responsible Officer. The implementation and delivery of the recovery process is in line with many of the pre-existing longer term organisational objectives. The Governance process for managing the planning process consists of the Stabilisation and Recovery Group in which the Executive Team and Divisional Directors are members to provide a joined up clinically led approach to reinstate services. The paper had been presented on the basis of changing environment and therefore the paper outlines an overview of the current plan as opposed to the detail, which is also being worked through. Mark Bailey asked what level of capacity would be re-established. Marie Purdue advised that there was at least 10% reduction in productivity expected, however with increased infection prevention and control measures, any potential of a second surge of Covid19 and the winter period it was likely be a higher reduction and this would be monitored closely. Pat Drake asked if the previous Theatres QI work had been factored in, along with the already received patient feedback. Marie Purdue advised that Qi methodology had been used to underpin the Post Implementation Review process to assess the many changes to practice many of which were substantial, such as digital transformation. Further refinement to and evaluation of changes would be required as the process had been undertaken quickly, however it was noted that local engagement wouldn’t be lost. Richard Parker added that post-Covid19 presents significant changes with distancing rules and therefore means that there would be a reduction in the number of procedures a surgeon could carry out in one list due to cleaning and donning and doffing of PPE. This would result in the NHS overall being less productive against any measures it had previously seen and it was expected that any appointments that can be undertaken virtually will only slightly offset what cannot be undertaken on site and therefore the expectation of delivery would be set. Jon Sargeant added that the key issue currently for moving forward was the lack of a reliable point of care test; and that decisions are made to ensure the right outcomes for the patients. Becky Joyce noted the caution in ensuring that the governance process and the outcomes were right but the main areas of transformation would be in outpatients which would be very different to any model undertaken previously. Testing and screening will be a large part of the transformation. Becky noted that it was heartening to see how teams were engaging with working in new and different ways. Kath Smart asked about the safety aspect, and it was confirmed that the oversight of changes and process change would be monitored within the Ethical Framework and Governance work stream. Richard Parker noted that in respect of all comments received, the changes that have been made have been equality impact assessed, and any future changes would undergo the same process. At the end of Covid19 the NHS would still be in a position of financial instability and therefore it was required that the model implemented was sustainable and would not incur huge costs that would present an issue for 2021/22. Thought would be taken on how public money would be spent to ensure sustainability and quality. Dr Tim Noble advised that currently the risk of Covid19 was high and therefore presents the compromise of not examining patients physically in all cases, however as the Trust


moves into the stabilisation and recovery phase, the Ethical Framework and Governance work stream will work to assess this on a speciality and condition basis. The risk and benefit of not assessing a patient face to face will vary from time to time dependant on the Covid19 situation. There was a backlog of work, however with the introduction of a point of care test, it would allow the Trust to operate in a different way. Neil Rhodes noted the topic was important to discuss in the presence of Governor colleagues, to demonstrate how the Trust was responding to the pandemic and how it would learn from lessons. Neil noted that at the Finance and Performance Committee on 30 June 2020 a major review of this topic would be undertaken to unpick the emergent findings to contribute to ways of moving forward. Sheena McDonnell asked for assurance that the objectives were reflective of what the Trusts objectives were as it seemed they were aimed at a shorter period of time, and some of the work outlined in the paper won’t be doable without the assistance of partners and in collaboration with others. Marie Purdue assured the Board that a lot of work was being undertaken that was not in the paper, as previously mentioned the Stabilisation and Recovery process was a changing environment. Discussions had been undertaken with Place and the ICS regarding discharge of patients, and with the Provider Alliance regarding working with colleagues, and the plans have been shared with the Primary Care Network. Richard Parker noted that the ICS’ role was the overall responsibility to ensure that services across South Yorkshire and Bassetlaw meet the needs of its residents. The ICS are looking at a coordinated effort in relation to the independent provision of surgery and diagnostics, along with a coordinated winter plan. An event will take place on 1st July 2020 to stress test the plans in place. Plan were being explored looking to make identified sites Covid19 light, and Bassetlaw could be one of those sites, alongside others in the region, potentially leading to the treatment of Covid19 positive patients at one site in the region.

The Board:

- Noted the information received on the Stabilisation and Recovery process.

