Board papers February 2016

Surrey and Sussex Healthcare NHS Trust

Board papers

February 2016

Trust Board Meeting – IN PUBLIC

Thursday 25th February 2016 - 11:30 to 13:30

AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA

1

11:30

GENERAL BUSINESS 1.1 Welcome and apologies for absence 1.2 Declarations of Interests 1.3 Minutes of the last meeting held on 28th January 2016 - For approval 1.4 Action tracker 1.5 Chairman’s Report

For assurance

1.6 Chief Executive’s Report For assurance

1.7 Board Assurance Framework & Significant Risk Register – For approval & assurance

A McCarthy A McCarthy A McCarthy A McCarthy A McCarthy M Wilson G Francis- Musanu

Verbal

Verbal

Paper

Paper

Verbal

Paper

Paper

2

11.50

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1 Patients Story For assurance 2.2 Chief Nurse & Medical Director’s Report

For assurance

2.3 Safety & Quality Committee Update For assurance

F Allsop D Holden/ F Allsop R Shaw

Paper

Paper

Paper

3

12:20

OPERATIONAL PERFORMANCE 3.1 Integrated Performance Report (M10)

For assurance

3.1.1 Operational & Quality Key Performance Indicators

3.1.2 Workforce Key Performance Indicators 3.1.3 Finance Key Performance Indicators

3.2 Finance & Workforce Committee Update For assurance

A Stevenson D Holden/ F Allsop F Allsop P Simpson R Durban

Paper

Paper

4

13:05

RISK, REGULATORY AND STRATEGY ITEMS 4.1 Standards of Business Conduct Policy For approval 4.2 Update from the Shadow Council of Governors For assurance 4.3 Sash Plus Update For assurance

G Francis-Musanu G Francis- Musanu M Wilson

Paper

Paper

Paper

5

13:25

OTHER ITEMS 5.1 Minutes from Board Committees

to receive & note 5.1.1 Finance and Workforce Committee

5.1.2 Safety & Quality Committee

5.2 ANY OTHER BUSINESS 5.3 QUESTIONS FROM THE PUBLIC

Questions from members of the public may be submitted to the Chairman in advance of the meeting by emailing them to: [email protected]

5.4 DATE OF NEXT MEETING

31st March 2016 at 11.00am

All A McCarthy A McCarthy

mailto:[email protected]

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Minutes of Trust Board meeting held in Public Thursday 28th January 2016 from 11:00 to 13:30

Room AD77, Trust Headquarters, East Surrey Hospital

Present

(AM) Alan McCarthy (MW) Michael Wilson

Chairman Chief Executive

(PS) Paul Simpson Chief Finance Officer / Deputy Chief Executive (DH) Des Holden (FA) Fiona Allsop

Medical Director Chief Nurse

(AS) Angela Stevenson Chief Operating Officer (PB) Paul Biddle Non-Executive Director (RD) Richard Durban Non-Executive Director (AH) Alan Hall Non-Executive Director (RS) Richard Shaw Non-Executive Director In Attendance

(GFM) Gillian Francis-Musanu (SJ) Sue Jenkins (AA) Azhar Ansari (CP) Colin Pink

Director of Corporate Affairs Director of Strategy (agenda item 4.4) Consultant Gastroenterologist (agenda item 2.1) Head of Corporate Governance (Notes)

1. General Business

1.1 Welcome and Apologies for absence The Chairman opened the meeting by welcoming Trust Board members, members of the public, shadow governors and staff. The Chairman also extended a special welcome to Mark Preston, the new Director of Organisational Development and People. Apologies for absence were noted from Pauline Lambert.

1.2 Declarations of Interest No declarations of interest where declared.

1.3 Minutes of the last meeting – 17th December 2015 The minutes of the meeting held on 17th December where discussed and approved as a true and accurate record.

1.4 1.4.1

Action Tracker GFM updated the Board on the following actions: TBU-01 is not due until 31.03.16 TBU-02 is not due until 31.03.16 TBU-03 Update annual plan is complete on the agenda for discussion TBU-04 Update finance BAF risks is complete on the agenda for discussion TBU-05 FA provided a verbal update. The SASH+ guiding team had considered the possibility of adopting and transitioning the 15 Step Challenge. There was agreement that this would be an effective use of time and there is value in both

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observing the working environment before and after changes have been made. TBU-06 is not due until 31.03.16 TBU-07 is not due until 28.02.16 There were no other matters arising.

1.5

Chairman’s Report for Assurance The Chairman thanked all those involved in the opening of the new East Surrey Macmillan Cancer Support Centre on the 27 January. It is a fabulous facility for our patients and growing development of the Trust’s network of partner organisations. It is also good to see that in such challenging times that the project was delivered on time and on budget. The Chairman went on to discuss the completion of the Integrated Reablement Unit (IRU) which had been opened to patients earlier in the week. The Unit has not yet been opened formally but the Trust has kindly been allowed to use the bed capacity and some 19 patients are already under our care within the unit. This short term extra bed capacity will be of significant benefit to the Trust. The Board duly noted the report.

1.6

Chief Executives report for Assurance The Board received and noted the Chief Executive’s report in advance of the meeting. MW introduced the report highlighting some key issues including Lord Priors visit to the Trust, he had met clinical teams and visited frontline services including the Emergency Department. The visit had been very positive. The Trust has been in period of black escalation and had initiated its internal business continuity processes. It is important to note this this reflects the whole system; GP, community providers and social care. MW commented on the IRU stating that it was an exciting development for Surrey and would see improvements in pathways for patients who are medically ready for discharge transitioning into primary care. It’s important to remember that this unit is not an enlarged discharge unit and that other discharge pathways will remain. The criteria for transfer to the unit will be key to its success. The junior doctor strike is still planned for the 10th February. It is expected that this strike will go ahead and the Trust has learnt from recent cancellation of industrial action and will put in mitigation to reduce the impact. The Board duly noted and took assurance from the report.

1.7 Board Assurance Framework (BAF) and Significant Risk Register (SRR) for Approval and Assurance GFM introduced the board assurance framework and significant risk register. The BAF detailed 13 risks to the trusts strategic objectives which had been updated by the Executive team through January. It was proposed that the BAF risk ‘5.2 Failure to stop divisional overspending

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against budget’ is reduced to reflect revised forecast as expenditure is on track. The Board discussed the proposal and agreed to keep the risk at 15. The significant risk register lists 10 operational risks which were duly noted. The Board duly approved and took assurance from the report.

2. Safety, Quality and Patient Experience 2.1 Clinical Presentation – for Assurance

DH introduced Dr Ansari (AA), Consultant Gastroenterologist who gave a presentation on the innovative chronic bowel disease service that he had been piloting. This is an exciting pilot and may well be adopted by other chronic illnesses such as diabetes. AA introduced his supporting team including Mr Campbell-Smith and the senior nursing team including Branita Mills. Chronic bowel disease effects a significant proportion of the Trust’s patient demographic as such AA has developed a new patient centred pathway with East Surrey CCG. The service improves access to specialist advice, empowers patients to self-manage, reduces flare ups, complication rates and outpatient appointments. There has been significant impact on numbers of appointments and reduced the need for surgical intervention. The pathway enables direct patient contact with consultant physicians and their teams and allows for greater speed of assessing symptoms and monitoring condition, by reducing the need for face to face consultations. The model has been developing over 6 years during which time the number of patients has increased with minimal impact on the service and there is significant patient demand for the model. Recently the team had started to pilot an App developed by Johnson and Johnson. This provides more information and opportunities for contact between consultant and patient. DH stated that the local Academic Health Science Network (AHSN) had agreed to buy time to explore how this could impact on other long term chronic conditions. AM asked why it was only Surrey patients, AA confirmed that although the lead for development had been Surrey CCG the service was offered to all appropriate patients. MW highlighted that it was a very promising model but reminded the Board that we need to ensure its appropriately funded. PS and AA confirmed that the tariff for phone consultations was been applied but this is not a true alignment of the level of care been provided. Mr Tim Campbell-Smith confirmed that there had been a reduction in complications of surgery particularly colitis. AM thanked AA and the MDT for the presentation stating that the potential improvements for outcomes for patients was very welcome. The Board noted and took assurance from the report.

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2.2

Chief Nurse and Medical Director’s Report for Assurance The Board received and noted the report in advance of the meeting. FA presented the Chief Nurse’s report highlighting that the first 11 nurses form the Philippines had commenced work, the Trust had developed its methodology for reporting establishment and would commence new agency reporting regime in April. Revalidation would commence in April and the corporate team had good assurance over systems to support the Trust’s first 90 nurses. The ward accreditation CQUIN pilot is very positive and it is expected that the process will develop and strengthen throughout. AH asked for assurance on the Trust’s ‘glide path’ to meet the new agency cap. FA state that there was risk to delivery of the 12% agency target at the end of March; the Trust is currently running at 20% and moving in the right direction. Going on to highlight that recruitment drives often have double running cost as new staff need to be supported. RS asked what the impact of revalidation could be for the Trust. FA confirmed the process and evidence requirement, highlighting that this was a formalisation of elements of continuous professional development which are already in place. FA went on to highlight that should a nurse fail to meet the expectation of revalidation they would only be able to work at Band 2 level until requirements had been met. DH presented the Medical Directors report commenting on the appointment of a new clinical lead for imaging who has links with the AHSN and a strong informatics background. This is a very positive appointment for the Trust. The Trust had been in negotiation with the University of Surrey and had agreed the funding for 6 academic posts (2 Professors, 2 Lectures and 2 Students) which is a very exciting development for the Trust and will look at new models of care in alignment with the 5 year forward view. The AHSN is negotiating with the Trust to develop models for testing industry innovation across Kent, Surrey and Sussex. MW has been appointed as chair of the steering group which will look to run industry pilots across the local health economy. The Board duly noted and took assurance from the report.

3.

Operational Performance

3.1 3.1.1

Integrated Performance Report (M09) for Assurance The Board received and noted the report in advance of the meeting. Operational & Quality Key Performance Indicators AS spoke to the access elements of the report, highlighting ED performance, continuing challenges with ambulance handover which is improving and efforts to reduce outliers and get patients in to the right bed first time. The Trust had achieved 62 week and 2 week cancer access targets but not met the 31 day diagnosis target, related to a short-term issue in dermatology. RTT remains very challenging with increased patient cancellation rates before Christmas impacting on surgical lists.

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3.1.2 3.1.3

RS asked for assurance on actions to mitigate against ambulance handover issues. AS stated that following review the capacity to open 4 extra assessment areas had been developed. This is to be used at times of peak demand and is proving successful it does however require that nursing staff move swiftly between models of assessment and is embedding. The Board discussed increases in non-elective admissions noting specific increases in emergency attendances form Crawley and Horsham. MW stated that the Trust was in regular conversation with the local CCGs noting that there had been an observed reduction in use of out of hours 111 calls, and foot fall at minor injuries units which correlated with non-elective attendances. MW went on to reflect that with the recent announcement that a proportion of NHS pharmacies could be closing indicated that the situation would only become more challenging. DH highlighted that the Trust’s mortality indicators continued to provide good assurance, going on to note that in the last published data the Trust had been not seen the reduction in mortality indicators which had been achieved by a handful of similar organisations. The Trust declared 6 cases of C. difficile in December and the number of Trust apportioned cases is higher than last year’s overall numbers. The Board noted that of the cases reviewed by the CCG only 2 had identified lapses of care against a ceiling target of 15 cases. The Trust had also not identified any cases of cross infection, based on results of laboratory tests. FA discussed the recent cluster of serious incidents linked to falls with harm. The Trust was providing support and education to the teams involved. Overall patient experience remains positive but there are ongoing issues in elements of Friends and Family Test. Workforce Key Performance Indicators FA presented the workforce elements of the report highlighting improvements in sickness absence, achievement review and staff turnover rates. The Board noted that 60 international nurses had joined the Trust since August and that the overall picture was improving. The Finance and Workforce Committee had reviewed theses KPI in detailed and noted wide variation in completion of achievement reviews, the Medicine Division had achieved circa 90% compliance. Finance Key Performance Indicators PS introduced the financial elements of the report. The Trust is £5.3 million pounds in deficit at the end of Month 9 which is £4.0 million adverse to the revised TDA plan. This is assuming an accrual of £0.4 million relating to reimbursement from the TDA following the Junior Doctors industrial action in December. Agency costs reduced in month but are still high. The Women and Children’s division and Estates are adverse to their financial plan. The Trust base forecast is now a £3.0 million deficit which has been acknowledged by the TDA. This includes £3.0 million non-recurrent funding from a capital to revenue transfer and assumed funding in respect of the lost income from the junior doctors strike. The TDA have been advised that lack of funding will mean the forecast deficit will worsen to £4.2 million to reflect the impact of 3 days cancelled activity from the Junior Doctor’s dispute.

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There remains risk to income, mainly emergency activity, activity impact of junior doctor’s industrial action and end of year penalties from the CCG. The Board noted that the TDA had reduced the delegated limit for capital schemes from £5.0 million to £1.0 million. PS noted that the metrics from Lord Carter’s review of efficiency indicated that the Trust was the 2nd most efficient hospital in England. The Board duly noted and took assurance from the report.

3.2 Finance & Workforce Committee Chair Update – for Assurance

The Board received and noted the report in advance of the meeting. RD presented the report. The FWC had reviewed and agreed with the financial report received as part of the IPR 3.1.3. It had considered the draft 2016/17 revenue budget and agreed the addendum and final payments of the power network capital project. RD went on to highlight review of workforce issues seeking assurance on delivery of achievement reviews and training provision. The FWC took assurance from the successful upgrade of Cerner. The Board noted that the Trust had delivered £3.2 million of its savings. The Board duly noted and took assurance from the report.

3.3 Audit & Assurance Committee Update– for Assurance The Board received and noted the report in advance of the meeting. PB introduced the report. The Committee had discussed financial risk and issues in detail and considered plans to apply for a £9.6 million loan. The Trust’s Standards of Business Conduct had been reviewed and agreed in principal for Board ratification in February. Management confirmed that RSM had successfully been appointed following tendering to provide internal audit and counter fraud services. It is anticipated that closer working will be beneficial for the Trust. PB highlighted that the Committee had adopted the three lines of defense model of assurance as best practice and will start to seek and identify all levels of assurance. The Board duly took assurance and approved the report.

4. Risk, Regulatory and Strategy Items

4.1 Review of Quality Impact Assessments for 2015/16 - for Assurance The Board received and noted the report in advance of the meeting. DH introduced the paper which looked to review the quality impact of Trust’s CIP

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program. Each CIP had been reviewed to form a judgment of degree of delivery versus impact. DH stated that no adverse impact on quality had been identified and went on to highlight that in the case of the high risk drug CIP the delivery had been faultless which had delivered a saving and increased quality benefits to patients. The Trust continues to learn from its implementation of CIPs, clinical engagement was proving to be the key to success of plans. RD asked for assurance that all lessons are being learnt and there is greater assurance on feasibility of 2016/17 plans. PS assured the Board that the Trust had learnt valuable lessons throughout 2015/16. The Board duly took assurance from the report.

4.2 Emergency Preparedness Resilience Plan – for Approval The Board received and noted the report in advance of the meeting. AS provided the annual assurance report to the Board. Governance processes had strengthened and known issues are being resolves this includes elements of training and strengthening telecoms resistance. The Board discussed and approved the report and took assurance that appropriate systems are in place and mitigating actions are achievable and realistic.

4.2.a NHS England Major Incident Assurance Return – for Approval

The Board received and noted the report in advance of the meeting. AS introduced the assurance return, which detailed the Trust’s assessment of its preparedness to a specific set of questions for a major incident. The assessment detailed issues that the Trust was still resolving with local partners. The main issues of note are the development of plans to support reduction of public transport services and provide specialist training/briefing for the management of ballistic injuries. The Board duly approved and took assurance from the report.

4.3 NHS Planning Guidance 2016/17 – 2020/21 - for Assurance The Board received and noted the report in advance of the meeting. MW introduced the which details the requirements for the Trust prepare plans to support a local health and care system ‘Sustainability and Transformation Plan’, and reflect the national plan. In order to start to flesh out the details the Trust needs to first review detail of national contract and tariff plans. The report details all national and local health economy priorities that need to be considered and the Trust’s initial issues to address. The Board duly noted the report.

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4.4 Annual Plan Update – Q3 - for Assurance The Board received and noted the report in advance of the meeting. SJ introduced the quarterly update highlighting that actions relating to enhanced recovery programs for C-section had been achieved. In total 78 actions had been completed and there was expectation that the majority of actions would be delivered by the end of March 2016. The Board noted that there were 2 actions recorded as red, reduction in non elective demand and HCAI. Both issues are well known to the Board as are actions to militate against impact of growing non elective demand. DH indicated that once all necessary reviews are complete the HCAI action plan delivery may well be moved to amber. The Board duly took assurance from the report.

Other Items

5.1 Minutes of Board Committees to receive and note

5.1.1 Finance and Workforce to receive and note The minutes of the Committee were noted with no questions raised.

5.1.2 Audit and Assurance The minutes of the Committee were noted with no questions raised.

5.2 Any Other Business No AOB was raised.

5.3

Questions from the Public There were no questions raised.

5.4 Date of the next meeting Thursday 25th February 2016 at 11.30am in Room AD77, Trust Headquarters, East Surrey Hospital

Note: This is a public document and therefore will be placed into the public domain via the Trust’s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation. These minutes were approved as a true and accurate record. Alan McCarthy Chairman: Date:

TRUST BOARD ACTION TRACKER - PUBLIC BOARD MEETING

Action Ref Forum Subject Action RO Date Open Date Due Date Closed Status

TBPU-01 TB Public Patient story

The Board requested that Dr J Webb update the Board on findings and actions of the sample group. Dr Zara Nadim will now be undertaking this work. ZN/DH 28/08/2015 31/03/2016 Not Due

TBPU-02 TB Public Patient story

The Board asked for feedback on the outcome of the retrospective audit to ensure that patients have received the correct follow up. SI action to be considered by the Effectiveness Committee. FA 26/10/2015 31/03/2016 Not Due

TBPU-03 TB PublicCost Improvement Programme

Provide a report on nurse recruitment and agency use including the recruitment vs saving calculation went to the FWC. FA 17/12/2015 31/03/2016 Not Due

TBPU-04 TB Public SaSH + (VMI Update) The Board agreed that they would like to have early sight of the Trust’s Clinical Compact with its staff. SJ 17/12/2015 29/02/2016

On the agneda to close

ACTIONS FROM PUBLIC BOARD MEETINGs - December 2015

TRUST BOARD IN PUBLIC

Date: 25th February 2016 Agenda Item: 1.6

REPORT TITLE: CHIEF EXECUTIVE’S REPORT

EXECUTIVE SPONSOR: Michael Wilson Chief Executive

REPORT AUTHOR (s): Gillian Francis-Musanu Director of Corporate Affairs

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) N/A

Action Required:

Approval ( ) Discussion (√) Assurance (√)

Purpose of Report: To ensure the Board are aware of current and new requirements from a national and local perspective and to discuss any impact on the Trusts strategic direction. Summary of key issues National: • Implementing the Forward View: Supporting Providers to Deliver • 2015 National Staff Survey Results

Local: • Visit of local MP • Health Education England Film Crew

Recommendation:

The Board is asked to note the report and consider any impacts on the trusts strategic direction.

Relationship to Trust Strategic Objectives & Assurance Framework:

SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment:

Legal and regulatory impact Ensures the Board are aware of current and new requirements.

Financial impact N/A

Patient Experience/Engagement Highlights national requirements in place to improve patient experience.

Risk & Performance Management Identifies possible future strategic risks which the Board should consider

NHS Constitution/Equality & Diversity/Communication

Includes where relevant an update on the NHS Constitution and compliance with Equality Legislation

Attachment: N/A

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TRUST BOARD REPORT – 25th February 2016 CHIEF EXECUTIVE’S REPORT 1. National Issues 1.1 Implementing the Forward View: Supporting Providers to Deliver On 11th February 2016, NHS Improvement launched a report setting out the task and clear expectations of what needs to be delivered by NHS provider organisations. It brings together all the key requirements of the Forward View into one document, for the first time, while providing links to the detail. It also shows how NHS Improvement and arm’s length bodies will provide support. The report also highlights the key priorities for NHS provider organisations in delivering high quality health and care this year and beyond. The report is part of a series of planned roadmaps that draw on messages from the NHS shared planning guidance, and set out the key priorities for the organisations responsible for delivering high quality health and care this year and beyond. Each roadmap reflects a shared vision for the health and care sector as set out in the Five Year Forward View about the challenges ahead, and the choices faced about the kind of health and care service we want and need in 2020. The report: • outlines the challenges and changes ahead • describes a coherent set of activities for NHS providers in the coming years • shows how providers across the country are beginning to deliver these • outlines the support providers can expect from NHS Improvement In summary report notes the challenge facing providers to 2020 is to deliver patient care of outstanding quality, regain NHS Constitution access standards, return to financial balance and eliminate unwarranted variation across all these areas, while at the same time making the transformation needed to ensure long-term sustainability. Getting the ‘quality, access, finance’ triangle right while transforming care adds up to an ambitious and stretching task. Provider boards will need clear strategies for achieving it, using the local Sustainability and Transformation Planning process to plan elements needing action across local health systems. Providers will also need to develop a new partnership with patients and their families. Quality: The vision for 2020 is that the vast majority of NHS providers will have an ‘Outstanding’ or ‘Good’ CQC rating and no trusts will be in special measures. At the same time, all providers will have to make improvements specified by national taskforces in the priority areas of cancer, mental health, maternity, dementia, and urgent and emergency care. They will also have made significant progress in eliminating unwarranted variation in clinical performance. Patient safety will have to consistently improve and all providers will be required to deliver seven-day services in line with the priority clinical standards. Access: The vision is that by 2020 all NHS providers will be delivering the agreed NHS Constitution access standards for urgent and emergency care, elective care and cancer care, and be meeting the new access standards for mental health services. Providers’ recovery plans will need to include measures such as better demand and capacity planning, better use of better quality data, better operational management within providers and across local systems, and improved referral management, responding to patient choice.

https://www.gov.uk/guidance/delivering-the-forward-view-nhs-planning-guidance-for-201617-to-202021

https://www.england.nhs.uk/ourwork/futurenhs/

https://www.england.nhs.uk/ourwork/futurenhs/

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Finance: The vision for 2020 is that all NHS providers will have balanced their books and released significant efficiency savings, maximising value for patients and improving the quality of care. Fortunately, quality and efficiency are two sides of the same coin in healthcare. To start with, providers will need to achieve the best possible outturn position in 2015/16 and develop a plan for 2016/17 based on agreed control totals. Providers are expected to become less reliant on temporary staff by sticking to recent guidance on agency staff controls. Acute trusts will need to plan to achieve the savings of up to 10% of their expenditure identified in Lord Carter’s recent report. All providers may need to take action to release the value in surplus NHS estate: for example, by co-locating primary and secondary care where possible. Transformation for sustainability: The vision for 2020 is of providers joining up with other organisations to transform services in ways that best meet the needs of their local population. Providers will drive a shift of emphasis in NHS financial, regulatory and performance management processes from individual organisation performance to the performance of whole local health and care systems, recognising that the success of individual organisations remains important. NHS Improvement and NHS England will support this shift by increasingly engaging jointly with local health and care economies, encouraging joint planning and collaboration across boundaries. All local health and care systems will need clear plans to move to new care models – such as the five the sector is currently testing – and to reconfigure services where required. Providers will play a big part in developing these plans, and a more prominent role in prevention, early intervention and improving life expectancy. As a Trust we will review the key requirements and ensure these are incorporated into our plans and strategic direction. A full copy of the report is available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499664/Summary_provider_roadmap_11feb.pdf 1.2 2015 National Staff Survey Results We have received the headline results from the 2015 National Staff Survey. Our response rate this year was 62% which is an improvement on the previous year (56 %). We have continued to increase our staff engagement score year on year for the past five years and both our response rate and staff engagement scores are in the top 20% nationally for 2015. The Survey is based on 32 Key Findings – of these we are placed in the top 20% nationally for 17. This is a positive and fantastic achievement and shows how we continue to develop as an organisation. Among our top scores staff told us that they:

• would recommend the Trust as a place to work and or receive treatment; • are satisfied with the quality of work and patient care that we deliver; • are motivated at work; • are recognised and valued by colleagues and managers; • recognise good team working • are satisfied with the resourcing and support they receive • feel confident in reporting unsafe clinical practice

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499664/Summary_provider_roadmap_11feb.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499664/Summary_provider_roadmap_11feb.pdf

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• recognise the effective use of patient and user feedback. • feel that management were interested in their health and well-being

The results also show that issues of work related stress at SaSH were lower than the national average. These are all indicators we are proud of, however we recognise there are other areas we need to focus on to ensure a positive experience for all staff. These include managing violent or abusive interactions with patients, parents and visitors and staff confidence in reporting such issues. Whilst the quality of appraisals scored in the top 20% nationally, the quantity was in the lowest quartile and we need to ensure that all staff have undertaken an appraisal in line with the Achievement Review schedule which is commencing in April. We will now undertake more detailed analysis of the results and develop action plans to deal with issues you have raised and present a more detailed report to the Board in the next couple of months.

