Board papers June 2016

Surrey and Sussex Healthcare NHS Trust

Board papers

June 2016

Trust Board Meeting – IN PUBLIC

Thursday 30th June 2016 - 11:00 to 13:30

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

AGENDA

1 11:00

GENERAL BUSINESS 1.1 Welcome and apologies for absence 1.2 Declarations of Interests 1.3 Minutes of the last meeting held on 26th May 2016 - For approval 1.4 Action tracker 1.5 Chairman’s Report

For assurance

1.6 Chief Executive’s Report For assurance

A McCarthy A McCarthy A McCarthy A McCarthy A McCarthy M Wilson

Verbal

Verbal

Paper

Paper

Verbal

Paper

2

11.30

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1 Clinical Presentation – Organ Donation Committee 2.2 Chief Nurse & Medical Director’s Report

For assurance 2.3 Quality Governance Assurance Framework - Progress Update - For approval 2.4 Safety & Quality Committee Update

For assurance

P Lambert/ Dr P Morgan F Allsop/ D Holden D Holden/ G Francis-Musanu R Shaw

Presentation

Paper

Paper

Paper

3

12.15

OPERATIONAL PERFORMANCE 3.1 Integrated Performance Report (M02)

For assurance

3.1.1 Safety & Quality Performance Indicators

3.1.2 Operational & Access Performance

Indicators 3.1.3 Patient Experience Performance Indicators 3.1.4 Workforce Performance Indicators 3.1.3 Finance Performance Indicators

3.2 Finance & Workforce Committee Update

F Allsop/ D Holden A Stevenson F Allsop M Preston P Simpson

Paper

For assurance

3.3 Audit & Assurance Committee Update For assurance

R Durban P Biddle

Paper

Paper

4

13.00

RISK, REGULATORY AND STRATEGY ITEMS 4.1 Quality Account 2015/16 For approval 4.2 Nomination & Remuneration Committee Annual Report - For assurance 4.3 2016/17 Annual Plan For approval 4.4 Information Governance Annual report

D Holden A McCarthy S Jenkins I Mackenzie

Paper

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 5.1.3 Audit & Assurance 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

28th July 2016 at 11.00am

A McCarthy A McCarthy A McCarthy

Paper

Paper

Paper

mailto:[email protected]

Page 1 of 8

Minutes of Trust Board meeting held in Public Thursday 26TH May 2016 from 11:30 to 13:30

Room AD77, Trust Headquarters, East Surrey Hospital

Present

(AM) Alan McCarthy Chairman (RD) Richard Durban Non-Executive Director and Deputy Chairman (MW) Michael Wilson Chief Executive (DH) Des Holden (FA) Fiona Allsop (AS) Angela Stevenson

Medical Director Chief Nurse Chief Operating Officer

(PL) Pauline Lambert Non-Executive Director (PB) Paul Biddle Non-Executive Director (AH) Alan Hall Non-Executive Director (RS) Richard Shaw

Non-Executive Director

In Attendance

(GFM) Gillian Francis-Musanu Director of Corporate Affairs (MP) Mark Preston (SJ) Sue Jenkins (IM) Ian Mackenzie (PBu) Peter Burnett (CP) Colin Pink

Director of Organisational Development and People Director of Strategy Director of Information and Facilities Deputy Chief Financial Officer Head of Corporate Governance

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. Apologies for absence were noted from Paul Simpson.

1.2 Declarations of Interest – For approval The Chairman asked whether any of the Board members had any additional declarations of interest; none were recorded.

1.3 Minutes of the last meeting held on 28th April 2016 The minutes of the meeting held on 28th April were discussed and approved as a true and accurate record with minor non-material changes agreed.

1.4 1.4.1

Action Tracker GFM updated the Board on the following actions which were due: TBPU-04: DH confirmed that this Action is now closed. The remaining actions are due in July 2016. There were no other matters arising.

Page 2 of 8

1.5

Chairman’s Report for Assurance AM stated that he had nothing to report or discuss with the Board that was not already covered in the Chief Executives report or other agenda items. AM noted that ‘NHS providers’ had just updated its good practice guidance on good governance, which included acknowledgement of the Trust’s contribution. This relates to the Board assurance framework and review of risk.

1.6

Chief Executives report for Assurance The Board received and noted the Chief Executive’s report in advance of the meeting. MW updated the Board on the development of Sustainability and Transformation Plan (STP). The focus remains on the development of financially stable system that that improves quality and reduces geographic gaps in outcome and quality metrics. The Trust’s International Nurses Day events had gone well, there had been some particularly inspiring speakers. The Pediatric Diabetes Team had been shortlisted as finalists at the recent BMJ Award relation to the innovations they had made in service delivery. The Board duly noted and took assurance from the report.

2. Safety, Quality and Patient Experience 2.1

Chief Nurse and Medical Director’s Report for Assurance The Board received and noted the report in advance of the meeting. FA reported on the Safer Staffing report which indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template. Reminding the Board that the data format was being reviewed and would change shortly. FA went to update the Board on the overall position for nursing recruitment which was providing good assurance against the plan. The Board discussed the Leading Change, Adding Value framework launched by NHS England’s Chief Nurse in May. FA commented that initial reviews suggested that the Trust’s alignment with the framework is good and that detailed reports would go to the Finance and Workforce Committee. DH discussed the pause in junior doctor’s industrial action and the Trust’s CQUIN position detailed in the paper. The Board discussed the impact of the industrial action and contract negotiations on Junior Doctor moral. DH stated that morale was bruised but there was confidence that the Trust would implement changes in a compassionate and pragmatic way. There is still detail to be resolved particularly the development of rotas. MW reflected on the impact of the STP and delivery of equitable 7 day services. AH asked for an update on end of year position for CQUIN. DH stated that the

Page 3 of 8

final end of year position was still to be agreed and that it would be reported to SQC shortly. The Board noted that 2016/17 CQUINs were still being agreed and that some will span over a two year period. The Board duly noted and took assurance from the report.

2.3 Safety & Quality Committee Update (SQC) for assurance The Board received and noted the report in advance of the meeting. RS presented the report highlighting conversations at the meeting relating to a review of March’s activity and impact on quality metrics. There had been good assurance taken from the quarterly incident report and meaningful discussion of data and themes presented in the complaints and PALS reports. The Committee had discussed the clinical audit program and are expecting an updated end of year position when all data is available. There was not confidence that each audit is considered appropriately to identify learning and action. It was felt that more can be done to gain value from the efforts already undertaken within clinical audit. RS went on to say that future plans included a deep dive into issues that have manifested in diagnostic serious incidents to build a full picture and level of assurance. PL asked for an update on the discussion relating to numbers of still births recorded in March. DH confirmed that the issue was being reviewed but that the Trust’s data indicated that incidence was 10% lower than the national average. An audit had identified no issues or concerns in individual cases focusing on growth scans and their interpretation. PL asked for an update on the Trust’s safeguarding training, FA confirmed that the position was improving at 70% coverage and that alternative vehicles for delivery are being explored to deliver training. The Board agreed that the proportion needs to continue to improve and be monitored. The Board went on to discuss the local framework for management and reporting of safeguarding issues. The system as it stands does not provide feedback to alerts that are raised by the Trust. The Trust is working with the system to strengthen processes such that learning can be shared across multi organisations. MW confirmed that children’s services are part of the review undertaken by the STP although the focus is service provision rather than the detail of safeguarding. The Board duly noted and took assurance from the report.

3.

Operational Performance

3.1 3.1.1

Integrated Performance Report (M01) for Assurance The Board received and noted the report in advance of the meeting. Operational & Quality Key Performance Indicators

Page 4 of 8

3.1.2

AS presented the operational elements of the paper highlighting ED performance at 91.3% and the overall national picture. Medically ready for discharge numbers remain on average at circa 135, this remains an area of local focus as does the management of handover delays between the ambulance service and the ED. Cancer access standards remain an issue, it is unlikely that we will meet the 2 week target for May. There is significant management focus on providing patient choice to improve compliance with the standard. The Board noted how NICE guidance was driving increases in referral rates across all cancer pathways. Referral to treat standards is being met and the Trust remains on its planned trajectory. There is also a drop in number of cases being cancelled on the day. AH asked what needed to be done to reduce the number of medically ready for discharge patients. MW reflected that at any time a percentage of those patients need continuing health care to be in put in place and that the focus remains on efforts to speed up the process and make clinical decisions that start the process as early as possible. The STP will drive this with the national focus on managing patients at home. Locally there is a need for affordable houses to support the demands on supply of workforce which is acutely felt in recruitment of nurses. FA presented the safety elements of the report highlighting that the Trust’s safety thermometer data is moving in the right direction which is positive and that there had been 2 cases of trust apportioned clostridium difficile. The risk of gastroenteritis remains high. DH presented the clinical effectiveness elements of the report, the Trust’s HSMR remains better than average. The Clinical Chiefs have agreed that we want, as an organization, to be very good at learning from deaths and as such we will move towards increasing the seniority of review of all deaths. The Effectiveness committee has also resolved to look what can be learnt from all readmissions. FA highlighted that patient experience metrics had improved with particular note of the maternity community response rate for the friends and family test which had significantly improved during April. The Trust’s visiting hours trial had finished, which had been well received. Feedback was being reviewed and the plans are being altered to take into account all the learning. Workforce Key Performance Indicators MP noted that the Trust’s vacancy rate has increased as has turnover rate which is driving the use of agency. Sickness rate has improved in month. The Board discussed achievement review compliance with completion targets, noting that it remained a high focus and that individual management targets are being set. RS noted the agency use and asked if it was known why overall usage had dropped. FA confirmed that this is due to reduction in escalation areas and the first impact of overseas nurses converting to substantive posts.

Page 5 of 8

3.1.3 Finance Key Performance Indicators PBu introduced the financial elements of the report noting that the Trust had reported a £1.3 million deficit at the end of April which is better than the planned position. This is being driven by extra outpatient activity and good delivery of saving plans to date. With the exception of Surgery there is overspending in all, Divisions. These overspends are being reviewed within the performance management framework in the Trust. The overall cash position is better than expected and indicators such as payment performance indicators are favorable. The Board noted that Capital plan was on track. RD agreed that payment to suppliers was improving and remained a focus. The Finance and Workforce Committee is reviewing the implementation of cost improvement plans as there is a £3 million risk attached to end of year delivery, there is however anticipation that this risk will be reviewed regularly. AM welcomed the news that the Trust had reported that the Trust was underspent by £1 million against the plan at the end of April. PBu asked that the Board delegated authority to the Audit and Assurance Committee to review and approve the Trust’s 2015/16 annual accounts. This was approved. The Board duly noted and took assurance from the report.

3.2 Finance & Workforce Committee (FWC) Chair Update – for Assurance

The Board received and noted the report in advance of the meeting. RD introduced the report echoing the issues discussed in the earlier agenda item. RD highlighted that the committee had received an overview of the Trust’s training plan which was a very positive start, noting that management were still working on the full detail. This had included a strategic review of the main mandatory and statutory training delivery. The Board duly noted and took assurance from the report.

4. Risk, Regulatory and Strategy Items

4.1 2016/17 - Vision, Values, Strategic Intent & Strategic Objectives – for Approval The Board received and noted the report in advance of the meeting. SJ introduced the paper for approval. As part of the business planning cycle each year a review is undertaken of vision, values, strategic intent and strategic objectives had been undertaken. This had been developed with comments and feedback from the Shadow Council of Governors. The vision has been updated to reflect our desire to be in pursuit of perfection in our journey to become an outstanding organisation. Our four key themes defined as our strategic intent remain the same but

Page 6 of 8

leadership has been clarified as to being leadership across the system to differentiate it from the well led strategic objective. The Board discussed the emphasis on patient led versus a patient focussed. DH stated that he believed it should be a patient led strategic intent rather than a patient focussed. This was discussed at length and the proposal was not agreed the emphasis would remain on patient focus and clinical leadership. The Board went on to ask SJ to put greater emphasis on IT, medically ready for discharge and development of local services. Action SJ The Board discussed what was meant by local services and agreed that this referred to the development and availability of accessible services aligned to right place first time. With the changes of emphasis agreed the Board duly noted and approved the 2016/17 - Vision, Values, Strategic Intent & Strategic Objectives.

4.2 Finance and Workforce Committee Annual Report – for Assurance The Board received and noted the report in advance of the meeting. RD introduced the report and the Committee adherence to the terms of reference. RD highlighted that there has been increased focus on assurance over productivity and financial planning and performance, reflecting their importance to the Trust. It had been a challenging year and the Committee had applied scrutiny to the assumptions and detail in forecast and financial reporting. There has been less focus on strategy, in part because of the stage reached in our FT journey but also because of agreement that the Board lead on strategy development with sub-committees seeking assurance over strategic delivery. There had been a positive shift in reporting of workforce and organisational development information in year, driven by Mark Preston. The challenge for the next year would be to ensure monitoring of benefits of investment are realised, development of service line reporting and output of the ‘Carter Report’ on costing. The FWC considers that it had met it’s Terms of Reference during 15/16. The Board went on to discuss the Trust’s FT journey the development of a refreshed long term financial model and board governance assurance framework compliance. AM drew the conversation to an end thanking RD for the report and agreeing that the committees objectives and terms of reference are sound. The Board duly noted and took assurance from the report.

4.3 SaSH + transformation partnership with the Virginia Mason Institute – Progress Update – for Assurance The Board received and noted the report in advance of the meeting.

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SJ introduced the paper which detailed an update on progress since February 2016. SJ highlighted the progress that had been made in each of the 3 initial value stream, the leaders training plan that had been developed and the extra advanced lean training that had been agreed. RS asked how the leaders program might impact on the value streams. SJ confirmed that the value streams are specific focus area and ran separately from the ideas and issues that managers may choose to work on. PL expressed concerns over the initial results following the cardiology work. SJ stated that there had been issues at the start of the program but that this resolving and was now back on track. The Board discussed the plan for organising opportunity walks for Board members. The current plan was to develop a schedule that aligns with the value streams. The Board asked for a more structured approach to be developed Action: GFM/SJ. AM highlighted the importance of the Board meeting the expectations in the ‘compact’ noting that its implementation and supporting communications plan would be key. The Board duly noted and took assurance from the report.

4.4 Update from the Shadow Council of Governors - for Assurance & Approval The Board received and noted the report in advance of the meeting. GFM introduced the report highlighting that The third Shadow Council of Governors had took place on 12th April 2016. The meeting had discussed the annual report from the Audit & Assurance Committee and initial involvement opportunities for governors. The Council had considered the review of the draft constitution and approval of a recommendation to reduce the number of nominated governor seats as Healthwatch had expressed a perceived conflict of interest. This agreement would reduce the council of governors from 29 to 28. The Board was asked to ratify this recommendation from the Shadow Council of Governors. The Board duly approved the recommendation to reduce the overall numbers of nominated governors and 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 Safety and Quality Committee to receive and note The minutes of the Committee were noted with no questions raised.

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5.2 Any Other Business AH asked for an update on the development of the Board Assurance Framework. GFM confirmed that the 2016/17 BAF was being developed by the Executive Team and would be considered at the June Private Board.

5.3

Questions from the Public There were no questions raised.

5.4 Date of the next meeting Thursday 30th June 2016 at 11.00am 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 - June 2016

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

TBPU-01 TB Public Staff survey report

MP to take an update report on staff survey action

delivery and effectiveness to FWC MP 31/03/2016 31/07/2016 Not Due

TBPU-02 TB Public 2016/17 Operational Plan

To devlop and bring plans for fraility unit to public

board AS 31/03/2016 31/07/2016 Not Due

TBPU-03 TB Public

2016/17 - Vision, Values,

Strategic Intent &

Strategic Objectives

To finalise the document and add greater emphasis

on IT, medically ready for discharge and

development of local services SJ 26/05/2016 30/06/2016 Due

TBPU-04 TB Public

SaSH + transformation

partnership with the

Virginia Mason Institute –

Progress Update

The Board asked for a more structured approach to

be developed to support Board and Govenor

involvement in the Trust's 'Opportunity walks' GFM/SJ 26/05/2016 31/07/2016 Not Due

ACTIONS FROM PUBLIC BOARD MEETINGs - December 2015

TRUST BOARD IN PUBLIC

Date: 30th June 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/Regional:

• New programme launched to fast-track cutting-edge innovations

• Workplace experiences of BME and white staff published for every NHS trust across England

Local:

• Fire at East Entrance of East Surrey Hospital

• Trust Shortlisted for Two Categories of the National Patient Safety Awards

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

2

TRUST BOARD REPORT –30th June 2016 CHIEF EXECUTIVE’S REPORT

1. National/Regional Issues

1.1 New programme launched to fast-track cutting-edge innovations

In his keynote speech to around 1,000 NHS leaders at the NHS Confederation Conference in Manchester on 16th June, Simon Stevens announced that for the first time the NHS will provide an explicit national reimbursement route for new medtech innovations. This will accelerate uptake of new medtech devices and apps for patients with diabetes, heart conditions, asthma, sleep disorders, and other chronic health conditions, and many other areas such as infertility and pregnancy, obesity reduction and weight management, and common mental health disorders. This new funding route will help reduce the time it takes for clinicians and innovators in getting uptake and spread across the NHS. This is because a new Innovation and Technology tariff category will remove the need for multiple local price negotiations, and instead guarantee automatic reimbursement when an approved innovation is used, while at the same time allowing NHS England to negotiate national ‘bulk buy’ price discounts on behalf of hospitals, GPs and patients.

