Copy of 201-Big 9 - M3-June - Presentation with RAG ... · Minutes of the DCHS Board Meeting held on Thursday 30 June 2016 Matlock Town Football Club, Causeway Lane, Matlock, DE4

Derbyshire�Community�Health�Services

Board

Board�Public�Session�28�July�2016

28�July�2016�-�12:30

University�of�Derby�Enterprise�Centre,�Bridge�Street,�Derby,�DE1�3LD

AGENDA

185 1.00�pmSpotlight�on�local�services

186 1.30�pmPART�2�–�Public�Session

187 INTRODUCTORY�ITEMS

188 Introductions�and�WelcomeOwner:�Prem�Singh

Verbal

189 Apologies�for�Absence:Owner:�Prem�Singh

Tracy�Allen,�Carolyn�White

190 Declarations�of�InterestOwner:�Prem�Singh

Verbal

191 Questions�from�the�PublicOwner:�Prem�Singh

Verbal�

http://www.eshareuk.com

192 Patient�StoryOwner:�Jo�Hunter

Paper�for�Information

192�Patient�Story 6

193 Draft�Minutes�of�the�meeting�held�on�30�June�2016Owner:�Prem�Singh

Paper�for�Decision

193�Minutes�June�2016 9

194 Matters�ArisingOwner:�Prem�Singh

Verbal

195 Actions�MatrixOwner:�Prem�Singh

Paper�for�Information

195�Actions�Matrix 17

196 Chairman’s�ReportOwner:�Prem�Singh

Verbal

197 STRATEGY,�VALUES�AND�VISION

198 Chief�Executive’s�ReportOwner:�Chris�Sands

Paper�for�Information�

198�CE�Report 20

199 QUALITY,�PERFORMANCE�AND�GOVERNANCE

200 Performance�ReportOwner:�Chris�Sands/�Amanda�Rawlings/�Jo�Hunter/�William�Jones

Paper�for�Information�and�Assurance

200�Performance�Report 33


201 Financial�Performance�ReportOwner:�Chris�Sands

Paper�for�Assurance

201�Financial�Performance�Report 48

202 Audit�and�Assurance�Committee�Summary�ReportOwner:�Nigel�Smith


202�AAC�Summary�Report 61

203 Quality�Service�Committee�Summary�ReportOwner:�Chris�Bentley


203�QSC�Summary�Report 65

204 Quality�People�Committee�Summary�ReportOwner:�Barbara-Anne�Walker


204�QPC�Summary�Report 72

205 Quality�Business�Committee�Summary�Report�inc�ToROwner:�Ian�Lichfield


205�QBC�Summary�Report�inc�ToR 78

206 Council�of�Governors�Summary�ReportOwner:�Prem�Singh


206�CoG�Summary�Report 87

207 Quality�ReportOwner:�Jo�Hunter

Paper�for�Information�and�Assurance

207�Quality�Report 90

208 NHSI�Oversight�Consultation�ResponseOwner:�Chris�Sands

Paper�for�Decision

208�Single�Oversight�Framework�Consultation 115


209 Board�Assurance�Framework�Quarter�OneOwner:�Kirsteen�Farrar

Paper�for�Information,�Decision�and�Assurance

209�Board�Assurance�Framework�Q1 158

210 NHS�Improvement�Self�Certification�Quarter�OneOwner:�Kirsteen�Farrar

Paper�for�Decision�and�Assurance

210�NHS�Improvement�(NHSI)�Self-certification�–�Qu 195

211 CONCLUDING�ITEMS

212 Any�Other�BusinessOwner:�Prem�Singh

Verbal

213 Self-Certification/Risk/Board�Assurance�FrameworkOwner:�All

Verbal

214 Questions�from�the�public�relating�to�today's�board�businessOwner:�Prem�Singh

Verbal

215 Review�of�the�Meeting�and�OutcomesOwner:�Prem�Singh

Verbal

216 Date�and�time�of�next�meetingOwner:�All

The�Peel�Centre,�High�St,�Dronfield,�S18�1PX.��Members�of�the�public�and�staff�are�invited�to�jointhe�Board�for�an�informal�discussion�over�lunch�from�12.30pm;�this�will�include�a�presentation�onthe�services�provided�in�that�area.��The�Public�Board�meeting�will�commence�at�1.30pm


Index192�Patient�Story.docx..............................................................................................................6

193�Minutes�June�2016.docx....................................................................................................9

195�Actions�Matrix.docx..........................................................................................................17

198�CE�Report.pdf.................................................................................................................. 20

200�Performance�Report.pdf.................................................................................................. 33

201�Financial�Performance�Report.pdf................................................................................... 48

202�AAC�Summary�Report.docx.............................................................................................61

203�QSC�Summary�Report.docx............................................................................................ 65

204�QPC�Summary�Report.docx............................................................................................ 72

205�QBC�Summary�Report�inc�ToR.pdf..................................................................................78

206�CoG�Summary�Report.docx.............................................................................................87

207�Quality�Report.docx......................................................................................................... 90

208�Single�Oversight�Framework�Consultation.pdf...............................................................115

209�Board�Assurance�Framework�Q1.pdf.............................................................................158

210�NHS�Improvement�(NHSI)�Self-certification�–�Quarter�1.do...........................................195


TRUST BOARD Document Title: Patient Story

Presenter/Title: Jo Hunter, Deputy Chief NurseContents of Paper were previously discussed by:

Author/Title: Maggie Moorcroft – Occupational Therapist Derby City Intermediate Care Team

Contact Email and Telephone Number:

[email protected] 01332 [email protected]

Date of Meeting: 28 July 2016 AgendaItem No: 192/16

No of pagesinc. this one: 3

Has an Equality Impact Assessment been undertaken Yes No xDocument is for:(more than one box can be ticked) Information x Decision Assurance

Purpose of Paper

To share Mona’s story which illustrates how coordinated integrated working in the Derby Intermediate Care team provided positive outcomes and experience for this lady.

Recommendations

That Trust Board notes: The quality of care provided by the Intermediate care team in Derby City, which joined

DCHS from Derby Hospitals Teaching FT in October 2015. The way that a coordinated effort from an integrated team can deliver positive outcomes

and a good experience for patients when their care is transferred from the acute inpatient setting into the home.

Board Assurance Framework Risk Reference

N/A

Financial Impact

None identified in this paper

Further Information and Appendices

Mona who is 75 years old was referred to Derby City Intermediate Care Services from Ward 5 London Road Hospital after a 10 day admission to hospital for investigations and management of severe abdominal pain and constipation. She also has Parkinson’s disease.

Mona lives alone in a two storey house and has a supportive family. Her hospital admission came at a very difficult time for the family due to a life changing diagnosis for one of the family members. In addition to this, Mona’s family work away for a lot of the time and as a result were unable to meet Mona’s increased care needs.

192�Patient�Story.docxOverall�Page�6�of�210Page�1�of�3

mailto:[email protected]



Prior to admission, Mona was very independent: able to shower and dress independently, prepare her own meals, manage her home and garden and enjoyed going out and about with friends and family. On discharge from hospital she had significantly reduced confidence levels. Due to issues with pain and fatigue, she required support with personal care and meal preparation. Mona was walking with one stick, was unable to go up and down stairs. She needed an additional rail which had been ordered by the ward.

Input received The initial assessment identified that Mona required physiotherapy to increase confidence, build strength and help manage issues with back pain. Occupational therapy was also identified as necessary to restore Mona to her previous level of independence in activities of daily living, along with assessment and support from the nursing staff to promote independence with medication management. Mona was initially provided with 4 calls a day from the intermediate care clinical support workers to promote independence with personal care and meal preparation. Mona was supported to administer her own medications as she lacked confidence and was now on increased levels of medication and needed practice and strategies to enable her to be independent.

Outcomes and experienceThrough the input from intermediate care Mona was able to progress from walking with one stick to walking without the need for equipment inside the home. She was also able to return to going upstairs to bed. She also reported that although issues with back pain did remain, they had improved and were far more manageable. Her stamina and strength improved and by discharge she was able to return to being able to go out of the house again with family and friends.

An occupational therapist was able to provide and give advice on suitable equipment and practice to enable her to wash and dress independently again and to be able to prepare her own meals as she was not keen on microwave meals. She was able to gain confidence and build her stamina and tolerance to enable her to undertake these tasks with input from the technical instructors providing the practice and support needed.

A seating assessment was completed to identify a back rest which she could use in her own chair and also in the car and on other seats. She found this very helpful for pain management. Working in conjunction with the nursing staff and clinical support workers, Mona was able to develop strategies which meant that she regained her independence with taking medication. She was referred onto the Parkinsons outpatient team by the physiotherapist and is receiving ongoing care for her Parkinsons Disease.

Mona stated she was very pleased with the service. She and her family were pleased with how quickly everything was acted upon. Everything that was agreed and discussed was provided. She found that the help and the equipment provided were of significant benefit for her immediate and ongoing needs.

The intervention was multi-disciplinary, relying on communication between the varying disciplines within the service to ensure that Mona was ultimately able to achieve her rehabilitation goals. Mona was able to return to her previous level of independence. The service provided support to the whole family during a time of distress related to an additional family member being diagnosed with a very serious medical condition.

Mona’s family is still in distress due to that diagnosis and so Mona did not feel up to coming to talk directly but was happy to share her story and experiences.



Monitoring Information Brief Summary

What are there Governor Involvement implications?

Patient stories are told at Council of Governors meetings and at other key group in which governors are core members.

What are the Equality and Diversity implications?

Mona is an older person with a disability. She should have equal access to services regardless of these, and any other, protected characteristics.

What are the Patient, Public, Staff, Member and Stakeholder Involvement implications?

Patient stories are one way that the patient’s voice is heard.

Risk Register

Is the issue on the current Risk Register? No If yes, what is the Risk Number? n/a

Does this update recommend a change in the current risk score? (If so, please provide your rationale below) No



Minutes of the DCHS Board Meeting held on Thursday 30 June 2016Matlock Town Football Club, Causeway Lane, Matlock, DE4 3AS

Name Job titlePrem Singh PS ChairmanTracy Allen TA Chief Executive Chris Bentley CB Non-Executive DirectorJohn Coyne JC Non-Executive DirectorWilliam Jones WJ Chief Operating OfficerIan Lichfield IL Non-Executive DirectorRick Meredith RM Medical DirectorAmanda Rawlings AR Director of People & Organisational EffectivenessChris Sands CS Director of Finance, Information and StrategyNigel Smith NS Non-Executive DirectorCarolyn White CW Chief Nurse (left at 3.30pm)Barbara-Anne Walker BAW Non-Executive Director

Present

Kirsteen Farrar KF Trust SecretaryApologies

Jim Austin JA Associate Director of TransformationMelanie Curd MC Deputy Trust SecretaryLouise Barling LB Community Occupational Therapist (left at

3.00pm)Tim Broadley TB Associate Director of Strategy

In Attendance

David Boddy DB Corporate Governance Manager

Item Description Action

160/16 PART 2 – PUBLIC SESSION

161/16 INTRODUCTORY ITEMS

162/16 Introductions and Welcome

163/16 Apologies for Absence Apologies were noted as above.