2. Local Issues

2.1 Visit of Local MP On Friday 5th February East Surrey MP Sam Gyimah came to see our new expanded and improved Surrey and Sussex Heart Centre and our cancer support centre. Sam was impressed to see our growing health campus and the increasing number of facilities and support we can offer to people closer to home. 2.2 Health Education England Film Crew We recently had a film crew from Health Education England at the Trust who interviewed one of our physician associates, Moni Choudhury. HEE are producing a series of short films to highlight the variety of health roles across the country and SASH is great example of a trust using physician associates (PAs). Our 12 PAs are invaluable in helping us to support clinical staff and enhance patient care. More details will be available once the videos are published.

3. Recommendation

The Board is asked to note the report and consider any impacts on the trusts strategic direction.

Michael Wilson Chief Executive 25th February 2016

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Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers Priority ID and reference 1.A Consistently meet national

patient safety standards in all specialties and across divisions

Director responsible Chief Nurse

Initial Risk S4 x L3 = 12 Key Action for 2015/16 objectives and description of any potential significant risk to this priority

1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties.

Current rating S4 x L2 = 8

Target risk score

S4 x L1 = 4

Linked to Risk 1009,1055

Controls in place (to manage the risk) Gaps in Control 1. Clinical teams in place to implement patient safety plans in the Trust (falls,

pressure ulcers and infection control) 2. Regular review of patient safety data including the Safety Thermometer at

divisional, executive and board level 3. Groups/Committee established including SQC, ECQR and its subcommittees,

N & M and Divisional Governance 4. Policies, procedures and guidelines provide the framework by which risks and

incidents are managed. 5. Work undertaken to deliver ‘5 sign up to safety pledges’ (Monitoring patients for

early signs of deterioration, Pain management for Dementia, Duty of Candor, COPD EQ pilot and improve shared learning from incidents)

6. Matron on site 7 days a week to monitor nursing patient care and staffing 7. Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) 8. Nursing staffing levels monitored daily and issues managed 9. Incident reporting policy in place and monitored 10. Ward safety boards updated regularly and ward performance discussed at

divisional level 11. Serious incident review group established to monitor and evaluate investigation

progress and progress against actions 12. Training undertaken for clinical staff in the assessment and management of

patients at risk of falls 13. Patient falls strategic group meet monthly and report KPIs to the patient safety

committee.

14. System developed to split Trust and Community acquired VTE events which are reviewed at Clinical Effectiveness, Patient Safety and ECQR.

1) Developing ward safety dashboards 2) Ward accreditation system under development as part of 15/16 CQUIN 3) Updating and planning RCA analysis training for new managers/leaders 4) Embedding DATIX incident review process within 14 day timeframe

Potential Sources of Assurance (documented evidence of controls effectiveness)

Actual Assurances: Positive (+) or Negative (-)

1) External reports and visits to clinical areas both scheduled and unscheduled (e.g. 15 step challenge)

2) Ward Dashboards 3) Divisional and Trust Level Dashboards 4) VMI/SASH Plus Program

Positive (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST audit (+) QGAF assessment and action plan (+) New EWS trialed and audited (+) Meeting minutes and action plans, evidence of presentations and board discussion (+) Patient safety related KPI agreed and monitored at Board and Divisional Level (+) Datix incident reporting and analysis including increase in reporting (+) Monthly trust wide reporting using national benchmarking (+) Falls Training data (+) Annual Falls Report 14/15

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(+) Clinical Nurse Consultant for Falls and Patient Safety commenced 4 December 2014 (+) 15 Steps quality program (+) Annual Falls report 2013/14 reduction in falls with harm in year (+) Resource focus on patient safety and falls (+) Strong evidence of improved SI investigation management and closures

(+) Improved reporting of patient falls has enabled the Trust to understand fall profile and identify gaps in the falls management strategies available (+) Established links with falls team within community Negative (-) Never events incidence (-) NRLS reporting

Gaps in assurance Assurance Level gained: RAG Ability to benchmark in real time

Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1) VMI/SASH plus development program 2) 5 work streams identified in Trusts sign up to Safety Pledges (Monitoring patients for early signs of deterioration, Pain management for Dementia, Duty of Candor, COPD EQ pilot and improve shared learning from incidents)

1) Ongoing 2) Ongoing action plan

Update by FA 10/02/16

Date discussed at board To be discussed at February Board

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Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers Priority ID and reference 1.A.1 Consistently meet national

patient safety standards in all specialties and across divisions

Director responsible Medical Director

Initial Risk S3 x L4 = 12

Key Action for 2015/16 objectives and description of any potential significant risk to this priority

1.2 Failure to maintain systems to control rates of HCAI will affect patient safety and quality of care


Target risk score S3 x L3 = 9

Linked to Risk 1049, 1050, 1401, 1514

Controls in place (to manage the risk) Gaps in Control

1)IPCAS Team and Group in place, Weekly taskforce in place 2)Infection control manual in place and information resources available 3)Antibiotic policy and guidelines in place 4)Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues. 5)MicroApp implemented for antimicrobial stewardship guidelines 6)Consultant led RCA and presentation of HCAI (MRSA, MSSA, C. diff). All cases C. diff joint review by CCGs and Trust. 7) Discussion group being setup to discuss any lapses of care in C. diff cases. 8) Prevalence studies and Enhanced surveillance of catheter-associated UTI part of annual programme. 9) 3 ICE-POD units in place – ED, HDU and Hazelwood. 10) Developed a system where site team and matrons during the weekend are responsible in checking wards that have received positive results (See 4 above) 11)Focus on risk and mitigation of VHF involving ED/Micro/ITU/PHE 12)Antibiotic Stewardship group revitalized 13)Decontamination group informing development of strategy for IPCAS 14)Policy on screening appropriate patients from abroad for CP Enterococci.

1)Risk assessment of patients with diarrhoea is not consistent, in particular on admission and at first onset 2)Variation in line care demonstrated by audit 3)High bed occupancy can cause infection control risk to increase (e.g. side room availability)



1)KPI indicators 2)Reducing numbers of cases of C. diff year on year 3)Divisional and departmental governance meeting minutes 4)Output of CCG and Trust meetings regarding lapses of care in C. diff cases

Positive (+)Antimicrobial prescribing audit compliance (+)Actions taken as part of annual program (updated July 2015) (+)1

st TDA visit inspecting controls and procedures

(+)2nd

TDA visit comparison with other Trusts and brokered meeting with CCGs (+)PHE and NHSE walkthrough ED for VHF risk provides good assurance (+)Management of diarrhoea agreed as one of first ‘VMI Value Streams’ (+)Initiation of ‘Stop, Access, Send’ initiative for the management of Negative (-)Incidence of CDI 2015/16

Gaps in assurance Assurance Level gained: RAG

Extensive auditing and monitoring in place. Trust position known

Page 5


1) Roll out of Urinary catheter Passport 2) Full list of actions in IPCAS Annual Programme of work (2015/16) 3) Ongoing discussion with commissioners about penalties applying only to cases with poor/inadequate care. This conversation is nationally mandated 4) Considering implementation of two low risk C. diff Antibiotics (Fidaxomicin and Chloramphenicol IV)

1) Embedding 2) 2015/16 3) Ongoing 4) Under review

Update by DH 22/01/16

Date discussed at Board To be discussed at February Board

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Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy Priority ID and reference 2.A Achieve the best possible

clinical outcomes for our patients Director responsible Medical Director


2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties


Target risk score

S3 x L1 = 3

Linked to Risk 1460


1) Safety thermometer data is reviewed by wards and specialties at regular meetings 2) HSMR/SHMI/Datix incidents are reviewed at divisional and trust level 3) Groups/committees established including SQC, ECQR, Effectiveness committee and its subcommittees 4) Specialty deep dive process identified areas of best practice and also areas for improvement, which have been actioned and monitored by relevant clinical leads

1) Evidence of learning from incidents/audit 2) Time lag with which some data sets are released



1. PROMS 2. Minutes of divisional meetings including M & M 3. Minutes of Clinical Effectiveness and Patient Safety and Risk

subcommittees 4. Patient tracking and analysis (whiteboard project) 5. Datix reporting and analysis 6. Clinical Nurse Consultant for Patient Safety and Falls commenced

02/12/14 7. Results from National Clinical Audit Programme 8. Benchmarked reports from Academic Health Science Network

Enhancing Quality and Recovery Programme 9. Reviewing all deaths proactively where coding wish to apply diagnostic

code 10. Working with the 4 other successful Trusts in the TDA/Virginia Mason

development program

Positive (+) Sharing data through VM program with identified peers (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) The latest HSMR data shows overall Trust mortality is lower than expected for our patient group (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) New EWS implemented (+) Increase in reporting trends (+) National falls data benchmarks favorably (Trust desire to improve position) Negative (-) Never events incidence (-) NRLS reporting (-) HSMR for low risk procedures is 116


Ability to benchmark in real time National Safety Dashboard to be implemented when available


1) Development of ward based performance dashboards 1) Start date 01/04/2015

Update by DH 22/01/16


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Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy Priority ID and reference 2.B Deliver services differently to

meet need of patients, the local health economy and the Trust

Director responsible Chief Operating Officer



2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.


Target risk score

S5 x L2 = 10

Linked to Risk 1221, 1480, 1601, 1405, 1547


1) Transformation Team in place 2) System Resilience Group 3) 3x3 meetings 4) CEO strategic meetings 5) Partnership boards 6) Trust part of national Virginia Mason transformation programme 7) Integrated Reablment Unit build complete

1) Pathway redesign needs to ensure its appropriate and fit for purpose 2) Repatriation of tertiary services effected and influenced by external factors 3) Clear action plans linked to root causes of efficiency issues and using service improvement methodologies not yet fully embedded



1) Contracts 2) Plans 3) Referral activity 4) GP Support 5) Breaking the cycle 6) Divisional Performance Reviews 7) Productivity reporting

Positive (+) Contract 14/15 signed with BICS (+) Internal audit of readmission figures provides positive assurance (+) Feedback following initial work on discharge process 2013/14 (+) Joint working with Royal Surrey County ( Chemo and Radiotherapy) (+) Pathology joint venture BSUH (+) Bowel screening (+) BOC respiratory unit (+) Extended theatre working days Crawley (20% increase capacity) (+) Second Cath Laboratory in place (+) VMI Guiding Team established, initial Value Streams agreed Negative (-) Medically ready for discharge (100 pts vs target 90) (-) Nationally an outlier on emergency length of stay by 1 day (-) Unplanned increase in >1 LOS emergency admission patients (10% vs 2% plan)


Agreed activity modelling across SEC National policy decisions and effective of general election


1) Full action plan development for productivity programme (theatres, outpatients, VMI Value streams) 2) Breaking the cycle and reducing LOS action plan

1) End of quarter 4 2) Ongoing

Update by BE 19/02/2016 Date discussed at Board To be discussed at February Board

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Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference 3.B Deliver high quality care around

the individual needs of each patient Director responsible Chief Nurse and Medical Director


3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits.



Linked to Risk 770, 1295, 1580, 1652


1. Workforce KPIs including vacancy rates, turnover and temporary staffing monitored by Nursing agency PMO, Workforce subcommittee, Exec Committee and the Board

2. Monitoring of Safety Thermometer, patient experience and staff turnover, sickness at ward level and at associated subcommittee, Exec and the Board

3. Planned versus actual staffing levels monitored on a shift by shift basis, reported daily by Matrons and issues escalated to DCNs with evidence actions taken

4. PMO in place to monitor agency use and progress of the five related work streams

a. E-roster- migration to v10 approved and project commenced b. Nursing recruitment plans developed by DCN and DCM in

response to Right Staffing review and monitored by Agency PMO, Workforce subcommittee and divisional team meetings

c. Recruitment process reviewed, KPIs in place to provide assurance

d. Bank recruitment in progress to reduce use of agency nursing staff

e. International recruitment undertaken but start date has been delayed. Further local and EU recruitment in progress. Monitored via temp staffing PMO

f. Weekly reporting in place to TDA/Monitor in place on all agency use above cap or outside framework

g. Monthly reporting of total agency spend against TDA/monitor agreed trajectory

5. SNCT/Birthrate Plus tool/NICE guidelines utilized to monitor patient

acuity and dependency presented to relevant committees including Board to determine future staffing demand

6. Work underway to develop SASH recruitment brand and retention strategy including the development of new nursing roles

7. SASH funded by HEKSS to develop and lead on physician associate training and recruitment for SEC

8. Foundation doctors workloads re-modelled such that 95% of time is spent with no more than 14 patients.

9. Strong relationship with HEKSS who place junior doctors in the organisation

10. Practice development nurses recruited to support ward nursing teams improve retention.

1. E-Roster system is not updated out of hours 2. Unfilled shifts both nursing/midwifery and medical 3. The Trust still carries a volume of vacancies specifically in clinical areas and

turnover in some areas is above Trust target 4. Imperfect induction for short notice, short term medical locums 5. Aiming for full nursing/midwifery and medical recruitment (influenced by HEKSS) 6. Medical trainees select a preference that affects the decision

Page 9



1. Ward staffing templates monitored daily by Matrons and escalated to the Divisional Chief Nurses to ensure safe levels to meet patient needs.

2. Staff absence reports and monitored in divisions 3. % of vacant shifts filled by Trust and agency staff 4. Revalidation (GMC) for locums 5. Monitoring agency utilisation and spend at PMO 6. Weekly & monthly reporting of agency use to TDA/Monitor

Positive (+)SNCT data (+) Recruitment plans developed by ward and reported monthly (+) Matron for workforce recruited (+) International recruitment for nurses undertaken (+) CQC Chief Inspector of Hospitals Report - Good rating

(+) Daily ward staffing review (+) Reports regarding reducing vacancy rates, sickness, absence (+) Incident reporting via Datix (+) Patient experience data by ward or unit (+) Junior Doctors feedback regarding quality of experience and breadth of exposure (+) European recruitment undertaken Negative (-)Benchmarked high proportion of agency staff usage against other Trust’s (-) Vacancy rates and turnover rates (-) Temporary staffing Internal Audit (-) Junior Doctors feedback relating to high workload


Trust position known - no identified gaps in assurance


1. Continue to monitor effectiveness of recruitment plans 2. 7 day working plans for medical staff under development across the Trust 3. Implement e-roster upgrade and utilize core functionality (bank and messaging)

4. Implement plans to manage staffing issues in Theatres 5. Increasing direct entry nursing students by 100% (40 to 80) from February 2016

1. Ongoing 2. Being implemented 3. Embedding and under review 4. Being implemented 5. February 2016

Update by FA 10/02/2016 and DH 22/01/2016


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4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference 4.A.1 Deliver access standards Director responsible Chief Operating Officer



4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage pressures has a significant impact on the Trust's ability to deliver high quality care



Linked to Risk 1220, 1491


1) EDD Patient Pathway 2) Site management team and Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches weekly to implement lessons learnt 5) Site Management Team and Discharge Team 6) Circa 50 additional community beds made available 7) 7 day medical consultant ward rounds established 8) Additional community beds 9) Tilgate annex opened providing extra surgical capacity 10) 10

th Theatre opened (May 15)

11) Increasing hospital at home capacity 12) Integrated Reablement Unit built

1)Identified on a rolling basis as part of weekly review 2)It is difficult for the Trust to influence the output of decision making across the local health economy 3)Ambulatory pathways yet to imbed (New Consultant undertaking review) 4)Support of partners required to effectively reduce and sustain numbers of patients medically ready for discharge



1) NHS England aware 2) Combined weekly Quality and Performance Dashboard for ED reporting on a combination of quality and safety standards and the ED national indicators reported to exec meeting weekly 3) Performance Management Framework and reporting to Trust Board 4) External stakeholder inspections 5) Daily sit rep reporting to the TDA 6) Daily winter Sit Reps (Commenced November) Urgent Careboard Area Team. 7) Whole system operational resilience plans signed off for 14/15 8) 2020 whole system review of discharge process, reviewing recommendations

9) Clinical audit of clinical pathways which impact on reducing emergency re-admissions.

Positive (+) MRD Summit June agreed map capacity available across Surrey and Sussex (+) ED Standard delivered April, May, Aug, Sept, Oct, Dec 2015 (+) Process improvement (+) Working with partners commissioners / partners to expedite flow through hospital (Medihome and community beds) (+) Top 20 patient delay weekly meetings (+) Monitoring and managing compliance #NOF, Stroke and medical outliers (+) Bed modelling refreshed including emergency demand increases Negative (-) ED standard not delivered June, July, Nov 2015 and Jan 2016 (-) Quality indicators for time to assessment / treatment. Surrey and Sussex local lead. (-) EDD Section 2 and section Patient tracking system (-) Number of patients safe to discharge at any one time (-) Adult Bed occupancy remains higher than plan due to increased activity Circa 100 medically fit for discharge patients (-) Local availability of Nursing home beds / ability to start complex packages of care (-)Unplanned increase in >1 LOS emergency admission patients (10% vs 2% plan)

Page 11


Winter plans and local health economy position going into winter months


1) Comparison between 2014/15 Q1 vs on 2015/16 Q1 assumptions and activity to identify variance 2) Refresh winter capacity plans based on assessment of Q1 activity 3) Planned local health economy summit regarding emergency growth

4) Agreed breaking the cycle 2 encompassing internal and external bodies

5) Planned breaking the cycle throughout weeks throughout winter 6) Demand and Capacity plans for 16/17

1) Complete 2) Complete 3) Complete 4) Complete 5) March 2016 6) March 2016

Update by BE 19/02/16 Date discussed at Board To be discussed at February Board

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Objective 5 – Well Led Priority ID and reference 5.A Live within our means to remain

financially sustainable

Director responsible Chief Finance Officer



5.1 Failure to deliver income plan Current rating S5 x L3 = 15


Linked to Risk 1689


1) Business Plans and budgets (activity and financial) savings / transformation plans. 2) Agreed contracts in place with main sets of commissioners (NHSE and CCGs) – all Contracts were finally signed in August. 3) Contract management process in place (this operated effectively in 2014/15). 4) Financial reporting, including periodic forecast scenarios, is in place and effective – a detail forecast was provided to Board in July and internal PMOs are based on that forecast. 5) Chief Officer meeting (which includes coordination of has been in place since Nov 2014. Its structures are still embedding.

1) There are issues with Sussex over the under commissioning of activity and contractual action has started in respect of this. 2) Winter demand has been a significant issue with the Health System declaring “black” status in January on two occasions. This has triggered a risk summit and the completion of a serious incident review (nb: focus isn’t income, but planning) 3) The strategic management of activity is not currently effective, but the Trust is doing all it can to support making it so. Note: other gaps in previous reports mitigated by actions currently in train with CCGs.



1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board (including CQUIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output and reporting from health system management (e.g.: System Resilience Groups and Chief Officer Meetings) 5) Output of Contract Management Process .

Positive (+) The reconciliation process is seeing payment for over performance against CCG contract plans {although the process has seen delay in payments] (+) Internal action on income delivery in specific specialties has, generally, been effective – part year shortfall, but underlying issues have now been corrected (+) Agreement now reached with Sussex over MRET and handover fines – surrey not expected to be far behind [but not yet agreed] Negative (-) Risk over income growth assumptions, now materialized – risk in last 3 months is from balance of emergency activity and capacity. This is the single biggest issue in the Trust’s financial performance in the last 6 months of the year - adverse income variance at M10 (-) Monitor response to MRET complaint provided no useful application in 2015/16 (although a deal done with Sussex over the original increase in the threshold) (-) Too much non elective activity, not enough elective – risk over emergency demand (-) disputes now received from Surrey – only one from Sussex – escalation status not confirmed by CCGs – 9 February letter to CCGs to clarify position (-) Tripartite letter on 19 January provides conflicting advice to that from the TDA about levying of fines in Q4.


Red because of level of risk, activity planning differences, issues with strategic health system management of urgent care activity and transactional processes with CCGs.

Page 13

Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1) Complete all contractual commitments according to timetable (we are about to start end-year discussions over the FOT for income for each CCG);

2) Revised forecast for elective activity completed, now being monitored – performance is not on plan; 3) The integrated reablement unit opened on 21 January. 4) Robust contractual processes being operated.

Actions proceeding to timetable.

Update by PS 15/02/16 Date discussed at Board To be discussed at February Board

Page 14





5. 2 Failure to stop divisional overspending against budget



Linked to Risk 1663,1688


1) Business Plans and budgets (activity and financial) savings / transformation plans 2) Divisional activity plans 3) Internal Performance Review (PMO) process and CEO review 4) Forecast scenarios presented to Board – a detail forecast was provided to Board in July and internal PMOs are based on that forecast. 5) TDA agency reduction plan now submitted

1) Management of increased levels of emergency activity subject to review; 2) Cost improvement plans are not fully delivering with adverse performance on

agency and escalation in particular. Red rated savings have been partially mitigated. The forecast provides a £3.3m risk to savings delivery.

3) There is overspending in 2 specific areas against agreed forecast control totals at M09, and again at M10.

The overspending risk has been revised to correct lower risk score in line with the January Board discussion.



1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board UIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output in financial reporting describes improvement and risk mitigation. 5) Agency PMO.

Positive (+) Budget changes made to match activity and main Divisions within forecast tolerance (bar 2 specific areas) (+) Internal audit advises CIP process is sound (but notes non-delivery, see below) Negative (-) Internal audit advises effectiveness of savings delivery rated red/amber. (-) Emergency activity pressures have continued to be greater than expected (-) Overall agency costs remain very high, with escalation still in use and significant costs (albeit within forecast) across Divisions. (-) The forecast provides an adverse variance to plan.


Overspending is the main area of risk and the ability of the Trust to reduce the rate of spend while maintaining services adequately.


1) PMO/Performance structure continues - Divisions have been required to produce recovery plans and PMO meetings have become more frequent for all Divisions. Nursing agency PMO and fortnightly agency steering group.

2) Controls are being exercised in divisions and centrally – vacancy restriction and non-clinical procurement. The latter tightened again in February (spend to be put off even if urgent)

3) Decisions on business cases are now taken in light of affordability against forecast.

Actions proceeding to timetable


Page 15





5. 3 Unable to deliver medium term financial plan



Linked to Risk 1603


1) Items referred to in 5.A.1 and 5.A.2 above 2) V7.0 long term financial model and integrated business plan

completed (submitted to Monitor in April 2015) 3) TDA Plan submitted in April 2015

4) Board to Board held with the TDA in November 2014, Monitor assessment now in train culminating in Monitor Board to Board in June 2015.

5) Cost improvement plan process in place (including PMO structure) 6) Elective/outpatient activity growth and income plan in place –

capacity created

7) Contracts with CCGs allow for payment for “over performance”

1) Items listed above (5.A.1, and 5.A.2) are applicable here 2) Lack of alignment between CCG activity plans and actual performance. 3) Reliance on centrally determined rules for PbR, Better Care Fund and the wider

NHS finance regime. 4) Risk over capacity from other operational pressures 5) Overall health system financial view (Chief Officer’s Finance Sub-Group)

describes significant loss of resource to BCF funding – this reduces resource available for health and social care overall.

6) Lack of clarity over tariff assumptions for 2016/17 – this is crucial to medium term planning [some information now available – consultation published 11 February]

7) Central actions over NHS overspend may have an adverse impact on Trust because of manner of application (e.g. withholding capital and cash).



1) Delivery of 2014/15 financial position and delivery of 2015/16 financial plan 2) Production of 2016/7 budget, revised long term financial model and integrated business plan documentation, and delivery against them

Positive (+) Delivery of performance in 2014/15 (noting a deficit was recorded, but position was as forecast) Negative (-) alignment with CCG plans is not complete with significant variances between actual performance on activity and CCG plans [CCGs are, in the main, paying over performance] (-) overall health system loss of resource Overall, on basis of current assumptions, RAG has turned red with the impact of urgent care activity and the level of risk to the forecast. Assurance RAG red. (-) 2016/17 sustainability and transformation funding and the applicable control total are not yet agreed with NHSi.


Central actions to manage costs across the NHS are not yet clearly described and the tariff is not yet defined, plus cumulative impact of other finance risks here.


Please see items above. Tariff information is now available (11 February) but potentially subject to change. The 2016/17 budget has been reported to Board and the 8 February plan submission made. The Board is aware of action in relation to control totals and S&T funding.