1.2 Workplace experiences of BME and white staff published for every NHS trust across England

On 2nd June the NHS Equality and Diversity Council published the inaugural report of the NHS Workforce Race Equality Standard (WRES), showing results of the experiences of BME and white staff from the staff survey 2015 at every NHS trust across England. This is the first time the WRES data has been collected and published nationally. The report provides feedback to every hospital and trust across the NHS about the experiences of their BME staff. It confirms that while some employers have got it right, for many others these staff survey results are a clear call to action. As this is the first year of the WRES, it provides a transparent baseline from which each employer will now be seeking to improve. The report looked at four indicators across acute trusts, ambulance trusts, community provider trusts, and mental health and learning disability trusts. The results show a picture of variation across the health service with some trusts making progress, whilst others still have a considerable way to go. The full report is available at: https://www.england.nhs.uk/wp-content/uploads/2014/10/WRES-Data-Analysis-Report.pdf

2. Local Issues

2.2 Fire at East Entrance of East Surrey Hospital On 6th June there was a serious fire outside of the East Entrance of East Surrey Hospital. Many of you will have seen pictures of the three burning ambulances and will be aware of how quickly the situation escalated. Incredibly no-one was injured and the team work that I witnessed in dealing with the incident by our staff and external agencies was fantastic. Our patients and visitors have taken the time to contact us to thank our staff.

3

On behalf of the Board I would like to thank all staff for their focus and hard work in making sure patients, visitors and colleagues were safe and ensuring that the hospital was fully operational within just a few hours. On behalf of SASH, I have also sent thanks to our colleagues in the fire, police and ambulance services whose prompt response and professionalism brought the situation under control quickly and safely. An investigation is underway to ascertain the cause of the fire. 2.2 Trust Shortlisted for Two Categories of the National Patient Safety Awards I am pleased to confirm that the Trust has been successfully shortlisted in two categories of the national Patient Safety Awards, Board Leadership and Best Organisation. This is great national recognition for SASH and the winners will be announced in early July.

3. Recommendation

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

direction.

Michael Wilson Chief Executive June 2016


Date: 30 June 2016 Agenda Item:

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

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

Action Required:

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

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.


• The Safer Staffing report (May 2016 data) indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template.

• Details care hours Per Patient Day reported for the first time in June • Provides a brief update regarding nursing recruitment • Note new consultant appointments • Note presentation as a finalist in both Organisation of the year and Board of the Year

in HSJ patient safety awards

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 & Yes

Page 1

Diversity/Communication Attachment: N/A

Chief Nurse/ Medical Director Report

30 June 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 – May 2016

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

Abinger Ward 430 - GERIATRIC MEDICINE 31 98.85% 100% 95.71% 100% 97.21% 100% 98.31%

Acute Medical Unit 300 - GENERAL MEDICINE 31 99.22% 100% 96.49% 96.77% 98.42% 98.83% 98.6%

Birthing Centre 501 - OBSTETRICS 31 100% 93.55% N/A N/A 100% 93.55% 96.77%

Bletchingley Ward 300 - GENERAL MEDICINE 31 99.72% 98.92% 101.99% 103.23% 100.74% 100.65% 100.7%

Brockham Ward 502 - GYNAECOLOGY 31 98.39% 100% 95.16% 93.55% 97.31% 98.39% 97.74%

Brook Ward 100 - GENERAL SURGERY 31 100% 100% 96.66% N/A 98.91% 100% 99.35%

Buckland Ward 101 - UROLOGY 31 97.09% 98.39% 99.57% 98.39% 98.06% 98.39% 98.19%

Burstow Ward 501 - OBSTETRICS 31 98.39% 89.25% 92.36% 95.16% 96.38% 91.61% 94.21%

Capel Annex l Ward 100 - GENERAL MEDICINE 31 98.39% 100% 95.7% 98.39% 97.24% 99.19% 97.95%

Capel Ward 430 - GERIATRIC MEDICINE 31 100% 97.85% 103.72% 100% 101.18% 98.71% 100.09%

Chaldon Ward 300 - GENERAL MEDICINE 31 94.78% 100% 96.77% 98.92% 95.62% 99.35% 96.91%

Charlwood Ward 301 - GASTROENTEROLOGY 31 102.51% 100% 99.1% 100% 101.22% 100% 100.74%

https://bi01/information/ddc-monthview-ward.php?period=2016-05&ward=O000000096












Page 1

Copthorne Ward 301 - GASTROENTEROLOGY 31 99.19% 96.77% 96.85% 100% 98.4% 98.39% 98.39%

Coronary Care Unit 320 - CARDIOLOGY 31 97.85% 98.41% N/A 103.33% 97.85% 100% 98.92%

Delivery Suite 501 - OBSTETRICS 31 96.56% 98.39% 94.04% 96.55% 95.93% 97.95% 96.93%

Discharge Lounge 300 - GENERAL MEDICINE 31 97.55% 100% 98.09% 100% 97.81% 100% 98.62%

Godstone Ward (Haem) 303 - CLINICAL HAEMATOLOGY 31 98.39% 100% 98.55% N/A 98.44% 100% 99.08%

Godstone Ward (Med) 300 - GENERAL MEDICINE 31 97.42% 100% 103.23% 98.92% 99.6% 99.46% 99.54%

Hazelwood 300 - GENERAL MEDICINE 31 100% 100% 97.85% 100% 98.92% 100% 99.35%

Holmwood Ward 320 - CARDIOLOGY 31 99.35% 100% 96.77% 98.39% 98.62% 99.19% 98.83%

ITU/HDU 192 - CRITICAL CARE MEDICINE 31 96.72% 98.97% 87.24% 96.77% 95.38% 98.8% 97.01%

Leigh Ward 110 - TRAUMA & ORTHOPAEDICS 31 98.55% 98.39% 104.41% 100% 101.07% 99.35% 100.4%

Meadvale Ward 430 - GERIATRIC MEDICINE 31 94.37% 100% 96.77% 100% 95.64% 100% 97.14%

Neonatal Unit 420 - PAEDIATRICS 31 93.99% 95.24% 103.28% 91.67% 96.82% 94.09% 95.5%

Newdigate Ward 110 - TRAUMA & ORTHOPAEDICS 31 100.31% 100% 109.01% 100% 103.97% 100% 102.42%

Nutfield Ward 430 - GERIATRIC MEDICINE 31 98.49% 100% 98.94% 98.39% 98.66% 99.19% 98.83%

Outwood Ward 420 - PAEDIATRICS 31 96.82% 98.71% 71.38% 83.87% 93.84% 96.24% 94.89%

Rusper Ward 501 - OBSTETRICS 31 97.58% 100% N/A N/A 97.58% 100% 98.39%

Surgical Assessment Unit 100 - GENERAL SURGERY 31 98.39% 100% 100% 100% 98.71% 100% 99.28%

Tandridge Ward 300 - GENERAL SURGERY 31 98.49% 98.39% 97.63% 91.94% 98.11% 95.16% 97.21%

Tilgate Annex 100 - GENERAL MEDICINE 31 100% 96.88% 98.92% 98.39% 99.6% 97.62% 98.93%

Tilgate Ward 300 - GENERAL MEDICINE 31 98.07% 100% 96.77% 100% 97.58% 100% 98.39%

Woodland Ward 100 - GENERAL SURGERY 31 100% 100% 97.8% 100% 99.19% 100% 99.46%

Total 98.18% 98.65% 98.09% 98.3% 98.15% 98.52% 98.3%






















Planned versus actual commentary The Trust has delivered planned versus actual staffing profile for April. The report shows a stable picture in relation to overall compliance with no red shifts at unit level in month. Care hours per patient day (CHPPD) In addition to reporting planned versus actual nurses on duty from 1 June 2016 NHS Improvement (NHSI) requires the Trust to report care hours per patient day (CHPPD). Care hours per patient day are calculated by dividing the total numbers of nursing hours on a ward or unit by the number of patients in beds at the midnight census. This calculation provides the average number of care hours available for each patient on the ward or unit. Currently the hours reported re for nursing only but it is intended to include other clinical staff including doctors in the future. The report for May is shown below. This tool links with planned versus actual reporting and other data such as safety thermometer, incident reporting, sickness rates, vacancy rates and professional judgement to determine the appropriate staffing levels for a ward or unit. Care Hours Per Patient Day Care hours per patient day have been developed to quantify the nursing time available to each patient by the available registered nursing staff and nursing assistants.

Only complete sites your organisation is accountable

for

Specialty 1 Specialty 2

Total monthly planned staff hours

Total monthly actual staff hours

Total monthly planned

staff hours

Total monthly actual

staff hours


staff hours


staff hours


staff hours


staff hours

Abinger Ward 430 - GERIATRIC MEDICINE 1,302 1,287 1,422 1,361 713 713 1,070 1,070 98.8% 95.7% 100.0% 100.0% 711 2.8 3.4 6.2Acute Medical Unit 300 - GENERAL MEDICINE 3,462 3,435 1,426 1,376 2,496 2,496 1,426 1,380 99.2% 96.5% 100.0% 96.8% 991 6.0 2.8 8.8

Birthing Centre 501 - OBSTETRICS 713 713 - - 713 667 - - 100.0% - 93.5% - 41 33.7 0.0 33.7Bletchingley Ward 300 - GENERAL MEDICINE 302 - ENDOCRINOLOGY 1,426 1,422 1,155 1,178 1,070 1,058 713 736 99.7% 102.0% 98.9% 103.2% 731 3.4 2.6 6.0Brockham Ward 502 - GYNAECOLOGY 1,426 1,403 713 679 1,070 1,070 357 334 98.4% 95.2% 100.0% 93.5% 556 4.4 1.8 6.3

Brook Ward 100 - GENERAL SURGERY 713 713 345 333 713 713 - - 100.0% 96.7% 100.0% - 308 4.6 1.1 5.7Buckland Ward 101 - UROLOGY 1,445 1,403 932 928 713 702 713 702 97.1% 99.6% 98.4% 98.4% 624 3.4 2.6 6.0Burstow Ward 501 - OBSTETRICS 1,426 1,403 713 659 1,070 955 713 679 98.4% 92.4% 89.2% 95.2% 531 4.4 2.5 7.0

Capel Annex l Ward 300 - GENERAL MEDICINE 1,426 1,403 1,070 1,024 713 713 713 702 98.4% 95.7% 100.0% 98.4% 665 3.2 2.6 5.8Capel Ward 430 - GERIATRIC MEDICINE 1,539 1,539 713 740 1,070 1,047 713 713 100.0% 103.7% 97.8% 100.0% 614 4.2 2.4 6.6

Chaldon Ward 300 - GENERAL MEDICINE 1,955 1,853 1,426 1,380 713 713 1,070 1,058 94.8% 96.8% 100.0% 98.9% 821 3.1 3.0 6.1Charlwood Ward 301 - GASTROENTEROLOGY 1,375 1,409 838 830 713 713 713 713 102.5% 99.1% 100.0% 100.0% 604 3.5 2.6 6.1Copthorne Ward 301 - GASTROENTEROLOGY 1,426 1,415 730 707 713 690 713 713 99.2% 96.8% 96.8% 100.0% 588 3.6 2.4 6.0

Coronary Care Unit 320 - CARDIOLOGY 1,070 1,047 - - 725 713 345 357 97.8% - 98.4% 103.3% 227 7.8 1.6 9.3Delivery Suite 501 - OBSTETRICS 2,139 2,066 713 671 2,139 2,105 667 644 96.6% 94.0% 98.4% 96.6% 134 31.1 9.8 40.9

Discharge Lounge 300 - GENERAL MEDICINE 611 596 602 590 357 357 357 357 97.5% 98.1% 100.0% 100.0% 74 12.9 12.8 25.7Godstone Ward (Haem) 303 - CLINICAL HAEMATOLOGY 713 702 311 306 713 713 - - 98.4% 98.6% 100.0% - 182 7.8 1.7 9.5Godstone Ward (Med) 300 - GENERAL MEDICINE 410 - RHEUMATOLOGY 1,783 1,737 1,070 1,104 1,070 1,070 1,070 1,058 97.4% 103.2% 100.0% 98.9% 788 3.6 2.7 6.3

Holmwood Ward 320 - CARDIOLOGY 1,783 1,771 713 690 713 713 713 702 99.4% 96.8% 100.0% 98.4% 841 3.0 1.7 4.6ITU/HDU 192 - CRITICAL CARE MEDICINE 4,536 4,387 745 650 4,451 4,405 357 345 96.7% 87.2% 99.0% 96.8% 468 18.8 2.1 20.9

Leigh Ward 110 - TRAUMA & ORTHOPAEDICS 1,591 1,568 1,201 1,254 713 702 1,070 1,070 98.6% 104.4% 98.4% 100.0% 852 2.7 2.7 5.4Meadvale Ward 430 - GERIATRIC MEDICINE 1,280 1,208 1,426 1,380 713 713 713 713 94.4% 96.8% 100.0% 100.0% 709 2.7 3.0 5.7Neonatal Unit 420 - PAEDIATRICS 1,598 1,502 701 724 1,449 1,380 690 633 94.0% 103.3% 95.2% 91.7% 560 5.1 2.4 7.6

Newdigate Ward 110 - TRAUMA & ORTHOPAEDICS 1,599 1,604 1,160 1,264 713 713 1,058 1,058 100.3% 109.0% 100.0% 100.0% 826 2.8 2.8 5.6Nutfield Ward 430 - GERIATRIC MEDICINE 1,783 1,756 1,081 1,069 713 713 713 702 98.5% 98.9% 100.0% 98.4% 857 2.9 2.1 4.9

Outwood Ward 420 - PAEDIATRICS 2,421 2,344 322 230 1,783 1,760 357 299 96.8% 71.4% 98.7% 83.9% 571 7.2 0.9 8.1Rusper Ward 501 - OBSTETRICS 1,426 1,392 - - 713 713 - - 97.6% - 100.0% - 248 8.5 0.0 8.5

Surgical Assessment Unit 100 - GENERAL SURGERY 1,426 1,403 357 357 713 713 713 713 98.4% 100.0% 100.0% 100.0% 254 8.3 4.2 12.5Tandridge Ward 300 - GENERAL MEDICINE 340 - RESPIRATORY MEDICINE 1,820 1,793 1,414 1,380 713 702 713 656 98.5% 97.6% 98.4% 91.9% 684 3.6 3.0 6.6Tilgate Annex 300 - GENERAL MEDICINE 1,783 1,783 1,070 1,058 736 713 713 702 100.0% 98.9% 96.9% 98.4% 642 3.9 2.7 6.6Tilgate Ward 300 - GENERAL MEDICINE 340 - RESPIRATORY MEDICINE 1,786 1,752 1,070 1,035 1,081 1,081 357 357 98.1% 96.8% 100.0% 100.0% 797 3.6 1.7 5.3

Woodland Ward 100 - GENERAL SURGERY 1,783 1,783 1,047 1,024 713 713 713 713 100.0% 97.8% 100.0% 100.0% 666 3.7 2.6 6.4

Registered midwives/

nursesCare Staff Overall

Registered midwives/nurses Care Staff

Average fill rate - registered

nurses/midwives (%)

Average fill rate - care staff (%)

Average fill rate - registered

nurses/midwives (%)

Average fill rate - care staff (%)Ward name

Main 2 Specialties on each ward Registered midwives/nurses Care Staff

Cumulative count over the month of

patients at 23:59 each

day

Day Night Day Night Care Hours Per Patient Day (CHPPD)

Agency Cap reporting to NHS Improvement Since November 2015, the Trust has been required to report to NHSI shifts that are above the rate cap, off of a framework or both. The Trust use Mayday nursing agency as the main tier 1 provider. At the current time, the majority of these shifts are above the agency capped rate. All shift above the rate cap are subject to use only in ‘break glass’ circumstances. The justification of use for each shift is recorded on the Healthroster system. For nursing this equates ot approximately 350 shifts per week. Recruitment The total nursing vacancies in whole time equivalents (WTE) for all nursing posts (registered, unregistered) including uplift are: Trust wide vacancy position 4 August 2015 12 February 2016 May 2016 Trust wide nursing workforce WTE

1595 1595 1606

Total nursing vacancies WTE 291 199 204 Vacancy rate % 18 12.5 13 Vacancy position by division 4 August 2015 12 February 2016 May 2016

WTE % WTE % WTE % Medicine 121 32 100 16 82 13 Surgery 123 20 77 13 93 15 Cancer 10 17 12 20 15 25 WACH 35 11 12 3 14 4.5 As can be seen this is an improving position with the exception of cancer services where there are 5 specialist nurse vacancies.