P20/06/C3 True North/Breakthrough Objectives (Enclosure C3)

Marie Purdue presented to the Board the revised True North objectives for 2020/21. The main change was Objective 1 which changed from “Achieve CQC Outstanding” to “Provide outstanding care and improve patient experience” to reflect the ambition to the provision of outstanding care first and foremost. A process was undertaken with Divisional Teams to develop the breakthrough objectives for 2020/21 towards achieving the True North. Pat Drake advised that the achievement of the objectives would be embedded into the Quality and Effectiveness Committee terms of reference, and it was expected at the next Quality and Effectiveness Committee meeting that a discussion take place on how the achievement of the objectives will be measured. Neil Rhodes warned that staff may not be focused on the performance picture post Covid19 and it would be required of every department to have a performance focused plan that links to the financial plan, because if performance measures aren’t met, the Trust would be less likely to meet the financial plan to move towards a better recurrent surplus position. Neil Rhodes suggested an amendment to the financial objective to enforce this as it would provide a major focus at the Finance and Performance Committee. Karen Barnard advised that the accountability meetings had been resurrected and KPIs had been set to cover a range of quality, performance and people, and within this was the


appraisal process which had been paused during Covid19, but would be picked up with a focus on priorities for teams and individuals going forward. This would link back to the Stabilisation and Recovery Plan. A range of offerings were being pulled together to engage staff and the Staff Family & Friends Test would be used to enquire how staff have felt during the pandemic. Richard Parker added that one of the Trust’s major successes with staff was their individual contributions to focusing on improvements to quality of their services and empowering staff as the ones who know and deliver the service, and where this was done it was successful. Finance and performance would not take a focus in isolation and therefore performance would link to each objective. David Purdue echoed that performance and quality would be dispersed throughout the 5 Ps, and would therefore be monitored against the four breakthrough objectives. The Chair highlighted that her appraisal would take place on 17 June 2020 and as part of that process would be discussed how she assists in achieving the objectives of the Trust and this would be replicated in the Non-Executive Directors appraisal with the assistance of Governors.

Action: True North/Breakthrough Objective measures of achievement would be added to the Quality and Effectiveness Committee agenda for July 2020.

DP/TN

The Board:

- Approved the amendments to the wording of the five year objectives developed for 2020/21.

P20/06/D1 COVID-19 Update

Rebecca Joyce provided an update on the Covid19 Pandemic, and highlighted that the incident still remained a level 4 national incident and therefore the Trust would maintain the Incident Control Room, however over the last month the leadership resource had been reduced to reflect the needs to increase the divisional work. Currently there were sixty Covid19 positive inpatients, two of which were on ICU. In total since the start of the pandemic, there had been a total of 59 treated on ITU, 402 discharged and a total of 205 had sadly passed away. Pragmatic decisions had been made the previous week to scale up outpatient activity work, the majority of which was either telephone or video activity; and a decision was taken last week to scale up routine radiography work. At the start of the pandemic all Endoscopy work had been paused with the exception of emergency, however over the past month the service provision had been increased for urgent and two-week wait scoping. It was important that the activity was increased as there was a backlog of 2,000. The next key area of focus would be surgical pathways and the capacity. This would remain a particular area of focus for Becky Joyce. Antibody testing was introduced on 28 May 2020 and in less than two-weeks 17,000 antibody tests had been undertaken. Key protocols had been introduced the keep elective patients safe.


Activity in the Emergency Department had increased however it still remained 40% lower than this time last year, however some analysis had been undertaken on majors activity which was showing similar levels to this time last year and therefore the key reduction was in minors and paediatrics. David Purdue provided an update on nosocomial infections which are hospital acquired infections which presents the biggest challenge currently as research had shown that hospital workers are 20% more likely to contract Covid19. Guidance received regarding measures to implement included that all people must wear a face covering in a hospital setting, or a face mask in a clinical environment. The Trust implemented this on 10 June 2020, ahead of the mandatory date of 15 June 2020. Patients must wear a face covering when they come into the hospital and they will be provided with a face mask when they arrive at their appointment. All staff are to wear a face mask whilst at work, and if there was anyone that was unable to do so must have an individual risk assessment undertaken by their manager. This measure was key in the reduction of infection rates. There had been guidance posted on the intranet for staff to advise of how to apply/remove masks and guidance on eating and drinking. Any member of staff that tests positive for Covid19 need to inform on who they have come into contact with, and this includes anyone that they have had face to face contact with of less than one-meter for more than fifteen-minutes. These individuals will need to self-isolate for fourteen-days. There had been eight-members of staff that had to self-isolate since the Track and Trace had been implemented. It had been identified that this was as a result of staff removing their face masks whilst on breaks in their break rooms. Chairs had been removed from break rooms to ensure that staff were undertaking distancing measures whilst on breaks. Kath Smart advised that she had seen comments regarding the wearing of face masks and understands that this had impacted support staff that would not usually wear a mask. Kath asked if the Trust had enough masks to support the new guidance and what the general feedback was from staff that don’t usually have to wear a face mask as part of their role. David Purdue advised that the Trust received a delivery of 28,000 face masks respectively on Friday, Saturday and Monday and therefore the Trust had ample supply. General feedback hadn’t been as negative as anticipated, however it had been noted that those who were asthmatic had found them claustrophobic. Staff are not able to use desk fans or air-conditioning with these new measures and therefore it had been difficult in areas when it was hot.