Progress is on timetable


Page 16





5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position



Linked to Risk 1604


1) Bi weekly review of forward cash flow by finance team and CFO 2) Cash and working capital management processes 3) Annual cash plan linked to business plan and capital plan ( see link with Risk 1134)

NOTE: This risk was reviewed at FWC 22 September and agreed to be maintained noting working capital facility. Additionally capital loan is now secure. An application for a £9.6m working capital loan has now been submitted

1) No agreement on medium term solution to liquidity – being pursued during 2015/16 – a loan application has been drafted and submitted – awaiting confirmation of agreement

2) Delay in receiving cash payments to match accrued income from CCGs, although main CCGs are providing cash advances

3) Threat of central cash controls in line with control totals (nb: which the Trust has not agreed). Confirmation has been received verbally of an increased working capital facility but this has yet to be formalized, along with its operation (i.e.: NHSi may restrict access to the level of S&T funding proposed for the Trust).

Rating maintained after past discussion at Board – position monitored.



1) Twice monthly reporting to CFO by finance team, SBS reporting on bank balance

2) Monthly finance reporting to Executive Committee, Finance and Workforce Committee and Trust Board

3) Confirmation of working capital injection (either through a loan, working capital facility or, if available, PDC)

Positive (+) Cash targets met in 2014/15 (+) Liquid ratio has followed expectations (+) Cash has been managed well in 2015/16 to date, Green internal audit report on cash management Negative (-) no additional cash to resolve underlying liquidity problem – restrictions being applied by NHSi as described in “gaps in control”. (-) cash flow dependent on financial outturn described in 5.A.1 and 5.A.2 above. Overall rating “red” noting risk to forecast I&E. No current cash problem but underlying problem unresolved.


In terms of cash flow management to end year, no material gaps in assurance. In terms of resolving the actual risk (liquidity), there is no confirmation of additional cash to resolve SoFP weakness. Assurance level “red” noting unresolved underlying cash issue.


1) Day to day cash control is main action, but coupled to action to maintain income and manage spend 2) Long term financial model, and TDA plan now provides additional validation of the level of cash

injection required and the interaction from an improving financial position within the model 3) Discussion will continue with NHSi over the cash facility they are making available.

Actions proceeding to timetable


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Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference 5.E We are an organisation that is

clinically led and managerially enabled.

Director responsible Director of Organisational Development & People


5.5 There is a risk we will fail to realize the strategic benefits of having an Achievement Review Process that effectively monitors and influences behavior and performance.


Target risk score

S3 x L2 = 6

Linked to Risk 1740

Controls in place (to manage the risk) Gaps in Control 1) New Achievement Review Policy with implementation /communication and

training plan. 2) Personal objectives are being linked to Trust/Divisional and team

objectives and the SMART methodology is being used to assess performance

3) New AR process includes assessment of Behaviours against Trust values 4) Personal Development Plans as part of AR identify development needs 5) Training Need’s Analysis at Divisional level extrapolated to Trust level to

inform strategic planning of development priorities 6) AR Task and Finish group continues to embed new process and

implement for medical staff during 2015/16

1) New system yet to reap full benefits 2) Operational activity levels in the Trust stated as reason by line managers for non-

compliance with expected appraisal completion rates 3) Change to annual timetable with delivery in first part of financial year yet to embed 4) An agreed model for medical and dental Achievement Review yet to be agreed



1) AR review audits focusing on objective setting and linked to quality of services 2) National Staff Survey results (2015 results - Level of appraisal completion is in the lowest 20% nationally, but quality of appraisals is in highest 20% nationally) 3) Feedback from junior doctors 4) Monthly reporting against AR completion timetable at Divisional and Trust level at ECQR&CC, Workforce Committee, and Finance Investment &Workforce Committee 5) Development of behavior based recruitment systems will support the long term strategic implementation of achievement reviews.

Positive (+) Task and Finish group successful launch of new policy and process slides and comms plan for launch at ESH and Crawley (+) development of toolkit and intranet resources (+)TNA update to August 2015 Finance Investment & Workforce Committee (+) recent audit personal quality objectives in appraisals (+) 2015 staff survey results for quality of appraisals puts us in the top 20% of Trusts nationally (+) Culture champion led initiative on standards of behavior (+) 64% compliance achieved following significant focused effort Negative (-) 2015 staff survey Q on appraisal in last 12 months is in bottom 20% (-) compliance rates for Achievement Review remains adverse to plan

Gaps in assurance Assurance Level gained: RAG New AR process is yet to provide any evidence that demonstrates mitigation of this risk or completion of AR’s


1) Recovery plan for 2015/15 compliance in place 2) Series of training courses to support implementation commenced and will run throughout 2015/16 and up to

end of June 2016/17 3) T&F to support development of AR for Doctors and dentists – acceptance that AR process needs to be the

same across all staff groups 4) Trust wide culture champion launch to include significant focus on the trust values and behavioural anchors 5) Establish process for annual performance review to identify and talent map for Medical & Dental, 8a’s and

above (Talent Management grid to be included in AR paperwork from 2016)

1) 31 March 2016

2) 30 June 2016 3) Piloting in Medicine Division in June 2016 4) Complete and ongoing 5) March 2016

Update by MP 15/02/2016 Date discussed at Board To be discussed at February Board

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Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference 5.G.2 We are a well governed

organisation Director responsible Director of Corporate Affairs



5.6 The Trust remains within the current FT pipeline and awaits national guidance on potential new organisational forms which could result in changes to the current timescale and associated requirements to the process. Due to the merger of the NHS TDA & Monitor and creation of NHS Improvement there is uncertainty over the longevity of the current FT model.



Linked to Risk 1531


1) Successful outcome from the formal Monitor assessment process 2) Achievement of FT project plan milestones 3) Formal approval by TDA Board to move to Monitor assessment phase target 4) Successful elections to the Council of Governors 5) FT Project Board 6) Implementation of Board development programmer

No significant gaps in control identified



1) LTFM agreed by the Board 2) Submission of Integrated Business Plan to TDA & Monitor 3) Public Consultation completed with positive outcome 4) QGAF External assessment completed with implementation of action plan 5) TDA Formal approval to move to the Monitor stage 6) Chief Inspector of Hospitals Inspection – “Good” 7) Elections to Shadow Council of Governors 8) HDD to be completed as part of Monitor phase 9) Submission of all current Monitor information requests

Positive (+) Completion of Monitor pre-assessment phase (+) Election to the Council of Governors complete (+) FT membership over 10,000 (+) Monitor Exe to Exe Challenge took place on 1

st June 2015

(+) External assessment of QGAF score 3.5 (+) Quality Governance Memorandum submitted to Monitor with score of 2.0 (+) Monitor confirmed QGAF score as 3.5 – Further actions being implemented (+) Successful elections - Shadow Council of Governors in place (+) Discussion with Monitor on final timescales & remainder milestones to re-start the process (+/-) Awaiting national guidance on future FT model (NHS Improvement)


Completion of Historical Due Diligence


1) Shadow Council of Governors in place 2) Monitor formal assessment currently paused

1) Ongoing 2) Plans are on track

Update by GFM 05/02/16 Update by To be discussed at February Board

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Objective 5 – Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference 5.F. Ensure IT support/optimise

patient experience by improving patient interface, sharing and capture of patient information and patient communication

Director responsible Director of Information and Facilities



5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems



Linked to Risk 1428, 999, 1483


1) Move to direct contract with Cerner now happened and Trust has exited NPfIT well ahead of schedule 2) IT Strategy aligned with Clinical Strategy and IBP and reviewed Oct 14 3) Clinical Informatics Group 4) Clinical IT leads 5) Various project groups (EPMA etc.) 6) Project management controls (Descried in Internal Audit of project management) 7) EPR costs identified in LTM 8) CCIO and CNIO roles being implemented – greater clinical buy-in 9) Cerner Optimisation Group now in place 10) IT Road Map presented to FWC and Executive 11) EPR Roadmap signed-off by Executive November 2015 and Trust working on implementation plan and business case with EPR Provider

1) Insufficient focus on change benefits realization due to financial constraints 2) Lack of operational involvement in identifying and delivering benefits



Efficiencies being delivered through IT enabled change

Positive (+) Improving infrastructure (e.g. Wi-Fi move to Windows 7) (+) Development of existing EPR platform (e.g. EPMA and move to Cerner) (+) EPR Contract signed and data center move finished (+) Trust moved to latest version of EPR software (+) Business Continuity System now in place (7/24)


Trust position known, no identified gaps in assurance


1. Procurement and implementation of replacement EPR - complete 2. Establishment of Chief clinical Information Officer role - complete 3. Clinical Cerner Optimisation Group now in place with strong leadership 4. Greater focus on IT in Capital Plan for 2015/16 and future years 5. EPR Roadmap now approved by Executive and approval to proceed agreed 6. Move to latest version of Cerner software now taken place

1. Completed 2. 724 Go-live November 2014. 3. PC Upgrade plan now complete 4. Network review first draft now complete and

approval to proceed approved

Update by IM 19/02/16 Date discussed at Board To be discussed at February Board

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Appendix 1

Page 21

Abridged consequence table taken from Trust guidance

Risk Type Insignificant Minor Moderate Major Extreme

Patient Safety • No obvious injury / harm • Non-permanent avoidable injury / harm requiring only first aid / minor treatment

• Short-term avoidable injury / harm with recovery / treatment up to 1 month

• Long-term (>1 month) / permanent avoidable injury / harm / illness or any of the following: � Infant abduction � Infant discharged to wrong family � Rape or serious assault

• Avoidable death

• Injury / illness requiring more complex treatment, e.g. stitching, plaster, medication course, minor theatre operation etc.

• Minor harm event involving >5 patients • Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

Patient 'Experience' & Care Pathways and Involvement of Service Users

• No significant impact on patient experience

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

• Major unsatisfactory patient experience related to poor treatment / care

• Upheld complaints regarding death in the Trust

• No complaints / concerns raised • Informal complaints raised / PALS contacted

• Formal complaints raised and/or MP / independent advice / advocacy contacted

• Legal action against the Trust initiated / local media involvement

• National media coverage / political action against the Trust

• Care pathway problems resulting in short-term treatment / care delay <3 hours

• Care pathway problems resulting in short-term treatment / care delays (3 hours – 1 day)

• Care pathway problems resulting in medium term delays (up to 1 month) or 5-10 patients affected

• Care pathway problems resulting in medium term delays (1-6 months) or 10-20 patients affected

• Care pathway problems resulting in long term delays (>6 months) or >20 patients affected

Health & Safety • No harm injury • Short term / non-permanent injury / ill health.

• Medical treatment required • Permanent or extensive injury / ill health / permanent disability or loss of limb (RIDDOR reportable)

• Death (RIDDOR reportable)

• Injury / ill health resulting in 0-7 days absence from work.

• Injury / ill health resulting in >7 days absence from work or restricted duties for >7 days (RIDDOR reportable)

Financial Management • Small loss <£1K • Minor loss £2K to £100k • Moderate loss, £100k - £1M • Major loss, £1M-£10M • Loss > £10M

Governance Arrangements

• Concern raised by internal or external systems that can be resolved through normal governance processes in < 3 months (e.g. one financial quarter)

• Concern raised by internal or external systems that will take > 3 months to resolve but does not fulfil the criteria of moderate consequence

• Concern raised in external inspection report or raised in single performance conversation with commissioners / TDA (or equivalent) due to a failure to provide “well led” services as described by the CQC

• Suspension of services provided due to a failure to provide “well led” services as described by the CQC

• Permanent removal of services and / or prosecution due to a failure to provide “well led” services as described by the CQC

• Any issue that would have to be recorded in annual governance statement or annual report (e.g. significant issue “red risk” audit produced by Internal Audit)

• Act or omission that could led to removal of the Board

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

Quality of Service

• Insignificant interruption of service(s) which does not impact on the delivery of patient care or the ability to continue to provide service

• Short term disruption to service(s) with minor impact on patient care

• Some disruption to service(s) provision with unacceptable short-term impact on patient care. Temporary loss of ability to provide service(s)

• Sustained loss of service which has serious impact on patient care resulting in major contingency plans being involved

• Permanent loss of core service or facility

1 An Associated University Hospital of

Brighton and Sussex Medical School



REPORT TITLE: Board Assurance Framework & Significant Risk Register

EXECUTIVE SPONSOR: Gillian Francis-Musanu Director of Corporate Affairs

REPORT AUTHOR (s): Colin Pink Head of Corporate Governance

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Executive Team throughout February 2016

Action Required:

Approval (√) Discussion (√) Assurance (√)

Purpose of Report:

The 2015/16 BAF highlights potential risks to the Trust’s strategic objectives, mitigating actions and the implementation of its programme of objectives for year two of the five year plan. The Significant Risk Register (SRR) details risks on the Trust risk register system that are recorded as significant which have been considered by the Executive Team and the links to the Board Assurance Framework.

Summary of key issues

The BAF details 13 risks to the trusts strategic objectives, 7 of which are recorded as key strategic risks and red rated. There are 11 significant risks recorded on the Trust risk register.

Recommendation:

The Board is asked to discuss and approve the report and consider the following:

• Does the Board agree with the recorded controls and assurances


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

Corporate Impact Assessment:

Legal and regulatory impact The report is a requirement for all NHS organisations.

Financial impact As discussed in sections 5 (Income generation linked to activity referred to throughout the document)



Patient Experience/Engagement Patient experience and engagement is one of the Trusts strategic objectives. .

Risk & Performance Management These are highlighted throughout the report.


Discussed throughout the report but with the greatest detail in objective 3.

Attachment:

February 2016 BAF and the current SRR



TRUST BOARD REPORT – 25th February 2016 BOARD ASSURANCE FRAMEWORK and SIGNIFICANT RISK REGISTER 1. Board Assurance Framework The Board Assurance Framework (BAF) describes the principal risks that relate to the organisation’s strategic objectives and priorities. It is intended to provide assurances to the Board in relation to the management of risks that threaten the ability of the organisation to achieve these objectives. The Trust has identified five main strategic objectives for 2015/16:

1) Safe: Deliver safe services and be in the top 20% against our peers 2) Effective: Deliver effective and sustainable clinical services within the local health economy

3) Caring: Ensure patients are cared for and feel cared about 4) Responsive to people’s needs: Become the secondary care provider and employer of choice for the catchment population 5) Well led: become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

These objectives are broken down into specific areas and the BAF details the key risks that the Trust faces to the delivery of these priorities. Each risk details the controls that are in place, the sources and effects of assurance and mitigating actions to reduce the likelihood of the impact of the risk materialising. (Some priorities have more than one associated risk) The Significant Risk Register (SRR) supports the BAF and details the highest rated operational risks that have been raised by the Executive Team and Divisional Management. The SRR is regularly reviewed and moderated by the Executive Team to ensure alignment with the BAF and other key risks to the Trust. 2. Current status One of the purposes of the BAF is to ensure that all risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to green (low impact, low likelihood). There have been minor amendments throughout regarding controls, actions and assurances. The 15/16 BAF (attached) details a total of 13 risks to the 5 Trust strategic objectives which are scored as follows:

Objective Red (15-25)

Amber (8-12)

Green (1-6)

1.Deliver safe services and be in the top 20% against our peers

0 2 0

2.Deliver effective and sustainable clinical services within the local health economy

1 0 1

3.Ensure patients are cared for and feel cared about

1 0 0



4.Responsive - Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex

1 0 0

5. Well Led - become an employer of choice and

deliver financial and clinical sustainability around

a clinical leadership model 4 3 0

Total 7 5 1

2.2 Headline information by objective (BAF)

Objective 1 - Safe Deliver safe services and be in the top 20% against our peers

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties.

S4 x L3 = 12 S4 x L2 = 8 S4 x L1 = 4

1.2 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care

S3 x L4 = 12 S3 x L4 = 12 S3 x L3 = 9

Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy



Target Risk Score

2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties

S3 x L3 = 9 S3 x L2 = 6 S3 x L1 = 3

2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.

S5 x L3 = 15 S5 x L3 = 15 S5 x L2 = 10

Objective 3 - Caring – Ensure patients are cared for and feel cared about



Target Risk Score


S3 x L4 = 12 S3 x L5 = 15 S3 x L2 = 6

Objective 4 – Responsiveness – Become the secondary care provider for the catchment population



Target Risk Score


S4 x L4 = 16 S4 x L4 = 16 S4 x L2 = 8



Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model



Target Risk Score

5.1 Failure to deliver income plan S5 x L3 = 15 S5 x L3 = 15 S4 x L2 = 8 5. 2 Failure to stop divisional overspending against budget

S5 x L3 = 15 S5 x L3 = 15 S3 x L2 = 6

5. 3 Unable to deliver realistic medium term financial plan S5 x L3 = 15

S5 x L3 = 15

S4 x L2 = 8

5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position

S5 x L3 = 15 S5 x L3 = 15 S4 x L3 = 12

5.5 There is a risk we will fail to realize the strategic benefits of having an Achievement Review Process that effectively monitors and influences behaviour and performance.

S3 x L3 = 9 S3 x L3 = 9 S3 x L2 = 6

5.6 The Trust remains within the current FT pipeline and awaits national guidance on potential new organisational forms which could result in changes to the current timescale and associated requirements to the process. Due to the merger of the NHS TDA & Monitor and creation of NHS Improvement there is uncertainty over the longevity of the current FT model.

S4 x L2 = 8 S4 x L2 = 8 S4 x L1 = 4

5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems

S5 x L3 = 15 S4 x L3 = 12 S3 x L3 = 9

2.3. Key risks Strategic risks Identified The BAF highlights the following 7 key red risks to the Trust objectives that have been identified at time of updating the framework (not including the proposed reduction). These are: Risk description Current

rating Target risk score

2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity to deliver the activity income that underpins the LTFM.

S5 x L3 = 15 S5 x L2 =10


S3 x L5 = 15 S3 x L2 = 6


S4 x L4 = 16 S4 x L2 = 8

5.1 Failure to deliver income plan S5 x L3 = 15 S4 x L2 = 8 5. 2 Failure to stop divisional overspending against budget S5 x L3 = 15 S3 x L2 = 6 5. 3 Unable to deliver medium term financial plan S5 x L3 = 15 S4 x L2 = 8 5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position

S5 x L3 = 15 S4 x L3 =12



3. Significant Risk Register The Executive Committee has reviewed and agreed the content of the significant risk register. There are 11 risks on the Trust significant risk register. Each risk is in date and has mitigating actions to reduce the level of risk to an acceptable level. 3.1 SRR Breakdown

ID Title Initial

Rating Current Rating

Residual Rating

Next Review

1401 Risk of outbreak of viral gastroenteritis

16 15 9 31/03/2016

1491 Failure to maintain Emergency Department performance

20 16 6 31/03/2016

1501 Patient admitted to the right bed first time

9 15 6 31/03/2016

1603 Unable to deliver realistic medium term financial plan

15 15 8 31/03/2016

1604

Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position

15 15 12 31/03/2016

1663 Risk of not achieving Cost Improvement Plan

9 15 6 31/03/2016

1672 Sickness Absence Levels with impact on day to day management and expenditure

15 15 9 31/03/2016

1678 RTT Access Standards 15 15 6 31/03/2016

1688 Risk of potential overspending from operational pressures

16 15 9 31/03/2016

1689 Risk of Contract income below plan

15 15 12 31/03/2016

1697

Financial risks linked to National Quality Board Paper, 7 day working and Carter productivity report

15 15 9 31/03/2016

4. Discussion/Action This report brings together the BAF for the Trusts strategic objectives and the Significant Risk Register into one report. The Board is asked to discuss and approve the report and consider the following:

• Does the Board agree with the recorded controls and assurances

• Note the updated risks included in the Significant Risk Register

Gillian Francis-Musanu Colin Pink Director of Corporate Affairs Head of Corporate Governance February 2016



Appendix 1: Risk Appetite – 2015/16 The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives. The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. The key following principles further define this stance with an opinion from the Board:

Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk only if, upon consideration, the benefits of the risk improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green

Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice both internally and across the wider health economy. Target: Amber

Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. The Board will seek to innovate and take risks where there is potential to develop inspirational leadership as it recognises that this is key to both becoming the local employer of choice and developing strategic partnerships with new bodies. Target: Green

Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. There will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber

Reputation: The Board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green

Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. The Board recognises the complications attached to recruitment and retention that are caused by geographical and national position and takes this into account when reviewing workforce related risks. Target: Amber



Appendix 2: SASH risk quantification matrix



Risk Type Insignificant Minor Moderate Major Extreme

Patient Safety • No obvious injury / harm • Non-permanent avoidable injury / harm requiring only first aid / minor treatment

• Short-term avoidable injury / harm with recovery / treatment up to 1 month

• Long-term (>1 month) / permanent avoidable injury / harm / illness or any of the following: � Infant abduction � Infant discharged to wrong family � Rape or serious assault

• Avoidable death

• Injury / illness requiring more complex treatment, e.g. stitching, plaster, medication course, minor theatre operation etc.

• Minor harm event involving >5 patients • Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

Patient 'Experience' & Care Pathways and Involvement of Service Users

• No significant impact on patient experience

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

• Major unsatisfactory patient experience related to poor treatment / care

• Upheld complaints regarding death in the Trust

• No complaints / concerns raised • Informal complaints raised / PALS contacted

• Formal complaints raised and/or MP / independent advice / advocacy contacted

• Legal action against the Trust initiated / local media involvement

• National media coverage / political action against the Trust

• Care pathway problems resulting in short-term treatment / care delay <3 hours

• Care pathway problems resulting in short-term treatment / care delays (3 hours – 1 day)

• Care pathway problems resulting in medium term delays (up to 1 month) or 5-10 patients affected

• Care pathway problems resulting in medium term delays (1-6 months) or 10-20 patients affected

• Care pathway problems resulting in long term delays (>6 months) or >20 patients affected

Health & Safety • No harm injury • Short term / non-permanent injury / ill health.

• Medical treatment required • Permanent or extensive injury / ill health / permanent disability or loss of limb (RIDDOR reportable)

• Death (RIDDOR reportable)

• Injury / ill health resulting in 0-7 days absence from work.

• Injury / ill health resulting in >7 days absence from work or restricted duties for >7 days (RIDDOR reportable)

Financial Management • Small loss <£1K • Minor loss £2K to £100k • Moderate loss, £100k - £1M • Major loss, £1M-£10M • Loss > £10M

Governance Arrangements

• Concern raised by internal or external systems that can be resolved through normal governance processes in < 3 months (e.g. one financial quarter)

• Concern raised by internal or external systems that will take > 3 months to resolve but does not fulfil the criteria of moderate consequence

• Concern raised in external inspection report or raised in single performance conversation with commissioners / TDA (or equivalent) due to a failure to provide “well led” services as described by the CQC

• Suspension of services provided due to a failure to provide “well led” services as described by the CQC

• Permanent removal of services and / or prosecution due to a failure to provide “well led” services as described by the CQC

• Any issue that would have to be recorded in annual governance statement or annual report (e.g. significant issue “red risk” audit produced by Internal Audit)

• Act or omission that could led to removal of the Board

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

Quality of Service

• Insignificant interruption of service(s) which does not impact on the delivery of patient care or the ability to continue to provide service

• Short term disruption to service(s) with minor impact on patient care

• Some disruption to service(s) provision with unacceptable short-term impact on patient care. Temporary loss of ability to provide service(s)

• Sustained loss of service which has serious impact on patient care resulting in major contingency plans being involved

• Permanent loss of core service or facility

Abridged consequence chart

ID Co

mm

itte

e

Op

en

Da

te

Sp

eci

alt

y

Ris

k O

wn

er

Ris

k T

yp

e

Title (Policies) Description (Policies) Existing controls Init

ial R

ati

ng

Cu

rre

nt

Co

nse

qu

en

ce

Cu

rre

nt

Like

lih

oo

d

Cu

rre

nt

Ra

tin

g

Treatment Plan Due date Done date Ne

xt R

evie

w

1697

Executive C

om

mitte

e

11/0

6/2

015

CO

RP

Sim

pson,

Paul

Fin

ancia

l M

anagem

ent

Financial risks linked to

National Quality Board

Paper, 7 day working

and Carter productivity

report

Risk of failure to meet the financial plan as a result of

a) increased costs to deliver staffing ratios, 7 day

costs and expectations detailed in national guidance

and plans, and b) failure to deliver adequate

adjusted treatment index (Carter).

The Trust has set aside reserve budget for the cost of

proposals to increase nurse/midwifery staffing, but

this is funded partly by income from CCGs, which is

not secure. 7 day working is already in place partially

(part of the forecast). Additional nursing staff to

deliver agreed ratios have been agreed, with

implementation spread over 2 years and recruitment

starting when agency is at acceptable levels.

15 3 5 15

Review and develop plans; to brief

the Board on progress against risks

of establishment targets not being

met and any potential action to

review the Board's decision on

implementation.