Predicted average demand for registered nurses over the 16/17 year remains at 20 per month and 5 for nursing assistants. Retention In addition to the retention strategies being developed at a local divisional level, the Trust is focusing on corporate retention strategies to support and retain existing staff. It is recognized that the large numbers of newly recruited nurses entering the organization requiring additional support is adding additional pressure to teams and support is being provided by the Practice Development nurses. Temporary staffing A trial of enhanced bank rates within the operating theatres, continues to yield a positive uptake in bank shifts and a reduction in agency spend in this area. The recent conclusion to a consultation on the opening hours of the temporary staffing bureau has resulted in the office being opening earlier two hours earlier and an hour later at the weekends and bank holidays. It is expected that this will enhance the timely booking of temporary staffing during this period Recruitment to the bank continues 3. New consultant appointments At time of writing this report we have appointed two consultant ophthalmology consultants to join our team. They are Mr. Anish Dhital and Mr. Sophocles Sophocleous. A consultant interview in the palliative care department is due to take place on 28th June. 4. finalists in HSJ patient safety awards. To note, the trust has given two presentations to the judging panels of the HSJ national patient safety awards. We are finalists and presented in the categories of trust Board of the Year and organization of the year. The results will be announced on 5th July. 5. Recommendation To note the report Fiona Allsop Dr Des Holden Chief Nurse Medical Director 24 June 2016

1 An Associated University Hospital of

Brighton and Sussex Medical School


Date: 30TH June 2016 Agenda Item: 2.3

REPORT TITLE: Progress Update on Quality Governance Assurance Framework Action Plan

EXECUTIVE SPONSOR: Dr Des Holden Medical Director

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

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) ECQR Jan 2016, March 2016 & May 2016

Action Required:

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

Purpose of Report:

To provide an update on actions taken to support Quality Governance.

Summary of key issues Since the rating of 3.5 by Monitor in June 2015, the Executive Committee for Quality & Risk has been regularly reviewing progress and actions. The action plan has been updated to reflect progress on::

• CIP actions, internal audit at AAC and Board reports (1B) • Actions completed in relation to process & structures (3A) • Focus on clinical audit & quality committees (3B) • Progress on Data Quality & Measurement (4A &4B)

The current scores have been updated by the Executive Committee which reflects the progress which has been made. Score is current 1.5

Recommendation:

To review progress and agree the current scoring along with any further actions required.



Legal and regulatory impact Report details actions to support Quality Governance

Financial impact Limited details actions to support CIP governance

Patient Experience/Engagement Report details actions to support Quality Governance



Risk & Performance Management Report details actions to support Quality Governance


Report details actions to support Quality Governance

Attachment: Updated QGAF action plan – June 2016

1

Refreshed QGAF Action Plan v0.5. – June 2016/gfm

REFRESHED QUALITY GOVERNANCE ASSURANCE FRAMEWORK

ACTION & DELIVERY PLAN – v0.5 – June 2016

QGAF Question

Monitor Commentary Monitor Provisional Score 2015

Trust Action Trust Evidence of compliance & Timescale

Lead RAG & Residual

Score Strategy: 1B

Is the Board sufficiently aware of potential risks to quality?

CIP process missing elements of good practice, relying on strong executive involvement rather than processes. Adequate for CIP programme for 2015/16 but would need to be improved for higher risk schemes in future. A/G score is dependent on the view that the Board is capable of strengthening current processes and making improvements in the future as they are required.

A/G

0.5

Board to review QIAs for 2015/16

Board approved initial 2016/17 CIP plan

Board to review 2014/15 QIA PIR

Completion of 2016/17 CIP plan, schemes & QIAs

Twice yearly review of 2015/16 CIPs & with a focus on Quality Impact

Review of CIP process & mechanisms – outcome reported to Board.

Completed – May 2015 – Board report and minutes Completed – June 2015 – Board report and minutes Complete – August 2015 – Board report and minutes

Indicative CIP plan presented to Public Board Dec 2015

Due – @ Board - Jan 2016 & July 2016

Complete Dec 2015, Internal Audit review reported to AAC Jan 2016

PS

PS

FA/DH

PS

FA/DH

PS

G

0.0

Moving to Green (0.0)

when all actions

complete

Processes & Structures: 3A

Are there clear roles and accountabilities in relation to quality governance?

The Trust has some missing good practice. The quality of SQC papers are variable, in particularly the quality report and the timing of the 5 quality sub-groups means that on occasion the latest quality information is not reported to SQC. This impacts the ability of the sub-committee to provide assurance to the Board on quality mitigated to some extent by other mechanisms through which the SQC has oversight of quality issues and the strength of clinical and executive management.

There is no forum for holding divisions to account for performance as a whole; although

A/G

0.5

Content of Quality Report & Integrated Performance Report to be signed-off by Directors with review of narrative

Review sub-committee reporting to ensure timely escalation & timing of 5 quality sub-committees, impact and reporting to SQC in order to improve assurance to SQC and Board

Executive Committee to review & document processes for holding divisions to account & recommend a refreshed process which is document &

Actioned and ongoing

Initial review completed. TOR updated to reflect risk management processes.

Complete - divisional performance reviews reinstated

Ward “heat maps” triangulated into a monthly report for ECQR & SQC.

BE/CP

CP

ECQR

G

0.0


when all actions

complete

2


executives are satisfied they have oversight of divisional performance as a whole though executive committee meetings.

implemented Developing speciality heat maps BE/CP

Processes & Structures: 3B

Are there clearly defined, well understood processes for escalating & resolving issues & managing quality performance?

There are some elements of good practice but some areas of weakness. The Trust is aware of weaknesses in incident reporting, clinical audit and complaints; plans to address these are at an early stage (particularly for the latter two areas). A number of escalation processes are not well documented or clear (such as the risk management policy, QIAs and reporting through sub-committees) and there is currently no clear plan to improve in these areas.

A/R

1.0

Risk management policy to be revised & updated to include role of sub-committees in reviewing & escalating risks

Quality sub- committee ToR to be updated to include responsibility for reviewing & escalating risks

Complaints reporting to be included in Quality Scorecard, IPR and reported to SQC

Clinical Audit plan for 2015/16 to be reflective of required changes

Clinical Audit progress report to be reported to SQC

6 monthly report to the Board on complaints, incidents, clinical audit etc. on progress, themes etc.,

Completed

Completed

Completed

Completed

SQC monitoring clinical audit programme

Regular theme specific reports being reviewed at Board and SQC

KH/FA

CP/GFM

KH/FA

JP/DH

JP/DH

JP/KH

A/G

0.5


when all actions

complete

Measurement: 4A

Is appropriate quality information be analysed and challenged?

The Trust has some missing good practice, with no speciality/ward level dashboards, although the Trust has plans to introduce ward/speciality level dashboards. The Trust also has plans to introduce metrics to allow monitoring of performance against specific quality goals and strategic risks.

A/G

0.5

Ward/speciality dashboards currently being piloted. A clear reporting implementation plan in place.

Completed Ward and Service Scorecards now available online each month

Programme of embedding into speciality and ward governance - June 2016

BE/AS

Execs

A/G - 0.5


when all actions

complete

Measurement: 4B

Is the Board assured of

The Trust has some significant areas of missing good practice, including no individual owners signing off data quality prior to inclusion in

A/R

1.0

Clear process for data quality sign-off which is consistently implemented for IPR & Quality Report

Process In place – Oct 2015

BE/AS

A/G

0.5

3


the robustness of the quality information?

reports (although draft dashboards are circulated to divisions prior to reporting), and a lack of clearly documented controls and processes for data quality. The Board has no oversight of the quality of data reported, although the Trust has plans to introduce kite marks. The Trusts Quality Accounts were qualified in both 2012/13 and 2013/14.

Review of implementation of data quality strategy, including introduction of quality kite mark

Process in place to enable Board to have clear data quality oversight.

External Audit on 2014/15 Quality Account Unqualified

External Audit on 2015/16 Quality Account Unqualified

Initial review of dashboards and reporting presented to SQC Oct 15. Final report to be completed

DQ Element to be added to scorecards – Planned for Q2 2016/17

Achieved – June 2015

TBC - June 2016

BE/AS

BE/AS

DH/GFM/LW

DH/LW/CP

Moving to A/G when

actions completed

Process to be put in place to ensure oversight of all other “Green” QGAF rating for sustainability – CP/GFM

On-going

Formal review planned March 2016 including review of TOR of committees

CP/GFM

TOTAL SCORES

2015

3.5 TOTAL CURRENT SCORES

June 2016

1.5



REPORT TITLE: Safety & Quality Committee Update

NON-EXECUTIVE SPONSOR: Richard Shaw, Chair Safety & Quality Committee

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


n/a

Action Required:

Approval () Discussion ( ) Assurance (��)

Purpose of Report:

To provide an update of the activities of the safety and quality committee.


The report provides a summary of the key agenda items which were discussed at the Safety and Quality Committee in June 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


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

Financial impact Serious incidents often become claims

Patient Experience/Engagement

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


Attachment: N/A

Trust Board Report – 30th June 2016 Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 2nd June 2016. The meeting was given over to a deep dive review of Diagnostics, which has appeared as a theme in Incidents in the Trust. The aim was to explore the processes involved in different aspects of diagnosis and see if areas for improvement could be identified. The Committee received five short presentations and discussed the implications for safety. A sixth presentation on The Emergency Department will be made to the next SQC meeting on 7 July. Histopathology There had been an increase in the number of requests as a result of changes in practice and the complexity of tests. Six Sis had been declared in this area over recent years, four of which related to malignant melanoma, which is a complex area to diagnose. A range of different audits were being used to drive improvement. Specimen Group The Committee explored the implications of an SI where a sample taken from a patient had not been sent to the lab for analysis. Discussion focused on the robustness of process where fewer samples were taken daily, such as wards, outpatients and radiology, and also on the use of temporary staff. Sash+ will review the diarrhoea pathway and this will include the transit of samples. Radiology There was some discussion about the risks of outsourcing work and the robustness of governance. But the main focus was on the importance of having clearly established responsibility for reviewing and acting on the results of radiological tests, especially where a Z5 code indicated a high possibility of cancer. It was important to be clear whether responsibility lay with the requesting clinician, the radiologist or another clinician who may have taken over responsibility for the patient. An audit to examine assurance that Z5 codes are acted on was underway and would be reported to Clinical Effectiveness in July. Consultant View Ben Mearns introduced a discussion on the Millennium System, which identifies the responsible consultant for each patient. Discussion focused on the risk of results being missed in the Message Centre and the risks around re-assignment of results to a new clinician where the patient had moved. The System did not highlight abnormal results or flag urgent issues for immediate action. There may therefore be a risk of delays or oversights, and it was considered that there was room for improvement. Cerner There followed a discussion about IT systems in the Trust, some stand-alone systems and gaps in functionality that could potentially be rectified so as to make them easier for clinicians to use. It was noted that some improvements could be made to the Millennium System and that a consistent strategy was important. Conclusions The discussion provided useful insights into a topic that has been a recurrent theme in incidents and that cuts across several different departments. In conclusion it was noted that Emergency Department was an important omission from the day’s discussions, as this is a department where patients move quickly to another part of the hospital or are discharged and there is therefore greater risk of laboratory analysis failing to follow the patient. A presentation on this

will be made to the next meeting of SQC. That aside, there was reasonable assurance that where benchmark data exists the Trust is not an outlier on diagnostics. There appears to be good use of audits to address and close off risks. There could potentially be opportunity to make better use of health informatics via training, and there may be potential for tightening up of some processes. Conclusions on next steps will be drawn after the presentation on ED. Next Meeting The next SQC meeting is at 2pm on Thursday 7th July. Richard Shaw Non-Executive Director Safety & Quality Committee Chair June 2016

An Associated University Hospital of Brighton and Sussex Medical School

1

Integrated Performance Report

M02 – May 2016

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



2 2

Patient Safety

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

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

• The Trust had no MRSA bloodstream infections and one Trust acquired C-Diff case in May 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 achieved with performance of 95.5% in May 2016

• While the key 62 Day GP Referral Cancer standard continues to be achieved, the TWR and TWR Breast Symptomatic standards remain a challenge and were not achieved in May 2016.

• 18 Weeks RTT - The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end of each month but referral growth from south of the Trust presents a risk.

Patient Experience • In May 2016 the Inpatient FFT remained at 95.6%. The ED FFT decreased from 95.4% to 94.9%.

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.

Performance – May 2016


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 Trusts YTD deficit at the end of month 2 was £(2.5)m, £1.5m better than the planned £(4.0)m deficit position. This improvement is

attributable to achieving more income than planned in April and underspends on staffing costs.

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, RTT Access Standards and Unplanned overnight stays in Recovery.

Performance – May 2016


4

Patient Safety

• There were no Never Events reported in May 2016.

• VTE – Manual validation of the VTE initial assessment for May is underway – 95% performance is expected as in previous months. VTE assessments are now live in the Trust’s Electronic Patient Record (Cerner) with a reminder notification when staff open the patients record. The embedding of this is expected to resolve the historic data capture issues.

• Safety Thermometer – performance increased for both indicators – 96.5% for the “New Harm” indicator and 94.7% for the “All Harm” indicator.

• The percentage of patient safety incidents causing severe harm or death remained at baseline levels - 0.2% in May 2016.

Patient Safety

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

No of Never Events in month 0 0 0 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

Safety Thermometer - % of patients with harm free care (all harm) 92.0% 95.0% 92.2% 93.2% 95.4% 90.3% 92.6% 91.2% 89.1% 90.2% 91.5% 94.7%

Safety Thermometer - % of patients with harm free care (new harm) 95.2% 97.7% 94.8% 96.7% 97.6% 95.0% 96.2% 95.1% 93.8% 94.5% 95.0% 96.5%

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

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

Number of Sis 6 1 1 4 6 2 7 3 6 10 7 3

Serious Incidents - No per 1000 Bed Days 0.33 0.05 0.05 0.23 0.32 0.11 0.38 0.16 0.33 0.51 0.38 0.16

Percentage of Patient Safety Incidents causing Severe harm or Death 0.7% 0.0% 0.6% 0.8% 0.6% 0.6% 0.8% 0.8% 0.5% 1.4% 0.7% 0.2%

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


5

• Three SIs were declared in May 2016 (in all cases full investigations have been started) and details are provided below:

• 2016/12433 - The incident is the cancellation and subsequent rebooking of an ophthalmology outpatient appointment four months later than the original clinical review period (4m). The patient was using steroid eye drops which have a known side effect of causing raised intraocular pressure. At the delayed appointment pressure was found to be raised and the optic nerve damaged with vision of hand movements. The raised pressure was treated with eye drops and reviewed 4/5/16 where the pressure was found to be controlled but there was no recovery of vision.

• 2016/12980 - A patient requiring coronary angiography was cancelled due to bed pressures. While awaiting the rescheduled appointment the patient died.

• 2016/14135 - The patient was sitting on an armchair over a round table eating some grapes. As one fell to the floor, the patient tried to catch it and fell in the process. A right fractured neck of femur was confirmed.

• The following risk is on the Trust's significant risk register:

• Patients being inadequately care for post-operatively by being kept in Recovery for long periods of time when no ward beds are available. There are inadequate supporting services - e.g. physiotherapy and pharmacy and patients are not managed within the Enhanced Recovery pathway. – Risk score 15 (Likelihood of 5 and consequence of 3).

Patient Safety


6

Infection Control

• There were no cases of MRSA in May 2016 and one case of Trust acquired C.diff.

• In light of the on-going 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 0 0 0 0 1 0 1 0 0 0 0

CDiff Incidences (in month) 3 4 4 2 6 2 6 2 1 0 2 1

MSSA 4 0 1 1 3 0 3 0 3 2 2 1

E-Coli 20 18 34 30 29 19 23 23 20 31 17 26


7

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 highlight increased Emergency C-Section rates and a higher than normal rate of admission to the Neo-natal unit. This will be monitored and reviewed by the Divisional Governance process as well as the Clinical Effectiveness Committee.

Clinical Effectiveness


HSMR (56 Monitored diagnoses - 12 Months) 96.2 95.4 96.4 98.3 98.4 97.1 95.9 96.0 94.7

Emergency readmissions within 30 days (PBR Rules) 7.1% 7.6% 7.4% 7.3% 6.3% 6.3% 7.1% 7.1% 6.8% 6.7% 6.4%


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

C Section Rate - Elective 10% 11% 13% 8% 13% 10% 9% 9% 10% 12% 11% 10%

Admissions of full term babies to neo-natal care 4.0% 5.0% 5.1% 5.8% 7.1% 6.6% 5.9% 3.8% 6.1% 5.0% 3.9% 7.0%


8

Emergency Department

• The ED 4hr standard was achieved in May 2016 with performance of 95.5%.