164/16 Declarations of InterestPS declared that he has become the Independent Chair of the Sustaining Services Board for the Nottingham University Hospitals/Sherwood Forest Hospitals merger, as part of his consultancy work.

WJ is no longer a Trustee of Helen’s Trust.

165/16 Questions from the PublicThere had been no formal questions from the public received.

166/16 Patient StoryThe patient story demonstrated the positive impact that a specialist

193�Minutes�June�2016.docxOverall�Page�9�of�210Page�1�of�8



Occupational Therapy (OT) assessment had on ensuring a family felt well supported in their home environment. The assessment resulted in specialist equipment being put into place to reduce the risk of falls, burns and potential harm to the patient.

The story demonstrated personalised care, good communication and compassion to ensure the patient and her husband kept their independence.

The Board discussed the positive impact of the OT assessment, recognising the good work of this service. JC said the story illustrated that patients seldom present with just one problem and how well DCHS staff work across disciplines. The story was a good example of why our services should be multi-functional.

LB, Occupational Therapist, joined DCHS in December 2015 after winning the Vice-Chancellor’s prize for academic achievement at Derby University. She was awarded best performance in the entire graduating year of 2015, as well as best in the health and social care college.

LB’s own story provides assurance that DCHS is in a position to attract and maintain talented staff to provide high quality care to our patients. LB said that one reason she chose DCHS was because of the values of the organisation. LB also said that patients trust DCHS through the good values of the staff representing the organisation. LB went on to say that DCHS, as an employer, was meeting her expectations.

AR described the work undertaken to engage students in order to successfully recruit in a competitive environment. JA recommended that DCHS consider innovative recruitment tools such as “recruit a friend” cards.

PS thanked LB for a great story and the difference she has made to the patient’s life. The Board agreed that it would be very important if LB could help DCHS with our student recruitment initiatives.

The Board received the Patient Story.

167/16 Draft Minutes of the meeting held on 26 May 2016The minutes of the meeting held on the 26 May 2016 were agreed as accurate.

168/16 Matters ArisingThere were no matters arising.

169/16 Actions MatrixThe Board noted the actions with a deadline of June were complete.

170/16 Chairman’s ReportPS began presentation of his report by reflecting on the EU referendum, the ensuing uncertainty in the nation and the potential impact on the NHS. PS said that the operating environment will test our collective system reliance and leadership.

To support DCHS continuous improvement (“Good to Great”) the Board




agenda has been revamped into Strategy, Vision and Values and Quality. Performance and Governance sections.

Prompted by the “Better Care Closer to Home” discussion topic in the public open session, the strategic theme is that we work with our communities and staff to encourage open and honest dialogue.

PS, WJ and TB met with members of our League of Friends from across the county to recognise their work and to look at how we can work more collaboratively. An annual meeting with the League of Friends has been arranged.

PS and TA attended a number of key system leadership meetings including the inaugural meeting of the joint Derby City Council and Derbyshire County Council Health and Wellbeing Board and a further Sustainability and Transformation Plan (STP) meeting.

PS and TA visited Spencer Ward in Cavendish Hospital. It was a privilege to hear about the excellent and compassionate care that is being delivered by the staff there.

PS’s governance and accountability activities this month included: The good progress of the NED recruitment campaign in June. A

recommendation will be made to the July Council of Governors meeting Completion of the annual appraisal for TA – this will be presented to the

Remuneration and Terms of Service Committee for endorsement A positive meeting of the Board’s Commercial Strategy subgroup that

discussed the changing environment A Board Development Session focussing on the CQC action plan, 21st

Century Joined Up and STP and System Leadership Care Nominations Committee and Governance Group meetings

With respect to the national agenda PS attended the NHS Employers’ Policy Board meeting. PS has also joined the NHS Confederation Finance and Performance Committee and has chaired the NHS Confederation Remuneration Committee.

Other highlights from the report included: Judging is now complete for the Extra Mile Awards and candidates have

been shortlisted DCHS received good publicity for our family centred care project during

National Carers’ Week Tenders have now been issued with respect to the Heanor Hospital

redevelopment The next stage of the redevelopment of Walton Hospital is moving

forward with work in late July on a new 105 space car park DCHS were invited to showcase its work on frailty at the NHS

Confederation Conference

The Board received the Chair’s Report.




171/16 STRATEGY, VALUES AND VISION

172/16 Chief Executive’s Report TA discussed the key national and local strategic issues affecting the Trust.

TA highlighted the progress made regarding the development of the Sustainability and Transformation Plan (STP). The draft Derbyshire/Derby City STP will be submitted on the 30th June to NHS England in line with national planning requirements. This is a ‘checkpoint’ stage in the development of the plan and system leaders will be working over the summer to continue to refine the plan. JC said that the STP was a very cogent piece of work.

Consultations have been launched regarding the 21st Century Joined Up Care Programme – “Better Care Closer to Home”. TA reiterated that the consultation proposals have significant implications for the way in which DCHS may provide services in the future. It is vital that the Board play an active role in the consultation supporting colleagues across the Trust, along with the public in the communities we serve. TA had been impressed by the thoughtful patient centred response from respectful colleagues during the initial staff briefings. Extra sessions have been arranged for next week, some specifically for Facilities Management and Community based staff

DCHS have received a letter from NHS Improvement highlighting the potential risks in 2016/17. All providers have been asked to take extra action this year

TA and CW, along with a number of governors, held the first Quality Always Gold Accreditation Panel in July to award gold accreditation to Linacre Ward and the Amberley Core Unit. Gold accreditation will also be awarded to Melbourne and Spencer Wards.

The Board welcomed the news that Castle Street Medical Centre had now joined with DCHS. Other news was that Dr Alan Blair and Malcolm Steward had retired – the Board acknowledged their impact on NHS services across Derbyshire.

The Board reviewed the Big 9 priority indicators. In response to a question from NS, AR discussed the ongoing work with respect to the reporting of days lost to stress and anxiety. In order to provide consistency with the other priorities, it was agreed to report performance by percentage.

JC commented that stress is often a result of uncertainty and that the current and future organisational changes may have further impact on the performance. Dr Alan Blair will be returning in September to support this work.

The Board went on to discuss feedback from the discussion with members of the public regarding the “Better Care Closer to Home” consultation, which had taken place prior to the Public Board meeting. Members of the public had raised questions regarding the location of specialist rehabilitation hospital beds, particularly with respect to Whitworth Hospital.

PS said that the briefing sessions will be difficult for our staff and our communities and we must do everything to encourage and support open

AR




dialogue and try and address concerns. The importance of the Staff Partnership and Resolve service in supporting staff to get their views across, and manage the ensuing uncertainty as individuals, respectively, was also emphasised.

The Board received the Chief Executive’s Report.

173/16 QUALITY, PERFORMANCE AND GOVERNANCE

174/16 Performance ReportThe Board reviewed the summary of DCHS’ performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. The Balanced Scorecard incorporated the contractual and other performance regime changes in 2016/17.

WJ highlighted from the Quality Service section: Ward occupancy continues to be below trajectory and provides

continued evidence that the strategies we have put in place to ensure patients receive care as close to home as possible are being effective. The overall occupancy rate for May was 75% against the target of 85%

The average length of stay has not increased The Pressure Ulcer performance remains a challenge - there were 4

avoidable grade 2, 3 & 4 pressure ulcers for the month. An improvement target of 29 has been developed for the year.

There were 5 falls in May – the falls have been investigated and it was found that they were not avoidable

AR discussed the Quality People section and highlighted: Focussed work is underway on staff wellbeing. Quality People

Committee (QPC) will receive a deep dive report on the work and a health needs assessment has been emailed to all staff

Two RIDDOR Zero Harm events occurred in May. The Board agreed that more work should be done to influence staff behaviour to avoid preventable trips and falls. It was requested that safety alerts should be issued after a RIDDOR has happened. Staff who suffered the falls will be asked if they will share their stories as part of the alerts

The Board discussed the Quality Business section: The Trust has yet to receive a control total for capital. We are therefore

progressing as per our plan. We are working with the estates team around developing performance metrics in line with the Carter review. This work will be informed by the ERIC return which will be completed in July 2016

The Trust continues to actively manage working capital in line with the Working Capital Framework. Next month the Head of Management Accounts will be undertaking a “deep-dive” of all accruals in conjunction with the Treasury team, ensuring accruals are accurate. In addition, theTreasury team will continue to chase outstanding debt and promote prompt invoicing of income. The deep dive will be reported to the July 2016 Quality Business Committee (QBC).

TA said that speakers at the NHS Confederation Conference stressed the importance of continuing to deliver short term technical efficiencies




in order to provide sustainable organisations to support delivery of STPs

The Board received the Performance Report and the assurance it provided.

175/16 Financial Performance ReportThe Board reviewed the financial performance of the Trust as at 31 May 2016.

The Trust is reporting a surplus position of £0.94m at month 2. The Trust is forecasting that it will meet all its statutory financial duties for the year.

The Board discussed the Agency Spend performance against targeted trajectory. The reported figure was high because this performance related to March and April. Beds have now reduced and the expectation is that there will be a reduction in spending. Additional measures around control are being taken forward and Quality People Committee continues to review agency spending.

The Board received the Financial Performance Report and the assurance it provided.

176/16 Quality Service Committee (QSC) Summary ReportCB discussed:

Patient Story – this highlighted the important role of the voluntary sector in supporting our services. It was acknowledged that in order to secure enough investment in the service a business case will need to be included in the 21st Century initiative

The Committee discussed the results of the Service Improvement Plan (SIP) which has been instigated within the Integrated Sexual Health Service following the recent CQC inspection. DCHS has undertaken an extensive audit and provided assurance to the CQC to show that we are managing patient results in a safe way. The CQC have confirmed that they have no concerns regarding patient safety

The CQC also provided good feedback regarding the robust processes in place regarding Gaining Consent. QSC discussed two red RAG rated areas and post meeting these were reviewed and reported as downgraded

The Leicestershire Dental Service has relocated to a purpose built theatre

DCHS are receiving a net gain of approximately 1,700 children following the change from registered to resident population coverage, many of whom have high vulnerabilities. The resource allocation has been reviewed and is being realigned accordingly

QSC reviewed analysis of all community services waiting times within DCHS. Work is being undertaken to provide information on these important waiting times. Action was agreed that the divisions will identify their top 5 concerns and analysis will be reported back to QSC. The output will be forwarded to QBC as part of a referral from QSC

The EDILF Annual Report was reviewed. The Committee was pleased with the substance of the actions undertaken this year. AR reported that the Equality metrics are to be discussed at QPC in July




Patient Experience and Engagement - the Committee took Significant Assurance from the Annual Patient Experience Report. The Committee praised the positive information that there had been over 24,000 pieces of feedback from patients and that there are now 23 patient groups. QSC were also pleased with the good progress of the Spiritual and Pastoral Care Action Plan

QSC also took Significant Assurance from the successful work of the NICE Consultation Group

The Board received the Summary Report and the assurance it provided.