31/03/2016 31/03/2016

1604

Executive

Com

mitte

e

18/0

6/2

014

CO

RP

Sim

pson,

Paul

Fin

ancia

l

Managem

ent Liquidity: Inability to pay

creditors/staff resulting

from insufficient cash

due to poor liquid

position

Risk of not being able to pay suppliers from in

sufficient cash due to poor liquidity problem

1) Bi weekly review of forward cash flow by finance

team and CFO

2) Cash and working capital policy and strategy

3) Annual cash plan linked to business plan and

capital plan

15 5 3 15

As described on the BAF 31/03/2016 31/03/2016

1689

Executive C

om

mitte

e

01/0

4/2

015

CO

RP

Sim

pson,

Paul

Fin

ancia

l M

anagem

ent

Risk of Contract income

below plan

Risk the Trust does not achieve its financial plan as

a result of lower than planned contract income.

i) Quarterly reconciliation with CCGs will inform

variations to the monthly contract values (over

performance at Q1 is likely to reduce the risk).

ii) Manage emergency activity within capacity through

structural changes to ward configuration, improving

length of stay (notably in cardiology to release beds)

and other actions to improve efficiency.

Iii) Ring fence elective beds after new capacity has

opened and monitor delivery.

15 5 3 15


1663

Executive

Com

mitte

e

09/1

2/2

014

CO

RP

Sim

pson,

Paul

Fin

ancia

l

Managem

ent Risk of not achieving

Cost Improvement Plan

Risk of not achieving financial plan as a result of non-

delivery of Cost Improvement Plans

i) Delivery of savings managed through PMO

(ongoing)

9 5 3 15


1688

Executive

Com

mitte

e

20/0

5/2

015

CO

RP

Sim

pson,

Paul

Fin

ancia

l

Managem

ent

Risk of potential

overspending from

operational pressures

Risk of failure to meet the Trusts financial plan due

to overspending.

i) Divisions to implement action plans and

contingencies to control/or recover overspending.

Specific action is required in all Divisions.

ii) Agency PMO to deliver outputs in respect of

reduced agency usage following recruitment. Position

being reviewed (ongoing).

16 5 3 15


1603

Executive C

om

mitte

e

18/0

6/2

014

CO

RP

Sim

pson,

Paul

Fin

ancia

l M

anagem

ent Unable to deliver realistic

medium term financial

plan

As described on the BAF 1)Items referred to in 5.A.1 and 5.A.2 above

2)V3.0 long term financial model and integrated

business plan completed (submitted to TDA in

February 2014) V4.0 now approaching completion

3)TDA Plan submitted January 2014

4) Timetable for refreshed IBP and LTFM going

forward is part of national planning guidance (next

iteration due 20 June)

15 5 3 15


1491

Responsiv

eness

29/0

8/2

013

CO

RP

Ste

venson,

Angela

Involv

em

ent

of

Serv

ice U

sers

Failure to maintain

Emergency Department

performance

Failure to maintain Emergency Department

performance because of lack of capacity in health

system to manage winter pressures has a significant

impact on the Trust's ability to deliver high quality

care.

1) EDD Patient Pathway

2) Discharge management

3) Plans for escalation areas agreed and

management tools in place

4) Reviewing all breaches on weekly to implement

lessons learnt

20 4 4 16

Implementation of divisional

escalation plan following key

triggers.

Escalation bed plan agreed

implementation plans in place for

each area.

Ambulance handover escalation plan

agreed and in place with new

process for managing handovers

agreed to maintain flow. Escalation

to division with clear triggers in

place.

Weekly ED review meeting to review

previous weeks performance and

implement lessons learnt

Plans in place to manage with

reduced capacity during January

through March 2016 whilst building

works are underway.

31/03/2016

30/09/2015

14/12/2015

31/01/2016

31/12/2015

30/09/2015

14/12/2015

Ongoing

31/12/2015

31/03/20161501

Responsiv

eness

19/0

9/2

013

CO

RP

Ste

venson,

Angela

Involv

em

ent

of

Serv

ice U

sers

Patient admitted to the

right bed first time

If the Trust does not maintain and improve ability to

allocate the right bed first time there is an increased

risk of receiving poor quality of our care

(effectiveness, experience and safety)

1) Operational meeting three times a day chaired by

AD Site Services with clinical involvement from

Matrons, Nurse Specialists and therapists

2) Daily Board rounds by clinical site team. Focusing

on #NOF, Stroke and Medical outliers

3) Live 'To come In' lists available to view in all

specialty wards to encourage active pull of patients

from AMU to the correct specialty bed

4) Matrons review ward areas on a daily basis

5) Matron on site 7 days a week

9 3 5 15

As described on BAF

Reviewing compliance to establish a

key baseline target

Build an integrated discharge unit to

increase community capacity

27/06/2014

31/08/2015

18/01/2016

31/03/2014

23/11/2015

31/03/2016

1678

Responsiv

eness

23/0

3/2

015

CO

RP

Ste

venson,

Angela

Serv

ice A

ccess

RTT Access Standards Due to on-going operational pressures and

increasing demand for elective services, the Trust

cannot offer all services within the 18 weeks

standards set out in the NHS Constitution. Longer

waiting times result in poor patient experience and

increase the number of formal and informal

complaints

1. Access Policy revised 2014

2. Weekly PTL / performance meetings to monitor

progress.

3. Service Level plans to increase capacity where

required.

4. Operational plan for winter 2015/16 to support

inpatient elective care

15 3 5 15

Manage the number of IPs booked

on lists to avoid cancellations

Improve Theatre Utilisation

Ring-fencing of Tandridge and

Woodland Wards

27/02/2015

20/06/2015

15/05/2015

09/02/2015

05/08/2015

18/09/2015

31/03/2016

1401

Safe

ty

23/0

1/2

013

CO

RP

Hold

en,

Des

Patient

Safe

ty

Risk of outbreak of viral

gastroenteritis

Risk of outbreak of viral gastroenteritis (outbreak of

diarrhoea and vomiting). Impact on patient safety

and trust reputation. Has operational impact due to

bed closures.

D&V policy

Hydrogen peroxide system for terminal cleaning

Use of Actichlor Plus for environmental cleaning

Use of Tristel Jet for commode and bed pan cleaning

Use of SEC Norovirus Toolkit

Outbreak control Group

Surveillance of diarrhoea and vomiting

Red aprons system

Stat and mandatory training

Policy

Communications messages to staff, visitors and

patients

Norovirus leaflets

Hand hygiene facilities

Restricted visiting

Use of signs at entrance to wards and bays, and red

aprons to facilitate communication that an outbreak is

taking place.

16 3 5 15

Develop RAG rated system for

terminal cleaning

Audit terminal cleaning

Implement ATP testing

Dedicated internal norovirus planning

meeting.

Use of red aprons during outbreaks

of D&V

Meeting with stakeholders regarding

norovirus preparedness

Audit of post-outbreak cleaning

Pilot Patient Hand Hygiene

Champions in Elderly Care

Stakeholders meeting to discuss

health system norovius planning

Monitor use of ED risk assessment

for patients admitted with diarrhoea

and/or vomiting

Monitor ward refurbishment

programme

Stakeholder norovirus study day

Prepare options appraisal for

emptying bays to facilitate terminal

cleaning following outbreak

31/03/2013

30/06/2013

01/04/2013

02/09/2013

31/03/2014

31/03/2013

20/03/2015

01/03/2015

22/09/2014

31/03/2014

30/03/2013

25/09/2013

31/01/2013

06/12/2013

26/07/2013

26/07/2013

02/09/2013

11/02/2014

06/12/2013

20/03/2015

22/09/2014

21/05/2014

26/07/2013

25/09/2013

26/07/2013

31/03/2016

1672

Work

forc

e

01/0

2/2

015

CO

RP

Park

er,

Y

vonne

Sta

ffin

g -

genera

l

Sickness Absence

Levels with impact on

day to day management

and expenditure

Continuing risk to the delivery of effective services

and Trust Strategic Objectives caused by the

resources required to actively manage the Trusts

rising Sickness Absence rate and ensure safe

services. This is also having a significant effect on

the ability to control the Trusts temporary staffing

costs.

Firstcare real time sickness absence monitoring

reports and daily updates to managers inbox.

Daily sit reps at ward level used to ensure shift by

shift safe levels of service.

eRostering software to manage rota's prospectively.

Agency PMO.15 3 5 15

Actions described in the Agency

PMO

Focused interventions to support the

Trust's Stress Management Policy

(Anxiety/Stress/Depression has

been highest reason for absence for

past 8 months)

29/02/2016

29/02/2016

31/03/2016


Date: 25 February 2016 Agenda Item: 2.1

REPORT TITLE: Patient Story

EXECUTIVE SPONSOR: Fiona Allsop, Chief Nurse

REPORT AUTHOR (s): Debbie Mayne – Matron Theatres


Action Required:

Approval () Discussion (√) Assurance ()

Purpose of Report: To provide an update on actions undertaken relating to WHO Safety Surgical Checklist following a Never Event in Theatres in 2015. Summary of key issues The Safer Surgery Saves Lives initiative was launched by the World Health Organisation (WHO) in 2008 to reduce the number of surgical errors and enhance patient safety during the perioperative phase of care. Part of this initiative was to introduce a surgical safety checklist for use in perioperative environments. The checklist highlights generic core safety standards that may be applied to all perioperative settings and forms part of the 5 steps to safer surgery (NPSA, 2010). The investigation following the Never Event highlighted that:

• Using the WHO Surgical Safety Checklist did not prevent the occurrence of a Never Event

• Monthly audit of the WHO Checklist, suggested that 100% of patients have a completed checklist and questioned the validity of this audit

Actions taken as a result included

• Dedicated governance education • Review of WHO Surgical Safety Checklist

Recommendation:

To note the report.



2 An Associated University Hospital of Brighton and Sussex Medical School


Legal and regulatory impact Yes

Financial impact Yes

Patient Experience/Engagement Yes

Risk & Performance Management Yes

NHS Constitution/Equality & Diversity/Communication Yes

Attachment: Patient Story Presentation

Theatre Patient Story

Review of the WHO Surgical Safety Checklist

An Associated University Hospital of Brighton and Sussex Medical School

Background

• A patient was scheduled for and had consented to ‘Total laparoscopic hysterectomy and left salpingo-oopherectomy, plus excision of endometriosis’

• A Never Event occurred: The patient also had her right ovary and fallopian tube removed during the procedure

• The event was not reported at the time. Trust managers only became aware, when the patient made a complaint a week after the procedure

• The patient expressed her concern to theatre matron and the lead investigator that this could happen again

After event review

• The after event review meeting reviewed the various steps that contributed to the incident taking place

• This included but was not limited to the use of the WHO Surgical Safety Checklist

The WHO Surgical Safety Checklist

The Safer Surgery Saves Lives initiative was launched by the World Health Organisation (WHO) in 2008 to reduce the number of surgical errors and enhance patient safety during the perioperative phase of care

The launch saw the introduction of a new surgical safety checklist for surgical teams to use in perioperative environments as part of a major drive to make surgery safer worldwide (DH, 2008)

The NPSA (2009) has adapted this checklist for use in England and Wales and it is intended for use with all patients undergoing surgical procedures.

The checklist highlights generic core safety standards that may be applied to all perioperative settings and forms part of the 5 steps to safer surgery (NPSA, 2010)

The 5 Steps to Safer Surgery

1. The pre-operative briefing

2. The sign-in phase

3. The timeout

4. The sign-out phase

5. The de-brief

The AAR found that:

the pre-operative briefing took place

the sign-in took place in the anaesthetic room; patient identity and the correct, consented procedure were accurately confirmed

the time-out step was completed

the sign-out was completed but largely unremarkable

there was no debrief at the end of the list

Concerns • Using the WHO Surgical Safety Checklist did not prevent the

occurrence of a Never Event

• Monthly audit of the WHO Checklist, suggests that 100% of patients have a completed checklist, so: • Is the checklist completed as a tick box exercise rather than a tool

to ensure safety? • The theatre team are not giving safety a high enough priority

Actions Development of the theatre vision to foster team building

Identification of team objectives to develop ownership by theatre team

Identification of team behaviours

These activities led to the identification of safety as a priority among theatre teams Dedicated governance afternoon sessions to raise awareness of:

Never events

What is an incident?

How to report incidents

Responsibility for reporting

Actions Review of WHO Surgical Safety Checklist by matron and

lead for practice development

First draft shared with theatre team leaders

Subsequent drafts shared at ‘WHO Clinics’ on governance afternoons - feedback given by theatre teams

Feedback invited via clinical leads, divisional meetings and two week pilot

The current WHO Surgical Safety Checklist

Surgical Safety Checklist

The differences

Key steps highlighted with colour

Lead for each step is described

Questions simplified

Change in staff between step 1 and 2 recorded

Specific record of incidents and responsibility for reporting

Next steps

New checklist in use in operating theatres at ESH and CSSU by 1 April 2016

two week audit of theatre team engagement with use of current and new checklist

Review brief and debrief forms

Develop specialism specific safety checklists



REPORT TITLE: Chief Nurse & Medical Director Report

EXECUTIVE SPONSOR: Fiona Allsop, Chief Nurse Des Holden, Medical Director

REPORT AUTHOR (s): Fiona Allsop, Chief Nurse Des Holden, Medical Director


Action Required:


Purpose of Report: To provide an update on continuing work in relation to safe and quality focussed patient care that sits outside the operational performance reports including monthly Safer Staffing information and exception reports. Summary of key issues • The Safer Staffing report (January 2016 data) indicates that the Trust has delivered

the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template.

• The current progress on nursing recruitment is outlined. • Information is provided outlining the proposal for an intermediate care role which sits

between the role of a Care Assistant with a Care Certificate and a graduate Registered Nurse.

Recommendation:

To note the report.


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment:

Legal and regulatory impact Yes

Financial impact Yes

Patient Experience/Engagement Yes


Risk & Performance Management Yes

NHS Constitution/Equality & Diversity/Communication Yes

Attachment:


Chief Nurse/ Medical Director Report – 25 February 2016 Chief Nurse Report 1. Introduction To provide an update to the Board on nursing staffing in relation to planned versus actual staffing, an update regarding safer staffing monitoring, a summary of the recent correspondence in relation to staffing and efficiency and on recruitment activity. 2. Staffing Planned versus Actual – January 2016

Ward Ward Specialty Entries RN Day RN Night NA Day NA Night Total Day Total Night Overall

Abinger Ward 430 - GERIATRIC MEDICINE 31 94% 100% 89.98% 100% 91.86% 100% 94.83%

Acute Medical Unit 300 - GENERAL MEDICINE 31 96.76% 98.16% 90.57% 95.16% 94.94% 97.07% 95.89%

Birthing Centre 501 - OBSTETRICS 31 100% 82.26% N/A N/A 100% 82.26% 91.13%

Bletchingley Ward 300 - GENERAL MEDICINE 31 97.83% 100% 95.6% 100% 96.77% 100% 98.05%

Brockham Ward 502 - GYNAECOLOGY 31 95.27% 91.4% 93.44% 109.68% 94.67% 95.97% 95.19%

Brook Ward 100 - GENERAL SURGERY 31 100% 98.39% 89.85% N/A 96.51% 98.39% 97.25%

Buckland Ward 101 - UROLOGY 31 95.32% 100% 92.77% 98.36% 94.41% 99.19% 96.18%

Burstow Ward 501 - OBSTETRICS 31 96.46% 81.72% 98.88% 98.39% 97.27% 88.39% 93.23%

Capel Annex l Ward 100 - GENERAL MEDICINE 31 99.19% 100% 97.48% 98.39% 98.46% 99.19% 98.72%

Capel Ward 430 - GERIATRIC MEDICINE 31 96.94% 98.91% 104.14% 96.83% 99.61% 98.06% 98.93%

Chaldon Ward 300 - GENERAL MEDICINE 31 93.12% 96.77% 98.4% 95.7% 95.37% 96.13% 95.63%

Charlwood Ward 301 - GASTROENTEROLOGY 31 91.66% 96.43% 100% 94.64% 94.63% 95.54% 94.97%

Copthorne Ward 301 - GASTROENTEROLOGY 31 100% 100% 100% 98.39% 100% 99.19% 99.68%

Coronary Care Unit 320 - CARDIOLOGY 31 89.2% 98.36% N/A 100% 90.28% 98.9% 94.54%

Delivery Suite 501 - OBSTETRICS 31 98.36% 96.77% 96.7% 98.39% 97.95% 97.18% 97.56%

Discharge Lounge 300 - GENERAL MEDICINE 31 90.38% 96.77% 96.49% 93.55% 93.39% 95.16% 94.01%

Godstone Ward (Haem) 303 - CLINICAL HAEMATOLOGY 31 100% 100% N/A N/A 100% 100% 100%

Godstone Ward (Med) 300 - GENERAL MEDICINE 31 94.84% 100% 102.15% 101.08% 97.58% 100.54% 98.85%

Hazelwood 300 - GENERAL MEDICINE 31 100.7% 98.39% 97.78% 98.39% 99.26% 98.39% 98.91%

Holmwood Ward 320 - CARDIOLOGY 31 97.84% 100% 95% 101.61% 97.05% 100.81% 98.42%

TU/HDU 192 - CRITICAL CARE MEDICINE 31 98.88% 99.47% 84.91% 93.33% 96.84% 99.01% 97.87%

Leigh Ward 110 - TRAUMA & ORTHOPAEDICS 31 101.17% 101.61% 94.68% 94.44% 98.27% 97.37% 97.93%

Meadvale Ward 430 - GERIATRIC MEDICINE 31 88.06% 100% 98.39% 100% 93.46% 100% 95.65%

Neonatal Unit 420 - PAEDIATRICS 31 96.15% 100.79% 98.56% 90.32% 96.89% 97.34% 97.1%

https://bi01/information/ddc-monthview-ward.php?period=2016-01&ward=O000000096

























Newdigate Ward 110 - TRAUMA & ORTHOPAEDICS 31 93.94% 98.39% 106.2% 95.65% 99.03% 96.75% 98.16%

Nutfield Ward 430 - GERIATRIC MEDICINE 31 94.69% 100% 100% 100% 96.62% 100% 97.73%

Outwood Ward 420 - PAEDIATRICS 31 95.08% 96.24% 83.18% 80.65% 93.73% 94.01% 93.85%

Rusper Ward 501 - OBSTETRICS 31 100% 100% N/A N/A 100% 100% 100%

Surgical Assessment Unit 100 - GENERAL SURGERY 31 97.58% 98.39% 96.77% 100% 97.42% 99.19% 98.21%

Tandridge Ward 300 - GENERAL SURGERY 31 94.09% 100% 94.09% 98.39% 94.09% 99.19% 95.72%

Tilgate Annex 100 - GENERAL MEDICINE 31 96.77% 100% 99.67% 98.39% 97.84% 99.2% 98.3%

Tilgate Ward 300 - GENERAL MEDICINE 31 102.75% 110.71% 101.14% 110.71% 102.16% 110.71% 104.96%

Woodland Ward 100 - GENERAL SURGERY 31 92.16% 93.33% 105.38% 95% 97.15% 94.17% 96.17%

Total 96.42% 98% 97.05% 97.6% 96.63% 97.85% 97.12%

Commentary The Trust has delivered planned versus actual staffing profile for January. The report in January shows an improving picture in relation to overall compliance which is up 0.6% and a l s o i n i n d i v i d u a l a r e a s w i t h n o r e d s h i f t s a t u n i t l e v e l i n m o n t h .

Nursing Recruitment National and international nursing recruitment continues. The Filipino recruitment is continuing and the first cohort of staff of 10 staff have commenced in the Trust. In addition 6 trained nurses have also commenced from the EU bringing the total number of international nurses to commence in the organisation to approximately 60 since July 2015. Nurse Associate Role Consultation Health Education England (HEE) released a consultation document on 29 January which outlines proposals to develop the role of Nursing Associate. HEE is seeking views on the new role intended to sit between a Care Assistant with a care Certificate and a graduate Registered Nurse. In particular views are sought to;

• Identify the principles for the proposed new care role. • Consider the learning outcomes that will need to be assessed to assure quality,

safety and public confidence in the proposed role. • Identify what academic achievement would be required, alongside the practical

skills and how this learning should be best delivered and assessed. • Consider whether or not the proposed role should be regulated – and if so, how

and by whom • Agree the title of this new role.

The proposed new role is intended to enable flexibility across the nursing and care workforce to ensure safe, high quality care and the principles of the proposed new role that it is:

• Firmly grounded in direct care provision working with patients, families and carers within communities

• Able to deliver care in a range of settings • Able to work across a range of population groups and conditions to a defined level

of competence with a greater emphasis on community and public health perspectives

• Aware of their boundaries of competence and expertise











• Able to work within multidisciplinary teams. The anticipated benefits to the wider nursing and care workforce are seen as:

• Freeing up Registered Nurse capacity to concentrate on expert patient care, with time for high quality preparation, interaction, communications, planning and assessment, raising their status and enhancing the patient experience.

• Recognising the importance of career progression for Care Assistants (working with the professional regulators to develop a career progression pathway for the current workforce into an undergraduate nursing programme which, if approved, would allow for recognition of accreditation of prior learning thereby enabling an accelerated route from a Nursing Associate to Registered Nurse).

• Widening of the nursing career framework enabling progression from apprenticeship to senior nurse level, with opportunities to step “off and on”.

• A flexible and portable skillset that enables care provision across health and care settings.

Parameters of the role The proposed scope of practice is focused on the delivery of the fundamental aspects of direct care. Its purpose is to improve standards of care, offer a new route into nursing and provide a higher skilled worker to enhance the current workforce. The Nursing Associate will work under the leadership of the Registered Nurse. HEE has stated that the role will be piloted across 30 sites in 2016 and SASH has expressed an interest to be one of the pilot sites. Responses are due by 11 March. 3. Recommendation To note the report Fiona Allsop Chief Nurse 25 February 2016



REPORT TITLE: SQC Chair Update

EXECUTIVE SPONSOR: Richard Shaw, Chair Safety & Quality Committee

REPORT AUTHOR (s): Richard Shaw, Chair Safety & Quality Committee

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) n/a

Action Required:

Approval () Discussion ( ) Assurance ()

Purpose of Report: To provide an update of the activities of the safety and quality committee. Summary of key issues The report provides a summary of the key agenda items which were discussed at the Safety and Quality Committee in February 2016.

Recommendation:

N/A


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about Corporate Impact Assessment:

Legal and regulatory impact Compliance with CQC, MHRA and Audit Commission

Financial impact Serious incidents often become claims

Patient Experience/Engagement Included in the report

Risk & Performance Management Reporting, investigation and learning from serious incidents informs risk management

NHS Constitution/Equality & Diversity/Communication Included in the report

Attachment: N/A

Trust Board Report – 25th February 2016 Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 4th February 2016. It considered its standing agenda items; the reports from ECQRM and CQRM meetings and the SQC Quality Report. Once a quarter the Committee focuses on quarterly reports covering priority areas for assurance, including Infection Control, Adult and Children Safeguarding, Incidents and Complaints, and all of these items were considered at the February meeting. ECQRM and Quality Report The Committee noted that most of the quality risks for the Trust are well documented and discussed, and primarily relate to the pressure on the hospital of increasing patient numbers, especially in A&E, in admission to an appropriate ward, and in timely discharge to the community. An exception to this pattern is VTE. The Committee noted that the VTE target was met in December and asked for a report at a future meeting on the progress that has been made and the outstanding challenges. The Committee also noted the recent discussion about Falls at ECQRM. This is a topic that has received a lot of attention during the last year or so, but while the incidence of Falls initially decreased, there have been more recent signs of this trend plateauing. The Falls Lead is also changing so it is a good moment to review the approach within the Trust. SQC asked for a report at the March meeting. The Committee was pleased to note that all Cancer metrics were met in December after a challenging autumn. An invitation to attend SQC was re-issued to the CCG, with the comment that attendance could provide a useful additional source of assurance about SASH services. Complaints The Trust is piloting a new process for managing complaints which is designed to ensure there is clear accountability for addressing each point in the complaint and that a clear record of learning and improvements in patient experience is drawn out. Each complainant will be telephoned within three days of the complaint being received. The Committee welcomed this approach. It also expressed concern at the drop off in reports from PALS and was assured that a review of the future direction of PALS is taking place. Incidents The Committee probed the reasons for the length of time it takes to open and close some investigations into incidents. It was assured that the most severe incidents are flagged up to senior management and that incident management will now be added to the Dashboard as an indicator of safety culture in the Trust. Safeguarding The Trust is an outlier locally in the reporting to Surrey Police of missing persons: we report a higher number than other acute trusts. Work is taking place with Surrey Police to understand whether this reflects differences in risk or reporting. The Committee takes good assurance from the handling of adult safeguarding concerns raised about the Trust. But it remains unsighted on how the much larger number of concerns raised about community care are dealt with. Information about this will be included in future reports. The Committee also probed compliance with training in adult safeguarding, and a report on this will be taken to Finance and Workforce Committee.