• Volumes /Acuity of emergency attendances / admissions continue to be an issue, with ED Attendances 10% higher than May 2015 and Non Elective Admissions 9% higher.

• Discharge delays are also a significant driver of performance with an average of 128 beds occupied by patients who are medically ready for discharge

• Ambulance turnaround performance has improved in May 2016 with a reduction in both 30 minute and 60 minute delays.

• 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 94.8% 94.3% 96.1% 97.1% 95.5% 92.9% 95.5% 92.8% 91.4% 88.6% 91.3% 95.5%

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

Ambulance Turnaround - Number Over 30 mins 206 238 220 225 225 231 191 227 255 296 231 172

Ambulance Turnaround - Number Over 60 mins 38 32 30 29 31 30 10 21 56 71 40 12


9

Cancer

• While the key 62 Day GP Referral Cancer standard continues to be achieved, the TWR and TWR Breast Symptomatic standards remain a challenge and were not achieved in May 2016.

• The Trust held a summit in relation to TWR in May 2016 and is progressing a number of actions to support improved delivery. The overall theme is moving towards treating the pathway as a “one week rule” with changes focussing on both process and capacity.

• Actions include:

• Internal process moved online to reduce delays from paper based processing of referrals

• Daily oversight process of pathway incorporating senior leads from all divisions.

• Short and medium term actions to increase capacity to support a more diverse level of appointments for patients (different days of week / time of day etc)

• Move to use of national E-Referral system for TWR – Target date of September 2016.



Cancer - TWR 93.1% 93.1% 93.0% 89.6% 90.0% 93.2% 94.3% 93.0% 93.3% 93.7% 91.0% 90.0%

Cancer - TWR Breast Symptomatic 90.6% 93.2% 93.3% 94.2% 93.8% 93.4% 96.2% 90.7% 84.1% 89.8% 87.1% 91.1%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 95.2% 100.0% 95.3% 95.8% 96.2%

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%

Cancer - 31 Day Diagnosis to Treatment 96.2% 98.3% 99.2% 99.3% 98.2% 96.6% 96.1% 96.2% 96.2% 96.0% 96.7% 96.9%

Cancer - 62 Day Referral to Treatment Standard 86.5% 80.7% 84.2% 86.2% 85.6% 88.3% 86.0% 81.1% 87.5% 87.9% 86.3% 85.0%

Cancer - 62 Day Referral to Treatment Screening 100.0% 87.5% 88.9% 100.0% 87.5% 90.9% 100.0% 100.0% 90.9% 100.0% 87.0% 100.0%


10

Referral to Treatment (RTT) and Diagnostics

• At aggregate level, the trust continues to deliver against the Incomplete pathways standard. Capacity challenges remain in General

Surgery, Trauma and Orthopaedics, Ophthalmology, Cardiology, Rheumatology and Neurology – outline agreement has been reached for budgets to support increased capacity (productivity work is also underway).

• Despite planned increases in capacity, referral growth is exceeding the system plan (May 2016 is 21% higher than May 2015) with significant changes in referral patterns to the south of the Trust.

• At the end of May 2016, one patient was waiting over 52 weeks on an incomplete pathway. The long wait resulted from bed pressures over winter followed by patient choice to have treatment in July (although earlier dates within 52 weeks were available). Clinical review of the patient was undertaken as part of the Trust’s processes for long waiting patients.

• 44 patients were cancelled at the “last minute” for non clinical reasons and 9 patients breached the 28 day standard day for treatment following a last minute cancellation

• The following risk remains 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 – Risk score 15 (Likelihood of 5 and consequence of 3)



RTT Incomplete Pathways - % waiting less than 18 weeks 92.6% 92.2% 92.0% 92.1% 92.2% 92.5% 92.1% 92.0% 92.0% 92.2% 92.6% 92.5%

RTT Patients over 52 weeks on incomplete pathways 0 0 0 0 0 0 0 0 0 0 0 1

RTT Admitted 92% 84% 82% 78% 79% 81% 81% 78% 77% 77% 76% 78%

RTT Non Admitted 93% 89% 89% 89% 88% 85% 85% 85% 85% 85% 86% 87%

Percentage of patients w aiting 6 weeks or more for diagnostic 0.8% 1.0% 0.1% 0.5% 0.2% 0.2% 0.1% 0.0% 0.0% 0.0% 0.1% 0.5%

Last Minute Elective Cancellations for non clinical reasons 45 24 25 44 41 133 65 112 133 119 25 44

No of operations cancelled on the day not treated within 28 days 1 0 0 0 0 0 0 7 3 13 32 9


11

Patient Voice

• There has been no change in the Friends and Family (FFT) score for inpatients over the past month, but the response rate has increased from 34% in April to 40% in May.

• In the Emergency Department (ED) both the score and the response rate have dropped slightly since April.

• In Maternity, FFT scores have decreased slightly for three of the four touchpoints (although the delivery score is the second best that has been achieved). The exception to this is the postnatal ward, which has increased (from 95.3% in April to 97.6% in May), this is the highest score ever. For the second consecutive month the postnatal community response rate is above 15%.

• The score for outpatients has dropped by 3 percentage points. It is the lowest it has been since August 2015 and is based on a low number of responses. Local work needs to be completed within the Trust to improve staff engagement with the FFT as well as to address the issues that are behind the low satisfaction with the Trust’s services.

Patient Experience


Inpatient FFT - % positive responses 94.7% 95.1% 95.3% 96.1% 95.0% 95.1% 95.1% 97.4% 95.0% 96.5% 95.6% 95.6%

Emergency Department FFT - % positive responses 93.7% 91.4% 95.8% 96.9% 95.3% 97.3% 97.5% 95.8% 96.3% 95.0% 95.4% 94.9%

Maternity FFT - Antenatal - % positive responses 83.3% 94.1% 98.8% 94.3% 96.5% 96.1% 96.0% 97.5% 98.5% 95.3% 98.9% 95.4%

Maternity FFT - Delivery - % positive responses 94.9% 93.8% 87.9% 95.4% 95.1% 97.6% 91.7% 95.5% 97.1% 94.7% 100.0% 98.8%

Maternity FFT - Postnatal Ward - % positive responses 86.5% 90.0% 87.7% 87.9% 88.9% 88.8% 88.9% 88.4% 92.0% 93.3% 95.3% 97.6%

Maternity FFT - Postnatal Community Care - % positive responses 97.7% 96.1%

Outpatient FFT - % positive responses 93.3% 91.9% 83.3% 88.3% 87.3% 89.3% 92.8% 90.0% 89.5% 89.0% 89.6% 86.7%

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

Complaints (rate per 10,000 occupied bed days) 27 29 33 27 24 19 17 26 29 29 26 31


12

• The carer’s passport has been launched across all wards. There will be an on-going need to ensure that staff are aware of it and how to use it to support carers that are visiting inpatients

• Plans are being developed to change the Trust’s approach to visiting hours. Greater flexibility will be introduced around when people can visit. Guidance will be put in place to encourage visitors to be more proactive in engaging with patients and their care

• Carers’ Day took place on 9th June. Attendance was higher than last year and early feedback suggests that the event was considered helpful to people attending

• The first meeting of the phone etiquette task & finish group has taken place and a plan of work developed

National comparisons for April • Nationally the ED was ranked 8th in April 2016 (FFT score of 95.4% compared to 86.1%), based on an above average response rate

(25% compared to 13%). Trusts with a response rate of less than 5% have not been included in the rankings.

• The average combined national FFT score for inpatients and daycases for April 2016 was 95.8%. The combined SASH score for April was also 95.8%. The combined response rate was 25% nationally and 21% at SASH.

Patient Experience


13

Workforce

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

• Sickness absence decreased to 3.2% in May 2016 and is no longer on the Trust’s significant risk register.

• Although lower than prior year, Turnover increased to 14.5% and vacancy rates increased from 8.4% in April 2016 to 10.4% in May 2016.

Workforce


Average fi l l rate – registered nurses/midwives (%) - Day 96.9% 93.3% 92.5% 95.0% 95.1% 95.4% 95.1% 96.3% 95.6% 94.5% 97.3% 98.1%

Average fi l l rate – care staff (%) - Day 93.5% 94.3% 94.5% 95.1% 97.2% 98.7% 97.1% 97.0% 97.3% 99.5% 98.2% 98.1%

Average fi l l rate – registered nurses/midwives (%) - Night 94.1% 95.2% 94.3% 96.4% 96.9% 97.2% 97.9% 98.0% 97.6% 97.6% 98.8% 98.6%

Average fi l l rate – care staff (%) - Night 94.9% 94.4% 93.8% 96.4% 96.9% 97.8% 98.2% 97.6% 97.4% 97.3% 97.2% 98.2%

Overall Sickness Rate 4.1% 3.9% 3.7% 4.4% 4.4% 4.0% 3.8% 3.8% 4.3% 4.0% 3.6% 3.2%

%age of staff who have had appraisal 58% 56% 57% 64% 72% 74% 74% 72% 70% 66% 0.4% 14.7%

Staff Turnover rate 15.6% 15.6% 15.2% 15.2% 15.0% 14.4% 13.8% 13.8% 13.8% 14.1% 14.4% 14.5%


14

Finance

• The Trust’s 2016/17 plan has been profiled as below, reflecting the phasing of the £9.7m sustainability funding, clinical activity and cost improvements.

• The Trusts YTD deficit at the end of month 2 was £(2.5)m, £1.5m better than the planned £(4.0)m deficit position. This improvement is attributable to achieving more income than planned in April and underspends on staffing costs.

• Although ahead of plan, there is no room for complacency. The agency PMO is now fully in place and the roster programme has reached its first milestone, however the reduction in agency spend is against the Mar 16 peak and not base levels of spend. A new risk is also becoming visible from a week on week increase in elective referrals from the South which is increasing the numbers on our incomplete pathway.


Outturn £m Surplus / (Deficit) - Plan 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 15.2 15.2

Outturn £m Surplus / (Deficit) - Forecast 1.6 1.6 1.6 1.6 1.6 1.6 (3.0) (4.2) (6.6) (6.5) 15.2 15.2

YTD £m Surplus / (Deficit) - Plan (2.0) (1.1) (0.7) (0.6) (2.0) (2.0) (1.3) (0.6) 0.0 1.6 (2.3) (4.0)

YTD £m Surplus / (Deficit) - Actual (2.0) (1.3) (2.6) (3.3) (3.6) (4.2) (5.3) (3.9) (4.8) (6.5) (1.3) (2.5)

Outturn UNDERLYING £m Surplus / (Deficit) - Plan 3.8 3.8 3.8 3.8 3.8 3.8 3.8 3.8 3.8 3.8 7.5 7.5

Outturn UNDERLYING £m Surplus / (Deficit) - Actual 3.3 3.3 3.3 3.3 3.3 3.3 (6.3) (6.3) (7.6) (7.2) 7.5 7.5

YTD Savings £m - Actual 0.8 1.3 1.9 2.1 2.5 2.8 3.2 3.6 4.1 5.4 0.2 0.5

OT Risk £m Surplus / (Deficit) - Assessment 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 (6.8) (6.8)

Outturn Cash position £m Fav / (Adv) - Forecast 7.6 2.6 1.2 2.4 2.4 2.4 2.5 2.5 2.5 2.5 2.3 2.1

YTD Cash position £m Fav / (Adv) - Actual 2.6 2.5 3.0 3.9 4.8 5.0 5.7 4.5 6.8 2.5 2.7 3.0

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

YTD BPPC (overall) volume £m 78% 78% 76% 69% 59% 60% 60% 53% 52% 47% 28% 32%

YTD BPPC (overall) value £m 75% 75% 74% 68% 61% 63% 63% 60% 59% 55% 41% 61%

Outturn Capital spend Fav / (Adv) - forecast 17.1 17.1 17.1 17.1 17.1 17.1 14.1 14.1 14.1 14.1 9.0 9.0


15

Finance

• There continues to be overspending in all Divisions, bar Surgery. These overspends are being reviewed within the refreshed performance management framework in the Trust and a forecast will be completed at M03.

• We have now signed contracts with all commissions bar Sussex MSK.

• The cash balance at the end of May 2016 was £3m. The trust has drawn down £4.2m of revolving working capital in May 16 and a further £1.8m in June 16.

• A capital budget of £9.0m has been agreed for 2016/17, which is £3.8m lower than the Trust’s Capital Resource Limit (CRL) application at £12.8m (which include potential schemes for EPR Digitise and Pathology).


Date: 30 June 2016 Agenda Item: 3.2

REPORT TITLE: Finance & Workforce Committee Chair Update – Public

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 28th June 2016 and was quorate.

M02 reports were received for Finance & the 16/17 CIP, Workforce and Organisational Development, Capital and IT.

The Trusts YTD deficit at the end of month 2 was £(2.5)m, £1.5m better than the planned £(4.0)m deficit position. This improvement is attributable to achieving more income than planned in April and underspends on staffing costs.

The Committee received the EPR Digitise OBC, a Headcount report and MAST update.

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 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 JUNE 2016

Finance & Workforce Committee Chair Update

The Finance and Workforce Committee met on 28th June 2016 and it was quorate. The key points from Public meeting were: IT Roadmap phases 4 & 5 OBC The Committee discussed the OBC in detail with a focus on the following:

- Implementation, including timing and risks - Benefits, both time and cash releasing - Capital, noting £4.0m was required in the current f/y - Procurement of both hardware and software - Buy-in to the proposal by staff and GPs - Options around balancing functionality and complexity.

The outcome of the discussion would be reflected in the FBC.

The Committee approved the EPR Digitise phase OBC which would now go to NHSI before the FBC was written.

Finance Performance & CIP M02 Reports

The Trusts YTD deficit at the end of month 2 was £(2.5)m, £1.5m better than the planned £(4.0)m deficit position. This improvement is attributable to achieving more income than planned in April and underspends on staffing costs. A new risk was noted - a week on week increase in elective referrals from the South which is increasing the numbers on our incomplete pathway. There continues to be overspending in all Divisions, bar Surgery. These overspends are being reviewed within the refreshed performance management framework in the Trust and a forecast will be completed at M03. We have now signed contracts with all commissions bar Sussex MSK. The cash balance at the end of May 2016 was £3m. The trust has drawn down £4.2m of revolving working capital in May 16 and a further £1.8m in June 16. A capital budget of £9.0m has been agreed for 2016/17, which is £3.8m lower than the Trust’s Capital Resource Limit (CRL) application at £12.8m (which include potential schemes for EPR Digitise and Pathology). The CIP report showed that at the end of May the Trust achieved savings of £488k and is (almost) on plan. The Trust remains confident the full £9.2m savings can be successfully delivered in 2016/17. The FWC received an update paper of the on the current loan and working capital agreements, and the options available to the Trust in respect of repayment of the revolving working capital (RWC). This will be discussed further at the next meeting.



Nursing agency CIP Report The Nursing Temporary Staffing Spend Cost improvement Plan (CIP) represents £3.9 million (40%) of the 16/17 Trust CIP valued at £9.2 million. The CIP aims to reduce expenditure on nursing agency as a % of pay costs by providing a fully recruited nursing structure with an effective bank. The specific objectives are to:

Reduce nursing agency spend so that it constitutes less than 10% of staff pay costs by 31 March 2017

Increase the general recruitment of nurses so that vacancy rates are no greater than 8% of base establishment and provide for a turnover indicator that is 10% by 31 March 2017

Increase the capacity of the bank so that the Trust can fill 80% of unallocated shifts with bank staff from 40% currently by 31 March 2017

Deliver financial savings of £3,810k by 31 March 2017

There are four work streams to underpin the project. These are:

1. Recruitment and Retention – including overseas recruitment 2. Temporary Staffing 3. E roster 4. Procurement nursing agency

There are unallocated savings against local recruitment and temporary bank staffing. In addition there are limited savings against agency procurement and it is anticipated that this this may yield further savings once the agency procurement process concludes in November 2016. The Committee welcomed the report and noted the use of contingency funds and the risks to the full delivery of the target.

Month 02 Workforce and Organisational Development The papers were received by the Committee. The following areas were highlighted: - Partial implementation of the new Junior Doctor’s Contract is on-going, including the

recruitment of the ‘Safer Working Guardian’, following extended discussion between the DoH and the BMA. Full implementation is dependent on the outcome of the BMA referendum on the proposed terms and conditions – the results of which are due on 6th July

- Current Achievement Review compliance below required target for May. It is planned that 90% of all staff with 12 months or more continuous service to be appraised by end of October 2016

- Bank and Agency Usage remains high although week-by-week usage across May showed wide variances

- The Trust’s ‘Freedom To Speak Up Guardian’ post is being recruited to - The Trust is running the first two cohorts of ‘Lean for Leaders’ training on 16th and 17th June. - Total Trust Establishment has increased but staff in post has decreased - Agency usage still remains high within the Trust – PMOs are being held to review this - Sickness rate has reduced - Number of ‘open’ Capsticks cases on a downward trend for the past two months



The Committee received an Annual Workforce (Headcount) Plan. This identified that the Trust’s established posts are within overall budget, the number of post holders are below the number of established posts and that there are significant vacancy levels in certain staff group (e.g. Nursing & Midwifery). The Committee welcomed a report on MAST training. It described the outcomes of a robust review of the definition and delivery of MAST training and the resulting proposed changes. It was to go to the Executive team shortly.