177/16 Audit and Assurance Committee Summary ReportThe extra-ordinary Audit Committee meeting took Significant Assurance from the 2015/16 Auditors Reports on the Annual Quality Report and the Annual Accounts.

The Audit Committee meeting also recommended to the Board the Annual Quality Report, Annual Governance Statement, Audited Annual Accounts and Financial Statements and the Annual Report.

The Board was updated with respect to a risk raised with the CQC about our Sexual Health service and management of results. The CQC have confirmed that they have no concerns over patient safety.

WJ asked that the wording with respect to demolition of Walton site be slightly amended to “part of the Walton site”.

PS said that it had been a tremendously positive performance and thanked the staff and the work of NS and CS.

The Board received the Summary Report and the assurance it provided.

DB

178/16 Quality ReportRM reviewed quality issues relating to DCHS during the past month and highlighted:Quality Always

Further detail regarding the first Quality Always Gold Award panels The positive safety culture that has been generated from the work of

Quality Always. TA reported that staff spoke of the benefits of Quality Always such as providing a sound knowledge base and evidence based practice. Knowledge has been shared via the network of Safe Care Champions

PS asked that the agreed funding for Quality Always should be expedited. The Board asked to be updated at the September meeting.

Flu Planning The Board discussed the challenge of the CQUIN target to vaccinate

75% of front line staff. A plan is to be discussed in QPC. In the meantime, CW is checking with commissioners the reports that there is a variance in the target for other trusts, with a view to potentially challenging the DCHS target

JC made a suggestion that vaccination of front line staff should be

CW




scheduled and that the emphasis should be on an opt out process rather than the current opt in approach.

Back to the Floor Arrangements for the new “Back to the Floor” initiative are now in

progress. The proposal was received enthusiastically at the Trust Management Executive with senior managers and executives agreeing that they would participate once a month.

The Board received the Quality Report and the assurance it provided across the areas of the Quality agenda covered by this report.

179/16 Annual NHS Improvement Self CertificationMC presented the Annual NHS Improvement (NHSI) Self-certification toBoard for approval prior to its submission.

Subject to minor amendments the Board approved the annual Self-certification of:

The requirements of the Corporate Governance Statement, The certification on Academic Health Science Centre (AHSC) and

governance The certification on training of Governors

180/16 CONCLUDING ITEMS

181/16 Any Other BusinessThere were no items of any other business.

182/16 Self-Certification / Risk / Board Assurance FrameworkThis is a standing item on the public Session of Board to provide an opportunity to reflect on the business discussed and consider any impact on Self-certification, risk, or the Board Assurance Framework.

183/16 Questions from the Public relating to Today’s Board BusinessNone.

160/16 Review of the Meeting and outcomesThe Board agreed the meeting had gone well.

161/16 Date of Next meetingThursday 28 July 2016 at University of Derby Enterprise Centre, Bridge Street, Derby, DE1 3LD. Members of the public and staff are invited to join the Board for an informal discussion over lunch from 12.30pm; this will include a presentation on the services provided in that area. The Public Board meeting will commence at 1.30pm.



DCHS BOARD – ACTIONS MATRIX DATE: July 2016 – Public Session

Date/Item No:

Item/subject: Decision taken and/or action required:

Progress: Responsible Person:

Deadline: Outcome:

Mar 201680/16

Quality Report Our services have experienced pressure from seasonal illness. The peak demand has led to a flexing up of beds and it is hoped to flex down to 16 beds in May. Analysis was requested regarding what has happened over winter and a referral to be made to QPC to look at flexing options.

A meeting is scheduled for May 2016 where key players are going to analyse our agency and flexible staffing usage over winter 2016 and plan for how we manage our workforce efficiently and proactively ahead of winter 2017. A paper has now been scheduled for July QPC to feedback on this work and provide assurance to QPC that we not only understand our winter 2016 usage, but that we are proactively planning for 2017

Carolyn White

July* 2016*Changed from May 2016

An update is on the QPC Summary Report. Further updates will go to QPC and will be provided to the Board via the QPC Summary Report.

Complete

Jun 2016172/16

Chief Exec’s Report – Big 9

Performance to be reported by percentage going forward, in order to provide consistency with other priorities

Amanda Rawlings

July 2016 Complete

Jun 2016177/16

Audit and Assurance Committee Summary Report

Wording with respect to demolition of Walton site be amended to “part of the Walton site”.

David Boddy July 2016 Complete

195�Actions�Matrix.docxOverall�Page�17�of�210Page�1�of�3


Date/Item No:



Deadline: Outcome:

Oct 2015267/15

Quality Report Derbyshire Youth Council to be invited to a future Board meeting

CW is liaising with the Council to agree the best time for them to attend.

Carolyn White

Sept 2016*Changed from Mar 2016

Dec 2015329/15

Quality Report The Board discussed the pros and cons of centralised teams and it was agreed that this would be discussed further at the Primary Care Development Session.

Primary Care Development Session organised for 28 July 2016

Tim Broadley Sept 2016*changed from May 2016

Jan 201615/16

QPC Summary Report

New sentencing guidelines to be included in the Board Development Session on H&S

This session has been arranged for 29 September 2016.

Amanda Rawlings

Sept 2016

Jan 20167/16

Patient Story To discuss discharge planning with the Chief Nurse at the Acute Trust

CW to meet with the Chief Nurse at Burton Hospital on 6 May 2016. To update the Board following that meeting.

Meeting deferred until 27 May 2016, and update to be given to Board following.

June Unfortunately this meeting had to be cancelled due to work required in sexual health a further date is being identified.

July Meeting arranged for 26 Aug 2016

Carolyn White

Sept 2016*Changed from June 2016



Date/Item No:



Deadline: Outcome:

Mar 201670/16

Patient Story The value of the work in Creswell to be demonstrated to GPs and an evaluation (including a cost benefit analysis) to be undertaken to produce a recommendation for future configurations of the service for the benefit of the North East Derbyshire population. This also to be included in the forthcoming Creswell and Langwith evaluation.

Tim Broadley Sept 2016

Mar 201676/16

QSC Summary Report

KF to consider the calibration of levels of assurance and to make a recommendation; and also to review and provide direction regarding what should come out of the Deep Dive reports

Progress discussed at QSC. Training is being provided in relation to assurance at the Q Committees.

Kirsteen Farrar

Sept 2016

May 2016135/16

Patient Story TB to discuss case for prevention of diabetic foot disease with commissioners

Tim Broadley Sept 2016*Changed from June 2016

June 2016178/16

Quality Report PS asked that the agreed funding for Quality Always be expedited. The Board asked to be updated at the September meeting

Carolyn White

Sept 2016



TRUST BOARD Document Title: Chief Executive’s Report

Presenter/Title: Chris Sands, Deputy Chief Executive Contents of Paper were previously discussed by:

Author/Title: Chris Sands, Deputy Chief Executive Contact Email and Telephone Number:

Cathryn Pearson, Executive Assistant, [email protected] 01629 817892

Date of Meeting: 28 July 2016 Agenda Item No: 198/16

No of pages inc. this one: 13

Has an Equality Impact Assessment been undertaken Yes No X

Document is for: (more than one box can be ticked) Information X Decision Assurance

Purpose of Paper

The report provides information on strategic policy, legislative and developmental issues affecting the organisation.

Recommendations

The Board is asked to note the report.


N/A

Financial Impact

The issues raised in this report will all have significant financial implications. These implications will be considered in separate plans, and business cases.


Chief Executive's Report July 2016 1. Purpose of the paper This paper is to provide the Trust Board with information about key national and local strategic issues affecting the Trust. 2. National Updates 2.1 Department of Health Leadership Changes The referendum on our continued membership of the European Union has now concluded with a vote to leave. David Cameron has resigned as Prime Minister, and has been replaced by Theresa May. A new Cabinet has been appointed, and the implications for health portfolios are

198�CE�Report.pdfOverall�Page�20�of�210Page�1�of�13



summarised below:

• Health Secretary – Jeremy Hunt • Minister of state (Portfolio to be confirmed) – Philip Dunne • Parliamentary Under-secretary of state for NHS productivity – Lord Prior • Parliamentary Under-secretary of state (portfolio to be confirmed) – Nicola Blackwood • Parliamentary Under-secretary of state (portfolio to be confirmed) – David Mowat

With the health Secretary remaining unchanged, we don’t expect any significant changes in health policy in the short term. 2.2 Strengthening financial performance and accountability in 2016/17 Over the past few weeks, there have been a number of national announcements which aim to introduce greater control and stability in provider sector finances. On 21st July 2016, NHS Improvement published a document which summarises these measures and packages them as a “financial reset”. The document has been issued as a result of the financial deficit the provider sector reported for 2015/16, and the need to significantly reduce that level of deficit in 2016/17. It is another reminder of the difficult financial position the NHS finds itself in. Appendix 2 includes a useful briefing on this document from NHS Providers. The impact on the Trust of the “reset” is minimal from an in-year financial perspective, so long as we continue to meet our financial targets. But this, together with the new proposed Oversight Framework, will further limit the freedoms that the Trust will have to operate in the future. The “reset” also emphasises the difficult financial climate that the Trust is operating in, and re-inforces the need for the Derbyshire health and social care system to work together to develop credible sustainable plans for the future. 3. System Transformation Updates 3.1 Developing the Derbyshire/ Derby City Sustainability and Transformation Plan (STP) The draft Derbyshire Sustainability and Transformation Plan was submitted on the 30th June to NHS England in line with national planning requirements. This was a “Checkpoint” submission. A group of Derbyshire leaders, including the DCHS Medical Director and myself, will be meeting with NHS England and NHS Improvement on the 25th July 2016 to discuss the plan in detail. A verbal update of the key issues from this meeting will be provided to the Board. The plan identifies 5 key priority areas for transformation:

• Developing place based care • Prevention • Urgent Care • Efficiency • Managing more effectively as a system

The focus for the next 3 months will be on the system work to support the delivery of 2016/17 plans, and the detailed preparation work required for 2017/18 plans. We are anticipating that we



will need to submit a further version of the plan around October 2016. The Board will discuss the plan further in the confidential session. 3.2 Update on 21st Century Joined Up Care Programme – Better Care Closer to Home Consultation North Derbyshire and Hardwick Clinical Commissioning Groups launched their Better Care Closer to Home public consultation at 12pm on Wednesday 29 June and the consultation will close at 12 pm on Wednesday 5 October. During July, a number of public meetings have been held across the North of the county. These have been very well attended by the public, and a number of themes are developing. The Trust will continue to support the Clinical Commissioning Groups in these meetings. We also continue to hold a number of events for our staff. We recognise that the proposed changes bring a high level of uncertainty, and that there are lots of questions that staff have. Drop in sessions have been arranged to have these discussions, and we will continue to review the best way to communicate as we have these discussions over the 14 week consultation, and then beyond. 3.3 Closer Working with Derbyshire Healthcare NHS Foundation Trust The Sustainability and Transformation Plan for Derbyshire outlines a county-wide approach to show how the local NHS will cope with a number of challenges over the next five years. This work brings together all local NHS providers and commissioners, Local Authorities and the voluntary sector, so we can develop a comprehensive – joined-up – local plan. The ethos of this plan requires a collaborative approach across the local health economy, to address three key challenges or ‘gaps’:

• The health and wellbeing gap – how can we prevent unnecessary ill-health and early death?