The Board:

- Noted the information in the COVID-19 Update.

P20/06/D2 Quality and Performance Report (Enclosure D2)

Performance Rebecca Joyce presented the highlights of the report including:

- The Trust achieved 90.78% for 4-hour access in April against a national target of

95% and a local target of 90%, which demonstrated an improving picture, however

this was in the context of reduced attendance;


- The Trust achieved 82.2% RTT against a national target of 92% and a local target

of 80.1%;

- The Trust reported 10 x 52 week breaches, all of which were due to Covid19

related reasons;

- Cancer performance for March 2020 presented an overall good performance

picture with the 62-day target being reached.

Becky Joyce noted the changing performance picture and advised there would be a focus on governance, transformation and the reported metrics for going forward. Sheena McDonnell noted that the exception report was clear and direct, however asked that a section be added on patient experience because although complaints was featured within the report, this isn’t the only element of patient experience and asked that it be developed further to demonstrate the good things that are happening in relation to patients. Sheena McDonnell queried the one reported serious incident for May 2020 in relation to the number of reported falls. David Purdue confirmed that one fall was still under investigation. It was anticipated that it would be reportable as a serious incident however until the investigation was complete it couldn’t be reported as such. Once the investigation was complete, the report will be updated. David advised the Board that ‘Sharing How We Care’ would be changed to ‘Learning How We Care’ as it was important that the Trust changes the way that it works and incorporates learning from different issues. Jon Sargeant advised that as part of the Audit and Risk Committee, quality elements will be added to the dashboard and David Purdue’s team was supporting this. Quality and Safety Dr T J Noble advised the Board that in the future HSMR will look very different because of the Covid19 pandemic. The Charlson Index does not predict Covid19 mortality and the mortality models require three years’ worth of data to produce predictive models. The mortality data would need to be interpreted in a whole new way. Pat Drake advised that an update paragraph on nosocomial Covid19 infections be added to the Clinical Governance Report for the Quality and Effectiveness Committee. Pat Drake advised that going forward information on Stabilisation and Recovery around clinical governance and outcomes associated with QPIAs would be received Pat asked that when reporting hospital acquired pressure ulcers to the Quality and Effectiveness Committee. Pat Drake asked that further information be received on hospital acquired pressure ulcers at the Quality and Effectiveness Committee going forward. Kath Smart noted that the crude mortality spike had started to happen but there was no narrative in the report to support this in the public domain, and requested that it be added to future reports including the plans on how this would be measured in the future. Dr T J Noble confirmed that this would be received at the Quality and Effectiveness Committee in July 2020, followed by Board in September 2020. David Purdue advised the Board that visiting guidance would be reviewed in line with an ICS led approach to ensure there was consistency across the region. This would be done in


a safe manner. The visiting rules are different for those patients at the end of life or with dementia and is based on an individual assessment by the ward at any one time.

Action: The Quality and Performance Report would be developed to integrate and report upon the positive aspects of patient experience.

RJ/DP

Action: An update paragraph on nosocomial Covid19 infections be added to the Clinical Governance Report for the Quality and Effectiveness Committee.

TN

Action: Associated narrative would be added to the Quality and Performance Report in relation to HSMR for further guidance and clarification on what the graphs received show.

TN

The Board:

- Noted the Quality and Performance Report.