The M02 Capital report was received and noted.


Date: 30st June 2016 Agenda Item: 3.3

REPORT TITLE: Audit & Assurance Committee Chair Update

NON EXECUTIVE SPONSOR: Paul Biddle (Non-Executive Director and AAC Chair)

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

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) Audit & Assurance Committee – 26/05/16

Action Required:

Approval (√) Discussion () Assurance (√)

Purpose of Report: This report provides the Board with an executive summary of the May Audit and Assurance Committee and introduces the committee’s report to Board. Summary of key issues The Audit Committee formally adopted the 2015/16 annual accounts on behalf of the Board. External Audit provided strong assurance on the quality of the accounts and a qualified Value for Money conclusion given in relation to the Trust’s deficit position. The Trust’s reference cost audit carried out by PWC had provided assurance that these had been prepared in accordance with the Costing Guidance issued by Monitor for 2014/15.

Recommendation:

To note the report.


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 AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all statutes applied to an NHS Trust. Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the “breakeven duty”.

2 An Associated University Hospital of Brighton and Sussex Medical School

The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all regulation applied to an NHS Trust. The main regulators, however are as follows: - External audit (the Audit Commission for this Trust) give 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 Committee review of Trust financial position

Patient Experience/Engagement No relevant aspects

Risk & Performance Management The committee provides assurance about internal control and risk management. This report discusses BAF reporting

NHS Constitution/Equality & Diversity/Communication No relevant aspects

Attachment: N/A


TRUST BOARD REPORT – 30/06/16 Audit & Assurance Committee (AAC) Chair Update The Audit and Assurance committee met on the 26/05/2016; it was quorate. 1) Review of Annual Accounts The Committee reviewed and adopted the Trust’s 2015/16 accounts noting External Audits comments on the quality of the accounts and thanking the finance, governance and communication teams. The accounts analysis was well received and it was agreed to share this document with the Board and Governors. The Committee noted and discussed two issues, achievement of CIPs in year and payment practice each of which is anticipated to improve throughout 2016/17. External Audit indicated that the financial statements were of a good quality, supported by clear working papers. A qualified Value for Money conclusion had been given as the Trust reported a deficit of £6.5 million. 2) Review of Internal Controls The Trust’s internal controls map was reviewed in order to develop a plan of work for 2016/17. In particular the Committee asked that the clinical governance element of the controls map, including clinical audit which was prioritised for review. The Committee also reviewed the updated workforce controls and received good overall assurance of actions taken and improvements made over the last 6 months. 3) 2014/15 Reference Cost Audit Management presented the final reference cost audit report highlighting that the Trust is compliant on Reference Costs and has an action plan that has been green rated by PWC. The audit provided assurance that reference costs have been prepared in accordance with the Costing Guidance issued by Monitor for 2014/15. 4) Internal Audit Update Internal audit presented its normal update highlighting strong assurance for the systems that support the Trust’s Provider to Provider activities. Internal audit had identified potential improvements in the Trust’s mortality and payroll systems providing good overall assurance. The Committee noted that the Trust performance on managing and closing agreed actions remains good. 6) Counter Fraud Update Counter Fraud provided a summary of work carried out throughout 2015/16 and plans for the coming year. A Trust wide fraud risk assessment is underway, which to date has not identified any significant new concerns.

-End-



REPORT TITLE: Quality Account 2015/16

EXECUTIVE SPONSOR: Dr Des Holden Medical Director

REPORT AUTHOR (s): Laura Warren Head of Communications


Executive Committee for Quality & Risk – March & April 2016 and Safety and Quality Committee - May 2016

Action Required:

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

Purpose of Report: The publication of an annual Quality Account is mandatory, as is some of the prescribed content and consultation with the local health and social care economy. The account will be uploaded to Department of Health NHS Choices website on 30th June. Summary of key issues This account builds on that of 12 months earlier and describes how we have performed against the quality targets we set ourselves at that time. The opinion of our partners and of the executive is that we continue to make progress towards the trust objectives of delivering care which is safe, effective, responsive to patients needs and is well led by clinicians and managers working together. Recommendation:

The Board is asked to review and approve the Quality Account.



Legal and regulatory impact Mandatory requirement

Financial impact Enabling

Patient Experience/Engagement As the account describes the quality of patient care, and experience it is relevant to this.

Risk & Performance Management Included in the report

NHS Constitution/Equality & The report will be made available on the NHS

2

Diversity/Communication Choices Website and the Trust Website.

Attachment: 2015/16 Quality Account

1



REPORT TITLE: 2015 / 2016 Annual Report from the Nomination & Remuneration Committee

NON-EXECUTIVE SPONSOR: Alan McCarthy Chairman

REPORT AUTHOR (s): Mark Preston Director of Organisational Development & People

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

Action Required:

Approval (√) Discussion ( ) Assurance (√)

Purpose of Report: All Board Sub-Committees and required to report to the Board on an annual basis outlining the work of the committee during the year. Summary of key issues The key issues addressed in the report are as follows: Purpose, meetings, business and areas for improvement for the committee including a summary of the work undertaken in 2015/16.

Recommendation:

To review and approve the attached report.


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 Committee is a statutory committee of the Trust Board

Financial impact There may be a financial impact given any agreement to amend remuneration of voting Board level Directors and the Chief Executive.

Patient Experience/Engagement N/A

Risk & Performance Management A key remit of the Committee is to review the performance of the Chief Executive and voting Board level Directors.


The Committee has due regard to equality & diversity legislation in undertaking its work

Attachment: Annual Report from the Nomination and Remuneration Committee - 2015/16

2

Trust Board Report – 30th June 2016 Annual Report from the Nomination and Remuneration Committee 2015/16 1. Purpose of the Committee The Nomination and Remuneration Committee’s role is to appoint, (and if necessary, dismiss executive directors), establish and monitor the level and structure of total reward for executive directors, ensuring transparency, fairness and consistency. The Committee shall receive reports from the Chairman of the Board of Directors on the annual appraisal of the Chief Executive, and from the Chief Executive on the annual appraisals of executive directors, as part of determining their remuneration.

The Committee shall develop and implement an effective succession plan to identify and develop internal personnel to fill key senior management posts as part of ensuring the availability of experienced and skilled employees when posts become available. For Executive Directors other than the Chief Executive, the Committee shall take advice from the Chief Executive. The Terms of Reference reflect the statutory requirements that apply to NHS Trusts. The Committee, which will meet at least twice per year, is comprised of the Board Chair and all Non-Executive Directors. A minimum of three members should be present at meetings who are independent of management. The Committee will report in writing to the Board at least once annually. 2. Meetings of the Committee The Committee met on two occasions during the period 1st April 2015 – 31st March 2016 and membership at each meeting was in accordance with the Terms of Reference of the Committee. The meetings were held in April and November 2015. 3. Business of the Committee 2015/16 The business managed by the Committee comprised:

• Consideration of the performance of the Chief Executive against agreed objectives for 2014/15. The outcome of this annual performance review was agreed by the Committee and reported to the TDA in June 2015.

• Agreeing the Chief Executive’s objectives for 2015/16

• Receiving information from the Chief Executive on the performance of each of

the Executive Directors and their objectives for 2015/16

3

• Consideration of information from the Chief Executive re: succession planning amongst Executive Directors and senior management

• Consideration given to Executive Director salaries on the basis of benchmarking undertaken in line with local Trusts and national recommendations

Note: Irrespective of the performance of the Chief Executive and Executive Directors no salary adjustments were made in 2015/16. 4. Recommendation The Board is asked to approve the annual report. Alan McCarthy Chairman June 2016


Date: 30 June 2016 Agenda Item: 4.3

REPORT TITLE: Annual plan 2016/17

EXECUTIVE SPONSOR: Sue Jenkins Director of Strategy

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: The purpose of this report is to approve the annual plan for 2016/17 Summary of key issues The annual plan has been in place for two years. It pulls together all of the key objectives and actions that are detailed in the Key trust strategies which include

• The strategic objectives delivery plan • The quality account • The quality strategy • The clinical strategy • The workforce and OD strategy • The market development strategy • Divisional plans

Updates against the key actions are reported to the Board on a quarterly basis. For 2016/17 the annual plan indicates those actions that have been brought forward from 2015/16 and shows the new actions for the year. The new additions reflect the most recent updates to the quality account and the most recent review of the Trust’s vision, values and strategic objectives which were presented to the Board in the form of a Strategy Overview in May 2016.

Recommendation:

The Board are asked to approve the annual plan for 2016/17.


• Safe – Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers

• Effective – As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy

• Caring – Working in partnership with staff, families and carers


• Responsive – Become the secondary care provider of choice for our catchment population

• Well led – Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model


Legal and regulatory impact The annual plan demonstrates delivery of key actions to support the strategic objectives

Financial impact Business cases will be developed for any significant resource developments.

Patient Experience/Engagement The annual plan includes a number of objectives linking to patient experience and engagement

Risk & Performance Management Delivery of the annual plan is monitored by the executive Committee and reported to the Trust Board


The annual plan demonstrates delivery of the organisations strategic objectives

Attachment: Annual plan 2016/17

Work stream off track and unlikely to deliver as described A Work stream off-track but plans in

place to recover G Work stream on track and to plan

BComplete

Got worse since last report Same as last report Improved since last report

Ref New or bf Source Lead director Lead manager/clinician

1.1 NEW

Strategic objectives delivery planQuality accountClinical strategyDivisional plans

Angela Stevenson Ben Emly

1.2 NEW Strategic objectives delivery planQuality account Fiona Allsop -

1.3 NEW Strategic objectives delivery planQuality account Sue Jenkins -

1.4 BF Strategic objectives delivery plan Des Holden -

1.5 BF Strategic objectives delivery plan Des Holden -

1.6 NEW Quality account Fiona Allsop Fiona Crimmins

1.7 BF Clinical strategyDivisional plans Des Holden Barbara Bray

1.8 BF Clinical strategyDivisional plans Fiona Allsop Michelle Cudjoe

1.9 BF Quality AccountQuality strategy Fiona Allsop Vicky Daley

1.10 BF Quality AccountQuality strategy Pressure damage

Maintain achievement of no hospital acquired major pressure damage and aim to reduce hospital acquired minor damage to below 159 for the year

Fiona Allsop Louise Evans

1.12 BF Quality AccountQuality strategy

World Health Organisation (WHO) safer surgery checklist

Continue to audit quality of safer surgery processes and achieve 100% compliance

Des Holden Barbara Bray

Implement falls strategy and demonstrate a reduction in the number of falls that cause harm to our patients to less than 1.5 per 1,000 bed days

Meet the DH central infection control targets of <15 Cdiff cases and no preventable MRSA blood stream infections

Develop and implement plans to ensure 100% of staff have received appropriate levels of PREVENT training by July 2018

Include safety goals in all clinical staff appraisals

SO1 - Safe - Deliver safe high quality and improving services which pursue perfection and be in the top 20% against our peers

Action

Consistently meet national patient safety standards and benchmark in top 20% against peers

Demonstrate 95% compliance with the safety thermometer and have as few never events as possible

Des Holden

Maintain the low incidence of surgical site infections

BF Quality AccountQuality Strategy Ashley Flores1.11 Healthcare acquired infection

Annual plan 2016/17 v1.2

Actively participate in national Patient Safety Collaborative in Kent, Surrey and Sussex area

Work in partnership with Virginia Mason Institute and develop a culture of continuous improvement

RR

Monitor and work towards compliance with national midwifery staffing guidance

1.13 NEW Quality Account Ian Mackenzie Carol Dixon

Ref New or bf Source Lead Director Lead Manager/clinician

2.1 NEW Strategic objectives delivery plan Des Holden Ben Emly

2.2 NEW Strategic objectives delivery planQuality account Des Holden Anne Shears

`

2.3 Continue and embed discharge to assess Angela Stevenson -

2.4 Support and develop Integrated Reablement Unit Angela Stevenson Nicola Shopland

2.5 Develop and implement frailty unit Des Holden Alison James

2.6 NEW Strategic objectives delivery plan Des Holden -

2.7 BF Clinical strategyDivisional plans Des Holden Ben Mearns

2.8 BFClinical strategyDivisional plansEstate strategy

Angela Stevenson Ed CettiMo Luqman

2.9 BF Clinical strategyDivisional plans Des Holden Ed Cetti

Mo Luqman

2.10 Progress appointment of hart failure specialist nurse Fiona Allsop Nicola Shopland

2.11Develop and implement policy for the management of patients with AF

Des Holden Alison James

2.12 BF Quality AccountQuality strategy Des Holden Jonathan Parr

2.13 NEW Quality account Des Holden Jonathan Parr

2.14 NEW Quality account Des Holden Jonathan Parr

Ref New or bf Source Lead Director Lead Manager/clinician

3.1 BF Strategic objectives delivery plan Fiona Allsop Cathy White

3.2 BF Strategic objectives delivery plan Fiona Allsop Vicky DaleyDCNs (Jamie Moore)

NEW Strategic objectives delivery plan

Deliver services differently to meet the changing needs of patients, the local health economy and the Trust

SO2 - Effective: As a teaching hospital deliver effective, improving and sustainable clinical services within the local health economy

Year on year recruit more research participants and ensure learning is published

Continue reporting of #NOF enhanced quality data to AHSN and demonstrate improvement in patient pathway

Maintain positive position for all three enhanced recovery pathways

NEW Quality accountDemonstrate full compliance with NICE guidance for heart failure and atrial fibrillation

Action

Maintain “better than national average” mortality rating for both HSMR and SHMI

Audit how patients feel cared about and respond to issues raised by YCM, FFT and inpatient survey

Progress academic appointments with Surrey University and HEKSS

Implement a managed equipment service which is supported by a rolling equipment replacement schedule

Show evidence of "you said we did" in all areas

Continue to maintain high standards of cleanliness and to listen and respond to feedback from patients and visitors

Redesign the stroke pathway to create a seamless in and out of hospital patient centred pathway across all providers

Achieve top 20% performance in benchmarked clinical outcomes

Redesign of service to support the installation of a digital mammography machine on the ESH site

SO3 - Caring - Working in partnership with staff, families and carers

Action

3.3 Continue to develop and deliver customer care training Mark Preston Nathaniel Johnston

3.4Demonstrate how patient listening events influence service development and improvement

Fiona Allsop Cathy White

3.5 Continue with values based recruitment Mark Preston Janet Miller

3.6Work with patients and carers as part of the patient experience strategy

Fiona Allsop Cathy White

3.7 Demonstrate how patients are involved in the planning of care Fiona Allsop Cathy White

3.8 Actively seek feedback from patients, carers and their families Fiona Allsop Vicky Daley

DCNs (Michelle Cudjoe)

3.9 Engage with the voluntary sector Angela Stevenson ADs (Bill Kilvington)

3.10Develop information to cover areas and in a format that patients have influenced

Fiona AllsopVicky DaleyADs (Jane Griffiths)DCNs (Jane Penny)

3.11 BF Quality accountClinical strategy Angela Stevenson TBC

3.12 Audit EoLC plan

3.13 Implement 7 day service

3.14 BF Quality Account Nutrition Continue to make improvements to protected meal times Fiona Allsop Vicky Daley


4.1 NEW Strategic objectives delivery plan Angela Stevenson Ben Emly

4.2 BF Strategic objectives delivery plan Des Holden Chiefs (Ben Mearns)

4.3 NEW Strategic objectives delivery plan Fiona Allsop Jane Penny

4.4 NEW Strategic objectives delivery plan Des Holden Laura Warren

4.5 NEW Strategic objectives delivery plan Sue Jenkins -

4.6 NEW Strategic objectives delivery plan Angela Stevenson Alison James

4.7 NEW Strategic objectives delivery plan Bruce Stewart Michael Rayment

BF

Continue to ensure there are no mixed sex breaches

Develop performance and benchmarking reports to track progress against delivery of national standards

Develop plans to define and deliver 7 day services

Quality AccountQuality strategy

Strategic objectives delivery plan

Listen to patients and their families and ensure their views shape clinical services that reflect their feedback and care needs

NEW

NEW Strategic objectives delivery planTreat patients, carers and their families with dignity, respect and compassion