• The care quality gap – how can we ensure we meet care targets and improve quality? • The finance gap – how can we make sure that we can deliver improved services within

the available money? At the confidential Board meeting in June and at the July Council of Governors meetings both Derbyshire Healthcare NHS FT and Derbyshire Community Health NHS Foundation Trust (DCHS) discussed initial ideas about how closer working between the two Trusts could have a significant positive impact and support the system to meet these challenges. A wide variety of options exist for defining the level of collaboration between the two organisations and we are at the very early stages of considering these possibilities. We have agreed to develop a ‘strategic options case’ to consider all possible options, benefits and impact. This strategic options case will be led through a new formal partnership-based programme. It is anticipated that initial thoughts would be presented to both Boards towards the end of the calendar year.

This direction of travel has been further re-enforced by a letter sent to all CEOs from Jim Mackey Chief Executive of NHSI, making it a clear expectation for STP areas to be able to provide details of how back office functions could be delivered with greater efficiency by the end of July 2016. In



Derbyshire we have commenced a piece of work to understand what the scale of such opportunities might be. In order to support the pace required for this providers have ‘paired up’ to explore options, with our Trust working with DCHS 4. Trust highlights and key operational issues 4.1 Castle Street GP Practice I am delighted to inform the Board that the transfer of Castle Street GP Practice to the Trust was made on 1st July 2016. I am sure the Board will join me in welcoming our new colleagues to the Trust. Castle Street is a high performing practice, and will bring valuable expertise and resilience to our General Practice portfolio. 4.2 Care Quality Commission (CQC) Inspection The draft inspection reports, following the comprehensive inspection at the beginning of May, have been delayed. We do not now expect to receive the draft reports until week commencing 22nd August 2016. The Quality Summit, previously arranged for the 19th August 2016, will now need to be re-arranged. The Trust is continuing to take forward its own internal actions from the initial feedback we received from the CQC inspectors. Progress with these actions will be reviewed through the Quality Services Committee.

4.3. Capital Developments We have now commenced the next phase of site development on the Walton Hospital site. The re-location of the waste compound has started and the new main entrance work contract has been awarded to a contractor to commence the work this summer. For the rebuild of Heanor Memorial Hospital, tenders to appoint the building contractor have been issued and are due for return on 29 July 2016. These will be evaluated to appoint very soon. The construction works are expected to start in September. 4.4 NHS Improvement Single Oversight Framework Consultation Our regulator, NHS Improvement, have issues a consultation document which sets out the proposed approach to overseeing providers. The new approach applies to both NHS foundation trusts and NHS trusts. The approach is based upon the provider license which is the legal basis of oversight of foundation trusts. The Trust will be considering its response to this consultation later on the agenda. 5. Organisational Performance June 2016 The Trust’s performance against our 2016/17 ‘Big 9’ for June is attached for information. Appendix 1: Headline organisational performance – ‘the Big 9’ Appendix 2: NHS Providers briefing





Governors will be kept abreast of issues through the CoG meeting and Strategy Group.


System transformation plans and Better Care Closer to Home consultation have equality and diversity implications that will be assessed and managed as the initiatives proceed.


Stakeholders will be engaged in plans as these develop.

Risk Register

Is the issue on the current Risk Register? No If yes, what is the Risk Number?

Does this update recommend a change in the current risk score? (If so, please provide your rationale below)



Objective Priorities 16/17 Target Performance to the end of June

Forecast

Quality Service

To deliver high quality and sustainable services that

echo the values and aspirations of the

community we serve

Patient Safety - To reduce the overall number of patients who incur

pressure damage

20% Reduction in Baseline of 793

Pressure Ulcers-57% 20%

Clinical Effectiveness - Assess frailty in our over 75 years

population by the introduction of a frailty screening tool – Prisma 7

95%0% 95%

Patient Experience - Improvement in time to respond to complaints

80% within 40 days55% 80%

Quality People

To build a high performance work

environment that engages, involves and supports staff to reach their full potential

Ensuring all staff are complaint with essential learning

96%94.6% 96%

Improving staff wellbeing by reducing work related stress and anxiety

20% reduction in days lost to stress and anxiety based on 15/16 averages

to below (1200 days)

-1% 20%

Improved position of staff reporting incidents of violence and

aggression they encounter at work

Month on month increase in reporting

compared to 15/16 data45 Increase

Quality Business

To ensure an effective, efficient and economical

organisation which promotes productive

working and which offers good value to its community and commissioners

Demonstration of efficiency across all DCHS services through the delivery of the Sustainable Quality Improvement

Plan (SQIP)

£5m Sustainable Quality Improvement Plan (£000) 1000.8 4,690

Measuring the progress towards becoming a more agile organisation

by reducing the spend on non-Clinical estate

Less than 5,399m24,649m2 <5,399m2

Responding to the main issue raised through staff feedback by monitoring

the perceived improvement in IT connectivity for staff

Less than 35% of staff Often or Always

Experiencing Connectivity Problems

33% <35%

The Big 9The Big 9 priority indicators: These are the key areas, which have been endorsed by the Board, where staff can make the greatest impact in delivering the Trust’s key operational and strategic objectives.

(RED)

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

GREEN

AMBER

RED

Complaints Response

Pressure Care

Staff Healthand Wellbeing

AMBER

AMBERGREEN

GREEN


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Appendix 1


21 July 2016

NHS Providers | ON THE DAY BRIEFING | Page 1

THE “FINANCE RESET” – ON THE DAY BRIEFING Over the past several weeks, there has been a series of announcements by NHS Improvement (NHSI) and NHS England (NHSE) on measures that are designed to introduce greater control and stability in the provider sector’s finances. They are:

A ‘reset’ and financial special measures criteria outlined today in Strengthening financial performance and accountability in 2016/17. This reset also restates and provides further detail on the following:

The criteria for accessing sustainability funding in 16/17, first released in a letter on the 8th of July (a FAQs has also been released).

A series of ‘practical’ measures designed to help cut the provider deficit in 16/17, first released in a letter on the 28th of June

This briefing draws together a summary of all these announcements, as well as our view on the new reset measures published today.

THE RESET DOCUMENT AND FINANCIAL SPECIAL MEASURES The document released today, Strengthening financial performance and accountability in 2016/17, summarises all of the recent measures and packages them as part of the finance ‘reset’. The items on sustainability funding and practical measures have already been announced to the sector, and the document simply provides further details. A short summary of these can be found later in this briefing. However, there are several other items in the reset document that have not yet been shared with the wider sector. They are:

Financial special measures for trusts

Special measures for CCGs

Greater capital controls

The move to a two year planning cycle

The annexes also publish new information, including:

Planned surplus/deficits for all NHS providers

Expenditure control totals for all CCGs

Analysis of 63 providers’ paybill growth (in line with the letter sent on the 28th of June).

CCG and CSU off-payroll staff controls

Ranking of all CCGs on the Improvement and Assessment Framework

Agreed operational performance trajectories for NHS providers

Financial special measures for trusts

Financial special measures for trusts is designed according to the document to “Help providers facing the biggest financial challenges, and will underline the importance of all providers adhering to their control totals”. It also shows that “NHSI is expecting providers to address finance challenges with the same degree of urgency as Special Measures requires for quality.” A provider will be considered for Financial Special Measures if any of the following three criteria applies: 1 The provider has not agreed a control total and is forecasting a deficit for 2016/17.


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Appendix 2

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2 The provider has agreed a control total but has a significant negative variance against the control total plan, has a significant deficit.

3 The provider has an exceptional financial governance failure (e.g. significant fraud or irregularity). In the first instance, NHSI intends to use only criterion one. Based on this five providers have been placed into the regime. Subsequently NHSI will use all three criteria, on the basis of quarterly information (from quarter one onwards). The document says as well as the three main criteria for entering into financial special measures NHSI “will also take into account other appropriate considerations.” Action(s) for trusts in special measures For trusts entering into the regime, a range of standard and possible actions will be applied to, or required of, them:

Type Standard actions Possible actions

Oversight and governance

• NHSI executive director sponsor (for key meetings)

• An improvement director, appointed by NHSI

• Board vacancies filled on the direction of NHSI

• Regular progress reviews

• Provider to publish on home page that it is in financial special measures, and the reasons for this

• Provider to notify governing body it is in financial special measures, the reasons, and the planned response

• NHSI-appointed board adviser

• Board changes

Control • Removal of provider’s autonomy over key spending decisions

• NHSI control applications for DH financing

• DH financing provided in exchange for assets (e.g. transfer of ownership of land) rather than loans

• Peer review of expenditure controls

Accelerated recovery

• A financial improvement notice issued for a time-limited period

• Rapid (by end of week 1) articulation of key issues

• Recovery plan - including accelerated proposals on service consolidation or closure, Carter implementation and organisational form and workforce review - agreed with NHSI by end of month 1

• Appointment of turnaround /recovery support (full time), possibly including peer support

• Development of detailed delivery plan (two months)

• Probationary period of a further three months to track early progress

• Support to reduce agency use

• Effective delivery of cost controls

Potential reasons for excluding a provider from entering special measures are listed as:

They have exceptional mitigating circumstances

They are already subject to a significant package of regulatory action and/or intensive support for financial recovery.

Their existing management “does not require additional support” – i.e. it has a recovery plan NHSI have confidence in.

They have a recent track record of full year delivery of plan and/or of agreed recovery actions.




Exiting special measures To exit financial special measures a provider must:

Have a robust recovery plan setting out the key changes required approved by the provider board and by NHSI (i.e. the one month process outlined in the table above).

Within two additional months, evidence of quick wins and a more detailed delivery plan.