P20/06/E1 People and Organisational Development Covid19 Update (Enclosure E1)

Karen Barnard presented the People and Organisational Development Covid19 which highlighted: Recruitment The Bring Back Staff campaign had been disappointing for the Trust and across the ICS. The numbers that have been seen on a national level have not been translated locally. There would be a second phase of the scheme however this would be focused on supporting care homes and nursing homes. The Trust hopes to retain those staff that have worked at the Trust during the Covid19 pandemic from NHS Professionals. Health Education England would look into the return to practice scheme as it had been flagged that there was an improvement required within the ICS region. Third-year students on placement at the Trust had been successful and a positive experience for them. Many will be moving in to the newly-qualified positions in September. A key issue identified was that the Trust was not able to accommodate all of the Year-2 students that wished to undertake their placement at the Trust due to capacity. Redeployment Update There were still a number of staff in redeployed roles and key discussions were being undertaken to identify what activity could be stepped back up. Staff Testing Between 23 March 2020 and 8 June 2020, 1,935 DBTH staff have been swabbed for Covid19, 501 of which tested positive for Covid19 which amounts to around 20% of those that were swabbed.


The staff swabbing strategy would be revisited to align with that of the asymptomatic screening programme and antibody testing. A pilot was underway on Ward A4 where regular testing was taking place as a test to keep the area Covid19 free. As mentioned in the media and from Public Health England there were a number of risk factors associated with the severity of the illness such as ethnicity, gender and the range of co-morbidities an individual has. A risk assessment process was in place for staff with risk factors. Absence There had been a rise in Covid19 related Absence during April 2020 which included those staff that were shielding, self-isolating, carers and positive with Covid19. It was noted that there had been a reduction during May 2020 and that data would be received at the Finance and Performance Committee on 30 June 2020. A piece of work was being undertaken to ensure that there was a comprehensive record of all staff that are shielding and whether they are able to work from home. There are 97 staff that are unable to work from home so a review was being undertaken to identify what was preventing them from working from home and to explore how the Trust can engage with them. Further guidance from the Government was expected soon for what will happen in relation to shielding post June 2020. Health and Wellbeing The Quality and Effectiveness Committee received a detailed paper regarding the Trust’s approach to health and wellbeing in order to support our people. The Talk Listen Care service had been successful so far, as it was in its infancy pre-Covid19. Vivup was the platform where all wellbeing material was held along with the financial saving incentive scheme and there had been an increase in registrations on the system. There had been a rise in the usage of the employee assistance scheme. The appointments were taking place via telephone and not face-to-face. Information on the support available for managers in supporting their staff was published on The Hive and in Buzz this week which included coaching and mentoring programmes. Sheena McDonnell noted that the support for leaders was critical during these difficult times. The message reflects that the organisation’s approach was one of compassion and care, and reflects the values of how we should treat one another. Sheena McDonnell noted that there had been a huge interest in the antibody testing and equated nearly to the whole workforce at in excess of 6,000. Richard Parker advised that there had been a huge demand both across the South Yorkshire region and across the workforce. The initial results demonstrated approximately 7-8% tested positive for the Covid19 antibody, however it was noted that this was not guaranteed to offer those any more protection, and therefore all measures must still be maintained. The platform for antibody testing had increased


Kath Smart asked for assurance on the members of staff that were on the higher agenda for change pay grades and therefore not eligible for recompense for overtime worked, who were involved in the stepping down of services and would be heavily involved in the stepping up of activity and how this would be managed. Karen Barnard advised that within the terms and conditions, staff banded 8a and above were not entitled to an overtime rate, however advised that it had been agreed at the beginning of the pandemic that those staff graded Band 8a would receive additional hours, however it had been encouraged that staff take the time back that they have over-worked during the pandemic. Staff who were at grades Band 8b and above were encouraged to manage their time effectively to avoid working excessive hours. Any staff working weekends and bank holiday were entitled to enhancements and some departments had introduced 7-day working or on call systems. Kath Smart noted that it was positive that people were accessing the counselling services on offer and asked if the offer included specialist counselling in light of the pandemic that may have been a trigger for some clinicians and managers across the Trust. Karen Barnard advised that the provider had been changed at the end of 2019 and this now included access to a much improved psychological support system, which included onsite presence, although this had since been moved to telephone due to the pandemic.