Continue series of hot topic events with patient involvement

Fiona AllsopEnd of life care

Involve patients in SASH+ work in partnership with the Virginia Mason Institute

Action

Using patient feedback further develop the Macmillan Cancer Information Centre

Review and increase use of SaSH@home beds

Complete Frontier pathology services joint venture implementation and delivery

Jane Penny

SO4 - Responsive - Become the secondary care provider of choice for our catchment population

4.8 Work towards achieving 80% bed utilisation Angela Stevenson Ben Emly

4.9 Work towards LOS being in top 20% Angela Stevenson Ben Emly

4.10 Deliver all elective plans Angela Stevenson Barbara Bray

4.11 BF Market Development strategy Paul Simpson Larisa Wallis

4.12 BF Market Development strategy Paul Simpson Larisa Wallis


5.1 NEW Strategic objectives delivery plan Paul Simpson Peter Burnett

5.2 NEW Strategic objectives delivery plan Des Holden Chiefs (Barbara Bray)

5.3 NEW Strategic objectives delivery plan Angela Stevenson ADs (Natasha Hare)

5.4 NEW Strategic objectives delivery plan Fiona Allsop Vicky DaleyDCNs (Nicola Shopland)

5.5 NEW Strategic objectives delivery plan Mark Preston Nathaniel Johnston

5.6 NEW Strategic objectives delivery plan Ian Mackenzie Peter Hodgetts

5.7 NEW Strategic objectives delivery plan Jim Davey ADs (Alison James)

5.8 NEW Strategic objectives delivery plan Michael Wilson -

5.9 NEW Strategic objectives delivery plan Mark Preston -

5.1 BF Membership strategy Gillian Francis -Musanu Laura Warren

5.11 BF IT strategy Ian Mackenzie Peter Hodgetts

5.12 BF IT strategy Ian Mackenzie Peter Hodgetts

5.13 BF Estate strategy Ian Mackenzie -

5.14 BF Workforce and OD strategy Mark Preston Janet Miller

5.15 NEW Workforce and OD strategy Mark Preston Nathaniel Johnston


Establish and deliver engagement and communications strategy for members following FT authorisation

Develop effective partnerships to design integrated services

Strategic objectives delivery planNEW

SO5 – Well led – Become an employer of choice and deliver financial and clinical sustainability around a patient focused clinical model

Provide upgraded email solution

Deliver estates capital programme

Deliver financial plan and develop and implement a viable long term financial model

Lead development of STP and influence effective delivery

Ensure that key service development decisions are underpinned by clinical evidence

Ensure staff are involved in key service developments

Accelerate delivery of EPR and increased use of technology

To explore opportunities for new services, joint ventures, partnerships and new markets

Ensure patients receive the right care, in the right bed, at the right

time, every time

Incorporate the vision and strategy into all recruitment, induction, appraisal, working life and people related policy and activities within the Trust

Develop integrated workforce plans (demand and supply) at divisional/ business unit level - identifying workforce changes required for 24/7 working in appropriate areas

Improve staff to patient ratios

Deliver ongoing staff development programmes including talent management

Develop and implement a health and well-being plan

Develop and incorporate the associated values and behaviours into job specifications and descriptions and selection processes

Complete Network Upgrade

To maintain and expand market share for elective activity

Action




Develop clarity on how to be an effective leader and manager in the Trust and what staff should expect from their managers and leaders

Ensure robust arrangements are in place for effective performance management and good quality appraisal of individuals

Integrate our vision and values into our learning programmes as core to the way we do business


Date: 30th June 2016 Agenda Item:

REPORT TITLE: Information Governance Annual report

EXECUTIVE SPONSOR: Ian Mackenzie

REPORT AUTHOR: Dipa Bhella


IGSG members: 27th May 2016

Action Required:

Approval ( ) Discussion ( ) Assurance (√)

Summary of Key Issues

The Trust is in its fourth year of achieving ‘satisfactory’ rating in the Information Governance Toolkit assessment. To achieve an overall organisational rating of ‘satisfactory’ (the highest level possible), all 45 requirements must be scored at level 2 or above.

• IG Toolkit Assessment 2015/16

• Assurance Framework

• Compliance with Legal and Regulatory Framework

• Information Security Incidents

• Risk Management and Assurance

• Development Plans for Next Year


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 for the catchment populations of Surrey & Sussex SO5: Well - led


Legal and regulatory implications Ensures the Board is aware of the Trust’s compliance with key legislation and broader information governance compliance

Financial implications N/A

Patient Experience/Engagement N/A

Risk & Performance Management Informs the Board of the Information Governance Risk and Assurance Framework


N/A

Attachments:



TRUST BOARD REPORT – Date June 2016 Information Governance Annual Report to the Board – Senior Information Risk Owner

1. Introduction

1.1. The purpose of this report is to provide assurance to the Board that the Trust

is addressing information governance (IG) obligations.

This report comments on:

1.1.1. compliance with the Information Governance toolkit and

improvements in relation to managing risks to information

1.1.2. organisational compliance with legislative and regulatory

requirements relating to the handling of information, including

compliance with the Data Protection Act (1998) and Freedom of

Information Act (2000);

1.1.3. any Serious Untoward Incidents within the preceding twelve months,

relating to any losses of personal data or breaches of confidentiality.

1.1.4. the direction of information governance work during 2015/16 and how

it aligns with the strategic objectives of Surrey and Sussex

Healthcare NHS Trust.

2. Information Governance Toolkit Assessment

2.1. The Information Governance Toolkit is the mechanism through which NHS and

related organisations demonstrate their compliance with a number of

information governance requirements – of which there are 45 for the acute

hospital sector.

2.2. The Trust is required to upload evidence to support its assessment of its

compliance against criteria set within the toolkit. This then determines the

scores for each requirement which range from level zero to three. To achieve

an overall organisational rating of ‘Satisfactory’ (the highest level possible),

each requirement must be scored at level 2 or above.

2.3. Caldicott 2 Performance Report – From August 2015 Trusts are now required

to submit an annual report demonstrating their performance against the

Caldicott2 recommendations. To show that a trust has fully implemented a

particular Caldicott 2 recommendation, they will need to demonstrate all

relevant IG Toolkit requirements within a recommendation are attaining level 3.



2.4. Prior to submitting its final assessment, the Trust’s internal auditors, RSM UK,

audited the requirements against the Caldicott 2 recommendations. Based on

the evidence available at the time of the audit, agreed the scores of all eleven

of the requirements. 10 out of 11 Caldicott 2 recommendations have been

fully implemented.

2.4.1 The audit report concluded, the Trust’s procedures for managing IG Toolkit

improvement plans, including monitoring, reporting, and compliance with the

three-stage reporting timescale set by HSCIC, were found to be robust, and

thus reduce the risk of failure or delay in implementing improvements to the

Trust’s submissions and achievement of target levels regarding Toolkit

compliance.

2.5. In the year ending 31st March 2016, the Trust achieved an overall rating of

‘Satisfactory’. The breakdown of the scores are shown in the table below:

Table 1: SASH IG Toolkit Final Assessment (2015/2016)

Assessment Level

0 Level

1 Level

2 Level

3 Total

Req'ts Overall

Score Grade

Information Governance Management

0 0 4 1 5 73% Satisfactory

Confidentiality and Data Protection Assurance


Information Security Assurance


Clinical Information Assurance


Secondary Use Assurance


Corporate Information Assurance


Overall 0 0 31 14 45 77% Satisfactory

2.6. The Trusts results are comparable with other Acute Trusts within Surrey and

Sussex as shown below:

Table 2: Overall IG Toolkit Scores: Acute Hospitals in Surrey & Sussex

Assessment Level

0 Level

1 Level

2 Level

3 Total

Req'ts Overall

Score Grade

ASPH 0 1 21 23 45 85% Not Satisfactory BSUH 0 0 44 0 45 66% Satisfactory East Sussex 0 0 39 6 45 71% Satisfactory Frimley Health 0 5 27 13 45 72% Not Satisfactory RSCH 0 0 40 5 45 70% Satisfactory SASH 0 0 31 14 45 77% Satisfactory Western Sussex 0 0 21 24 45 84% Satisfactory



2.7.1. Ashford and St Peter’s Hospital and Frimley Health were deemed ‘not

satisfactory’ because they have requirements at level 1.

2.7. Information Governance Training: 96% of staff completed their annual

information governance training during 2015/2016 this now needs to be

refreshed for 2016/17. 95% of staff must complete their training each financial

year, for the Trust to achieve level 2 in this requirement of the IG Toolkit

assessment.

3. Assurance framework

3.1. The Trust’s Information Governance Management Framework was reviewed in

June 2015. It identifies the roles and responsibilities of key staff within the

Trust and the reporting structures.

3.2. The Information Governance Steering Group (IGSG) is chaired by the Trust’s

Senior Information Risk Owner (SIRO), who is the Director of Information and

Facilities. Membership includes the Caldicott Guardian (the Medical Director)

and representatives from Human Resources, Finance, Information

Technology, Information Management and Data Quality, Health Records,

Communications and Information Governance.

3.3. The reporting framework is as follows:



4. Trust Compliance with Legal and Regulatory Framework

4.1. Compliance with key legislation, such as the Data Protection Act 1998 (DPA)

and Freedom of Information Act 2000 (FOIA) is regulated by the Information

Commissioner’s Office (ICO). Internally, the IGSG monitors compliance with the

FOIA and DPA at each of its meetings.

4.2. Freedom of Information Requests: The Trust received 561 FOI requests

during 2015/16. There were 56 breaches of the FOI 20 working day response

standard in the year to date. These have largely been due to delays in staff

supplying information.

4.3. Compared to previous year the Trust has maintained its compliance, achieving

an overall compliance rate of 90%.

4.4. Table 3: FOIA Compliance

2015/2016 Q1 Q2 Q3 Q4 Grand

Total

Received 125 169 116 151 561

Compliant 115 144 109 137 505

Breach 10 25 7 14 56 % Compliance 92% 85% 94% 91% 90%

4.5. Subject Access Requests: In the year 2015/16 the Trust received 1207 enquiries relating to accessing health records (101 monthly average).

4.6. Table 4: SAR Compliance

2015/2016 Q1 Q2 Q3 Q4 Grand

Total

Received 348 324 254 281 1207

Compliant 287 322 254 284 1144

Breach 61 2 0 0 63 % Compliance 82% 99% 100% 100% 95%

There have been a small number of SAR breaches in quarter one mainly due to the complex process for reporting SAR’s alongside staff shortage. Since July 2015, an improved process for SAR’s reporting has helped maintain compliance, improved governance arrangements; enabled potential issues to be identified earlier; and improved visibility and performance monitoring.



The Trust did receive two complaints via the regulator, the Information Commissioner, over the Trust’s handling of subject access requests. The complaint related to the patient’s request for access to their health records. Both complaints have now been closed which demonstrated the request

had been dealt with appropriately.

5. Information Security Incidents

5.1. Staff are encouraged to report information governance risks and incidents. All

incidents were classified as either level zero or level one in accordance with

DH guidance1. Incidents greater than level 2 are reportable to the Information

Commissioners Office. As table 4 below shows the majority of incidents

reported, relate to patient records; these incidents include failure to secure

records, records found in a public place and disclosed in error.

The introduction of the new radio frequency identification tagging system that

has been applied to the medical records has shown a reduction in incidents

reported compared to previous year figures.

5.2. Table 4: Information Security Incidents

2015/16 Q1 Q2 Q3 Q4 Total

Email 0 3 1 0 4

Patient records confidentiality 13 24 24 20 81

Post 4 5 6 5 20

Printer / Fax 2 1 4 3 10

Smartcards / Passwords 1 0 2 0 3

Staff records 0 1 1 0 2

Verbal breach 2 1 1 1 5

Other 1 1 1 0 3

Total 23 36 40 29 128

6. Risk Management & Assurance

6.1. As well as line management responsibility for information governance

manager, the SIRO is responsible for overseeing the development and

implementation of the Trust’s information risk strategy.

6.2. The SIRO is supported in this by the Information Governance Manager and by

Information Asset Owners (IAOs) within each business area. The IAOs are

responsible for managing information risks to the assets within their control.

This involves developing system security policies and business continuity

1 Checklist for Reporting, Managing and Investigating Information Governance Serious Untoward

Incidents Requiring Investigation: Version 5.1_May 2015



plans as well as documenting their personal data information flows, updating

asset registers, conducting regular information risk assessments, and ensuring

staff have completed their annual information governance training.

6.3. The IAOs reviewed the system security policies and risk assessments for their

information assets. Overall no information assets have been highlighted as

‘red risks’, and show that robust controls are in place to reduce the impact of

risks that may occur.

6.4. During 2015/2016 all IAO’s completed their annual training in Information Risk

Management via the e-learning tool.

6.5. Whilst progress was made, the Trust recognises that further work is required to

embed further assets to these processes.

7. Development plans for next year

7.1. The Trust has a dynamic action plan to refresh and improve its compliance

with the IG Toolkit standards. This will be formally reviewed once the toolkit is

published for the year ahead.

7.2. Evidence for many of the toolkit requirements is readily refreshed as part of

established daily business or monitoring activities. However, some objectives

are harder to achieve and for this reason they are being targeted early on.

7.3. Key areas identified for 2016/17 are to:

7.3.1. Review evidence and maintain the scores of the IG toolkit at level 2

and above

7.3.2. Identify the evidence required to achieve level 3 on the requirements

7.3.3. Promote and monitor the uptake of IG training which requires 95% of

staff to undertake or refresh their training annually

7.3.3.1. Identify IG champions in key areas to promote training and

increase compliance.

7.3.3.2. Promote IG refresher packs to clinical and non-clinical areas

7.3.4. Improve compliance with Subject Access Requests and Freedom of

Information requests.



8. Summary and recommendations

8.1. In summary, much has been achieved in the last year, which is supported by

the ‘Satisfactory’ rating in the IG Toolkit assessment and internal audit opinion.

8.2. The Board is asked to receive and note this report.

Ian Mackenzie Director of Information & Facilities May 2016

Minutes of the Finance and Workforce Committee

Held on 24 May 2016 at 8.30am

In AD77, East Surrey Hospital, Redhill

PUBLIC

Present

Richard Durban

Alan Hall

Fiona Allsop

Angela Stevenson

Ian Mackenzie (part meeting)

Mark Preston

Gillian Francis-Musanu (part meeting)

Non-Executive Director (Chair)

Non-Executive Director

Chief Nurse

Chief Operating Officer

Director of Information & Facilities

Director of Organisational Development

and People

Director of Corporate Affairs

In attendance

Alan McCarthy

Peter Burnett

Catriona Tait

Trust Chair

Deputy Chief Finance Officer

Head of Costing & Service Line Reporting

(Committee Secretary)

1 WELCOME AND APOLOGIES FOR ABSENCE

Apologies:

There were apologies from Paul Biddle (Non-Executive Director) and Paul Simpson (Chief Finance

Officer).

Declarations of Interest: There were no declarations of interest.

2 MINUTES OF THE PREVIOUS MEETING

The minutes of the 26 April 2016 meeting were approved.

Action Tracker

It was agreed that the IT Roadmap business case, the Workforce plan and the Details of the

Nursing agency CIP would be taken at the June meeting. All other actions are on the agenda or

due to future meetings.

3 BUSINESS PLANNING

Replacement of Cerner EPR PIR

Ian Mackenzie presented the Post Implementation Review (PIR) for the Cerner EPR Business Case

and advised that the data flip was successful, achieved its targets and had a minimal impact on

hospital. One issue the PIR highlighted that was learnt from was how we bring users back on to

the system.

Alan Hall asked about the finances of the project and Ian Mackenzie advised that the project had

underspent.

Richard Durban asked about the confidence of the Radiology team in the new system and the

Trusts relationship with Cerner. Ian Mackenzie replied that he had no issues that had been raised

by the Radiology Consultants and the relationship with Cerner is good and the support strong.

3 FINANCE

Financial Performance M01

Peter Burnett presented the M01 Finance performance report. The Trusts deficit was £(1.3)m,

£1.0m better than the planned £(2.3)m deficit position. This improvement is attributable to

achieving more day case and outpatient income than planned. There was overspending in all

Divisions bar Surgery, and two Divisions (Radiology, in Cancer, and WaCH) had overspends greater

than 2%. These overspends are being reviewed within the refreshed performance management

framework. The cash balance at the end of April 2016 was £2.7m.

The Committee had a discussion on the working capital facility and the Trusts ability to pay this

back. Points raised included the sustainability of the Trusts activities and the predicted future cash

flows.

Action: Working capital assumptions and loans to be advised to the Committee. – Paul Simpson

The Committee sought and received assurance around the impact of the Junior Doctors Strike on

the Trust with Angela Stevenson highlighting that the extra consultant cover in ED helped achieved

a better flow of patients in the short term.

Richard Durban asked for clarification on the over establishment and overspending currently being

seen in Nursing. Fiona Allsop commented that the Filipino nurses are currently in the

establishment at Band 2 but that we would have vacant band 5 posts. We would expect everything

to balance out in the long run.