NHSI may also, at its discretion, require:

Within a further three-months, evidence of demonstrable progress in implementing change. If a provider in financial special measures does not meet exit criteria in the prescribed time limits (i.e. 3-6 months depending on the mix of the 3 options taken above), NHSI will consider using any of the following options:

Extending financial special measures by 3-6 months, making changes to the approach to address reasons for delay.

Making changes to board membership.

Initiating an organisational form change.

Initiating a wider local health economy process ‘if the issues are structural’.

Areas of remaining ambiguity on provider financial special measure proposals

There are several areas where we will be seeking additional clarity from NHS Improvement in order for providers to better understand the potential implications of the new proposals. How does the success regime and financial improvement programme align with this new system? The document says that “It is possible but will not always be the case that specific organisations in a Success Regime area will also be in special measures”. This will need greater definition. For example, one of the potential exclusion criteria for financial special measures is that a provider is already “being subject to a significant package of regulatory action and/or intensive support for financial recovery“? What is the balance in the process between turnaround and investigation? On exiting special measures, one of the options that NHSI has after running process is to take the provider out of the measures and “initiate a wider local health economy process if the issues are structural”. There needs to be clarity over whether the special measures process is meant to be about turnaround of existing and known issues at the institutional level, or a diagnostic investigation of the root causes of problems that may lead to a success regime or wider local health economy solution. How does the single oversight framework align with the new system? NHSI are currently consulting on the new oversight frame work. However the concept of ‘financial special measures’ does not yet seem to integrate with the oversight framework, or indeed with special measures for quality. For example, while all trusts in financial special measures are likely to be in segment four of the oversight framework that is not necessarily the case – for example in theory a trust may have a deficit and have not signed up to a control total, but could be achieving its sustainability and efficiency ratings in the oversight framework. It would be unhelpful to have an NHS Improvement ‘Single Oversight Framework’ that does not clearly define or encompass the range of their regulatory and oversight activity. What are the thresholds around the entry criteria? More clarity is needed on the entry criteria for special measures to ensure this is an unambiguous and fair process Criteria two for entry into special measures is a significant variance to the control total plan. Is the ‘significant’ variance

against plan spoken of in criteria two the same as the thresholds for the same measure in the finance oversight




framework?

If a trust is failing against its oversight framework criteria (e.g. significant variance against plan) and gets put into segment four, and then also has a significant deficit (which is not one of the criteria in the oversight framework) do they automatically go into special measures?

On criteria two what is the definition of a ‘significant’ deficit - a % of turnover or another measure? How are any potentially subjective elements going to be resolved? The document says as well as the three main criteria for entering into financial special measures NHSI “will also take into account other appropriate considerations.” It also notes an exclusion for providers entering special measures is “exceptional mitigating circumstances”. Further details on the types of issues and scenarios NHS Improvement envisage are required to provide assurance to the sector that the processes around special measures are objective, transparent and fair.

SPECIAL MEASURES FOR CCGS As well as special measures for providers, the reset document also outlines new special measures for clinical commissioning groups. NHSE introduced the “Improvement and Assessment Framework” for CCGs in March. It sets out core performance and finance indicators, outcome goals, and transformational challenges across four domains: better health, better care, sustainability and leadership. The sustainability domain contains a range of measures of in year financial delivery and allocative efficiency. It has assessed CCGs against this framework and has rated 26 as inadequate. Those that have been rated inadequate will have improvement actions taken against them, some of which will be to address finance and efficiency challenges:

They will be required to produce a performance improvement plan that will be monitored by NHSE. In addition, a range of other interventions can also be applied as necessary, including:

Issuing legal directions to a CCG. For example, NHSE may take on particular functions, direct another CCG to perform functions on its behalf, or terminate the appointment of a CCG’s Accountable Officer.

Varying the constitution of the CCG by adjusting its area and membership, or disbanding the CCG and transferring its functions to a neighbouring CCG.

Requiring that a CCG shares a joint management team with a high-performing, neighbouring CCG.

Creating an Accountable Care Organisation with other organisations to take responsibility for the cost and quality of care for a defined population within an agreed budget.

CAPITAL CONTROLS The Department of Health, as directed by HM Treasury, will introduce capital controls during Q2 2016/17 that apply to all providers for spending above pre-specified levels. These controls will be overseen by NHSI and the Department and will vary according to NHSI’s assessment of the financial performance of providers.

A TWO YEAR PLANNING CYCLE The document also outlines the intention to provide more stability to the system via a two-year planning and contracting cycle, through early publication of a National Tariff, CQUIN, NHS Standard Contract, provider STF regime, and NHS commissioner business rules that cover both 2017/18 and 2018/19.




OTHER AREAS ADDRESSED IN THE RESET DOCUMENT

Criteria for accessing sustainability funding

These criteria were originally released to the sector on the 8th of July, with a FAQs released on the 14th. Summary points are:

Trusts must hit their financial control total targets in order to access their tranche of sustainability funding in any given quarter. There is no tolerance for missing this target – it is binary – if the quarterly target is missed by any amount then no sustainability funding will not be forthcoming in that quarter.

However the guidance suggests that funding is not permanently ‘lost’ if a quarterly finance figure is not attained if in a subsequent quarter a trust gets back on track with delivery of the control total plan: The guidance says: “[T]he STF will operate on a cumulative basis so that if a provider misses the YTD [financial] control total in a quarter but achieves the control total in a subsequent quarter it could receive the full amount of funding.”

If a finance control total is hit in any given quarter, then the trust will receive 70% of its tranche of sustainability funding for that quarter.

Receiving the remaining 30% of the funding is based on attaining agreed performance trajectories for RTT (12.5%), A&E (12.5%) and Cancer (5%) waiting times. Diagnostics waiting times will be a performance trajectory, but no sustainability funding will be awarded/ retained on its attainment or failure to attain.

Attaining performance trajectories is more flexible than the financial control totals:

In quarter one, simply having agreed your performance trajectories is enough to receive the entire 30%.

In quarter two, trusts will be able to miss any performance trajectory by up 1% and still receive all of the funding for that particular trajectory. The tolerance reduces to 0.5% in quarter three, and then there is no tolerance for quarter four.

Practical measures to limit the 2016/17 deficit

NHSI wrote to NHS providers on the 28th of June setting out three areas where further action is required to improve their financial position in 2016/17. The additional actions aim to help reduce the provider sector deficit for 2016/17 to c£250m.

Pay growth - NHSI state that analysis of 2015/16 cost trends and 2016/17 plans indicates significant growth in 63 providers totalling £356m. NHSI states that it will work with those trusts so that by the end of July there is an assessment of how much of the planned growth can be eliminated and how far they can limit any unplanned cost growth. This assessment process will particularly look at curtaining the use of agency staff.

Lord Carter requirements on back office savings - All STP areas have to report back on identified opportunities to implement Lord Carter’s recommendations on back office and pathology consolidation by the end of July, focusing on opportunities that have a positive impact in 2016/17.

Service consolidation - NHSI want to identify where planned care services are heavily reliant on locums and where these services can either be consolidated, changed or transferred to a neighbouring provider. By the end of July STPs will have been required to review services which are unsustainable and developed plans to re-provide these services in collaboration with other providers to secure clinically and financially viable services.




NHS PROVIDERS VIEW NHS Providers welcomes some of the wider measures announced as part of the reset of finances. We welcome that the CCG special measures regime aligns with the CCG oversight framework and provides a level of oversight of CCG performance that we have long called for - in particular it is welcome that it recognises that all players in the health system have to contribute to turning around the financial situation. We continue to advocate greater central support is needed to help drive down the deficit in 2016/17 - therefore the move towards supporting practical, collaborative measures on how the deficit can be reduced this year is something we agree with. We also welcome the move to a two year planning cycle, something we have called for previously, as a measure that potentially helps provide more stability for the system. The proposals contained within financial special measures however require very careful assessment. We recognise the pressing need for financial grip from everyone in the NHS. Placing a trust in special measures is one of the most significant regulatory decisions that can be made, and we have heard from members in the past that placing trusts in special measures can have a significant impact on staff morale and recruitment. As things stand, there are several elements of ambiguity in the measures as well as a lack of alignment with other existing proposals. This means further clarity is needed from the national bodies to help providers understand what the full effect of financial special measures will be. For example, if NHSI takes the radical action to make decisions regarding managing a trust’s expenditure or influence operational decisions via NHSI-appointed board adviser, we think it is important that NHSI is then held to account for the outcomes of those decisions - in the same way that a provider would be. When board autonomy is eroded, then accountability should be commensurately transferred to those who are now taking part in running the organisation. Whether or not this will be the case is as yet unanswered.

Also there is a conflation, in our view, as to whether special measures are about providing a short, sharp shock to turnaround performance, or is the start of a more in-depth analysis process. The timelines for providers to create plans and the high level nature of the entry criteria seem to suggest that it is the former. However on exiting special measures, one of the options that NHSI has after running the process is to take the provider out of the measures and “initiate a wider local health economy process if the issues are structural”. If the process is about rapid turnaround of performance, then establishing (via working in-depth with the trust in question) whether issues are actually due to the local health economy should be done before a trust is put into special measures, not after. However, if special measures is meant to be the start of collaboratively investigating whether issues are structural or not, this should be more clearly reflected in guidance and messaging that surrounds these proposals so that trusts placed into the regime are not unfairly disadvantaged. Additionally, it is not yet clear how the financial special measures integrate with other areas of national policy and regulation. The newly proposed NHSI single oversight framework introduces a range of new measures to assess if providers are financially well managed, but only some of them align with the criteria outlined in special measures. The oversight framework is explicitly designed to provide ‘single view’ of provider financial management. Having a separate special measures regime risks undermining that single view. Finally, beyond the ambiguities, the tone of financial special measures seems to suggest that all providers need to see this as a wake up call for the sector to turnaround their finances. However, NHS Providers believes its members are already very alert to the perilous position that the sector finds itself in financially. They have been working flat out to achieve particularly stretching efficiency targets now for a number of months, and have shown real willingness to




address the deficit by signing up to demanding control totals and/or continuing to deliver considerable cost improvement plans. However it is becoming increasingly clear that the deficit is the product of a system-wide, structural problem. Therefore restoring financial balance to the NHS must be based on more than exhorting providers to improve their own individual financial positions. Putting the NHS on a sustainable long-term footing will depend on all parts of the health and social care system coming together to find solutions, with the right central support to do so. As ever, we will work closely with NHS Improvement on the detail of the reset proposals.