In Children’s Safeguarding, the Committee welcomed the new multi-agency hub now in place for Surrey and Sussex and hoped that this would provide effective support for collaborative working. It also noted the challenging volume of work in the action plan and will monitor progress in delivering it. Mental Health Ahead of the recent national report on mental health services, the Committee welcomed the decision to nominate a Board-level lead in Mental Health and will take regular reports on the Trust’s work in this area. Infection Control The Committee received a half-year report on Infection Control. There have been two cases of MRSA blood stream infection in the last year, against a target of zero, and the Committee took time to understand the particular circumstances of each case. Of 24 cases of CDiff that have been reviewed, two were judged to have involved lapses of care on behalf of the Trust; although in neither case did this cause the infection. Nine other cases are yet to be reviewed. The Trust will face financial penalties if it exceeds 15 lapses of care in this financial year, and the Committee therefore took reasonable assurance from this. The Committee has previously probed the effectiveness of alerts on Cerner. Infection Control nurses put alerts on Cerner where patients are at risk of MRSA or CDiff. Clinical l staff are expected to check this as it may affect treatment options and bed allocation. A snapshot audit found that not all clinical staff were aware of the alerts and some wards, with high turnover, were not using the white boards effectively in relation to alerts. . The Committee asked for this to be discussed at the next meeting of the Infection Control meeting and the outcome of the discussion to be reported to ECQRM. Next Meeting The next SQC meeting is at 2pm on 3rd March. Richard Shaw Non-Executive Director Chair – Safety & Quality Committee February 2016

An Associated University Hospital of

Brighton and Sussex Medical School 1

Integrated Performance Report

M10 – January 2016

Presented by: Angela Stevenson (Chief Operating Officer) Des Holden (Medical Director) Fiona Allsop (Chief Nurse) Paul Simpson (Chief Financial Officer)




Brighton and Sussex Medical School 2 2

Patient Safety

• There were three SIs declared in January 2016 and no Never Events.

• Patient safety indicators continue to show expected levels of performance.

• The Trust had no MRSA bloodstream infections and two Trust acquired C-Diff cases in January 2016.

Clinical Effectiveness

• Mortality is lower than expected for our patient group when benchmarked against national comparators.

• Maternity indicators continue to show expected performance.

Access and Responsiveness

• The 4hr ED standard was not achieved with performance of 92.8% in January 2016 (YTD Performance is 95%)

• All Cancer Access Standards except the TWR Breast Symptomatic and the 62 Data Referral to treatment standards were achieved

in January 2016

• 18 Weeks RTT - The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end

of each month.

Patient Experience

• In December 2016 the Inpatient FFT increased to 97.4%. The ED FFT decreased to 95.8%

Workforce

• The Trust is actively reviewing initiatives to improve recruitment and retention, such as reducing time to recruit and ongoing local

and overseas recruitment.

• The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in

place. Agency usage reduced in January, but the Trust is adverse to its agency trajectory.

Performance – January 2016


Brighton and Sussex Medical School 3 3

Action: The Board are asked to note and accept this report

Legal: All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance on safe high quality

care (Including mortality).

Regulation: The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore license

care services under the Health and Social Care Act 2009 and associated regulations.

Patient experience/

engagement: This paper includes significant detail on both patient experience and access to services.

Risk & performance

management

This is the main Board assurance report for performance against quality and financial measures and is linked to risk management

through the SRR.

NHS constitution; equality &

diversity; communication. This report covers performance against access standards with the NHS Constitution.

Finance

• The Trust forecast has worsened to a £(4.2)m deficit (after donated asset technical adjustments), as the anticipated reimbursement

from the TDA in respect of lost income resulting from the Junior Doctors industrial action has not materialised. This position also

includes £3.0m non-recurrent income from the TDA (capital to revenue transfer). The YTD variance to the forecast is £0.4m adverse.

Key Risks

• The Significant Risk Register for the Trust includes five quality risks in relation to “Right bed first time”, ED Access standards,

Outbreak of viral gastroenteritis, Increasing sickness absence levels and RTT Access Standards.

Performance – January 2016



Patient Safety

• Patient safety indicators continue to show expected levels of performance.

• There were no Never Events reported in January 2016.

• VTE risk assessment performance for January 2016 is undergoing validation - performance of 95% is expected. A dedicated session of

the Executive Committee for Quality and Risk will focus on VTE including the systems for recording assessment completion

• Safety Thermometer (all Harm) – performance decreased to 91.2% driven by an increase in patients with Catheters / UTIs (3.1% / 19

patients compared to 2% in December 2015)

Patient Safety

Indicator Description Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Trend

No of Never Events in month 0 0 1 1 0 0 0 0 0 0 0 0 0

No of medication errors causing Severe Harm or Death 0 0 0 0 0 0 0 0 0 0 0 0 0

Safety Thermometer - % of patients with harm free care (all harm) 93.0% 92.0% 92.0% 91.3% 93.5% 92.0% 95.0% 92.2% 93.2% 95.4% 90.3% 92.6% 91.2%

Safety Thermometer - % of patients with harm free care (new harm) 96.0% 95.0% 96.0% 95.9% 97.3% 95.2% 97.7% 94.8% 96.7% 97.6% 95.0% 96.2% 95.1%

Percentage of patients who have a VTE risk assessment 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% TBC

WHO Checklist Usage - % Compliance 96% 96% 100% 98% 100% 98% 96% 100% 100% 100% 100% 100% 100%

Number of Sis 5 6 5 3 3 6 1 1 4 6 2 7 3

Serious Incidents - No per 1000 Bed Days 0.26 0.35 0.26 0.16 0.16 0.33 0.05 0.05 0.23 0.32 0.11 0.38 0.16

Percentage of Patient Safety Incidents causing Severe harm or Death 0.6% 0.7% 0.6% 0.2% 0.6% 0.5% 0.0% 0.2% 0.8% 0.6% 0.4% 0.8% 0.8%

Number of overdue CAS and NPSA alerts 1 1 0 0 0 0 0 0 0 0 0 0 0



Three SIs were declared in January 2016 (in all cases full investigations have been started):

• 2016/559 Fall (Newdigate)

Patient had an unwitnessed fall which resulted in a fractured neck of femur.

• 2016/618 Diagnostic Incident – delay

Patient with a diagnosis of bowel cancer was admitted for an elective laparoscopic right hemi colectomy on 26th March 2015; patient

was transferred post operatively to ICU and died on 30th March 2015. Post mortem found cause of death to be sepsis.

• 2016/1212 Fall (ED)

The patient was found on the toilet floor having sustained an unwitnessed fall, the patient later reported that he had slipped. An x-ray

confirmed fracture to the left hip, shoulder and hand.

Infection Control

• There were no cases of MRSA in January 2016 and two cases of Trust acquired C.diff.

• There was no outbreak in January, but in light of the risk of outbreaks of viral gastroenteritis, the following risk is on the Trust's

significant risk register:

• Risk of outbreak of viral gastroenteritis - Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on

patient safety and experience – Risk score 15 (Likelihood of 5 and consequence of 3).

Patient Safety


MRSA BSI (incidences in month) 0 1 0 0 0 0 0 0 0 0 1 0 0

CDiff Incidences (in month) 2 6 1 1 3 3 4 3 2 6 2 6 2

MSSA 0 2 1 1 0 1 0 0 0 3 0 0 0

E-Coli 14 18 12 11 23 20 18 34 27 29 18 23 22



Mortality and Readmissions

• Latest HSMR data for the Trust shows mortality remains lower than expected for our patient group when benchmarked against national

comparators.

Maternity

• Maternity indicators continue to show expected performance.

Clinical Effectiveness


HSMR (56 Monitored diagnoses - 12 Months) 92.8 92.6 93.4 93.0 95.0 95.1 93.8 943.0 95.7 95.3

Emergency readmissions within 30 days (PBR Rules) 6.9% 6.7% 6.6% 6.4% 7.0% 7.2% 7.7% 7.4% 7.3% 6.3% 6.3% 6.9%


C Section Rate - Emergency 18% 16% 17% 13% 17% 18% 14% 17% 17% 14% 15% 16% 17%

C Section Rate - Elective 7% 11% 8% 11% 9% 10% 11% 13% 8% 13% 10% 9% 9%

Admissions of full term babies to neo-natal care 6.0% 6.0% 6.0% 7.0% 6.2% 4.0% 5.0% 5.1% 5.8% 7.1% 6.6% 5.9% 3.8%



Emergency Department

• The ED 4hr standard was not achieved in January 2016 with performance of 92.8%.

• Volumes /Acuity of emergency attendances / admissions continue to be an issue and with overnight non-elective admissions up 7%

(3% for East Surrey CCG and 16% for Crawley CCG) compared to last year.

• Discharge delays are also a significant driver of performance with an average of 114 beds occupied by patients who are medically

ready for discharge

• Despite the positive work taken on the Ambulance handover process, Ambulance turnaround performance showed an adverse

movement in January 2016 driven by volumes of Ambulance attendances.

• In light of the on-going operational pressures in the Trust, the following risks are on the significant risk register:

• ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system –

Risk score 16 (Likelihood of 4 and consequence of 4)

• Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed first

time, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5

and consequence of 3)



ED 95% in 4 hours 92.0% 91.3% 95.0% 96.8% 96.0% 94.8% 94.3% 96.1% 97.1% 95.5% 92.9% 95.5% 92.8%

Patients Waiting in ED for over 12 hours following DTA 0 0 0 0 0 0 0 0 0 0 0 0 0

Ambulance Turnaround - Number Over 30 mins 163 259 247 199 170 206 238 220 225 225 231 191 227

Ambulance Turnaround - Number Over 60 mins 26 51 31 19 34 38 32 30 29 31 30 10 21



Cancer

• In January 2016, all Cancer Access Standard except the TWR Breast Symptomatic and the 62 Data Referral to treatment standards.

• On the Breast Symptomatic pathway, 10 patients breached the standard. This was driven by patient deferrals in December resulting in

attendance over two weeks in January.

• 18 patients (14.5 breaches) breached the 62 Day Referral to Treatment Standard across a range of pathways (Urology – 4 breaches,

Skin – 3 breaches). Root cause analysis is being undertaken of all breaches to ensure pathway improvements are made and any

capacity issues / internal delays are resolved.



Cancer - TWR 93.1% 93.1% 93.1% 93.3% 94.2% 93.1% 93.1% 93.0% 89.6% 89.9% 93.2% 94.3% 93.0%

Cancer - TWR Breast Symptomatic 93.4% 96.3% 93.8% 93.8% 93.8% 90.6% 93.2% 93.3% 94.2% 93.8% 93.4% 96.2% 90.7%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.0%

Cancer - 31 Day Second or Subsequent Treatment (DRUG) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer - 31 Day Diagnosis to Treatment 97.1% 100.0% 100.0% 98.2% 97.0% 96.2% 98.3% 99.2% 99.3% 98.2% 96.6% 92.4% 97.6%

Cancer - 62 Day Referral to Treatment Standard 85.4% 88.0% 83.7% 86.4% 83.9% 86.5% 80.7% 84.2% 86.2% 85.6% 88.3% 85.8% 80.4%

Cancer - 62 Day Referral to Treatment Screening 92.3% 100.0% 92.3% 84.6% 92.3% 100.0% 87.5% 88.9% 100.0% 87.5% 90.9% 100.0% 100.0%



Referral to Treatment (RTT) and Diagnostics

• At aggregate level, the trust continues to deliver against the incomplete pathways standard which measures % of patients waiting less

than 18 weeks at the end of each month.

• Challenges remain in General Surgery, Trauma and Orthopaedics and Cardiology. A number of newly recruited consultants will

increase capacity and support reduction in patients over 18 weeks with performance expected to improve over the coming months.

• The diagnostic standard continues to be achieved

• 90 patients were cancelled at the “last minute” for non clinical reasons, the increase on December being due to bed pressures

• The following risk is on the significant risk register:

• RTT Access Standards - Due to on-going operational pressures and increasing demand for elective services, the Trust cannot

offer all services within the 18 weeks standards set out in the NHS Constitution. Longer waiting times result in poor patient

experience and increase the number of formal and informal complaints. (effectiveness, experience and safety) – Risk score 15

(Likelihood of 5 and consequence of 3)



RTT Incomplete Pathways - % waithing less than 18 weeks 92.1% 94.0% 93.7% 93.6% 93.5% 92.6% 92.2% 92.0% 92.1% 92.2% 92.5% 92.1% 92.0%

RTT Patients over 52 weeks on incomplete pathways 0 0 0 0 0 0 0 0 0 0 0 0 0

RTT Admitted - 90% treated within 18 weeks 90.2% 82.1% 88.4% 91.6% 90.1% 92.0% 84.0% 81.5% 77.9% 78.5% 80.7% 81.1% 78.1%

RTT Non Admitted - 95% treated within 18 weeks 91.7% 91.0% 93.5% 93.6% 95.3% 93.4% 89.4% 89.1% 88.7% 87.9% 85.2% 85.4% 85.2%

Percentage of patients waiting 6 weeks or more for diagnostic 0.9% 0.7% 1.4% 1.0% 0.2% 0.8% 1.0% 0.1% 0.5% 0.2% 0.2% 0.1% 0.0%

Last Minute Elective Cancellations for non clinical reasons 18 26 45 11 37 45 24 25 44 41 133 54 90

% of operations cancelled on the day not treated within 28 days 0.0% 0.0% 0.0% 0.0% 0.0% 2.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%



Patient Voice

• Inpatients – The January Friends and Family Test (FFT) score for inpatient wards has increased slightly to 97.4%, based on a slightly

increased response rate of 34% (compared to 30% in December).

• Emergency Department – The January FFT score has dropped slightly to 95.8%. The response rate remains stable at 20%.

• Maternity – FFT scores for both the antenatal and birth touchpoints have increased to 97.5% and 95.5% respectively. The antenatal

score is based on a marked improvement in the response rate, up to 23% compared to 13% in December. This brings the response

rate in line with that achieved for touchpoints two and three. The FFT score for the touchpoint three has remained very similar for the

last four months

National comparisons for December

• Inpatients/daycases – The Trust was ranked average (95.4% against a national average of 95.3%). The combined response rate was

below average (18.0% compared to 22.6%).

• Emergency Department – Of those trusts with a response rate of greater than 2% SASH is ranked second, based on an above average

response rate (19% compared to a national average of 13%).

• Maternity – The Trust score for touchpoint one is in line with the national average. For touchpoints two and three the Trust’s score is

below average

Patient Experience


Inpatient FFT - % positive responses 95.7% 96.9% 94.2% 94.4% 95.1% 94.7% 95.1% 95.3% 96.1% 95.0% 95.1% 95.1% 97.4%

Emergency Department FFT - % positive responses 95.8% 97.1% 94.7% 95.4% 95.3% 93.7% 91.4% 95.8% 96.9% 95.3% 97.3% 97.5% 95.8%

Maternity FFT - Antenatal - % positive responses 97.6% 97.1% 97.0% 96.3% 100.0% 83.3% 94.1% 98.8% 94.3% 96.5% 96.1% 96.0% 97.5%

Maternity FFT - Delivery - % positive responses 95.5% 97.2% 100.0% 94.7% 97.0% 94.9% 93.8% 87.9% 95.4% 95.1% 97.6% 91.7% 95.5%

Maternity FFT - Postnatal Ward - % positive responses 85.9% 91.0% 97.3% 86.7% 91.0% 86.5% 90.0% 87.7% 87.9% 88.9% 88.8% 88.9% 88.4%

Mixed Sex Breaches 0 0 0 0 0 0 0 0 0 0 0 0 0

Complaints (rate per 10,000 occupied bed days) 18 26 22 25 22 27 29 33 27 24 19 17 27



Workforce

• Sickness absence remained at 3.8% in January 2016, 0.5% less than the prior year.

• The increasing trend on sickness absence levels which impacts on day to day management and expenditure remains on the Trust’s

significant risk register – Risk score 15 (Likelihood of 5 and consequence of 3)

• Streamlined nursing recruitment with a new recruitment tracker with ward dashboard to highlight blockages is now in place and is

discussed on a weekly basis. Activity around international recruitment continues.

• Agency usage reduced in January, with a favourable impact from new bank arrangements in theatres, but the Trust is adverse to its

agency trajectory.

• Staff Turnover fell remained at 13.8% in January 2016 as initiatives to improve retention and staff experience take effect.

• The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place.

Workforce


Average fi l l rate – registered nurses/midwives (%) - Day 94.8% 95.9% 96.5% 96.8% 95.7% 96.9% 93.3% 92.5% 95.0% 95.1% 95.4% 95.1% 96.3%

Average fi l l rate – care staff (%) - Day 92.6% 93.8% 94.5% 96.1% 93.8% 93.5% 94.3% 94.5% 95.1% 97.2% 98.7% 97.1% 97.0%

Average fi l l rate – registered nurses/midwives (%) - Night 97.2% 97.7% 96.7% 96.5% 97.1% 94.1% 95.2% 94.3% 96.4% 96.9% 97.2% 97.9% 98.0%

Average fi l l rate – care staff (%) - Night 93.3% 94.9% 94.9% 95.2% 95.9% 94.9% 94.4% 93.8% 96.4% 96.9% 97.8% 98.2% 97.6%

Overall Sickness Rate 4.3% 4.4% 4.2% 4.2% 4.3% 4.1% 3.9% 3.7% 4.4% 4.4% 4.0% 3.8% 3.8%

%age of staff who have had appraisal in last 12 months 67% 68% 73% 71% 68% 58% 56% 57% 64% 72% 74% 74% 72%

Staff Turnover rate 15.7% 15.7% 15.2% 15.5% 15.9% 15.6% 15.6% 15.2% 15.2% 15.0% 14.4% 13.8% 13.8%



Finance

• The Trust is reporting against the revised plan submitted to the TDA in September 2015 and the forecast notified to the TDA in

December.

• The Trust forecast has worsened to a £(4.2)m deficit (after donated asset technical adjustments), as the anticipated reimbursement

from the TDA in respect of lost income resulting from the Junior Doctors industrial action has not materialised. This position also

includes £3.0m non-recurrent income from the TDA (capital to revenue transfer). The YTD variance to the forecast is £0.4m adverse.

• At the end of month 10 the Trust has a YTD I&E deficit (after donated asset technical adjustments) of £(3.9)m which is £(3.3)m

adverse to the revised TDA plan. A £1.5m improvement from last month due to the inclusion of £3m TDA healthcare support income,

partially offset by a reduction in elective income due to industrial action. Elective activity has been impacted by emergency activity (as

in past months).

• The underlying position at the end of January is a £(4.5)m deficit.


Outturn £m Surplus / (Deficit) - Plan 2.3 2.3 2.3 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6

Outturn £m Surplus / (Deficit) - Forecast 2.3 (2.5) (2.4) 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 (3.0) (4.2)

YTD £m Surplus / (Deficit) - Plan 1.9 1.4 2.3 (0.8) (1.2) (2.0) (1.1) (0.7) (0.6) (2.0) (2.0) (1.3) (0.6)

YTD £m Surplus / (Deficit) - Actual 1.9 (2.9) (2.4) (0.8) (1.1) (2.0) (1.3) (2.6) (3.3) (3.6) (4.2) (5.3) (3.9)

Outturn UNDERLYING £m Surplus / (Deficit) - Plan 3.4 3.4 3.4 3.8 3.8 3.8 3.8 3.8 3.8 3.8 3.8 3.8 3.8

Outturn UNDERLYING £m Surplus / (Deficit) - Actual (5.2) (5.2) (5.2) 3.8 3.3 3.3 3.3 3.3 3.3 3.3 3.3 (6.3) (6.3)

YTD Savings £m - Actual 8.6 9.8 11.0 0.3 0.5 0.8 1.3 1.9 2.1 2.5 2.8 3.2 3.6

OT Risk £m Surplus / (Deficit) - Assessment (5.5) (0.7) 0.0 0.0 (1.0) 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Outturn Cash position £m Fav / (Adv) - Forecast 2.6 2.6 2.6 7.6 7.6 7.6 2.6 1.2 2.4 2.4 2.4 2.5 2.5

YTD Cash position £m Fav / (Adv) - Actual 3.8 3.8 2.6 3.2 2.9 2.6 2.5 3.0 3.9 4.8 5.0 5.7 4.5

YTD Liquid ratio - days (8.0) (18.0) (21.0) (20.0) (21.0) (23.0) (22.0) (25.0) (19.0) (13.0) (16.0) (16.0) (15.0)

YTD BPPC (overall) volume £m 87% 86% 82% 62% 75% 78% 78% 76% 69% 59% 60% 60% 53%

YTD BPPC (overall) value £m 83% 83% 81% 65% 73% 75% 75% 74% 68% 61% 63% 63% 60%

Outturn Capital spend Fav / (Adv) - forecast 19.3 19.3 19.3 17.1 17.1 17.1 17.1 17.1 17.1 17.1 17.1 14.1 14.1



Finance

• The Trust has achieved £3.6m of savings to date (a £2.6m shortfall measured against the TDA plan). The forecast CIP position is

£3.5m adverse to the full year plan and this has been factored into the overall Trust forecast.

• The Trust’s cash balance at the end of January was £4.5m, with a forecast year end cash balance of £2.5m. Backlog creditors

decreased by £2.0m to £11.3m. The TDA have advised that the Trust’s loan/PDC application will be replaced to an increase to our

existing working capital facility.

• The capital spend forecast this year has reduced by £3.0m, from £17.1m to £14.1m following an application to TDA for Capital to

Revenue transfer which has been approved.

• Further risk to the I&E position has been provided by the interpretation applied by CCG’s to a letter issued nationally on 19th January

which discusses the suspension of fines. CCG’s appear to wish to continue to levy the fines to improve the CCG position.



REPORT TITLE: Finance & Workforce Committee Chair Update – Part 1

EXECUTIVE SPONSOR: Paul Simpson (Chief Financial Officer)

REPORT AUTHOR (s): Richard Durban (Non-Executive Director and FWC Chair)


No – Board Update

Action Required:

Approval ( ) Discussion ( ) Assurance (√)

Purpose of Report:

To update the Board on the discussions and actions from the Finance and Workforce Committee.


The Finance and Workforce Committee met on the 23rd

February 2016 and was quorate.

• M10 reports were received for Finance & the 15/16 CIP, Workforce and Organisational

Development, Capital and IT.

• The Trust has year to date I&E deficit of £(3.9m) which is £(3.3m) adverse to the revised

TDA plan.

• The Trust’s cash balance at the end of January was £4.5m, with a forecast year end cash

balance of £2.5m

• The Trust has delivered £3.6m of savings and is behind both the TDA plan and also the

internal plan

Recommendation:


SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model


Legal and regulatory impact

The FWC reviews assurance in respect of workforce, capital

and investment projects, business planning (which includes

financial planning) and cash aspects. Employment law: laws

governing the rights of individuals and terms and conditions

terms include: National Minimum Wage Act 1998; the

Working Time Regulations 1998; Employment Rights Act

2An Associated University Hospital of


1996; Equality Act 2010; Employment Rights Act 1996, and;

the Transfer of Undertakings (Protection of Employment)

Regulations 2006. Other key laws affecting employees

include the Pensions Act 2004 and the Trade Union and

Labour Relations (Consolidation) Act 1992.

Financial performance is subject to Schedule 5 of the NHS

Act 2006 which provides the “breakeven duty”. Legal aspects

related to capital works will depend on the nature of the

works.

The main regulators, are as follows:

- External audit (the Grant Thornton for this Trust)

gives an opinion on the Trust’s compliance with

International Financial Reporting Standards and with

NHS accounting conventions – this is not purely

financial and deals with procurement, fraud,

transparency and legal duties. It also gives a Value

for Money Conclusion on the Trust’s ability to put in

place arrangements to deliver economy, efficiency

and effectiveness in its use of resources.

The Care Quality Commission registers the Trust according to

its compliance with regulations concerning the safety and

quality of services

Financial impact The report provides assurance about savings, capital spend

and the structure of the business planning process.

Patient Experience/Engagement Indirect impact through Trust planning and workforce.

Risk & Performance Management The committee, and this report, provides assurance about

workforce and capital management.


Attachment:

Report Paper



TRUST BOARD REPORT –23 February 2016

Finance & Workforce Committee Chair Update

The Finance and Workforce Committee met on 23rd

February 2016 and it was quorate. The key

points from Public meeting were:

Finance Performance M10 Report

M10 Finance performance report was received by the Committee. The Trust has year to date

I&E deficit of £(3.9m) which is £(3.3m) adverse to the revised TDA plan. The Trust’s cash

balance at the end of January was £4.5m, with a forecast year end cash balance of £2.5m. The

Trust has been granted an extension to its working capital facility which will cover the Trust

cash requirements until the end of the financial year.

Month 10 CIP report

The savings target YTD in the submitted TDA plan for 2015/16 is £6.2m and at month 10 the

Trust has delivered £3.6m of savings and is behind both the TDA plan and also the internal plan.

Contingency savings of £0.6m have been used to achieve this position.