2016/17 CIP Update

Peter Burnett presented the 2016/17 CIP paper and highlighted that the CIP target YTD in the

submitted NHSI plan for 2016/17 is £0.2m and at month 1 the Trust has delivered this and is on

plan. The Committee noted that (£3.6m) of risk was recorded in the Finance report and asked

that the M2 report showed the CIP projects against the Gateways and QIA

Action: CIP Paper to include gateway analysis – Paul Simpson

BPPC Performance

Peter Burnett presented a report of the Trust BPPC performance against its target of paying 95% of

suppliers within 30 days. The Trust has not met the BPPC target for several years and over the last

financial year the Trust’s performance had deteriorated due to our cash and financial position.

The trajectory for 16/17 shows a further decline in performance as the payables backlog is

reduced but then an improvement to 50% - 60% by year end.

Action: BPPC performance for other local NHS Trusts to be distributed to the Committee. – Paul

Simpson

4

WORKFORCE AND ORGANISATIONAL DEVELOPMENT

Workforce and Organisational Development Report M01

Mark Preston presented the Workforce & Organisational Report to the Committee. The following

areas were highlighted:

- Lean for leaders programme

- Freedom to Speak up Guardian

- Due to the referendum on the new junior doctor contract the Trust has to

maintain a pause on its implementation until after the result of the 6th

July vote.

- New Achievement Review programme was launched and by the end of April the

Trust had achieved 12%.

- The Trust had received a good staff friends & family test result.

- NHSi is going to run a survey with our staff to look at how VMI is changing the culture of

the organisation. This will be done in May and then in year 3 and year 5 of the

programme.

- Bank and agency has shown a downward trend in the last couple of weeks and the Trust is

setting up agency PMOs to monitor divisional performance.

The Committee received an Annual Training plan overview. This is being developed by the HR

Department and balances individual development needs and Trust priorities. An expanded plan

will come to the FWC later in the year.

The Committee had a discussion around the current levels of appraisals and Mark Preston agreed

to present the data in the format requested.

Action: Level of appraisals to be shown in Workforce report as percentage of the number that

need to be done e.g. Number of 8As, number done and percentage done. – Mark Preston

The Committee received an Annual Training Plan overview. This is being developed by the HR

Department and balances individual needs and Trust priorities.

Action: An expanded plan with come to the FWC later in the year.

Workforce and Organisational Development M01 KPIs

Mark Preston presented to the Committee the monthly W&OD KPIs.

The Committee discussed the agency and bank shifts worked figures with Fiona Allsop

commenting that continental travel nurses are included in the agency figures but we would not

include them in our figures.

Richard Durban sought clarification on employee relation and Capsticks with Mark Preston

providing assurance that this related to advice to managers but that how we use Capsticks was

being monitored to insure that we remain within the contract that we have.

It was noted by the Committee that sickness levels of 4% is high compared to other Trusts but that

other areas are comparable.

The Committee sought clarification on the consequences of breaking the agency cap. Fiona Allsop

confirmed that to date we had no known consequences.

5 CAPITAL AND ESTATES

Capital & Estates Report M01

Ian Mackenzie presented the Month 01 Capital report and highlighted that the Medical Records

building is progressing well and that the first part of the Resus development in ED has been

completed.

The Committee discussed the use of the proposed users of the new office space in the medical

records development and the Capital Resource Limit (CRL).

Action: Details of the proposed occupants of the top floor of Medical Records building to be

advised to the Committee - Ian Mackenzie

Action Ensure the Capital Report reflects the Trusts CRL - Ian Mackenzie/Paul Simpson

6 IT

IT Report M01

Ian Mackenzie presented the IT report to the Committee and advised that the new OP electronic

booking in system had been trailed as a proof of concept and was being used by a significant

number of patients.

7 GENERAL

Date of next meeting

Tuesday 26th

June 2016 8.30am – AD77

SQC Minutes 5th May 2016

Page 1 of 10

Safety & Quality Committee

Thursday 5th May 2016, 14.30-16.30 AD65 Trust Headquarters, East Surrey Hospital

Minutes of Meeting

Present: Richard Shaw RS Non-Executive Director (Chair) Alan Hall AH Non-Executive Director Des Holden DH Medical Director Fiona Allsop FA Chief Nurse Paul Simpson PS Finance Director

Ed Cetti EC Chief, Cancer Division Barbara Bray BB Chief, Surgical Division Ben Mearns BM Chief, Medical Division Zara Nadim ZN Chief, WaCH Katharine Horner KH Patient Safety & Risk Lead Ben Emly BE Head of Information Colin Pink CP Corporate Governance Manager

Vicky Daley VD Deputy Chief Nurse Sue Moody SM Clinical Quality Manager

Horsham and Mid Sussex CCG Presenting papers: Laura Warren LW Head of Communication Julie Chivers JC Adult Safeguarding Lead Ruth Morely RM Children’s Safeguarding Lead

Apologies: Alan McCarthy, Pauline Lambert, Angela Stevenson, Jonathon Parr, Paul Simpson 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 AH noted that he had been present at the meeting, KH to update. The minutes of the last meeting were accepted as an accurate record.

KH

1.3. Actions from previous meeting were discussed as follows C/F 1st October Readmission audit This action arose from a spike in one of the readmission metrics earlier in the year. Five random readmissions from Medicine and Surgery, which occurred during the winter period, were selected for assessment. The Medical Division concluded that none could have


Page 2 of 10

been avoided. Surgery concluded the same but also found that some of the cases were frequent readmissions. While none could be avoided they did identify issues in the care received by the patients in the community. The audit provided reassurance that readmissions were not the result of patients having been discharged too quickly. C/F 4th February Data Quality Audit (date of death) update This item was deferred to July. The data quality team have had to prioritise the TARN audit. C/F 3rd March Breaking the Cycle will be rescheduled to July because Angela Stevenson could not be present. C/F 5th April Feedback on stroke network discussions EC reported that a meeting to develop a new thrombectomy service had taken place at St Georges Hospital in London which had been attended by the stroke physicians and the clinical lead for radiology. There is still some outstanding work to do on how images will be transferred between sites in timely fashion for review. BM explained that the thrombectomy pathway is one of the biggest advances in stroke care in the last ten years. It involves the removal or dissolution of a clot from the inside (like an angiography). There is evidence that it is more effective than thrombolysis. The service will be offered 8-8 at St Georges, the Trust will need to be prepared to undertake the imaging and transfer to SGH. The snap audit shows that the Trust rated A for access to CT, so BM does not anticipate a problem. RS asked about the access to MRI for all stroke patients, BM reported that discussions are ongoing with Radiology and that an additional MRI scanner has been proposed. It is hoped that in time the Trust Radiologists will develop neuro-radiology skills so that the service can be offered in house. Summary of VTE deep dive to be included in ECQR report CP confirmed that the first part of the deep dive is included in the report on the agenda. The second part, surgery, was not included because the second ECQR meeting was cancelled.

1.4 Highlights from Executive Committee for Quality & Risk CP presented the summary report, noted that the second meeting of the month had been cancelled due to the Doctors Strike. AH asked for clarification on the timescales set for the Divisions to produce their VTE reports to ECQR. CP reported that WaCH were given a shorter timeframe because they needed to provide more


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narrative around the issues. Surgery had put actions in place and wanted time to access the impact of the changes. CP confirmed that the Surgical output would be on the next ECQR agenda. RS asked for further information on the piece of work regarding safety and activity. He asked whether the increase in falls, PALS concerns, complains might be as a result of increased activity. FA confirmed that it would. DH agreed that it might be expected that these issues would triangulate but that a further analysis of the data would be necessary before this could be concluded. AH noted that PALS concerns were presented in absolute numbers rather that per 1,000 bed days. He noted that more people would increase the number of incidents/complaints but not necessarily the risk. It was agreed that the output of this work should be presented at the July SQC alongside the Breaking the Cycle work. RS asked whether there had been any clarification on the antibiotic CQUIN. DH replied that it would be looking at total antibiotic use and that more work has been done by the anti-microbial team to pin point that figure.

DH

1.5 Highlights from Clinical Quality Review Meeting BE presented the paper which summarised the meeting on 9th April, which reviewed February performance. RS asked for a brief summary of the outstanding issues prolonging the Doctors strike. DH reported that the total wage bill for junior doctors needs to stay the same, however junior doctor cover at weekend needs to increase; therefore there will be less junior doctor cover during the week. Junior doctors are concerned that this will reduce safety to patients during the week and more work which will remain undone. BM added that junior doctors believe that Saturdays should not be considered a normal day, as for other professional groups within the NHS. BM reported that the Medical Division is currently working through the impact of the new contract on working rotas.

2 QUALITY PERFORMANCE 2.1 Quality Report

RS asked for questions on the March Quality Report. BE confirmed that the report was not in the usual format because ECQR had not met, however the same level of detail has been summarised in a scorecard format. RS asked whether there was anything of unusual activity. BE noted the continued reduction in the ED standard, bed occupancy was up at 94.2% and ITU/HDU at 94.4%. ED FFT dropped off this month, but the inpatient FFT went up, so despite the operational pressure the response from patients has been positive. The number of serious incidents reported was high; this was discussed at Board. There have been no incidents of MRSA or Cdiff. From the elective access standards, the two week wait standard for breast symptomatic was not achieved and as a consequence the whole year was not achieved. There will be a two week wait summit in May to resolve the


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issues. RS asked whether the April figures would show the same pressure on ED. BE reported that the MRD figure had got higher. BM reported that during April there had been a week of respite in ED attendances (~240 per day), but that has reverted to ~317. BE confirmed that the ED trajectory for April had been achieved. AH asked about operations cancelled. BE pointed out that cancellations are not reported until they are treated therefore as the Trust moves out of the winter period these will be reported more. The clinical impact of the delays on the outcomes for patients will be assessed as part of the winter review. RS asked whether MRD patients coming to harm will be included in the review, BE confirmed that it would. RS asked about crude mortality birth which showed a spike. BE confirmed that the metric included stillbirths. There had been an unusual number in March. ZN reported that WaCH are reviewing each case. RS asked whether these numbers are surprising. ZN agreed that the division were concerned. RS asked ZN to inform the meeting of the outcome of their review work in July.

ZN

3 PATIENT EXPERIENCE 3.1 Q4 Compliments, Comments and PALS Concerns report

FA presented the report. AH asked about the resourcing in PALS. FA acknowledged that this is a concern; the team is supported by bank staff and a large number of volunteers. Entering data within the system has been problematic and it takes time to train new volunteers and bank staff. AH asked whether it was a budget issue and FA confirmed that it was but that she is hopeful that it will be resolved soon. RS asked whether the issue of appointments is as a result of capacity or the process of managing the cancellation/rebooking process. In addition he asked whether this information was informing the SASH+ work. DH confirmed that the SASH+ work starts with the process in the booking office; the specialty under review is Ophthalmology. There are five work streams to be completed before the issues encountered on day of appointment processes are addressed. Therefore a separate piece of work is underway led by Angela Stevenson through the Outpatient Board. Some of the issues identified will be addressed by rules around clinical cancellations and ad hoc clinics. FA confirmed that there has been a lot of work on the environment in OPD and the training of staff. The patient experience workgroup are focusing on the format and content of letters. RS asked about the issue of patients not knowing how long their wait will be in ED. BE reported that there are now two screens in the ED waiting room which informs patients of the current wait time. AH asked whether anything had changed regarding the categorization of


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upheld/not upheld, because the report shows an increase in the number of concerns that have been upheld. BM stated that he felt that this was a cultural change in the approach to complainants. FA agreed to check whether there had been any changes in process.

FA

3.2 Q4 Complaints report FA presented the report. RS noted that the report presented good assurance around the lessons being learnt from complaints. RS observed that the process of handling complaints is getting better but the volume of complaints is going up. KH noted that the volume of complaints received in Q4 was the same as Q2 although Q3 was low. RS expressed concern that the volume is increasing, KH noted that the more an organisation seeks feedback (FFT, Your care matters etc.) the more complaints will be received. DH noted that the nature of the complaints and themes identified is a better indicator of quality than pure numbers alone. BM asked whether a record is kept of issues raised by patients that are moved into the complaints system by staff. KH replied that the source of the complaint (letter, e-mail etc) is recorded on Datixweb. CP commented that if the reopened complaint by quarter figure was shown by bed days, it might demonstrate a clear improvement in the process.

KH

4 SAFETY

4.1 Safety Thermometer VD summarised the report, describing it as a temperature check within the organisation. Point prevalent study recorded data on a single day in the month. It gives the Trust the opportunity to compare performance with other Trusts. VD made the point that the Trust will need to understand the data better, where there are anomalies and why that might be. Ward accreditation will give the Trust an opportunity to understand the data at a more granular level, set a benchmark for the completion of the submission but also to triangulate the data with the other performance metrics that we have. FA has met with a number of ward managers which has highlighted that there is not a single data collection methodology, therefore refresher training is important. Some Trusts display their information outside their wards on electronic boards; FA suggested that this might be worth considering. The collection process and the purpose of the data needs to be made more relevant to staff. BE confirmed that it would be possible to have a screen outside every ward to display the information patients and visitors. RS asked that the committee be kept up to date on whether this is implemented. SM added that the consensus nationally is that the project was rolled out with very little training which has weakened its value.


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RS asked whether UTIs in patients with catheters should figure on the scorecard. The data collection methodology is unclear. It has not been flagged as concern. RS asked whether the Trust is an outlier on patients with catheters with a UTI. VD stated that it has not been flagged as an issue. BM reported that there is a tension between the demands of the sepsis pathway which indicates the insertion of a catheter and the ongoing risk management of catheters. This is currently under review by the Care for the Elderly team and the Sepsis group. BM made the point to the committee that the VTE outcome is reassuring.

4.2 Q4 Incident Report FA asked whether the committee had any questions. FA noted that the latest NRLS report has been published which places the Trust in the lower quartile with 28.85 incidents per 1,000 bed days reported. In terms of context, Frimley Park reported 29.13 per 1,000 bed days and Western Sussex reported 23.05 incidents per 1,000 bed days, both CQC rated as outstanding. KH noted that the value of reporting incident lies in what is done with the data, not the volume. AH noted that WaCH are able to consistently review 80% of their incidents within the appropriate timescales, where the other Divisions struggle to achieve 60%. AH asked for assurance that the investigations still underway from 2015 was due to late reporting. KH stated that this was not the case. BM acknowledged that the investigations have not been done when they should. KH confirmed that all reviewing managers have been made aware on a number of occasions of their responsibility with regard to open, overdue incidents. BM gave the committee assurance that this matter is being addressed within the Division. It was agreed that a summary of outstanding incidents would be brought back to the next meeting for further discussion. KH reported that week commencing 27th April the Trust reported the lowest number of open overdue incidents since November 2014, so the situation is improving. BM was clear that he was unhappy with the recent strategy of reassigning the overdue incident to the line manager for action. ZN reported that within WaCH there is good clinical engagement with the risk team which ensures that incidents are reviewed promptly.

KH

4.3 Q4 Children Safeguarding Report The report was presented by RM outlining the work of her team which is to refer vulnerable children to the appropriate agencies to ensure that they get the help and support that they need. RS asked what the top concerns are for the team within the Trust. RM noted that training is a priority, that the team are committed to ensuring staff are trained and aware of their responsibilities. The team are working to improve the use of IT with a move away from faxing to secure e-mail. AH noted that there is not much feedback within the report to gauge the level of success and outcomes. RM noted that their job is to prevent harm which is not a reportable outcome. RM reported that there has been feedback from


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MARAC (multi-agency risk assessment committee) that families have been made safer as a direct result of ESH referrals. AH asked whether there is any evidence of where the trust has got things wrong. He noted the ongoing serious case review mentioned in the report. RM explained that the preliminary findings from the review are reassuring. RM explained that the team are alert to the possibility that situations may exist where a referral should be made, but was not made. Therefore the team undertake regular audits. The team reviewed every set of notes from the 151 attendances at the Child Assessment Unit over the period of a week. The team assessed whether information sharing forms were appropriate and whether there was evidence that they had been done. This was a re-audit and the results were better than last year. The team has put in place some additional training and measures to reduce the figure further this year. SM asked whether feedback is give as part of the weekly meeting with Social Services. RM pointed out that the volume of referrals made would

make individual feedback difficult. RM’s team keeps a database and record

feedback as and when they get it. West Sussex MASH (multi-agency safeguarding hub), brings together and shares all relevant data which is an improving process. RM stated that a national priority for 2016 will be the emotional and mental well-being of children. RM suggested that by focusing on this cohort of children and getting help to them earlier may result in fewer admissions to hospital. RS asked for an update on the progress of the action plan which was presented at the last SQC. VD explained that it is reviewed and monitored through the Trust Safeguarding committee. RS thanked RM for her time and noted the good work that is in progress.