NHS PROVIDERS PRESS RELEASE Responding to today’s financial 're-set' announcement by NHS England and NHS Improvement, Saffron Cordery, director of policy at NHS Providers, said: “The NHS is facing up to its most profound financial challenge, with constrained budgets, rising demand and now the fallout from Brexit. There is mounting evidence of a clear gap between the quality of care we all want the NHS to provide and the funding available. Leaders of acute, mental health, community and ambulance services know the service cannot continue on ‘business as usual’, and they are doing all they can to regain financial control. Today’s announcement from NHS England and NHS Improvement is a welcome recognition of the scale of this challenge. “The difficultly that the department of health has had in trying to balance its budget has not come without a cost, for example cutting down on much needed capital investment. The wafer-thin margin also demonstrates the fragility of the system and proves just how precarious NHS finances actually are. It’s becoming increasingly clear that the financial deficit is the product of a system-wide, structural problem. Restoring financial balance and putting the NHS on a sustainable long-term footing will therefore depend on all parts of the health and social care system coming together to find solutions, with the right central support to do so. “Simply loading up providers with savings targets they can’t achieve and exhorting them to try harder won’t work. Some trusts can improve their financial performance and NHS Improvement and NHS England have outlined a number of ways to do this. Putting Clinical Commissioning Groups as well as Trusts into financial special measures is one approach. The NHS has been down this road before so it’s important that we have learned the lessons about the potentially demotivating impact on staff. This action can be stigmatising and can undermine organisations already struggling to balance their books and attract staff. So, as well as creating clear criteria for when an organisation enters and exits financial special measures, the central bodies in the NHS must do all they can to support them through the process quickly and in better shape. “Today’s announcement outlines a plan to try and stabilise finances in the immediate term. But we need a revised approach to financial planning in the long term and a much smaller set of priorities on which the NHS ruthlessly focuses in the short term, with everything else taking second place. Without these we cannot even begin to tackle the likely consequences of the middle years of this parliament when available funding reduces dramatically. “Finally, as The King’s Fund, Health Foundation, Public Accounts Committee and other independent organisations have also argued, we need honesty, realism and an urgent public debate about where we go from here.”

Contact: Edward Cornick, Policy Advisor (Finances) [email protected]�CE�Report.pdfOverall�Page�32�of�210Page�13�of�13


TRUST BOARD Document Title: Performance Report - June 2016

Presenter/Title: Chris Sands, Director of Finance, Information and Strategy Contents of Paper were previously discussed by:

Author/Title: David Caddy, Senior Management Accountant - Performance and Costing

Contact Email and Telephone Number: [email protected] 01246 253042



Has an Equality Impact Assessment been undertaken Yes No x

Document is for: (more than one box can be ticked) Information x Decision Assurance x

Purpose of Paper

The purpose of this paper is to present the Board Performance Report. The Performance Report sets out a summary of DCHS’ performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. The Balanced Scorecard has been reviewed to incorporate the contractual and other performance regime changes in 2016/17. There are 18 green, 6 amber, 4 red, and 2 unrated indicators this month.

Recommendations

Note and comment.


The performance framework impacts upon all risk areas in the Board Assurance Framework.

Financial Impact

The report contains a number of issues and risks that have a financial impact on the organisation.


Report attached

200�Performance�Report.pdfOverall�Page�33�of�210Page�1�of�15



What are there Governor Involvement implications? The Council of Governors receive performance reports


Equality and Diversity measurements are recorded in the report


The report includes measurements of service experienced by patients

Risk Register





Board Performance Report – July 2016 Background The Board Performance Report sets out a summary of DCHS performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. Section Index Document Page Number 1.1 - Executive Summary 2-3 2.1 - Performance Dashboard 4-5 3.1 - Quality Service Narrative 6-7 4.1 - Quality People Narrative 8-9 5.1 - Quality Business Narrative 10 6.1 - Appendix 1 – Exception Reports 11-13



1.1 - EXECUTIVE SUMMARY Key Issues The key issues for the Board to discuss are:

Quality Service

• Length of stay for June was 21.0 days and 20.7 days for the 3 month year to date. An exception report is presented at page 11.

• The Delayed Transfer of Care score for June was 10.1% against a target of

7.5%. This has been red rated. An exception report is presented at page 12.

• The overall occupancy rate for June was 78.7% against a target of 85%

• There were 4 avoidable grade 2, 3 & 4 pressure ulcers for the month. An

improvement target of 34 has been developed for the year.

• There were 2 falls in June. An improvement target is under development for the next Board report. An exception report is presented at page 13.

Quality People

• Staff Attendance was 95.65% against a target of 97% and 95.49% for the average of the past 12 months.

• 94.6% of staff have completed their Essential Learning within the past 2 years, as at the end of June. This is amber rated.

• There were no Riddor Zero Harm events in June against the zero harm target.

• Agency costs as a percentage of the pay bill were at £0.53m for the year to

date. The target is £0.32m. This has been discussed in the Finance Report.

• 1,517 days were lost due to stress and anxiety in June. The Big 9 target is 1,200 days per month. This has been red rated.



Quality Business

• The Sustainable Quality Improvement Plan (SQIP) stood at 20.0% for June against at target of 19.6%. This has been green rated. Details have been discussed in the Finance Report.

• Progress against the IM&T Plan is 61.6%. A revised target trajectory for this measure is being developed.

Quality Governance • Our Governance rating is green rated. We are currently meeting all our

Risk Assurance Framework targets and are forecasting to maintain our green rating for the year.



DCHS Board Performance Report 2016/1715/16 Month

Month June Outturn Current Current Trend Plan for Month Outturn Plan Outturn Forecast Benchmark Notes

QUALITY SERVICE

Friends and Family Score 99% 96.8% 98.0% 98% 98%

Length of Stay 20.3 21.0 20.7 20 20 Inpatients

Delayed Transfer of Care 8.4% 10.1% 7.9% <7.5% <7.5% Mental Heath 0.9%. Inpatients 13.2%

Occupancy 78.9% 78.7% 79.0% 85% 85% OPMH & Inpatients. For information

Information Sharing 78.4% 78.4% 79% 88%

Caseloads - - 0 0 Under development

RTT Admitted 94.4% 92.3% 92.3% 90% 90%

RTT Non Admitted 96.6% 95.4% 95.4% 95% 95%

A&E 4 Hr Wait 100% 99.9% 100.0% >95% >95%

Harm Free Care 92.9% 93.9% 93.0% 94% 94%

Pressure Ulcers 63 4 10 13 34 Grade 2,3,4 avoidable-Improvement trajectory of34 for year

% of Qualified Shifts Covered 87.4% 87.4% 80% 80% 80%

Falls Resulting in Severe Injury 20 2 9 3 9

Never Events 0 0 0 0 0

Outurn

CARING

EFFECTIVE

RESPONSIVE

SAFE

Year to Date



DCHS Board Performance Report 2016/1715/16 Month

Month June Outturn Current Current Trend Plan for Month Outturn Plan Outturn Forecast Benchmark Notes

OuturnYear to Date

QUALITY PEOPLE

Appraisal Rate 94% 91% 91% 96% 96%

Attendance Rate 95.62% 95.65% 95.49% 97% 97%

Engagement Index 0 77 77 75 75

RIDDOR Reported Injuries 17 0 2 8 17 None for June

Mandatory Training Compliance 96% 95% 95% 96% 96%

Agency Costs as percentage of Paybill (£m) 0.18 0.53 0.32 1.46 1.46 3% calculation - £1.46m for 16/17

QUALITY BUSINESS

I&E Surplus -2,654 -2,252 -2,252 -2,104 -4,560 -4,560

Cash 16,974 16,631 16,631 16,346 16,846 17,901

Sustainable Quality Improvement Plan 100.9% 20.0% 20.0% 19.6% 100.0% 99.2%

Progress against IMT Plan 61.2% 61.6% 61.6% 61.6% -

Estate Utilisation - - 0% 0% Proportion of space unoccupied (%) under development

QUALITY GOVERNANCE

NHS England Quality Surveillance Rating Green Green Green Green Green

Governance Rating Green Green Green Green Green Green

CoS Rating 4 4 4 3 3 4

AMHAM Audits 0 5 5 10 Associate Mental Health Act Manager

AMHAM Audit Results - Significant Assurance 100% 100% 100% 100% Associate Mental Health Act Manager



3.1 – QUALITY SERVICE NARRATIVE Operational and quality performance during June (M4) has continued positively with the majority of targets being met or exceeded and, which overall, demonstrate appropriate controls are in place. It is positive to report that no avoidable pressure ulcers have been verified in June. The falls resulting in serious harm reported in June is 2 a reduction from the 5 reported in May. An exception report detailing the individual cases is provided. As in all STEIS reportable cases the care of these patients will be carefully investigated and duty of candour letters sent to the patients detailing the outcome of our investigations. Ward occupancy continues to be below trajectory and provides continued evidence that the strategies we have put in place to ensure patients receive care as close to home as possible are being effective. Reviewing the length of stay of patients in inpatient beds continues to show that we are slightly over our target of 20 days. Analysis of the exception report shows that in many cases discharge home is being delayed due to challenges establishing complex care packages in the community, this is in line with concerns our staff have raised which result in patients being in hospital longer than they need to be. Pressure Ulcer Information

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Graph 1 - Total number of Pressure Ulcers vs Activity for DCHS

TOTAL ACTIVITY TOTAL PUs Mean No. of PUs UCL LCL



Graph 1 provides a breakdown of the total number of pressure ulcers reported within the organisation (including Derby City) during June, of which 57% developed under DCHS care. The graphs control limits have been adjusted in line with strategic shift from October 2015.

Graph 2 relates to pressure damage developing or deteriorating within DCHS services including Derby City. There were 7 reported grade 1 ulcers (3.4 %), this low number is due to a change in reporting where grade 1 ulcers are reported on SystmOne as it is not mandatory to report this level of damage as they usually resolve after 3-5 days. 144 (70%) were reported as grade 2/ multiple grade 2 ulcers. There were 12 (5.8%) confirmed grade 3 and multiple grade 3 ulcers. There were 2 grade 4 ulcers reported (0.9%) and a further 20 incidents (9.7%) were reported as potential grade 3 and the remaining ulcers 20 incidents (9.7%) reported as deep tissue injuries of which the severity have not yet been confirmed as still in the early stages of evolution, so that it is not possible to see extent of damage. These incidences are being monitored on Datix. Drilling down into the locality level data, the 3 highest reporters of incidents of developed or deteriorated include the following; Derby City teams reported, 75 incidents (36.5%), North East & Bolsover reported 34 incidents (16.5%) and Chesterfield reported 29 incidents (14%) during June.

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Graph 2 - Developed and Deteriorated Pressure Ulcers for DCHS

TOTAL ACTIVITY TOTAL PUs Mean No. of PUs UCL LCL



4.1 – QUALITY PEOPLE NARRATIVE

• Temporary Staffing Costs (Agency) – Board are aware that DCHS has a challenging £1.46 million ceiling for its agency staff expenditure this year, which has been set by NHS Improvement. In April, May and June, we have not met the forecast we estimated we need to in order to achieve this target at year-end. NHS Improvement therefore requested an exception report on this target and this has been submitted. In June, QPC received a paper detailing the current position on this target and steps we are taking to pull this position back during the rest of the year. This is available in Board Packs should Board members wish to assure themselves of work underway to manage this extremely challenging target.