Month 10 Workforce and Organisational Development

The paper was received by the Committee. The reported highlighted the results of the staff

survey where the Trust scored in the top 20% in the country for 17 of the findings. The

Committee discussed the 3 where the Trust was in the bottom 20% and the actions that are

being taken to identify the reasons for the scores. The achievement review timetable was

shared. Achievement review appraisals will be cascaded down from the executive team with

90% of staff who have been employed at the Trust for more than a year having had their

appraisal by the end October. The Committee noted the improvement in the recruitment

shown in the report.

Month 10 Capital report

The Committee noted the completion of the Theatres refurbishment project and the Cardiology

Unit.

Draft 2016/17 Capital plan

The Committee receive the draft Capital Plan. This reflected the reduced scale of funding -

£9.0m v £17.1 (plan) and £14.1m (forecast) in 15/16. The Committee noted the need to ensure

benefits are realised and the greater emphasis on productivity gains to increase capacity.

- The IT report was noted and the Committee.

[END]


Date: 25TH February 2016 Agenda Item: 4.1

REPORT TITLE: Standards of Business Conduct Policy




Joint Consultative Committee 12.1.16 Executive Committee 13.1.16 Audit & Assurance Committee 15.1.16

Action Required:


Purpose of Report:

This policy has been updated to reflect new regulation and overall strengthening processes for the Trust.


This policy is due for review and has been updated with the following requirements (red text):

• Updating the Summary short guide for staff – Pg 5

• Inclusion of the Fraud Act 2006 – Pg 7

• Inclusion of the Fit & Proper Person Regulations – Pg 9

• Reference to the Policy for Commercial Representatives – Pg 13

• Reference to the Council of Governors – Pg 13

• Reference to the Drugs & Therapeutic Committee & Medical Devices Group – Pg 14

• Results of failing to making a declaration and the requirement for annual declarations – Pg 14

• Requirements on awarding contracts – Pg 15

• Re-wording of requirements under intellectual property, confidential and sensitive information – Pg 16

• Trust Board responsibility for ratifying the Policy.

Recommendation:

The Board is asked to Ratify this policy.






Legal and regulatory impact There are a number of legal and regulatory requirements included in the policy

Financial impact Non-adherence to the policy may have financial impacts on the Trust

Patient Experience/Engagement N/A

Risk & Performance Management Adherence to the policy reduces risks to individual members of staff and protects the reputation of the Trust


This policy is disclosable under the Freedom of Information Act 2000.

Attachment:

Revised Standards of Business Conduct Policy – Final February 2016

Surrey & Sussex Healthcare NHS Trust

AN ORGANISATION WIDE POLICY ON STANDARDS OF BUSINESS CONDUCT

Draft/revision

Key words:

Openness, integrity, public funds, gifts, sponsorship, declaration, interests, business, conduct, transparent, hospitality, commercial, accountability

Version: 2.0

Status: Final Version for Ratification

Date ratified: 12/12/2012

Name of Owner Director of Corporate Affairs &

Director of Human Resources

Name of Sponsor Group Audit & Assurance Committee

Name of Ratifying Group Trust Board

Type of Procedural document Policy

Policy Reference: To be completed by Policy Coordinator

Date issued: 12/12/2012

Review date: December 2015

Updated: February 2016

Review date: February 2019

Target audience: All Trust Staff, Volunteers and Agency/Contract workers.

Human Rights Statement The Trust incorporates and supports the human rights of the individual, as set out by the European Convention on Human Rights and the Human Rights Act 1988

EIA Status Completed (Appendix 7)

This policy will be made available in different languages and formats upon request. Requests of this nature should be made to the Patient Advice Liaison Service (PALS) at East Surrey Hospital, whose contact details are provided below: Telephone: 01737 768511 extensions 6922 or 6831 E-Mail: [email protected] Correspondence: PALS at East Surrey Hospital, Canada Avenue, REDHILL, Surrey, RH1 5RH

2

The latest approved version of this document supersedes all other versions. Upon receipt of the latest approved versions all other version should be destroyed, unless specifically stated that the previous version(s) are to remain extant. If in any doubt please contact the document owner or Policy Coordinator.

Version Control Date//Lead Comment 1.1 January 2016

G Francis-Musanu Updating to include new regulations (FPPT) Revising requirement to submit annual declarations forms Including the Shadow Council of Governors Inclusion of Fraud Act 2006 Reference to the NHS Fraud and Corruption Reporting Line Overall strengthening of the policy

3

Contents Page No. Summary 5 1. Introduction 7 2. Purpose 7 3. Public Service Values 8 4. Scope of Policy 8 5. Organisational Responsibilities 8 6. Fit & Proper Persons Test 9 7. Conflict of Interests 11 8. Employment external to the Trust 14 9. Contracts 15 10 Private Practice 15 11. Intellectual Property 16 12. Confidentiality – Sensitive Information 16 13. Consultation and Communication with Stakeholders 16 14. Approval and Ratification 16 15. Review and Revision 17 16. Dissemination and Implementation 17 17. Archiving 17 18. Monitoring and Compliance 18 19. References 17 20. Associated Documents 18 Appendix 1 Brief Overview of Bribery Act 2010 19 Appendix 2 Short Guide to Standards of Business 20 Conduct for NHS Staff HSG (93)5 Appendix 3 Form – Declaration of Interests 22 Appendix 4 Form – Declaration of Gifts/Hospitality/sponsorship 23 Appendix 5 Form – Declaration of Relationship with Candidate 24 Appendix 6 Nolan Principles 25 Appendix 7 Equality Impact Assessment 26

4

Equality statement This document demonstrates commitment to create a positive culture of respect for all individuals, including staff, patients, their families and carers as well as community partners. The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief, and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 to promote positive practice and value the diversity of all individuals and communities. This document is available in different languages and formats upon request to the Trust Procedural Documents Coordinator and the Equality and Diversity Lead.

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Summary - of the Standards of Business Conduct Policy To assist NHS employers and staff in maintaining strict ethical standards in the conduct of NHS Business in 1993 the NHS Executive published HSG (93) 5 – Standards of Business Conduct for NHS Staff. (Please refer to the statement in the ‘Introduction’ of this document relating to HSG (93) 5. In brief, the guidelines cover the declaration of interests and acceptance of gifts and hospitality. It is the responsibility of all NHS staff to ensure that they are not placed in a position which risks, or appears to risk, conflict between their private interests and their NHS duties. The Trust’s Director of Corporate Affairs holds the Register of Interests, Gifts and Hospitality, which is checked periodically by the Audit Committee, internal and external auditors and the Trust Board. If you have anything to declare, please complete the declaration form and forward to the Director of Corporate Affairs, Trust Headquarters, East Surrey Hospital. Short Guide for staff Do:

• Make sure you understand the guidelines on Standards of Business Conduct (HSG (93) 5) referred to in your terms and conditions of employment and consult your line manager if you are not sure

• Make sure you are not in a position where your private interests and NHS duties conflict.

• Declare any relevant interests. If in doubt, ask yourself:

1. Am I, or might I be, in a position where I (or my family/friends) could gain from the connection between my private interests and my employment, or where it could be perceived by others that a gain could be made?

2. Do I have access to information which could influence the Trust’s purchasing or

contracting decisions, or could it be perceived by others that I have such access?

3. Could my outside interests be in any way detrimental to the NHS or to patients’ interests, or could other perceive them to be detrimental?

4. Do I have any other reason to think I may be risking a conflict of interest?

IF IN DOUBT – DECLARE IT

6

Always :

• Adhere to the ethical code of the Institute of Purchasing and Supply if you are involved in any way with the acquisition of goods and services.

• Seek your employer’s permission before taking on outside work, if there is any question of it adversely affecting your NHS duties.

• Obtain the Trust’s permission before accepting any commercial sponsorship.

Do Not

• Abuse your past or present official position to obtain preferential rates for private deals.

• Unfairly advantage one competitor over another or show favoritism in awarding contracts.

• Misuse or make available ‘commercial in confidence’ information.

• Accept gifts, inducements or inappropriate hospitality.

Casual gifts offered by Contractors or others e.g. at Christmas time, may not be in any way connected with the performance of duties so as to be committing an offence under the Bribery Act. Such gifts should nevertheless, be politely but firmly declined. Articles of low intrinsic value totaling £25 such as diaries or calendars, or small tokens of gratitude from patients or relatives, i.e. chocolates etc. need not be refused. In cases of doubt staff should either consult their line manager or politely decline acceptance. Modest hospitality provided it is normal and reasonable in the circumstances i.e. lunches in the course of working visits may be acceptable, though it should be similar to the scale of hospitality which the NHS as an employer would be likely to offer. Receipt of such hospitality should be declared. Staff should decline all other offers of gifts, hospitality or entertainment. If in doubt they must seek advice from their line manager and/or declare it.

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1. Introduction Public service values must be at the heart of the National Health Service (NHS). High standards of corporate and personal conduct based on a recognition that patients come first, have been a requirement throughout the NHS since its inception. Moreover, since the NHS is publicly funded, it must be accountable to Parliament for the services it provides and for the effective and economical use of taxpayers’ money (NHS code of conduct: code of accountability in the NHS: Appointments Commission/DOH - 2nd Rev: 2004). The Trust is committed to the highest standards of openness, probity and accountability so that its employees remain beyond suspicion. In addition, under the Bribery Act 2010, it is an offence for any employee to corruptly accept any gifts or consideration as an inducement or reward for: • doing, or refraining from doing anything, in his or her official capacity, or • corruptly showing favor or disfavour, to any person in their official capacity. A brief description of the Bribery Act can be found at Appendix 1. All staff should be aware of the NHS Management Executive Health Service Guidelines on ’Standards of Business Conduct for NHS HSG (93)5 see Appendix 2. Guidance contained within this document referring to the ‘Prevention of Corruption Acts 1906 and 1916’ has been superseded by the Bribery Act 2010. However, much of the information contained within HSG (93) 5 is still relevant and until the document is either updated or replaced by the Department of Health it should still be issued to employees, alongside a ‘Code of Conduct for NHS Managers’ 2002 as it still contains useful guidance. This policy has been written to take account of latest legislation as well as guidance and recommendations received from the Trust’s Local Counter Fraud Specialist, with particular reference to the new provisions under the Bribery Act 2010, which received Royal Assent and is now part of UK Law. www.legislation.gov.uk/ukpga/2010/23/introduction 2. Purpose The purpose of this policy is to provide employees with an awareness of their own personal responsibilities in their conduct at work as a public service employee in the NHS. It is also to make them aware that any breach of the provisions legislated in the Bribery Act 2010 is a criminal offence for which they could be prosecuted. The Fraud Act 2006 came into force in 2007 and created three ways of committing an offence of fraud, by false representation, by failing to disclose information and abuse of position. This policy offers guidelines intended to assist employees in being aware they have a duty to demonstrate high ethical standards of both business and personal conduct. Specifically it deals with gifts and hospitality and conflicts of interest to minimise placing themselves in a position which risks, or appears to risk, conflict between their private interests and their NHS duties. All suspected breaches of this policy will be reported to the Local Counter Fraud Specialist for investigation and may result in criminal proceedings being commenced and/or disciplinary action being taken.

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3. Public Service Values The NHS code of conduct: code of accountability in the NHS (Appointments Commission/DOH - 2nd Rev: 2004) defines three crucial public service values which must underpin the work of the health service. i) Accountability – everything done by those who work in the Surrey and Sussex Healthcare NHS Trust must be able to stand the test of parliamentary scrutiny, public judgments on propriety and professional codes of conduct; ii) Probity – staff should have an absolute standard of honesty in dealing with the assets of the NHS: integrity should be the hallmark of all personal and professional conduct in decisions affecting patients, colleagues and suppliers and in the use of information acquired in the course of NHS duties; iii) Openness – there should be sufficient transparency about Surrey and Sussex Healthcare NHS Trust’s activities to promote confidence between staff, patients and the public. These Public Service values are in accordance with the Seven Nolan Principles of Public Life. See Appendix 6 4. Scope of Policy This policy applies equitably to all employees of the Trust and includes all those who work for the Trust, whether full-time, part-time, self-employed, or employed through an agency, a contractor or as a volunteer. 5. Organisational Responsibilities 5.1. Trust Board – Executive and Non Executive Directors The Trust Board must ensure compliance with the NHS Code of Conduct: Code of Accountability (Appointments Commission/DOH – 2nd Rev: 2004), the principles of which are contained in this policy and the reference documents. The Trust Board are responsible for ensuring all Executives, Non Executives and Senior managers complete declaration of interest forms on appointment and that these are reviewed. The Register of Interests is presented to the Trust Board on an annual basis for monitoring purposes and corrective action if appropriate. Any changes to declaration of interests should be made immediately and the CEO must be informed if these changes relate to an Executive Director. The Chairman must be in informed if this relates to a Non-Executive Director. 5.2. Managers Managers must ensure compliance with the NHS Code of Conduct for Managers 2002, the principles of which are contained in this policy and the reference documents. They must ensure all staff under their direction are aware of this policy and the referenced documents.

9

5.3. Employees All employees of, and those who work for, Surrey and Sussex Healthcare NHS Trust have a duty to ensure they are aware of and comply with this policy and referenced documents. In so doing employees and those working for the Trust must: a) ensure the interest of patients remain paramount at all times, b) be impartial and honest in the conduct of their official business and c) use the public funds entrusted to them to the best advantage of the service, always ensuring value for money Employees and those working for the Trust must also ensure that they do not: a) seek to advantage a private interest which is of such value that it could improperly influence performance of their official duties - for example to benefit their family and friends, religious belief, professional affiliation or political alignment, personal assets, investments or debts or b) seek to advantage a private interest which is of such value that it could improperly influence performance of their official duties for personal gain - for example a business interest, or an opportunity to make a financial profit or avoid a loss. 5.4. Human Resources HR will provide advice and guidance on the interpretation of this policy to managers and staff. 5.5. Trade Unions and Professional Organisations Trade Unions and Professional Organisations are required to be aware of this policy and the referenced documents and to advise staff accordingly. 6. Fit & Proper Person’s Test The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) places a duty on NHS providers not to appoint a person or allow a person to continue to be an executive director or equivalent or a non-executive director (NED) under given circumstances. Providers must not appoint a person to an executive director level post (including associate directors) or to a non-executive director post unless they are: • Of good character; • Have the necessary qualifications, skills and experience; • Are able to perform the work that they are employed for after reasonable adjustments are made; • Can supply information as set out in Schedule 3 of the Regulations (see the Role of the CQC below). Paragraph 5 (4) of regulations states that in assessing whether a person is of good

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character, the matters considered must include those listed in Part 2 of Schedule 4.’ Part 2 of Schedule 4 refers to: • Whether the person has been convicted in the United Kingdom of any offence or been convicted elsewhere of any offence which, if committed in any part of the United Kingdom, would constitute an offence, and • Whether the person has been erased, removed or struck off a register of professionals maintained by a regulator of health care or social work professionals. The Care Quality Commission’s (CQC) definition of good character is not the objective test of having no criminal convictions but instead rests upon a judgement as to whether the person’s character is such that they can be relied upon to do the right thing under all circumstances. This implies discretion for boards and councils in reaching a decision and allows for the fact that people can and do change over time. The regulations list categories of persons who are prevented from holding the office and for whom there is no discretion: • The person is an undischarged bankrupt or a person whose estate has had a sequestration awarded in respect of it and who has not been discharged; • The person is the subject of a bankruptcy restrictions order or an interim bankruptcy restrictions order or an order to like effect made in Scotland or Northern Ireland; • The person is a person to whom a moratorium period under a debt relief order applies under Part VIIA (debt relief orders) of the Insolvency Act 1986(40); • The person has made a composition or arrangement with, or granted a trust deed for, creditors and not been discharged in respect of it; • The person is included in the children’s barred list or the adults’ barred list maintained under section 2 of the Safeguarding Vulnerable Groups Act 2006, or in any corresponding list maintained under an equivalent enactment in force in Scotland or Northern Ireland; • The person is prohibited from holding the relevant office or position, or in the case of an individual from carrying on the regulated activity, by or under any enactment; • The person has been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity, or discharging any functions relating to any office or employment with a service provider. It will be the responsibility of the Chair of the provider to discharge the requirement placed on the provider, to ensure that all directors meet the fitness test and do not meet any of the ‘unfit’ criteria. The CQC expects senior leaders to set a tone and culture of the organisation that leads to staff adopting a caring and compassionate attitude. It is important therefore that in making appointments boards and councils take account of the values of the organisation and the extent to which candidates provide a good fit with those values. The regulations give the CQC powers to assess whether both executive and non-executive directors (but not foundation trust governors) are fit to carry out their role and whether providers have put in place adequate and appropriate to ensure that directors are fit and proper persons. The CQC has the right to require the provision of information set out in Schedule 3 of the Regulations and such other information as is kept by the organisation that is relevant to the individual as follows:

• Proof of identity including a recent photograph.

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• Where required for the purposes of an exempted question in accordance with section 113A(2)(b) of the Police Act 1997(38), a copy of a criminal record certificate issued under section 113A of that Act together with, after the appointed day and where applicable, the information mentioned in section 30A(3) of the Safeguarding Vulnerable Groups Act 2006 (provision of barring information on request)(39)

• Where required for the purposes of an exempted question asked for a prescribed purpose under section 113B(2)(b) of the Police Act 1997, a copy of an enhanced criminal record certificate issued under section 113B of that Act together with, where applicable, suitability information relating to children or vulnerable adults.

• Satisfactory evidence of conduct in previous employment concerned with the provision of services relating to:

(a) health or social care, or, (b) children or vulnerable adults

• Where a person (P) has been previously employed in a position whose duties involved work with children or vulnerable adults, satisfactory verification, so far as reasonably practicable, of the reason why P’s employment in that position ended.

• In so far as it is reasonably practicable to obtain, satisfactory documentary evidence of any qualification relevant to the duties for which the person is employed or appointed to perform.

• A full employment history, together with a satisfactory written explanation of any gaps in employment.

• Satisfactory information about any physical or mental health conditions which are relevant to the person’s capability, after reasonable adjustments are made, to properly perform tasks which are intrinsic to their employment or appointment for the purposes of the regulated activity.

The guidance states the following:

(a) ’the appointed day’ means the day on which section 30A of the Safeguarding Vulnerable Groups Act 2006 comes into force; (b) ’satisfactory’ means satisfactory in the opinion of the Commission; (c) ’suitability information relating to children or vulnerable adults’ means the information specified in sections 113BA and 113BB respectively of the Police Act 1997

The Trust has procedures in place to ensure that Directors and Non-Executive Directors are fit and proper persons. 7. Conflict of Interest A ‘conflict of interest’ involves a conflict between the public duty and the private interest of a public service individual, in which a public official’s private interest could improperly

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influence the performance of their official duties or responsibilities. Situations can arise in which there appears to be a conflict of interest but this is not in fact the case, or may not be the case. This situation is regarded as an “apparent conflict of interest”. Having an “apparent conflict of interest” as a public official, however, can be as serious as having an actual conflict because of the potential for suspicion of the official’s integrity and that of the organisation. An employee may have private interests which may be such as to cause a conflict of interests to arise in the future this is called a “potential conflict of interest”. 7.1 Managing a Conflict of Interest Employees must notify any conflicts, apparent conflicts or potential conflicts, to their Line Manager as soon as they become aware of such conflict and complete a declaration of interest form at Appendix 3. This form will be retained on the Trust’s Register of Interests and a copy retained in the employee’s personal file. . Managers should consider how a conflict of interest be managed. In the first instance advice should be sought from the Chief Financial Officer or Director of Corporate Affairs, where one or more of the following options may be considered:

• removal of the interest

• removal of the employee from involvement in an affected decision-making process • restriction of access by the employee to particular information • transfer of the employee to duties in a non-conflicting function • re-arrangement of the employee’s duties and responsibilities • assignment of the conflicting interest in a genuinely ‘blind trust’ arrangement.

7.2 Benefits – Gifts, Hospitality and Sponsorship The Trust is required to keep a record of all gifts or hospitality offered and/or received, even when refused. All employees must complete the Declaration of Gifts and Hospitality Form (see Appendix 4) when offered any gift or hospitality, however small. This will be recorded on the Trust’s Gifts and Hospitality Register held by the Director of Corporate Affairs. Sight of the Trust’s Gifts and Hospitality Register is a frequent feature under the Freedom of Information Act and the Trust is obliged to produce this on request. The following guidelines should be followed when offered any gift or hospitality:

• One off casual gifts of low intrinsic value (£25) such as diaries, calendars, pens and such small tokens of gratitude are considered acceptable and do not need to be declared but if multiple gifts of such value (£25) are offered, either at one time or over a period of time, this would not be acceptable, if such offers are made they should be politely but firmly declined and a declaration form completed to confirm declining the

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offer.

• Gifts above the value of £25 are not acceptable and should be politely but firmly declined and a declaration completed to confirm declining the offer.

• Modest hospitality is normally considered reasonable e.g. working lunches may be acceptable in the right circumstances.

• All other offers of hospitality or entertainment should be declined. In cases of doubt employees should either consult their manager, the Chief Financial Officer or else politely decline acceptance.

Employees should only accept commercial sponsorship to attend relevant conferences or courses after they have received advance permission from the Trust by referring the matter to their Line Manager and on completion of the gifts and hospitality form at Appendix 4 for inclusion on the Register. Employees should refer offers of drugs and/or clinical equipment/devices to their Line Manager or Chief Financial Officer and acceptance of the offer can only be made after they have received advance permission from the Trust and on completion of the gifts and hospitality form at Appendix 4 for inclusion on the Register. There are strict guidelines contained in the Policy for Commercial Representatives which should be followed. Employees should also refer to their Line Manager in the first instance and also the Chief Finance Officer when seeking, or being offered, sponsorship funding from an external source towards costs, or for the cost, of a specific event or work programme. 7.3 Declaration of relationship to candidates The Trust Board, Senior Officers, Medical Staff and any other staff involved in the recruitment and selection of candidates must declare the relationship (see Appendix 5). Candidates for any staff appointments must declare if they are related to any employee of the Trust. This includes partners and anyone whose affairs are so closely connected with the affairs of the candidate that a benefit derived by the other person, or a substantial part of it, could pass to the candidate, or could constitute a conflict of interest. A copy of such declaration must be retained on the Personal File (see Appendix 5). 7.4 Declaration of Interests If an employee has interests in any outside business they should declare this to the Trust as their employer. The following are examples of situations where a declaration must be made:

• The individual (or their family or friends) has a financial interest in a business which may compete for a contract to supply goods or services to the Trust

• The individual has access to information that may influence where the Trust is to place a contract for goods or services

• The individual has outside interests that may be in any way detrimental to the NHS or to

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patients’ interest.

• A role or interest undertaken in a capacity which is paid or unpaid which a member of staff wishes to place on record but does not fall into the categories above.

A full list of examples is listed in the declaration of interest forms at Appendix 3. 7.5 Council of Governors As part of our journey to become an NHS Foundation Trust we have elected a shadow council of governors. The shadow council consists of elected and appointed governors. All governors are required to declaration any interest. Declarations are held in the Governors Declaration of Interests Register. 7.6 Pharmacy Staff who present applications for additions to the formulary are required to make a declaration of interest as part of that process. All members of the Drugs and Therapeutic Committee and Formulary committee are asked to make a declaration of interest each time an application is considered by the committee. All declarations are recorded in the minutes of the meeting even if no relevant interest is declared.

7.7 Medical Devices Staff who present applications to the medical devices group are required to make a declaration of interest as part of that process. All members of the Medical Devices Group should make a declaration of interest each time an application is considered. All declarations should be recorded in the minutes of the meeting even if no relevant interest is declared.

7.8 FAILURE TO MAKE A DECLARATION

Should it be suspected that a member of staff has failed to appropriately declare an interest, or failed to demonstrate compliance with the conduct outlined in this policy, it may be deemed appropriate to take action in line with the Trust’s Disciplinary Policy and/or make a referral to the Trust’s Local Counter Fraud specialist (LCFS). Staff can obtain details via the intranet should they have any concerns It is the responsibility of ALL staff to ensure that declarations must be updated on an annual basis using Appendix 3 and sent to the Director of Corporate Affairs. 8. Employment external to the Trust 8.1 Working Time Regulations To comply with the Working Time Regulations (1998), it is a requirement that employees notify the Trust of any outside employment, including private work or work for outside agencies, particularly where their total time worked is in excess of 48 hours a week and they will be required to sign an “opt-out” agreement.