4.4 Q4 Adult Safeguarding Report

JC presented the Q4 report. JC noted that the implementation of the Care Act in 2015 had lowered the threshold for safeguard which combined with an increase in Trust activity had resulted in a significant increase in the number of investigations carried out by the team. RS asked whether pressure damage to patients on admission is captured by the safeguarding team. JC confirmed that it was. RS asked whether the Trust is seeing a decline in the numbers as a consequence. FA explained that pressure damage is multi-factorial and it is hard to draw that conclusion from the data. FA confirmed that if a trend was identified around a particular care home or agency then the Trust would report the findings to the relevant Council and the CQC. SM noted that many of the care homes are independent providers therefore CQC is the only overseeing body. The CCG collects data from acute and community providers. VD noted that the whole care sector is a challenged environment at the moment. RS asked whether there had been any instances where a referral to the


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Channel panel was considered necessary. JC replied that one referral has been made in the last year, which was reviewed and no concerns were identified. From September 2016 the Safeguarding team will be undertaking WRAP training (workshop to raise awareness of prevent), this is a statutory duty. Training compliance has been set at 100%. JC highlighted that training is currently 48% and that capacity on the allocated training day is an issue. FA confirmed that WRAP training is pre-determined script of an hours duration which combined with the other Safeguarding requirement necessitates two hour slot in the day. Other options for delivering the training are being considered. JC reported that a review of the core skills framework might release additional time in the day. RS thanked JC for her report and the assurance that it had given the committee.

5 QUALITY

5.1 Q4 Update on Audit plan DH presented the report. It was brought to the committee’s attention that there are inconsistencies in the report which have been discussed at the Clinical Effectiveness Committee. DH acknowledged that notwithstanding the errors in the numbers, the position is not as good as the Trust had hoped. DH confirmed that it had been agreed by the Chiefs at the Clinical Effectiveness Committee that the audit programme needs to be at a size where it can deliver 100%. DH will table a paper at the next SQC meeting in June to update the committee and take questions if required. AH expressed concern that the 15/16 audit programme had been re-dimensioned from previously over ambitious programmes on the basis that the revised plan was achievable and could be delivered. However, the trust is in the same position despite the steps taken. DH agreed that a well-considered plan and good delivery had been the strategy. The intention had been for more local, relevant audits arising from complaints and incidents at the expense of national audits and local interest audits. However, this does not appear to have been cascaded to local teams and Divisions lost sight of their audit plan through the year. It was accepted that two divisions lost their audit facilitators during the year; however the move to an electronic system will provide better monitoring over 16/17. RS asked Chiefs for their view. BB noted that there were only 8 audits for surgery that had not been started which is less than 10% and that circumstances and priorities during the year will change. She confirmed that these are being looked at in some detail. BB agreed that it was disappointing that more action plans were not completed, but reiterated that electronic tracking will make this much easier to manage. BB noted that the audits are completed and reported within the department, but miss the final stage of documenting actions. BM stated that audit is still owned and completed by the clinical teams who are perhaps not aware of the importance of documenting and recording

DH


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results centrally. He added that the process feels passive when it should be more active. He confirmed that audit activity is good, but that it needs to be directed. The electronic system will allow audits to be linked to incidents and be far more visible as a tool for improvement. ZN echoed the comments of BB and BM and acknowledged that the WaCH audit plan needs to be reviewed. RS noted that it is difficult to take assurance from the evidence being presented to the committee that the audit programme has been of value to the Trust; that important audits have been identified, undertaken and learning used to inform future practice. DH expressed concern that this assurance has not yet been given. The paper for the June meeting will give a short qualitative summary of what the 15/16 audit programme has delivered

5.2 2015/6 Trust Quality Account LW introduced the report and requested that any changes or additions be forwarded as a priority as the report needs to be circulated to stake holders on Monday 9th May for their comments to be included in the report. LW noted that it is slightly less formulaic this year, to make the report easier to read. It is hoped that the report is reflective of the achievements of the Trust over 2015/16 and the standards that have been delivered. RS asked for clarification on the process, which was confirmed to be consultation, comments from stakeholders, internal audit review, then to Board. The Trust is required to upload to the internet by 30th June 2016. Meeting confirmed that a paper copy of the report is still required. RS whether it is sent to public libraries. LW can be supplied for significant conferences. Members and governors will be signposted to the online version. RS asked about PROMS and whether this was a topic that SQC should review. DH explained that the work is underway on non-mandatory PROMS which are currently reported to the Board, he noted that there are surprisingly few mandatory PROMS. RAS confirmed that the committee was happy for the report to go out for consultation. LW reiterated that any changes should be notified to her by Monday.

6.1 Any other business

No items raised.

6.2 Proposed agenda for next meeting RS summarised the agenda for the next meeting which is an in-depth focus on issues of safety and quality in the area of diagnostics.


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DATE OF NEXT MEETING Thursday 2nd June 2016 14.00 – 16.00 AD77

Audit & Assurance Committee Page 1 of 6 Minutes March 2016 An Associated University Hospital of


AUDIT & ASSURANCE COMMITTEE

Meeting held on 10th March 2016, 10:00am – 13:00pm Venue: Room AD77, Trust HQ, East Surrey Hospital

Present: Paul Biddle PB Committee Chair / Non Executive Director Richard Durban RD Non Executive Director Richard Shaw RS Non Executive Director In attendance: Paul Simpson PS Chief Finance Officer Gillian Francis-Musanu GFM Director of Corporate Affairs Djafer Erdogan DE Financial Controller Marcus Ward MW External Audit Darren Wells DW External Audit David May NA Internal Audit Gemma Higginson GH Local Counter Fraud Specialist Michael Harling MH Local Counter Fraud Specialist Colin Pink CP Head of Corporate Governance

Action by

1 1.1 Welcome and Apologies for absence

The Chair welcomed members and attendees to the meeting. No apologies from were received in advance of the meeting.

1.2

1.3

Minutes of last meeting The Committee reviewed and agreed the minutes of previous meeting were a true record. Actions from previous meetings: The action tracker was reviewed and the Committee noted the actions that had been closed prior to the meeting. Action 3.1, relating to workforce controls, is not due until May 2016.

2 2.1 Review of Board Assurance Framework and SRR process GFM introduced the BAF and SRR for review prior to the March Public Board meeting, highlighting that both would be reviewed by the Executive throughout March.



GFM went on to highlight the plan for development of the 2016/17 BAF which would rely heavily on the agreement of new/revised strategic objectives for 2016/17

The Committee noted the report.

2.2 Review of Board Assurance Framework and SRR The Committee reviewed the BAF focussing on financial risks, sustainability, control targets and dependencies on the income plan. This relies heavily on NHSI review and agreement of the caveats described by the Trust. The Committee noted that the Liquidity Risk in particular could be updated to reflect the recent non recurrent fund transfer Action PS.

The Committee went on to discuss the description of the FT risk indicating that it no longer reflected the Trust’s stand point. Action GFM to update narrative of FT BAF risk.

The Committee discussed potential areas of strategic risk for the coming year and plans in place by the Board to review and develop the 2016/17 BAF, focussing on transformation, sustainability and financial control targets against a background of increasing activity, the balance of elective activity and increasingly aspiring cost improvement plans. There is also potential for describing productivity gains and other benefits of the SASH+ program.

The Committee asked that as the BAF was developed linkages with the SRR remained the focus with less emphasise on mirrored risks.


PS

GFM

3 3.1 Losses Comps and Waivers DE introduced the paper highlighting recent activity detailing losses comps and waivers. The Committee were assured by management’s discussion on how waivers are handled in a pragmatic manner, particularly those of significant value as detailed in the SFIs. Noting that the numbers of waivers are reducing as the procurement functions of the Trust strengthen and that end of year forecasts are robust.

The Committee discussed the management of overseas debt taking assurance that processes remain sound and that efforts to recover debt are often disproportionate to the results.

DM suggested that External Audit may be able to carry out benchmarking activity to support the assurances provided by



management. Action External Audit to consider benchmarking data available to bench mark bad debt management.


External

Audit

3.2 Accounting policies

DE presented the report highlighting that there had been no major changes to the Trust’s accounting policies and that new standards would have minimal impact on 2015/16 accounts. The Committee noted that the annual review of Standing Financial Instructions would be postponed until May to reflect national changes in guidance. DE noted that the Valuer had carried out their site visit and that there may be a technical adjustment to the end of year accounts based on the final figures. The Committee was assured that the Trust’s recent non recurrent revenue adjustment had been carried out as per instructions from the TDA.


4 4.1 Draft HoIA Opinion DM introduced the daft HoIA Opinion which gives a positive opinion on overall controls and highlights areas for improvement. In particular it highlights adequate risk and internal control. The Committee discussed issues raised in the opinion, particularly the effectiveness of CIP delivery in year. The Trust had demonstrated learning from the 2015/16 CIPs plans and had strengthened controls and review going into 2016/17. DM highlighted that as a draft opinion it was unlikely to change significantly but the wording may alter to include any other audits completed in year. The Committee noted the draft opinion



4.2 Internal Audit Progress Report DM introduced the paper and highlighted the audits completed since the January (Pharmacy Stock, Infection Control, Information Governance, Financial Feeder System and Workforce Data). All audits had provided good assurance of control systems. All actions necessary are agreed with management. The Committee noted that more could be done to provide specialities with data on their drug use and the ongoing need to reduce the gap in provision of statutory and mandatory training. The Committee asked for assurance that the issues highlighted in the pharmacy stock audit would be discussed at local level. GFM confirmed that amendments had been made to the standards of business conduct and there was particular focus on sharing relevant policy issues with pharmacy and those in decision making roles. The workforce data quality audit provided good assurance and there are plans to review and develop the Board level KPIs. The Committee noted the report.

4.3 External Audit Report MW presented External Audit’s plan for completing end of year activity, in particular noting the review of ‘value for money’ which will focus on planning, partnership working and business processes. The plan has been developed with the Trust and will focus on revenue and control. The Committee noted the Trust’s practice of managing divisional budgets which takes into account income modifications to facilitate pragmatic budget management conversations. External Audit will be looking at this as part of the end of year review. The Committee went on to discuss the emerging changes in local healthcare provision which included the STP and uncertainties of future plans. There will be a balance between local priorities, neighbouring organisations, commissioners and central needs. GFM confirmed that the STP would be discussed at a Board Seminar. External Audit confirmed that they would be using national guidelines to review the Trust’s going concern position.



MW went on to highlight the annual report benchmarking paper. The Committee discussed the 2015/16 annual report. The focus will be on producing a relevant and accessible document that would benchmark well against peers. The Committee agreed that it was a very useful document and noted that the Trust annual report and AGS are being developed using the benchmarking report as guidance.

4.4 LCFS Report MH introduced the report, highlighting planned work to take an overall view of systems and fraud risk systems. This review is timetable for presentation at the July meeting. Since taking over the provision of services there has been work to build rapport with NHS Protect and work has started on two newly identified potential cases. The Committee was assured that Counter Fraud was under taking a Trust wide review and risk assessment of the Trust’s fraud prevention and mitigation.The Committee noted the report.

5 5.1 Draft Annual Governance Statement CP introduced the draft annual which is based on national guidance and includes details identified by External Audits benchmarking report.

The Committee discussed the draft report and suggested changes throughout that should be made for the April meeting and draft deadline. In particular noting updates on CQC compliance, the recent re-inspection of outpatients and the narrative that details the Trust’s journey to become a Foundation Trust.

Action CP to coordinate further review of draft AGS in time for sign off at the April AAC.

CP

5.2 Review of Terms of Reference GFM introduced the review of the terms of reference (TOR) of the Committee, which had been considered and updated as part of the review of the Trust’s Rules of Procedure. The Committee noted that there should be reference to the Audit Panel and minor changes to counter fraud elements of the TOR.



With these changes the TOR were agreed.

6 6.1 PS stated that the 20th April had been set for the Committee to meet and agree the draft annual accounts. No further AOB was raised.

6.2 Date of Next Meeting: 20th April 2016, 09:00am

Audit & Assurance Committee Page 1 of 4 Minutes April 2016 An Associated University Hospital of


AUDIT & ASSURANCE COMMITTEE

Meeting held on 20th April 2016 , 09:00am – 12:00pm Venue: Room AD77, Trust HQ, East Surrey Hospital

Present: Paul Biddle PB Committee Chair / Non Executive Director Richard Durban RD Non Executive Director Richard Shaw RS Non Executive Director In attendance: Paul Simpson PS Chief Finance Officer Gillian Francis-Musanu GFM Director of Corporate Affairs Djafer Erdogan DE Financial Controller Jamie Bewick JB External Audit David May DM Internal Audit Laura Warren LW Head of Communications Colin Pink CP Head of Corporate Governance

Action by

1 1.0 Welcome and Apologies for absence

The Chair welcomed members and attendees to the meeting.

2 2.0 Agreement of draft accounts PS introduced the draft accounts covered in two papers. These unaudited accounts require approval prior to submission to the Department of Health and the start of the external audit.

The unaudited I&E position is a bottom line £4,116k deficit, plus a net technical deficit of £2,393k resulting in a net £6,509k deficit for NHS reporting purposes.

The comprehensive income position includes movements in assets showing a gain of £6.9 million.

This technical adjustments relate to donated asset receipts and final valuation of the new cancer centre and the integrated reablement unit

RS commented on the asset income relating to the MacMillan



Centre. The Committee went on to talk about the details of the donated asset items such that the detail was clear and understood.

PS highlighted the £3 million capital to revenue transfer from the TDA which was described as non recurrent income.

The Trust met the terms of its loan agreements in 2015-16, took out a further £4.4m capital loan and drew down £12.5m from its working capital facility. The balance on the loans and working capital facility drawn down as at 31st March 2016 is £26 million split as follows; Working Capital Loan £3.5 million, Original Capital Investment Loan £2.1 million, Capital Investment Loan £7.9 million and Revolving Working Capital Drawn Down £12.5 million.

PS highlighted that the Trust continues to be in breach of its statutory break even duty. JB advised that External Audit were taking advice on whether a Section 19 letter would be required.

The quinquenial revaluation of the Trust was carried out as at 31st March 2015 and the subsequent valuation adjustment for 2016 described an increase in value of fixed assets of £9.8 million (net).

RS asked about the Trust’s ability to repay loans and their affordability. PS indicated that the Trusts prudential borrowing limit was last calculated at £42 million pounds and that the ability to repay loans is part of the Trust’s long-term financial model and which currently covered repayments.

Loan rates are generally lower than the PDC dividend.

The Committee went on to discuss the financial issues of the Trust and how they would impact on the next years I&E budget noting capital projects, activity, income, surplus generation and the ongoing capital position.

The bad debt provision was noted, which follows established accounting policies.

The Committee went on to discuss the overall staffing numbers in the Trust, noting that the Trust had invested in staffing to provide capacity. The Trust is aligning staff records systems with the ledger



for greater overall control. This work will be completed in July.

PS highlighted the formal administrative targets that the AAC should be aware of, focussing on payments to suppliers and the poor performance against the Better Payment Practice Code. The Committee discussed this and it was noted that cash flow had been an in issue in year. To date the management of supplies has been ok and no issues had materialised.

The Trust has also hit targets for external financing and capital resource limits.

The Committee expressed their thanks for the analysis and summary of accounts.

The Committee agreed to sign off the draft accounts, delegating authority to make minor amendments if necessary to the Chief Financial Officer. Any significant changes to the draft accounts should be highlighted with RD and PB.

2 2.0 Review of Draft Annual Report LW introduced the draft annual report highlighting the content that had been prepared and commentary that will follow once data is finalised. The report has been drafted using guidance available and now falls into 3 sections performance, governance and finance. The Committee discussed the draft report and asked for minor changes to be made. The Committee agreed that summary of the finances was good but there may be too much detail in plans for 2016/17 budget. The report should also align with CIP and STP papers discussed at public board. The Committee asked to have early sight of the final annual report for sign off. The Committee agreed the annual draft report.



3 3.0 Review of Draft Annual Governance Statement CP introduced the draft annual governance statement, highlighting the changes that had been made following the first review at the March meeting. The report follows guidance with minimal extra content, mostly included from External Audit’s benchmarking exercise of the 2014/15 annual report content.

PS indicated that the section on counter fraud would need to be checked as commentary on the recent external assessment was not correct. CP confirmed that this would be checked. The draft AGS would also be submitted to the TDA by the 22nd April 2016.

The Committee agreed the draft annual governance statement..

4 4.0 AOB The Committee asked that any unexpected final amendments be discussed with RD and PB. The Committee discussed the recent visit by Deloittes carrying out assessment for NHSI. To date no challenges or issues had been raised. JB commented that the Trust’s approach and stand point relating to the review was good. PB asked how the Trust reported its “going concern”. PS commented that the focus was on other accounting issues, the Trust is a going concern however the risk is well defined and has been audited. This is also included in disclosures reported at Board. There was no further AOB.

5 5.0 Date of Next Meeting: 26th May 2016

Documents

Board papers June 2016