• Reduction in Time Lost to Stress and Anxiety – 1,517 days were lost due to stress and anxiety in June. The Big 9 target is 1,200 days per month, so this has been red rated this month. The new DCHS Staff Wellbeing Lead commenced in post on 11th July, and his appointment is hoped to make an impact on this KPI; one of his key areas of focus is mental wellbeing. Progress this month in the area of mental wellbeing has included: - A meeting between representatives of DCHS and Price Waterhouse

Coopers’ to share ideas, learning and best practice on the area of mental wellbeing, for which PWC have a reputation for its innovative approach. This was an informal contact made through our external auditors. This meeting highlighted a number of ideas which could be transferred to DCHS (and the other way round for PWC!) and we are now looking at implementing some of these. For example, PWC have found that having senior managers speak out about their own personal experience of mental health concerns and then acting as ambassadors of mental wellbeing raises awareness and promotes an open culture around mental wellbeing. A second example is that PWC train staff to become Mental Health First Aiders who are able to recognise the symptoms of mental ill health and offer basic advice and support to support staff suffering with this.

- Establishment of a mental wellbeing social movement group led by Amanda Rawlings, with support from a number of key senior leaders who are willing to tell their own story of working through times of mental ill health.

• Zero Harm: RIDDOR Reportable Injuries (no) – There were no incidences

of RIDDOR injuries, diseases and dangerous occurrences in June.

• Staff Attendance (%) – This continues to be the only People KPI that DCHS is not making significant progress on, despite lots of actions and effort. In June, although attendance increased to 95.65%, this would be expected due to seasonal variation. The average attendance for the last 12 months is 95.49%. This remains a key area of concern and focus in the Quality People domain, an, we hope the introduction of our new Staff Wellbeing Lead will



start to give us the fresh focus we need in this area. QPC have also asked that we conduct some statistical analysis to help us understand on a more tangible basis what we need to achieve to reduce our absence levels. For example, calculating how many long term members of staff need to be back at work to represent a 1% increase in attendance. It is hoped that making this KPI more tangible will help engage leaders in proactive attendance management.

• Essential Learning (% Compliance) – 95% of staff have completed their

Essential Learning within the past 2 years, as at the end of June. This is amber rated, against a target of 96%. QPC were assured at their July meeting that we have not seen any dramatic decline in performance on this KPI at the start of the financial year as we have done in previous years, perhaps meaning that regular training is now embedded in our culture, and giving assurance that this target will be achieved this year.

• Training - Resuscitation & Safeguarding (% Compliance) – Despite overall training compliance remaining strong, resuscitation and safeguarding training compliance are both red/amber in June, with compliance at 84% for resuscitation and between 84 and 92% for the various levels of safeguarding training. An exception report has been provided for resuscitation training giving reasons behind this, and it has been red-rated against a target of 95%. Safeguarding training compliance is lower this month due to most of the face-face training happening at the very end of June, with some registers not yet arriving to be input. Compliance is therefore expected to improve next month.

• Staff with Appraisal Completed (% Compliance) – Similar to Essential

Learning, performance has remained strong since the end of last financial year, with only a 2.5% drop, which compares much more favourable to previous years, which saw a drastic drop off in performance after year-end. The current compliance stands at 91.3%, so is currently amber rated, but we forecast achievement of the 96% target by the end of the year.

.



5.1 – QUALITY BUSINESS NARRATIVE The month 3 financial position is broadly in line with plan. At this early stage of the financial year, the key areas of focus going forward will be achieving activity plans, achieving SQIP plans, and maintaining strong control of budgets. No significant risks have been identified in the month 3 position. The Derbyshire wide financial plan will be challenging for 2016/17. Committee members will have received a briefing previously on the agenda. The Trust has yet to receive a control total for capital, but capital plans are progressing in line with the Operational Plan. We have met with the estates team to develop our metrics based upon the ERIC return. A key area for this year will be about improving the use of our estate. Progress reports will be brought to future meetings on this work. A number of projects have received investment to enable the Trust to provide care in different innovative ways. We have plans in place to evaluate the effectiveness of these interventions, and these will be reported back to QBC in the second half of the year. There has been no tender activity in month 3. The STP work is progressing at pace, and the plan was submitted at the end of June 2016. An update on the financial aspects of this plan was presented to Committee members earlier on the agenda.



Measure Type Frequency Director2016/17 Full Year Target

YTD Target Q1 Apr-16 May-16 Jun-163 month

YTD

Inpatient Average Length of Stay (days) External Monthly DoSD 20 20 20.7 20.8 20.5 21.0 20.7

1-Summary of Issues:

2-Action Plan: (actions taken, including assignment of responsibility for this plan)

3-Timescales

4-Effect of this Exception on the Forecast Plan (how we get to our final forecast position from here)

The action plans are unlikely to have a major impact on July figures for LOS but there should be a reduction in August.

Exception Report Analysis

During June 2016 the average length of stay in community hospital beds rose from 20.4 in May to 20.7. Most of those that exceeded the target of 20 days were patients that required longer rehab than could be achieved in 20 days, some were people that became medically unwell during their stay.There were some issues with accessing social care assessments and some getting social care packages.Alton ward – 1 patient had 49 days in hospital but required 24 hour one to one care on discharge. Several care homes were unable to accommodate his complex needs.Fenton ward had 4 patients who between them exceeded the 20 day target by 23 days, all waiting for care packages.Manners ward had 2 patients exceeding 20 days, remaining in hospital for a further 20 days each. One was expected to return home but was unable to cope so an alternative solution and further assessments were undertaken.Hudson ward had 2 patients who each had a period of 60 days on the ward, both nursed at end of life. One other, also end of life, was transferred to a nursing home after 93 days, having originally been admitted for rehab. Three others were patients requiring extended rehabilitation and one needed environmental issues at home resolving prior to discharge.Oker ward – 5 patients averaged 43 days as an inpatient. These were due to family not arranging for furniture to be moved so patient could return home. Two were for care packages and one was due to infection control issues.

DCC Adult Care are planning to introduce the same system that has worked for acute trusts in allowing care packages to restart without re-assessing. DCCAC are also planning to introduce the same timescales for community hospitals as are in place for acute discharges which would mean an assessment within 24 hours of receiving referral which could have a considerable impact.

DCC and DCHS general managers are to meet within next 4 weeks to move to implementation.System resilience lead and RDH discharge manager to meet 14/07/2016

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YTD Target Q1 Apr-16 May-16 Jun-16 YTD

Delayed Transfer of Care (%) - Inpatients & OPMH External Monthly DoHR <7.5% <7.5% 7.9% 6.0% 7.9% 10.1% 7.9%

`



3-TimescalesThe first meeting is scheduled for 21st July with planned implementation for August 1st

4-Effect of this Exception on the Forecast Plan (how we get to our final forecast position from here)Accessing assessments for social care in a timely manner should reduce delays for patients in community hospitals. Currently some patients can wait up to 2 weeks before they are allocated a social worker.Restarting existing care packages eliminates the need for reassessment, which also reduces delays.


During June 2016 the overall RUC/OPMH DTOC rate is 10.1% for the month, which is greater than our target of 7.5%. The rate for the year to date is 7.9%.There has been a marked increase from 9.5% during May to 13.2% in RUC beds in June with a particularly high number of delays at both St Oswald’s and Babington (102 and 86 days respectively).Out of a total 509 delayed days 111 were recorded at patient/family choice. A further 94 days were due to care packages not being available at the time the patient was ready for discharge.In detail; Baron ward at Babington had one patient waiting 35 days whilst family found a nursing home, there were a further five patients delayed waiting either for allocation to a social worker, commencement of a care package or for a DST by Continuing Health Care (CHC).Oker ward at Whitworth also had 6 patients delayed. 4 patients waited for a total 67 days for social care assessments, residential or community care packages. Two others were delayed assessments and meetings due to infection control issues.Five patients on Butterley ward at Ripley were delayed for a total 68 days. One waited for CHC assessment, one was patient choice, one waited for a care package and the other two were waiting for residential and nursing home managers to assess and accept the patient. Manners Ward at Ilkeston had 2 patients delayed both were to long-term care, one for nursing and one for residential care. Both were more complex than usual, one being out of area and family needing to identify an appropriate care home in Wolverhampton and the other because initially it was expected the patient would be able to return home with increased care.Hudson ward at Bolsover had 3 delayed transfers, 2 to care homes and one waiting for a care package.Hopewell ward at Ilkeston had the lowest DTOC for June with 10 days delay involving 2 patients both waiting for assessments involving the whole MDT.Alton Ward, Rowsley, Fenton and Spencer had a further 67 days delayed affecting 7 patients. Accessing social care packages and long term care were the main reasons for these delays.

Action PlanDCHS and Derbyshire County Council Adult Care (DCCAC) are working together on the following issuesA review of the reporting of DTOC to ensure consistency across all the community hospitals.DCCAC will be accepting referrals from the wards to restart packages of care without the need for reassessment.DCC are considering introducing the same response times to new referrals as are used in Acute hospitals, namely that an assessment will take place within 48 hours of the referral being received.

DCCAC and general managers to meet in next 4 weeks to implement both processes

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Falls resulting in severe injury or death (no.) External Monthly DoNQ 0 0 9 2 5 2 9



3-Timescales

4-Effect of this Exception on the Forecast Plan (how we get to our final forecast position from here)


W62085 - This 80 year old lady was an inpatient on Okeover ward, St Oswalds Hospital. At 23:20, the patient was found at side of bed, sitting on crash mat with back against the bed and legs stretched out in front. The patient was in a lot of pain and her left leg was twisted outwards. This unintentional fall was not witnessed by staff, it is unclear the exact mechanism of the fall from bed. Paramedics requested at 23:30, paramedics arrived on ward 00:20, oramorph 10mg administered, transferred to RDH A&E 01:00.

W61727 - This 87 year old gentleman was an inpatient on Rowsley ward, Newholme Hospital. At 07:50, bed sensor had been activated and a nurse was responding when a shout was heard followed by a bang from Bay 1, patient found on floor by bed 2, unconscious, with cut to right side of forehead. Patient checked using ABCDE approach, unresponsive at first, emergency ambulance requested, became responsive to voice, checked for injuries, other than head wound none other apparent, transferred on to bed, neurological observations commenced, wound to fore head cleaned and closed using steristrips. The patient was lifted from the floor to the bed (at the lowest setting) on a sheet and 4 staff. This has been reported to the matron and the general manager. An investigation will be carried out about the moving and handling technique of the staff involved. Staff are reminded not to use a manoeuvre like this and to ensure the patient's comfort but not to transfer the patient until the ambulance attends.

W62085 - RCA in progress by ward manager.