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An opt-out form can be accessed from the Trust Intranet. 8.2 Conflict of Interest with outside employment Employees should not engage in any activities outside the Trust which may impact on their ability to fulfill their duties and responsibilities without first obtaining consent, which will not be unreasonably withheld. The Trust retains the right to review this position, should it become aware of issues affecting the employee’s employment with the Trust. Employees are advised not to take on outside employment or become involved in another company that may conflict with their Trust employment or be detrimental to it. This includes any work in or on behalf of a business owned by the employee, a member of his/her family or friends, as well as work for outside agencies. 9. Contracts All Trust employees who are in contact with suppliers and contractors, in particular those who are authorised to sign purchase orders, or place contracts for goods or services, must ensure that they are familiar with the Trust’s Standing Orders and Standing Financial Instructions. 9.1 Favoritism in Awarding Contracts Fair and open competition between prospective contractors or suppliers for Trust contracts is a requirement of the Trust’s Standing Financial Instructions, NHS Standing Orders and the EU Directives on Purchasing. Employees involved in placing or awarding contracts must not unfairly advantage one contractor or competitor over another, or show any favoritism in awarding contracts. This means that: � no private, public or voluntary organisation which may bid for NHS business should be given an advantage over its competitors. � each new contract should be awarded solely on merit, taking into account the requirements of the NHS and the ability of the contractors to fulfil them. All invitations to potential contractors to tender for NHS business should include a notice warning with regard to the consequences of engaging in any corrupt activity involving employees of the Trust. All contractors should be made aware of the Trust’s Whistle Blowing policy (Public Interest Disclosure Act). NHS Fraud and Corruption Reporting Line is available on Freephone 0800 028 4060 or by completing an online form at www.reportnhsfraud.nhs.uk 10. Private Practice Consultants and Associate Specialists are permitted to carry out private practice subject to the provisions of their Trust contract of employment and clearly identified in their job plan.

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Other grades of staff may undertake private work or work for outside agencies provided this work does not conflict with their Trust employment or take place during their contracted hours with the Trust and complies with the requirements in their Contract of Employment and clearly identified in their job plan. Any work should also be subject to the conditions outlined in the NHS Code of Conduct for Private Practice and the Trust’s Policy on Private Patients and should be declared to the Trust using the declaration of interests form Appendix 3. 11. Intellectual Property Managers should ensure that they are in a position to identify intellectual property rights (IPR) as and when they arise so that they can exploit them properly. This will ensure that the Trust receives any reward or benefit (such as royalties), both in respect of work carried out by third parties, or work carried out by employees of the Trust. To ensure this is achieved managers should build appropriate specifications and provisions into the contractual arrangements before work is commissioned or begins, and seek legal advice in relation to specific cases. This complex area relates to copyright, patents, new inventions and collaborative research projects. Before any work is undertaken in this area, legal advice, in liaison with the Chief Finance Officer on intellectual property should be sought and contractual arrangements drawn up with the Trust, as to how rewards or benefits in respect of this work may be allocated. 12. Confidentiality – Sensitive Information Staff should ensure they are aware of information relating to business conducted by the Trust which is “commercial in confidence”. All such information should be restricted with regard to disclosure particularly if its disclosure would prejudice the principle of a purchasing system based on fair competition. This refers to both private and public providers of services. The term “commercial in confidence” should not be taken to include information about service delivery and activity levels, which should be publicly available, under the Freedom of Information Act. The exchange of data for medical audit purposes is subject to the rules governing patient confidentiality and data protection. 13. Consultation and Communication with Stakeholders The policy has been drawn up in consultation with the trade unions, counter fraud, the Executive Committee and the Audit and Assurance Committee. 14. Approval and Ratification The following groups were responsible for the discussion, approval and ratification of this policy:

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Joint Consultative Committee The Executive Committee The Audit & Assurance Committee The Trust Board 15. Review and Revision All policies will be monitored and data presented to the relevant committee on a quarterly basis to analyse trends, and act on any areas of concern. 16. Dissemination and implementation The Trust process for dissemination of policies will be followed as described in the Organisation-wide Policy for the Management and Development of Procedural Documents. It will be posted on the dedicated Policies and Procedures page of the intranet and a notification to all staff of the new policy placed on the next available E Bulletin. All forms which are attached (Appendices 2 – 5) are available as individual forms on the Form section of the intranet. Standards of Business Conduct are also referred to in all Employee Statement of Main Terms and Conditions of Employment. 17. Archiving This policy will be held in the Trust database and archived in line with the arrangements in the Organisation-wide Policy for the Management and Development of Procedural Documents. . 18. Monitoring and Compliance The Department of Corporate Affairs will monitor the daily operation of this policy. Breaches of the policy will be monitored and reported on an annual basis. Registers will be maintained by the Department of Corporate Affairs to record declarations of gifts/hospitality/sponsorship received or refused and disclosures of interest. Registers will be presented for review at the Audit & Assurance Committee and the Trust Board on a bi-annual basis. Annual reports will be made to the Trust Consultative Committee. Periodic communications to maintain a level of awareness of responsibilities of staff will be undertaken through the SASH news, e Bulletin, counter fraud initiatives, any other appropriate medium as identified. Executive and Non Executive Directors and Senior Managers will be written to on an annual basis to ensure compliance with the policy.

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19. References Trust’s Standing Orders Trust’s Standing Financial Instructions Trust Policy for Commercial Representatives Standards of Business Conduct HSG (93)5 Code of Conduct for NHS Managers 2002 Professional Codes of Conduct Contracts of Employment Bribery Act 2010 Nolan Principles Standards for Members of NHS Boards 2011 (Professional Standards Authority for Health & Social Care) Private Patients Policy Fit & Proper Persons Regulations Working Time Directive Policy Fraud Act 2006 20. Associated Documents Disciplinary Policy Code of Conduct for Confidentiality Counter Fraud Response and Bribery Plan Policy for Raising Serious Concerns (Whistleblowing) Intellectual Property Policy Private Patients Policy Working Time Directive Policy Contracts of Employment Professional Codes Conduct Medical Devices Policy Trust Policy for Commercial Representatives

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APPENDIX 1

Bribery and Corruption The new Bribery Act 2010 replaces the fragmented and complex offences at common law and in the Prevention of Corruption Acts1889 – 1916. The Act sets out four offences:

1. Offering, promising or giving a bribe to another person to perform improperly a relevant function or activity, or to reward a person for the improper performance of such a function or activity (the active offence). It does not matter whether the person to whom the bribe is offered or given is the same person who is to perform the function or activity concerned. This applies to both public and private functions.

2. Requesting, agreeing to receive or accepting a bribe to perform a function or

activity improperly (the passive offence). It does not matter whether the recipient of the bribe requests or receives it directly or through a third party, or whether it is for the recipient's benefit or not. In some cases, it is not necessary for the recipient to know or believe that the performance of the function or activity is improper. This applies to both public and private functions.

3. Bribing a foreign public official – where a person directly, or through a third party,

offers, promises or gives any financial or other advantage to a foreign public official ("FPO") (or to a third party at the request or acquiescence of the FPO) in an attempt to influence them in their capacity as a FPO in order to obtain or retain business, or to obtain an advantage in the conduct of business. To constitute bribery under the Act the FPO must be neither permitted nor required by applicable law to be influenced by the offer, promise or gift.

4. Failure of a commercial organisation to prevent bribery (the "Corporate

Offence"). A commercial organisation will commit an offence if a person associated with it bribes another (in the UK or overseas) intending to obtain or retain business or a business advantage for that commercial organisation. An associated person includes any person who performs services for the commercial organisation. So, for example, an associated person may include not only employees, agents and subsidiaries, but also entities over which the organisation has no ownership or control.

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APPENDIX 2

Short Guide to Standards of Business Conduct for NHS Staff To assist NHS employers and staff in maintaining strict ethical standards in the conduct of NHS Business in 1993 the NHS Executive published HSG (93) 5 – Standards of Business Conduct for NHS Staff. (Please refer to the statement in the ‘Introduction’ of this document relating to HSG (93) 5. In brief, the guidelines cover the declaration of interests and acceptance of gifts and hospitality. It is the responsibility of all NHS staff to ensure that they are not placed in a position which risks, or appears to risk, conflict between their private interests and their NHS duties. The Trust’s HR Director holds the Register of Interests, Gifts and Hospitality, which is checked periodically by the Audit Committee, internal and external auditors and the Trust Board. If you have anything to declare, please complete the declaration form and forward to the Chief Financial Officer, Maple House. Short Guide for staff Do:

• Make sure you understand the guidelines on Standards of Business Conduct (HSG (93) 5) referred to in your terms and conditions of employment and consult your line manager if you are not sure

• Make sure you are not in a position where your private interests and NHS duties conflict.

• Declare any relevant interests. If in doubt, ask yourself:

5. Am I, or might I be, in a position where I (or my family/friends) could gain from the connection between my private interests and my employment, or where it could be perceived by others that a gain could be made?

6. Do I have access to information which could influence the Trust’s purchasing or

contracting decisions, or could it be perceived that I have such access?

7. Could my outside interests be in any way detrimental to the NHS or to patients’ interests, or could others perceive them to be detrimential?

8. Do I have any other reason to think I may be risking a conflict of interest?

IF IN DOUBT – DECLARE IT

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Always :

• Adhere to the ethical code of the Institute of Purchasing and Supply if you are involved in any way with the acquisition of goods and services.

• Seek your employer’s permission before taking on outside work, if there is any question of it adversely affecting your NHS duties.

• Obtain the Trust’s permission before accepting any commercial sponsorship.

Do Not

• Abuse your past or present official position to obtain preferential rates for private deals.

• Unfairly advantage one competitor over another or show favoritism in awarding contracts.

• Misuse or make available ‘commercial in confidence’ information.

• Accept gifts, inducements or inappropriate hospitality.

Casual gifts offered by Contractors or others e.g. at Christmas time, may not be in any way connected with the performance of duties so as to be committing an offence under the Bribery Act. Such gifts should nevertheless, be politely but firmly declined. Articles of low intrinsic value such as diaries or calendars, or small tokens of gratitude from patients or relatives, i.e. chocolates etc need not be refused. In cases of doubt staff should either consult their line manager or politely decline acceptance. Modest hospitality provided it is normal and reasonable in the circumstances i.e. lunches in the course of working visits may be acceptable, though it should be similar to the scale of hospitality which the NHS as an employer would be likely to offer. Receipt of such hospitality should be declared. Staff should decline all other offers of gifts, hospitality or entertainment. If in doubt they must seek advice from their line manager and/or declare it.

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APPENDIX 3

DECLARATION OF INTERESTS

Name …………………………………………………………………………………. Title ………………………………………………………………………………….. Under the Codes of Conduct and Accountability, the Trust’s Standing Orders and Standing Financial Instructions and the content of the Standards of Business Conduct Policy I declare my interests as follows:

If this situation changes during the next 12 months I will advise you accordingly Signed …………………………………………………………………………………………………………………………. Date ……………………………………………………………………………………………………………………………. Countersigned Director /Chief of Service/Assistant Director………………………………………………………………………………… Date……………………………………………………………………………………………………………………………… Copy to be placed on employee’s file and original to be retained by the Corporate Affairs Team on the Register of Interests File.

Category Details (include start date of interest & all locations)

Category A Directorships, including non-executive directorships held in Private companies or PLCs (with the exception of those of Dormant companies ) i.e. being a Board Member of a Statutory Organisation

Category B Undertaking of private practice at any facility.

Category C Ownership or private companies, business or consultancies likely or possible to do business with the NHS or any other organisation.

Category D Majority, controlling or large shareholdings in organisations likely to possibly seek to do business with the NHS

Category F A position of authority in a charity or voluntary organization in the field of health and social care

Category F Any connection with a voluntary or other organisation contracting for NHS services

Category G Any additional role or other interest undertaken in a capacity is paid or unpaid which a member wishes to place on record but does not fall into categories A-E above

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APPENDIX 4

Declaration of Gifts, Entertainment, Hospitality/ Sponsorship/Sample Medical Equipment or Drugs

Please complete this form if you receive or have offered any of the above that is beyond that set out in the Policy

Declaration I declare that the above record represents a complete and accurate statement of the hospitality/gift/sponsorship/ sample medical equipment/drugs I have given/received Signed……………………………………………………. Date ………………………….. Name …………………………………………………………. Countersigned…………………………………………………………………. Director/Chief of Service/Assistant Director/ …………………………………………………Date………. …………. Copy to be placed on employee’s file and original to be retained by the Corporate Affairs Team on the Register of Interests File.

Please complete this form if you receive or have offered any of the above that is beyond that set out in the Policy Nature of Hospitality /gift given: ………………………………………………………………………………………….. Hospitality/gift offered to: ……………….………………………………………………………………………………… Name of organisation: ……………………………………………………………………………………………………. Date ………………………………………………………………………………………………………………………… Value (Approx.)……………………………………………………………………………………………………………… Description of hospitality/sponsorship/gift/entertainment/sample medical equipment or drugs: ……………………………………………………………………………………………………………………………….. ………………………………………………………………………………………………………………………………..

Do you have any personal relationship with, or personal business connection with the person/organization from whom you received, or to whom you offered hospitality/gift/sponsorship/sample medical equipment /drugs declared above Yes No If yes, please describe

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APPENDIX 5

Declaration of relationships with Candidates

Guidance:

• Candidates will be required to disclose in writing whether to their knowledge they are related to the Chairman, Director, Consultant Medical staff or other staff with responsibilities for the recruitment process. Failure to do so shall disqualify from the recruitment and selection process. If an appointment is made, it shall render the appointee liable to dismissal.

• Relationships to which these rules apply are those of husband, wife, where two persons live together as partners, sons, daughter, grandson, granddaughter, brother, sister, nephew, nieces of either partner.

• Direct or indirect canvassing of the Chairman or Directors or of any committee of the Trust by or on behalf of any candidates shall disqualify the candidate from the appointment.

• Employees of the Trust shall not solicit for any person or any appointment with the Trust or recommend any person for such an appointment. However, this does not preclude the member of staff from giving a written or verbal reference on request concerning a candidate’s ability or experience for submission to the Trust.

Name …………………………………………………………………………………… Job Title ……………………………………………………………………………….. Declaration of Relationship Name of Candidate ………………………………………………………………….. Post applied for ……………………………………………………………………… Nature of relationship………………………………………………………………… Signed…………………………………………………Date…………………………. Countersigned

Director of HR ………………………………………………………………………… Copy to be placed on employee’s file and original to be retained by the Human Resources Team.

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APPENDIX 6

The Seven Principles of Public Life (Nolan)

1. Selflessness Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends. 2. Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties. 3. Objectivity In carrying out public business, including making public appointments, awarding contracts or recommending individuals for rewards and benefits, holders of public office should make choices on merit. 4. Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. 5. Openness Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands. 6. Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. 7. Leadership Holders of public office should promote and support these principles by leadership and example. The Committee on Standards in Public Life has set out “Seven Principles of Public Life” which it believes should apply to all in the public service. www.public-standards.gov.uk

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APPENDIX 7

Equality Impact Assessment

Names of assessors carrying out the screening procedure (min of 2- author / manager and staff member / patient representative)

• Gillian Francis-Musanu

• Sally Knight

Name of lead author /manager & contact number

Gillian Francis-Musanu

1. Name of the strategy / policy / proposal / service function

POLICY ON STANDARDS OF BUSINESS CONDUCT

Date last reviewed or created & version number. New, December 2012

2. Who is the strategy / policy / proposal / service function aimed at? All staff, whether full-time, part-time, self-employed, or employed through an agency, a contractor or as a volunteer 3. What are the main aims and objectives? The purpose of this policy is to provide employees with an awareness of their own personal responsibilities in their conduct at work as a public service employee in the NHS. It is also to make them aware that any breach of the provisions legislated in the Bribery Act 2010 is a criminal offence for which they could be prosecuted 4. Consider & list what data / information you have regarding the use of the strategy / policy / proposal / service function by diverse groups? Workforce data, Employee relations data.

5. Is the strategy / policy / proposal / service function relevant to any of the protected characteristics or human rights below? If YES please indicate if the relevance is LOW, MEDIUM or HIGH Protected Characteristics Patient, their

carer or family

Staff

• Age NO NO

• Disability NO NO

• Gender Reassignment NO NO

• Race/ Ethnic Communities / groups NO Yes. Low negative

• Religion or belief NO NO

• Sex (male female) NO NO

• Sexual Orientation(Bisexual, Gay, heterosexual, Lesbian)

NO NO

• Marriage & Civil Partnership NO NO

• Pregnancy & Maternity NO NO

• Human Rights NO NO

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6. What aspects of the strategy / policy / proposal / service function are of particular relevance to the protected characteristics? Race and potential for disciplinary action

7. Does the strategy / policy / proposal / service function relate to an area where there are known inequalities? If so which and how? Allegations of fraud may result in disciplinary action. In the past the number of BME staff in disciplinary cases has been disproportionate to the overall number in the Trust.

8. Please identify what evidence you have used / referred to in carrying out this assessment. See q 4 and authors knowledge

9. If you identify LOW relevance only can you introduce any minor changes to the strategy / policy / proposal / service function which will reduce potential adverse impacts at this stage? If so please identify here. Annual monitoring of breaches of the policy by protected characteristics of the staff involved will help identify any potential discrimination. This can be reported on as a subset of the employee relations report.

10. Please indicate if a Full Equality Impact Assessment is recommended. (required for all where there is MEDIUM & HIGH relevance)

NO

11. If you are not recommending a Full Equality Impact assessment please explain why. The policy follows national guidance, good practice and UK legislation. The policy is identified in all employment contracts. Monitoring and reporting of the breeches by protected characteristics annually will provide additional assurance.

12. Signature of author / manager

Date of completion and submission

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Definitions of relevance Low

• The policy may not be relevant to the Equality General Duty* as stated by law

• Little or no evidence is available that different groups may be affected differently

• Little or no concern raised by the communities or the public about the policy etc when they are consulted – (recorded opinions, not lack of interest)

Medium

• The policy may be relevant to parts of the Equality General Duty* in the policy etc regarding differential impact

• There may be some evidence suggesting different groups are affected differently

• There may be some concern by communities and the public about the policy High

• There will be relevance to all or a major part of the Equality General Duty* in the policy regarding differential impact.

• There will be substantial evidence, data and information that there will be a significant impact on different groups

There will be significant concern by the communities and relevant partners on the potential impact on implementation of the policy etc.

• Human Rights

1 the right to life 2 the right not to be tortured or treated in an inhuman or degrading way 3 the right to be free from slavery or forced labour 4 the right to liberty 5 the right to a fair trial 6 the right to no punishment without law

7 the right to respect for private and family life home and correspondence

8 the right to freedom of thought, conscience and religion 9 the right to freedom of expression 10 the right to freedom of assembly and association 11 the right to marry and found a family 12 the right not to be discriminated against 13 the right to peaceful enjoyment of possessions

14 the right to an education 15 the right to free elections



REPORT TITLE: Update from the Shadow Council of Governors




Shadow Council of Governors Meeting 26.01.16

Action Required:

Approval ( ) Discussion ( ) Assurance (√)

Purpose of Report:

To provide an update to the Board on the work of the Shadow Council of Governors.


The second Shadow Council of Governors took place on 26th January 2016. The meeting

was quorate and very well attended by both elected, nominated governors and Trust

Executive Directors. Key area of Focus for this meeting:

• Trust Update from the Chief Executive

• Review of Quality Account Priorities

• Trusts Patient Experience Strategy

• Patient Experience Forum Legacy Report

• Update from the Membership Development Sub-Group

It was noted that one elected Governor from the Crawley constituency had resigned due

to personal reasons.

Recommendation:

The Board is asked to note the report.


SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model


Legal and regulatory impact A Council of Governors is a statutory requirement for an NHS Foundation Trust and forms part of the governance structure

Financial impact Limited – mainly relating to claiming of reasonable travel expenses

Patient Experience/Engagement A significant and important part of the role of the Council of Governors

Risk & Performance Management Relevant aspects included in the report


Important to the role and function of the Council of Governors

2

Attachment: N/A

3

TRUST BOARD REPORT – 25th February 2016 UPDATE FROM THE SHADOW COUNCIL OF GOVERNORS

1. Introduction

The Shadow Council of Governors held its second meeting on 26th January 2016. The

meeting was well attended by elected, staff and nominated Governors.

1.2 Main Agenda Items The following items were discussed: Trust and FT Journey Update: The CEO presented the current developments taking place at the Trust including an update on quality, performance, finance and estates. Discussion also took place on the current status of the Trusts FT application and the possible next steps. The requirements for the Governors input to the 2016/17 NHS Planning Guidance were also noted. Review & Input into the 16/17 Quality Account Priorities: The Medical Director presented the progress being made on the development of next Quality Account and sought feedback from the Governors on the draft priorities for the coming year. The governors agreed that these were appropriate and looked forward to seeing the draft version of the 2015/16 Quality Account. Update on the Patient Experience Strategy: The Chief Nurse and Patient Experience Survey Manager presented the Trusts Patient Experience Strategy and detailed the variety of methods the Trust uses to obtain and use the experience of patients and their carers as an important way of improving the quality and experience of services provided by the Trust. Legacy Report from Patient Experience Forum: One of the Governors presented the legacy report from the Patient Experience Forum, which gave an overview of the range of groups and committees where patients’ representatives had been involved and had worked with the Trust over a number of years. The Council agreed to discuss ways in which Governors could become more involved in similar activities over the coming months. Update from the Membership Development Group: One of the Governors gave feedback on the first meeting of the membership development group (a sub-group of the council of governors) and shared a range of approaches being implemented proactively by governors to engage with and to gain feedback from foundation trust members as well as looking at ways of increasing membership from particular constituencies. The Council also received feedback from the Director of Strategy which included an update on how the Trust Board had given consideration to the feedback from governors on the Trusts Vision, Values and Strategic Objectives. 1.3 Governor Resignation The Shadow Council was informed that Richard Miller one of the elected Governors for the Crawley Constituency had resigned due to personal reasons. This will warrant a bi-election for the Crawley Constituency in due course.

4

2. Recommendation

The Board is asked to note the report from the Shadow Council of Governors. A report on

the work and activities of the Shadow Council of Governors will be provided to the Board

on a quarterly basis.

Gillian Francis-Musanu Director of Corporate Affairs February 2016



REPORT TITLE: SASH+ (in partnership with the Virginia Mason Institute) update

EXECUTIVE SPONSOR: Michael Wilson Chief Executive

REPORT AUTHOR (s): Sue Jenkins Director of Strategy

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) Executive Committee

Action Required:

Approval () Discussion () Assurance (√)

Purpose of Report: This report provides the Board with assurance that the SaSH + work (in partnership with Virginia Mason) is progressing to plan. Summary of key issues

This paper provides the Trust Board with an update on progress since December 2015 including details about:-

• each of the value streams • training and development • the communications plans • the compacts • the Kaizen Promotion Office (KPO)

Recommendation:

The Board is asked to consider this report and ensure that it provides assurance around delivery of the SaSH + work (in partnership with Virginia Mason).


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment:

Legal and regulatory implications The Trust has a contractual commitment to participate fully in this programme for a five year period

Financial implications The programme is being centrally funded by the Trust Development Authority (TDA) and the


Department of Health. The programme is expected to achieve improvements in quality, performance and efficiency over the next five years

Patient Experience/Engagement Patients will be involved in value stream work wherever possible

Risk & Performance Management A Trust Guiding Team has been established to oversee this work. This group reports to a national Trust Guiding Board


A national communications plan is being delivered to support the work and internally communications is being rolled out across the organisation

Attachment: SaSH + update Appendix A – SASH+ compact


TRUST BOARD REPORT –25 February 2016 SASH+ update – working in partnership with the Virginia Mason Institute 1. Introduction 1.1 In December 2015 the Trust Board received its first update on the SASH+ work which

is being progressed in partnership with the Virginia Mason Institute and NHS Improvement. It was agreed that regular reporting on continued progress should take place on a bi-monthly basis.

1.2 This paper provides the Trust Board with an update on progress since December

2015 including details about:- • each of the value streams • training and development • the communications plans • the compacts • the Kaizen Promotion Office (KPO)

2. Value stream updates 2.1 The Trust has identified three value streams which will be the initial focus of

improvement work.

2.2 They are:- • Inpatient flow – cardiology

• Outpatients

• Management of diarrhoea

2.3 The following table confirms the progress that has been made against each of the

value streams so far. Value Stream 1 Inpatient flow - cardiology Scope From: decision to refer to cardiology

To: Discharge from cardiology ward Executive Sponsor Michael Wilson – CEO KPO lead Sue Jenkins Sponsor development session

Held on 3 December 2015 Facilitated by VMI Included 15 staff from cardiology team Agreed high level current state value stream map Agreed high level future state value stream map Agreed 4 priorities and draft project plans for RPIWs

• Right patient right bed • Discharges • Cancellations and amendments to lists • Ward rounds

Value Stream Sponsorship Team

James Sneddon Nandu Gandhi Rachel Danvers Alison James Caroline Pinney


Victoria Bailey Keith Middleton Michael Wilson - chair Sue Jenkins Meet weekly

High level metrics agreed

*RPIW#1 topic *An RPIW is a 5 day workshop focused on a particular process in which people who do the work are empowered to eliminate waste and reduce the burden of work

Right patient right bed

RPIW#1 dates 8 – 12 February 2016 RPIW#1 sponsor Alison James RPIW#1 process owner Diane Winchester

5 An Associated University Hospital ofBrighton and Sussex Medical School

RPIW#1 workshop leader

Rhonda Stewart (VMI sensei)

RPIW#1 team leader Sue Jenkins RPIW metrics agreed These metrics will be monitored and reported at 30,60 and

90 day intervals post RPIW

Notable successes that were recorded when the new process was tested

30 day report Due 14 March 2016 60 day report Due 12 April 2016 90 day report Due 11 May 2016 Successes Great engagement from all involved in RPIW

Excellent and active patient involvement all week Team talk was a great forum to use to do final report out of the week to the whole organisation. The report out has been videoed and will be available to view once final edits are complete.