The Board:

- Noted the information in the People and Organisational Development Covid19 Update

P20/06/F1 Finance Report – May 2020 (Enclosure F1)

Jon Sargeant, presented to the Board, the Finance Report for May 2020, highlighting: The Trust’s deficit for month 2 (May 2020) was £119k before the retrospective top up. However, in line with national guidance the Trust had accrued a central retrospective top up payment of £119k in order to report a break even financial position. It was expected that expenditure will start to increase in the following months as the Trust moves into the next phase of COVID response and activity starts to increase. It should also be noted that the Trust was yet to receive planning guidance for financial arrangements post July. Deloitte’s had been engaged by NHSI/E to audit all NHS Trusts Covid19 submissions to ensure that they have been appropriate and managed effectively. Feedback would be expected in July 2020, although a report would not be received by the Trust, only by NHSI/E. Jon Sargeant advised the Board that the Trust had a robust process in place to manage the Covid19 submission and spend. Capital expenditure spend in month 2 was £0.9m, including COVID‐19 capital spend of £0.3m. This was £0.4m ahead of plan, due to Estates (£0.1m ahead of plan), IT (£0.1m ahead of plan) and COVID‐19 (£0.1m ahead of plan). Year to date capital expenditure spend was £2.5m, including COVID‐19 capital spend of £1.4m. A revised capital plan submission to the ICS and NHSI/E had been made as set out to the Finance and Performance Committee. The ICS had not submitted the HSDU case as part of an agreed budget for the Trust, however it had requested that the Trust makes a phase 3 Covid19 capital bid for the funding. The Director of Finance had declined to note the scheme as an ICS priority until a full process had been undertaken to agree all priorities across the ICS. There was no clear


process to do this at the current time. The Trust had commissioned this work, however to ensure that the facility can be used in the event of a second wave of corona virus later in the year, and to provide resilience for the flu alongside Covid19 in the coming winter.

The Board:

- Noted the information in the Finance Report for May 2020.

P20/06/G1 Corporate Risk Register (Enclosure G1)

Fiona Dunn presented the Corporate Risk Register which demonstrated the heat map which shows the 31 risks that can be seen to impact on the Trust’s strategic aims of which 19 are logged separately on the Corporate Risk Register within the Datix. It was noted that risk ID1245 F&P5 Risk of failing to address the effects of medical agency gap had been downgraded and therefore removed from the Corporate Risk Register. The Covid19 pandemic had had an impact on the reviewing of the risk management process and existing risks that are on the Corporate Risk Register, and Fiona suggested that a focus now be taken on a full review in the light of the impact Covid19 had had on the current risks as some may no longer be relevant. A review would be undertaken to identify the strategic risks that link to the True North Objectives via a task and finish group made up of the responsible Executives for the risks. Neil Rhodes welcomed the new focus and the heat map, however asked that on the heat map there be an indicator of the risk as opposed to just the numerical reference, to avoid a cross reference to Appendix 1. Kath Smart noted the improvements in the Corporate Risk Register however added that further improvement was required. The Board and Committee would need to see the mitigated actions. Neil Rhodes welcomed this and added that mitigating risks relevant to a particular Committee should be received in more detail.

Action: A review of the Corporate Risk Register would be undertaken to identify the strategic risks that link to the True North Objectives via a task and finish group made up of the responsible Executives for the risks.

FD / EXECS

Action: A written indicator would be added to the numerical indicator on the heat map of the Corporate Risk Register to identify what each risk is, without having to cross reference to the full report (appendix 1).

FD

Action: The mitigation of risks relevant to each Committee would be received in further detail at the respective Committee’s.

FD

The Board:

- Noted the information in the Corporate Risk Register.

P20/05/G2 Chairs’ Assurance Logs for Board Committees (Enclosure G2)

Finance and Performance Committee – 26 May 2020 No questions were raised.


Quality and Effectiveness Committee – 26 May 2020 Pat Drake advised that a focus on patient and staff safety relating to Covid19 at the 28 July 2020. Audit and Risk Committee Year-End – 04 June 2020 No questions were raised.

The Board:

- Noted the update from the:

- Finance and Performance Committee on 28 April 2020

- Quality and Effectiveness Committee – 26 May 2020

- Audit and Risk Committee Year-End – 04 June 2020

P20/06/G3 Audit and Risk Committee Annual Report (Enclosure G3)

Kath Smart advised that the year-end meeting took place on 04 June 2020 which was focused on the annual accounts process. Kath Smart commended the Finance Team and Management Team for the positive outcome and read out the quote from Ernst Young: “no organisation who has got itself into such a pickle has got out of it in such a positive way”. The Board of Directors took this as a huge pat on the back for the work that the Finance and Management Team had undertaken to get to this point.

The Board:

- Was assured by the Audit and Risk Committee Annual Report

P20/06/G4 NHS Providers License Self-Assessment/Certification (Enclosure G4)

No questions were raised.

The Board:

- Approved the NHS Providers License Self-Assessment/Certification.