Lessons learned Timing and amount of information to the home team (those working in cardiology but not part of the RPIW) is critical Each area represented learned about each others areas and how they affect their work Sharing information empowers staff


Five days were used to do something constructive. There was designated time, a helpful structure, ambitious targets, rapid change and time for reflection The process works

RPIW#2 topic Discharge RPIW#2 dates 4 – 8 April 2016 RPIW#2 sponsor Keith Middleton RPIW#2 process owner TBC RPIW#2 workshop leader

Sue Jenkins

RPIW#2 team leader Allana Hansell Metrics To be agreed 30 day report Due 9 May 2016 60 day report Due 14 June 2016 90 day report Due 13 July 2016 Value Stream 2 Outpatients Scope From: decision to refer

To: attendance at first follow up appointment or discharge Executive Sponsor Des Holden – Medical Director KPO lead Allana Hansell Sponsor development session

Planned for 2 March 2016 Agenda shared with participants To be facilitated by VMI Have invited 25 outpatient staff to the event Observations currently underway to prepare high level current state value stream map Metrics being discussed


Des Holden (chair) Angela Stevenson Natasha hare Sian Griffith Pramit Patel Linda Judge Jamie Moore Ben Emly Allana Hansell First meeting due on 22 February 2016


Currently being agreed

RPIW#3 topic

Priority topics to be agreed at Sponsorship development session on 2 March

RPIW#3 dates 23 – 27 May 2016 RPIW#3 sponsor TBC RPIW#3 process owner TBC RPIW#3 workshop leader

Sue Jenkins

RPIW#3 team leader Allana Hansell Metrics To be agreed 30 day report Due 27 June 2016 60 day report Due 27 July 2016 90 day report Due 2 September 2016


Value Stream 3 Management of Diarrhoea Scope From: onset of symptoms

To: resolution of symptoms Executive Sponsor Ben Mearns – Chief of medicine KPO lead Katy Morris Sponsor development session

Planned for 28 April 2016 Observations currently underway to prepare high level current state value stream map Metrics being discussed


Ben Mearns (chair) First meeting due on 22 February 2016


Currently being agreed

RPIW#3 topic

Priority topics to be agreed at Sponsorship development session on 28 April 2016

RPIW#3 dates 18 – 22 July 2016 RPIW#3 sponsor TBC RPIW#3 process owner TBC RPIW#3 workshop leader

Allana Hansell

RPIW#3 team leader Helen Gallon Metrics To be agreed 30 day report Due 22 August 2016 60 day report Due 21 September 2016 90 day report Due 21 October 2016

3 Training and development 3.1 SaSH recognise the importance of having a cohesive training and education plan that

supports the roll out, implementation and delivery of the SaSH+ work over the next five years.

3.2 The current plan includes a range of courses delivering varying levels of expertise and knowledge to a range of staff:-

Type Format Frequency Duration Audience

Induction Presentation Monthly 5 minutes

all new starters

Grand round

Presentation Twice yearly

30 minutes

trainees and consultants

Taster session

presentation and practical exercises

Monthly 2 .5 hours

All staff wanting to understand what SASH+ work is all about


One day masterclass (planned)


Quarterly 1 day All staff interested in improvement Wider healthcare system staff

Leadership orientation


One off 1 day 30 Staff in leadership roles

Lean for leaders

6 days taught, work based assignments, coaching and mentoring

June 2016 – January 2017

8 months 40 Staff in leadership roles

Learning conference (planned)

Presentation, sharing learning, visits to the genba and practical exercises

annual 1 day wider healthcare system internal staff

ALT 7 days taught 12 assignments over 6 weeks RPIW x 2 sign off

September 2015 – July 2016

8 months 4 KPO specialists

3.3 A draft training and education plan has been developed including cohort numbers,

course content and target audiences over the coming five years. This plan seeks to ensure that there is an opportunity for every single member of staff in the organisation to experience some learning and development about the SaSH+ work over the coming years.

3.4 A gap analysis has also been undertaken which indicates that additional capacity may

be required of the following courses

o Leadership orientation

o Lean for Leaders

o Advanced Lean Training certification

3.5 Discussion is underway with the national team to consider the feasibility of additional procurement of the above courses

4 Communication


4.1 Communication activity is already underway and a communications plan is being developed to ensure that internal and external communications and stakeholder management is focused and that staff, external audiences, stakeholders and the media are engaged throughout and their views are listened to. This will be aligned to the national TDA VMI Communications Strategy. The Head of Communications and the KPO lead will meet their counterparts from the participating Trusts on a monthly basis to ensure that there is alignment, consistency of messages and open communication at a national and local level.

4.2 At a local level the Trust is a developing a communications plan which will include:- 4.2.1.1.1.1.1 Stakeholder engagement – both locally and as part of the

national programme of stakeholder engagement • Regular Kaizen bulletins sharing the improvement story as it unfolds • Regular updates at TeamTalk meetings • Tailored SASH+ TeamTalk meetings for RPIW report outs and updates on

value streams • Specific reference to the work in the CEO’s weekly message • A KPO wall which will visually depict the value stream progress • A web page sharing information and the stories from the SASH+ work as it

progresses • Updates in Staff News and Yammer • Updates shared through our social media platforms • Media engagement – in-line with national partnership timeframes • Regular board reports which provides updates of the work undertaken

along with delivery against key metrics as this progresses • A series of videos displayed on the trust information screens and the web

page sharing progress, updates successes and learning • A visual identity for SASH+ and branded templates for all materials and

corporate communications messages

5 Compact development 5.1 Underpinning the improvement work at both a national and trust wide level is the

development of a compact which details reciprocal commitments and an explicit set of responsibilities from all parties engaging in this development work.

5.2 At a national level a compact has been developed between the TDA and the five

participating NHS Trusts. 5.3 In order to support the improvement work at a SASH level a draft compact has been

developed between the organisation and clinicians. This work has been led by Amicus, who are specialist experts in compact development, working in partnership with VMI.

5.4 The draft compact which is being shared and considered across the organisation for feedback is attached at Appendix A

6 Kaizen Promotion Office 6.1 In order to lead the SaSH+ work across the organisation, a Kaizen Promotion Office

(KPO) has been established. The KPO is responsible for:- • providing specialist support and advice for SaSH+ across the organisation and

wider health system • building improvement expertise capacity and capability across the organisation • leading the initial value stream work to support the launch of SASH+ • developing and rolling out an education and training plan to share improvement

tools, techniques and skills


• providing ongoing coaching and mentoring to those leading improvements in the work place

• acting as a repository for all Kaizen work including monitoring of metrics and collating stories of success and learning

• sharing progress, learning and achievements both internally and externally • hold the organisation to account for maintaining rigor and compliance with the

improvement process methodology 6.2 All four members of the KPO team have commenced their advanced lean training

which is certified by VMI. Completion of this training in April 2016 for the first of the candidates.

7 Recommendation 7.1 The Board is asked to consider this report and ensure that it provides assurance around delivery of the SaSH + work Sue Jenkins Director of Strategy & Kaizen Promotion Office (KPO) Lead February 2016


SQC Minutes 8th December 2015

Page 1 of 6

Safety & Quality Committee

Thursday 8th December 2015, 12.00-14.00 AD77 Trust Headquarters, East Surrey Hospital

Minutes of Meeting

Present: Richard Shaw RS Non-Executive Director (Chair) Pauline Lambert PL Non-Executive Director Alan Hall AH Non-Executive Director Fiona Allsop FA Chief Nurse Paul Simpson PS Finance Director

Barbara Bray BB Chief of Surgery Ben Mearns BM Chief of Medicine Katharine Horner KH Patient Safety & Risk Lead Ben Emly BE Head of Information Colin Pink CP Corporate Governance Manager Jonathan Parr JP Clinical Governance Compliance

Manager Cathy White CW Patient Experience Survey Manager

Apologies: Angela Stevenson, Des Holden Action 1 COMMITTEE BUSINESS 1.1. Chair welcomed everyone to the meeting and apologies were

noted. All attendees introduced themselves.

1.2. Minutes of the previous meeting The minutes of the October and November meeting were formally approved.

1.3. Actions from previous meeting were discussed as follows C/F 2nd April Look back paper This information will be combined with a report which will assess the impact of each Breaking the Cycle week. It was agreed that the audit of emergency readmissions would be discussed at the February 2016 meeting. C/F 1st October Review of gender bias in Trust BE presented a short summary. There are 174 consultants in the Trust of which 64 (37%) are female. Since October 2012 53 new consultants have been appointed 25 (47%) are female. 2/5 Chiefs and 6/19 clinical leads are female.


Page 2 of 6

AS is setting up a focus group which will meet in the new year to look at key issues affecting female consultants: clinical excellence awards, maternity leave, childcare access to mentoring, and promotion. BB noted that there are fewer female consultant surgeons 7 out of 40, and there are three departments in surgery with no women consultants (the fourth is ED). RS asked whether this is grounds for concern, BB responded that this position reflects the national picture. The Trust is currently recruiting for lower and upper GI consultants but there have been no women applicants. In addition BB noted that surgical training is not family friendly, it is much harder to be part-time. BM noted that AMU is 50% female consultants, but a number of women have opted to work part-time, so a straightforward review of hours might be misleading. FA suggested that the focus group report back to the workforce sub-committee, and update to SQC in six months. C/F 5th November Update on VTE compliance Taken as part of the Quality Report.

1.4 Highlights from Executive Committee for Quality & Risk CP presented his report which covered the meeting which took place on the 25th November 2015; he noted that ECQR met once in November due to Breaking the Cycle (BTC). AH asked what the SSNAP audit is. BM provided a short summary of the purpose of the audit and recent results which have been positive, but noted that there is continuing work to raise the score to an A or a B. AH asked how

a D rating would impact a patient’s care. BM summarised the issues that

have adversely affected the score which the team are working to improve:

• Admission to the stroke unit in less than 4 hours

• 90% of admission on stroke unit

• Early supported discharge (working with CCG)

• Seven day therapy and consultant service

• SALT assessment (reflective of national shortage of staff) BM notes that the team score highly for the following:

• Swallow assessment

• Early clinical review of patient

• Prompt and appropriate thrombolisation.

• CT scan within an hour PS noted that at one stage the Trust scored a B and that the service has fallen back. BM explained that the results do fluctuate, but by addressing the access target and seven day service will ensure a more consistent result. RS asked whether the issue is bed availability, BM explained that experience had shown that this is not the case, more work is being done on timely transfer from ED.


Page 3 of 6

RS noted the discussion which had taken place at ECQR clarifying that the low VTE figures are a recording rather than a safety issue. CP explained that DH had discussed the national changes in safety data which are likely to happen in the next year. CP explained that more work would be needed to understand new metrics and how they can be monitored within the Trust. RS asked for an explanation of LOCSSIPs and NATSLIPs. CP explained that there is a national drive to ensure that any invasive procedure has a locally agreed procedure that the organisation is aware of them and is assured by them. The Steering Group is chaired by FA, only one meeting has taken place.

JP noted a mistake in the report “parental mortality” should “perinatal

mortality”.

1.5 Highlights from Clinical Quality Review Meeting This meeting was held on the 17th November 2015 to review September performance. PS presented a summary of the meeting. No concerns were escalated to the Single Performance Conversation. No issues were identified by the CCG. PS noted that nothing is being escalated however East Surrey CCG have mentioned in their own quality reporting that stroke and #NOF are of concern. FA noted that there had been a site visit to review the stroke service, so it is not clear what the concerns are. PS will follow this up. PS noted concern that the Single Performance Conversation is not happening; this is a meeting at Chief Executive level. MW has escalated concerns regarding the number of times this meeting has been cancelled.

2 QUALITY PERFORMANCE 2.1 Quality Report

BE presented the highlights of the report. PL asked about the GAP Audit (Good antibiotic prescribing). BM explained that this is a review of antibiotic prescribing on every ward in the Trust. It reviews the management of the patient looking at six key factors including; whether the correct antibiotic has been prescribed (normally 100%), if there has been a review within 2 days and the duration of course. BM anticipates better control with the introduction of electronic prescribing. RS asked whether the Trust has similar rates of CDIFF to other Trusts within the region. BE explained that it has not been benchmarked but anecdotal evidence from IC team would suggest that this is true. Norovirus is less easy to monitor because it is not a notifiable condition. PS asked BE to ensure that the Cdiff figures are being accurately reported on the dashboard, BE intends to include a second indicator showing cases where a lapse in care has been identified and agreed. PL asked about the mandatory training figures. FA explained that the MAST will be re-launched in January which is expected to improve the training


Page 4 of 6

figures. Training has been reviewed to look at different methods of delivering the training for example what can be done prior to start date and virtual training.

3 PATIENT EXPERIENCE 3.1 Presentation: Update on the Dementia Strategy

SA presented his report, which highlighted some of the key successes of the dementia strategy and work yet to achieve. He cited the successes as being strong nurse leadership and 1,300 staff trained on dementia awareness. The areas for improvement were highlighted as the establishment of what constitutes a dementia friendly template for a ward, training for non-clinical staff and medical staff. The establishment of a dementia strategy group and care pathways for patients with dementia and delirium.

RS asked FA about some of the issues and challenges raised by SA’s

report. FA formally noted her thanks for SA’s hard work and the significant

progress that has been made for this cohort of patients. FA felt that the problem was that the pathways were very nursing orientated and need to incorporate some of the other professional groups within the

Trust. FA welcomed that Dr Broomhead’s involvement in the pathways as an

key interface with clinical colleagues. FA explained that the barriers to progress can be summarised as competing priorities, but stressed that it is not a lack of will or intention. PL asked about the personalised care plan. SA stated that this is connected to the Butterfly Scheme and the importance of working with family and carers to understand the person, their preferences and life experiences and to adapt care appropriately. The problem has been ensuring that staff recognise where and when applying the Butterfly Scheme would be appropriate. AH commented that he found the report very balanced. He asked for more understanding on the extent or prevalence of dementia. SA explained that recently only 44% of dementia patients ever received a formal diagnosis. BM explained approximately 30-40% of inpatients have a degree of dementia or cognitive impairment. BM highlighted that dementia patients often have a longer length of stay and are no longer confined to the elderly care ward, that they access the full range of Trust services. FA thanked SA for leaving a clear indication of future strategy.

At this point RS noted that the meeting was no longer quorate as BB left the meeting.

3.2 Management of FFT and Patient Feedback CW presented her report, highlighting the problem of sentiment analysis when looking to identify themes, the strategies used to feedback compliments to wards and encourage feedback from patients. CW noted the


Page 5 of 6

engagement of the ED. RS asked for clarification on Your Care Matters (YCM) and Friends and Family Test (FFT). CW explained that YCM is the Trust bespoke survey across all pathways. The Friends and Family question is the first question on all YCM surveys, but to supplement that, FFT is done separately for inpatients, ED and maternity. AH asked how VMI manage feedback from their patients. BM explained that soliciting patient feedback is a new strategy for them. RS asked about the low response rates. CW commented that she felt it was leadership and process. BM added that he felt that it can be dependent on the environment, for example it is easier in a protocol driven environment like OP or ED. PL asked what sort of response rates are being aimed for. CW replied that ED the target is 20% and in-patients is 30%. OP remains a big challenge. Texts are sent to patients with a number of appropriate exclusions. FA noted that the Trust needs to develop a clear communication strategy with patients with a Corporate identity. RS asked whether it was time to review or refresh the strategy. CW commented that the current approach is initiative and well received. The contract for YCM is being renewed in March 2016 which might be a break point to relaunch the strategy. CP noted that the recent comments on Patient Opinion have been very positive. PS asked whether a simple metric should be developed to capture this data, for example the number of positive comments. CW agreed to look into whether this would be possible. FA noted that this is one of a number of feedback mechanisms.

3.3 Q2 PALS report FA presented the Q2 report. PL commented that she found the key themes very helpful. AH asked how sustainable the PALS service is. KH summarised a number of different models in place in other Trusts and that in 2016 NHS England intend review their own recommendations regarding PALS services within Trusts based on their observations that there is a danger that it can disenfranchise front line staff from problem solving. FA agreed that further work needs to be done to ensure that the PALS service is robust and can cope with the needs of patients.

4 SAFETY 4.1 Safer staffing

FA presented the highlights of her paper. PL asked about the nursing hours per patient day which FA explained would be available from the Health Roster system currently being used by the Trust.


Page 6 of 6

AH asked for the clarification on the wording in paragraph two and the double negative. It was agreed that it should read “there are no clinical areas which fell below 90%

4.2 Adolescent Mental Health update

Deferred to February’s meeting

4.3 Clinical Diagnosis report

Deferred to February’s meeting

5 QUALITY

See private section of the agenda

Proposed agenda for next meeting

The agenda was agreed with the caveat that an extra half hour should be added.

Any other business There were no items of any other business.

DATE OF NEXT MEETING Thursday 4th February 2016 14.00 – 16.00 AD77

Minutes of the Finance and Workforce Committee

Held on 25 January 2016 at 3.30pm

In AD65, East Surrey Hospital, Redhill

PUBLIC

Present

Richard Durban

Paul Biddle

Alan Hall

Angela Stevenson

Ian Mackenzie

Gillian Francis-Musanu

Mark Preston

Fiona Alsop

Non-Executive Director (Chair)

Non-Executive Director

Non-Executive Director

Chief Operating Officer (Part Meeting)

Director of Information & Facilities

Director of Corporate Affairs

Director of Organisational Development

and People

Chief Nurse

In attendance

Michael Wilson

Janet Miller

Peter Burnett

Laura Warren

David Knight

Chief Executive (part meeting)

Deputy Director of Organisational

Development and People

Deputy Chief Finance Officer

Head of Communications(part meeting)

Senior Cost Accountant (Committee

Secretary)

1 WELCOME AND APOLOGIES FOR ABSENCE

Apologies:

Apologies were received from Paul Simpson (Chief Finance Officer) (Peter Burnett deputised)

Declarations of Interest: There were no declarations of interest.

2 MINUTES OF THE PREVIOUS MEETING

The minutes of the 15th

December 2015 meeting were approved.

Action Tracker

Bowl Screening update due to the February meeting. All other action on the agenda or due to

future meetings.

3

BUSINESS CASE INVESTMENT

UKPN Full Business Case (FBC) Addendum

Ian Mackenzie updated the Committee on the current legal and financial situation between the

Trust and UK Power Networks (UKPN) and following negotiations the extra claim has been reduced

to £61K plus VAT. The Committee sort and received assurance that no further costs should now

arise.

Alan Hall sort clarification on the financial year in which this cost would materialise. Ian

Mackenzie confirmed it would be the current financial year.

The Committee approved the addendum on a “full and final” basis.

4 BUSINESS PLANNING

Communication Planning

Laura Warren presented the Communication plan to the Committee. The Committee welcomed

the plan which provides a set of actions for 16/17 across all platforms. The Committee noted the

progress made to date. It asked for an update on outcomes and a view on achievement against

the strategic objectives at an appropriate time.

3 FINANCE

Financial Performance M09

The month 9 Financial Performance paper was presented to the Committee by Peter Burnett.

At Month 9 the Trust is reporting an income and expenditure deficit (after donated asset technical

adjustment) of £(5.3m) which is £(4.0m) adverse to the revised TDA plan. Month 9 includes a

£0.4m income accrual in respect of anticipated reimbursement from the TDA in respect of lost

income from the Junior Doctors industrial action. Subsequent to the preparation of the accounts

the Trust has been informed that this money will not now be reimbursed nor any loss of income

from future industrial action days.

Peter Burnett highlighted that the Junior Doctor reimbursement risk amounted to £1.6million.

Mark Preston informed the Committee that this week’s strike had been postponed with both sides

working with ACAS. A further strike is planned for the 10 February.

The Committee was informed that the Trust is applying for a £9.6m loan which comes with the

condition that the earlier £6m working capital loan is paid back leaving a net position of £3.6m.

The £9.6m loan will be treated as PDC. In addition a Capital to Revenue adjustment of £3m has

been agreed with the TDA.

Action: Accounting treatment of the Capital to Revenue transfer to be provided to the

Committee. – PBurnett/PS.

The Trust’s cash balance at the end of December was £5.7m, with a forecast year end cash balance

of £2.5m. Backlog creditors increased by a further £2.2m in month. The Committee requested a

breakdown of backlog creditors.

Action: Breakdown of 60-90 day old creditors to be provided to the Committee – PBurnett/PS

2015/16 CIP Update

Peter Burnett presented the CIP paper to the Committee highlighting that the savings target YTD in

the submitted TDA plan for 2015/16 is £5.3m and at month 9 the Trust has delivered £3.2m of

savings and is behind both the TDA plan and also the internal plan. Non recurrent contingency

savings of £0.6m have been used to achieve this position. The Committee noted that achieving

the year end forecast of £4.8m would require delivery of £1.6m in Q4 against a quarterly average

of £1.1m.

2016/17 draft Budget update

Peter Burnett presented the Budget Update to the Committee. The draft budget shows a deficit of

£(4.1m). This position is predicated on achieving the 15/16 forecast of £(6.0m) set off by the

capital to revenue transfer of £3m i.e. a net position of a deficit of £(3.0m) . There are four main

actions required to firm up the budget:

- Complete a demand & capacity plan for emergency activity

- Surgical Division to provide a capacity plan for elective activity describing cost and income

- Complete a demand and capacity plan for outpatients

- Directors to complete actions on the CIP

The Committee noted that the CIP is set at £9.2m v a forecast outturn of £4.8m for 15/16 although

it recognised the contingency in the budget of £3.5m of which £1.5m is specific to nurse costs.

The Committee asked that a percentage of the saving be applied depending on which gateway had

been achieved; that the CIP is phased to show the rate required by quarter and that a total in

excess of £9.2m be scoped to allow for underachievement; the Carter analysis may be helpful.

The Committee sought assurance around the agency cap and the hourly rate. Fiona Allsop

commented that how effective the cap is going to be is still not clear. Paul Biddle sought

clarification on whether the negotiations with agencies are local or being conducted on a national

scale. Fiona Allsop confirmed that the negotiations are on a local basis.

Richard Durban asked if the Carter work had been included in the budget with Peter Burnett

confirming that Carter were not specifically included.

Alan Hall highlighted that the phasing in the budget would result in the savings doubling and given

the current run rate this would appear unrealistic. Saving would have to hit £1 million a month.

Fiona Allsop commented that nursing saving that make up the bulk of savings would start to feed

in from March. Gillian Francis-Musanu commented that savings planning had started earlier this

year and many savings are ready to start from the beginning of the new financial year and hence

are expected to deliver early.

Actions: CIP: a percentage of confidence to be added to the budgets reflecting the likelihood of

being achieved; savings to be phased by quarter – PS

Carter : the M10 CIP update to discuss the integration of the Carter findings – PS

Nurse recruitment and Agency use ; an update report to the February FWC - FA

The Committee then discussed the demand and capacity issues facing the Trust and the planning

for this and noted that the status of the actions around Emergency, Elective and Outpatients

would be reported to the February FWC as part of the 16/17CIP update.

A discussion was had around the use of the restricted amount of Capital in the next financial year

with Ian Mackenzie highlighting the more robust business case process that ensures better quality

of capital spend.

Action: Draft 16/17 Capital Plan to be presented to the February FWC IM

4

WORKFORCE AND ORGANISATIONAL DEVELOPMENT

Workforce and Organisational Development Report M09

Mark Preston presented the Month 9 Workforce and Organisational Development paper. The

Committee noted plans against each of the 6 strategic objectives would be refreshed, that a new

set of KPIs would be in place for the new financial year, that work to deliver the Achievement

review target would continue and that the definition and approach to delivering mandatory

training was being reviewed.

5 CAPITAL AND ESTATES

Capital & Estates Report M09

The Month 9 Capital report was presented. The Committee noted the openings of the IRU and the

Macmillan Information Centre.

6 IT

IT Report M09

The IT report was noted and the Committee extended their congratulations to the IT team in the

successful upgrade to the new Cerner version.

8 GENERAL

Date of next meeting

Monday 23rd

February 2016 8.30am – AD65