P20/06/H1-H8

Information Items (Enclosures H1 – H8)

The Board:

- Noted the minutes of the Finance and Performance Committee meeting held on 28 April 2020;

- Minutes of the Quality and Effectiveness Committee held on 28 January 2020;


- Minutes of the Audit and Risk Committee held on 23 March 2020;

- Minutes of the Management Board meeting held on 11 May 2020;

- Noted the Board work plan;

- Noted the Trust Annual Report 2019/20 including the Annual Governance

Statement;

Richard Parker advised that there was a legal requirement to produce an annual report and accounts however it had been undertaken in a less comprehensive way. The Quality Report was not complete however this would be added. The annual report demonstrates a summary of activities from the Trust during 2019/20, the financial performance of the trust and an indication of the Trust’s delivery and obligation to the public that it serves. It will be presented in full at the Annual Members Meeting on 24 September 2020. The External Audit Report received was positive and was mirrored by the Trust’s objectives. All four objectives for 2019/20 were achieved.

- Noted the Annual Accounts 2019/20;

Jon Sargeant thanked the Finance Team for the work they have put into the development of the Annual Accounts for 2019/20.

- Noted the ISA 260.

Jon Sargeant informed the Board that the ISA260 was a formal document from the Auditors that sets out the responsibilities in the audit and describes the process in identifying risks and how they assess them for assurance. Kath Smart added that the Quality Accounts would usually have been audited however there was no legal requirement to audit them and a revised timetable had been agreed for the production of them. The Quality Accounts would be received at the Annual Members’ Meeting on 24 September 2020 and by the Board of Directors by August 2020.

P20/06/I1 Minutes of the Meeting held on 21 April 2020 (Enclosure I1)

The Board:

- Received and Approved the Minutes of the Public Meeting held on 19 May 2020.

P20/06/I2 Any Other Business (Verbal)

Freedom to Speak Up Update Sheena McDonnell advised the Board that the National Guardian’s Office had released a report on the findings from a review of the Whittington Health NHS Trust, which outlined a series of recommendations that all Trusts must adhere to. A number of these practices are already undertaken by the Trust but there are others that will be worked through by Paula Hill. Sheena McDonnell noted that she would be the Non-Executive Director Freedom to Speak Up Champion. Karen Barnard advised that during Covid19 eleven concerns had been raised, four of which were received from more than one person. These will be added to the next Freedom to Speak Up Report received at Board.


P20/06/I3 Governor Questions Regarding the Business of the Meeting (Verbal)

P20/06/I3(i) Hazel Brand Hazel Brand expressed her thanks on behalf of the Governors for the ongoing hard work and dedication across all disciplines through the challenging times. Hazel Brand thanked David Cuckson for his nine-year service as a Public Governor for the Rest of England and Wales; and also noted the thanks for other Governors that were at the end of their term of office, Lorraine Robinson, Staff Governor, Duncan Carratt, Staff Governor, Karl Bower, Staff Governor, Lynne Logan, Public Governor, Peter Abell, Public Governor, Mark Bright, Public Governor and Sheila Walsh, Public Governor. Hazel Brand advised that she had contacted Governors prior to the Board meeting to collate any specific questions or comments relating to the Board Papers to raise at the meeting on their behalf. Hazel had one question in total. Question: With reference to the Integrated Quality & Performance Report, which asks Is the Trust providing a quality service for the patients? and the COVID-19 update… If an operation has been delayed due to the current crisis, how does the patient get advice if they feel that their problem has worsened? Should, as a matter of course, the Trust be giving advice and updates to people whose procedures have been delayed? Richard Parker advised that when a patient is listed for a procedure, it doesn’t detract from the primary care support to admission or pre-operative assessment, and therefore if the condition changes or worsened, the first port of call for a patient would be their primary care physician. All services remain as normal. The Trust does not offer advice or guidance on the procedures that have been delayed. Dr T J Noble added that patients do frequently contact the Consultant Secretaries and advice is always given if asked for.

The Board:

- Noted the comments raised, and information provided in response.

P20/06/I4 Date and Time of Next meeting (Verbal) Date: Tuesday 21 July 2020 Time: TBC Venue: Star Leaf Videoconferencing

The Board:

- Noted the date of the next meeting.

P20/06/I5 Withdrawal of Press and Public (Verbal)

The Board:

- Resolved that representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest.


P20/06/J

Close of meeting (Verbal)

The meeting closed at 12:10.

Suzy Brain England Date Chair of the Board 06 July 2020