W61727 - First draft of RCA submitted, reviewed by Falls Prevention Lead. Further information to be added by ward prior to completion. Verbal discussion with ward manager and Falls Prevention Lead regarding manual handling concern, post fall actions flowchart available for all staff in policy. no lapses in patient manual handling training.

W62085 - submission date to Falls Prevention Lead 14.07.2016, STEIS submission date 22.08.2016.

W61727 - submission date to Falls Prevention Lead 07.07.2016, STEIS submission date 16.08.2016

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TRUST BOARD Document Title: Financial Performance Report

Presenter/Title: Chris Sands, Director of Finance, Information and Strategy Contents of Paper were previously discussed by: QBC held on Wednesday 20th July 2016

Author/Title: David Gray, Head of Financial Management Contact Email and Telephone Number: [email protected] 01246 253046




Document is for: (more than one box can be ticked) Information Decision Assurance x

Purpose of Paper

The paper sets out the financial performance of the Trust as at 30th June 2016. The report details performance against statutory and internal targets. The Trust is reporting a surplus position of £2.25m at month 3, which represents a £0.15m surplus variance against the planned surplus of £2.1m. The cash position is £0.5m ahead of plan. A year end surplus of £4.56m is forecast which represents an agreed increase in line with the letter received from NHS Improvement. The revised surplus assumes full delivery of the SQIP programme. The cash position is forecast to be £17.9 million at the end of March 2017. The Trust is forecasting that it will meet all its statutory financial duties for the year.

Recommendations

Board Members are asked to receive the Report for Information.


3.7 There is a risk to the financial stability of the organisation of not meeting future Sustainable Quality Improvement Programme over the next two years.

3.8 There is a risk to the organisation due to the inability to meet contractual activity targets, resulting in financial risk.

Financial Impact

The report contains a number of issues and risks that have a financial impact on the organisation.

201�Financial�Performance�RepoOverall�Page�48�of�210Page�1�of�13




Report attached



Governors will hold the Board to account around its financial position

What are the Equality and Diversity implications? None


None

Risk Register





WORKING CAPITAL16.63 G 17.90 G0.93 G 0.50 G

£m % £m % % £m % £m % £m % (1.49) G 1.30 GEBITDA (3.70) (7.74) (3.82) (7.94) 3.11 (10.94) (5.76) (10.59) (5.56) 0.34 (3.14)

Net (surplus)/deficit (2.10) (4.40) (2.25) (4.69) 7.03 (4.56) (2.40) (4.55) (2.39) 0.01 (0.22) RISK RATINGSFinancial Sustainability Rating - Liquidity (days) 20.80 G 28.68 G

I&E SURPLUS (excl. IMPAIRMENT) I&E SUMMARY AS AT 30 JUNE 2016 Financial Sustainability Rating - Liquidity 4 G 4 GFinancial Sustainability Rating - Capital Servicing (x times) 6.11 G 4.45 G

DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST FINANCIAL PERFORMANCE REPORT

PLAN ACTUAL VARIANCE PLAN FOT VARIANCE

JUNE 2016 KEY FINANCIAL INDICATORS

EBITDA AND SURPLUS AS AT 30 JUNE 2016YTD 2016/17 FULL YEAR

JUNE 2016

FOTYTD

Current Assets Variance (£m)Cash at bank as per the ledger (£m)

Current Liabilities Variance (£m)£m

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Financial Sustainability Rating - Capital Servicing 4 G 4 G

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Financial Sustainability Rating - I&E margin 4 G 4 G(£m) (£m) (£m) (£m) (£m) (£m) Financial Sustainability Rating - I&E margin variance (%) 0.29% G 0.00% G(47.82) (48.03) (0.21) (189.99) (190.44) (0.45) Financial Sustainability Rating - I&E margin variance 4 G 4 G

PAY 32.37 32.36 (0.01) 130.25 130.31 0.06 Overall Financial Sustainability rating 4 G 4 GNON-PAY 11.75 11.86 0.11 48.80 49.54 0.74 Agency spend (£m) 0.53 R 1.46 GOTHER 1.60 1.56 (0.03) 6.38 6.03 (0.34)

(2.10) (2.25) (0.15) (4.56) (4.56) 0.00 PERFORMANCE AND CIP YTD FOTContract over/(under) performance (£m) (0.15) G 0.00 G

CAPITAL PROGRAMME MONTH END CASH BALANCE Over/(under)achievement of CIP target (£m) 0.02 G (0.04) G(Over)/underspend against investments (£m) 0.00 G 0.00 GNet impact of CIP/investments/NR savings (£m) 0.02 G (0.04) G

ADDITIONAL TRIGGERS YTD FOTReceivables aged over 90 days (%) 5.0 24.6 R 5.0 GPayables aged over 90 days (%) 5.0 54.3 R 5.0 GChange in Finance Director in last year 2 0 G 0 GInterim Finance Director in place over QE 2 0 G 0 GDays expenditure covered by QE cash 10 34.3 G 36.3 GCapital Expenditure % of plan (%) 85.0 80.8 R 100.0 G

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DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST

MONTHLY FINANCIAL PERFORMANCE REPORT FOR TRUST BOARD AS AT 30th JUNE 2016

1. Introduction

The purpose of this report is to update and inform the Trust Board on performance against key financial criteria for month 3 of the current financial year, 2016/17. The Trust is reporting a surplus position of £2.25m at month 3, which represents a £0.15m surplus variance against the planned surplus of £2.1m. It should be noted that as this is only quarter 1 of the new financial year the position still requires tight financial control. A year end surplus of £4.56m is forecast which represents an agreed increase in line with the letter received from Bob Alexander NHS Improvement dated 25th May 2016 which covered additional funding of £1.14m from the “targeted element” of the Sustainability and Transformation Fund and considered the revised control total of £4.56m, an increase of £1.14m over the original control total of £3.42m. The Trust has now received guidance from NHS Improvement on the ‘Criteria to access the Fund’. This was shared and discussed with QBC. To access the fund, the Trust will need to demonstrate that it has met its control total trajectory, and met the national targets for Referral to Treatment and A&E (through our minor injuries units). All these targets were met in quarter 1. The revised surplus assumes full delivery of the SQIP programme. The general mitigation reserve of £1.3m remains uncommitted and unallocated at Month 3.

2. Summary Financial Position The financial risk of the Trust is measured by the Financial Sustainability Rating as part of the provider license. A rating of 4 is low risk, whilst a rating of 1 is high risk. The Trust is forecasting a rating of 4 at the year-end. This reflects the strong balance sheet of the Trust and the forecast surplus position. The Trust is forecasting a surplus of £4.56m. This is supported by £2.14 million non-recurrent income, and £0.21m non recurrent efficiencies. Therefore the underlying forecast outturn surplus position of the Trust is £2.21m surplus.



Table One – Financial Sustainability Rating The Trust’s Performance against the new Financial Sustainability ratings is detailed in the table below. The Trust achieved a rating of 4 at year-end. This reflects the strong balance sheet of the Trust.

Measure Indicator Weight Year to date Year End Outturn Value Rating Value Rating

Liquidity Days Number of days operating expenditure covered by current working capital balances

25% 20.80 4 28.68 4

Capital Servicing

Revenue cover available to service debt repayments

25% 6.11

4 4.45 4

I&E Margin (%)

Year to date I&E margin as a % of total income

25% 4.69 4 2.39 4

I&E Margin Variance (%)

Year to date variance from plan

25% 0.29 4 0.56 4

Overall Rating 4 4

To move to a forecast outturn rating of 3, there would need to be a deterioration in the income and expenditure position of £4.8m. A further reduction to the position of £1.6m or a total of £6.4m would move the overall rating to a 2. Table Two – “Agency Spend” metrics The Trust’s performance against the Agency Spend metric is detailed below which shows our spend is behind the submitted planned run rate due to the impact of Flexing the number of beds DCHS have open and the complexity of patients currently in the beds and out in the Community.

Measure Indicator Year to date Year End Outturn Actual

£m Target

£m Actual

£m Target

£m Agency Spend Spend against

Planned Trajectory

0.53 0.32 1.46 1.46



The actions to improve performance in this area were discussed at the July Quality People Committee.

3. Income & Expenditure Appendix 1 details the Income & Expenditure Statement as at month 3. More detail on the income and expenditure position is provided below.

3.1 Clinical Income At month 3 the clinical income position is showing an over performance of £0.146m against plan. Over performance has been seen in Accident and Emergency £0.08m, Planned Care Day Case £0.07m and Community Podiatry £0.11m. This has been offset by under performance in the Integrated Sexual Health service of £0.083m. The cost and volume financial plan has been reduced by £0.175m to reflect the Trust decision to stop Endoscopy services at Ilkeston Hospital. The service is currently reviewing mitigations to cover the remaining loss of income of £0.113m. In the month 3 position the block clinical income plan has increased by £3.24m. The funding for the Erewash Vanguard MCP has been reflected in the month 3 position increasing it by £2.1m. The remaining £1.14m increase is due to the additional STP funding to support the revised DCHS outturn surplus requirements. Activity against plans will be closely monitored throughout the year to ensure early identification of under / over –performance and any associated risks to income.

3.2 Non-Clinical and Other Income

Following the realignment of Budgets as part of the Annual Budget Setting Process overall across all Services and Divisions Other Income is ahead of plan by £0.07m.

3.3 Expenditure Overall, the Trust is reporting a slight overspend against the expenditure plan of £0.06m at month 3. Overall Pay costs are slightly underspent compared to plan by £0.01m which is predominantly due to the level of Bank and Agency Spend across Integrated Care Services, however the continued vacancies within Health and Wellbeing, Estates and Corporate Divisions are helping to offset the underlying overspending areas. Other Pay issues relate to Locum cover within General Practice and the impact of the Living Wage mostly within the Facilities Management Service. Total Agency and Flexible Workforce (DCHS Bank Staff) costs remain in line with the monthly average spend and combined together overall represent 3.2% of the Total Pay Spend to date. Agency Spend during June 2016 remains in line with the average run rate and represents 1.6% of the Total Pay Spend to date. Non-pay Costs are overall showing a slight overspend against plan of £0.08m.



With the exception of Health and Wellbeing most Divisions have cost pressures within their Non-Pay Budgets however due to the additional non recurrent Non Clinical Income received the majority are offset. The main pressures on the Non-Pay Budgets are centred around increased Medical and Surgical Costs and recharges from neighbouring Foundation Trusts associated to increased activity levels within Planned Care. Within the Corporate Division Printing costs associated to statutory documents for Clinical Services and the centralised spend on VOIP and Mobile Phones are the key areas of concern. The underspend within the Tendered Services of the Health and Wellbeing Division (£0.3m) is caused by a reduction in activity which as reflected in reduced expenditure to Accredited Providers, Voluntary Sector and Chlamydia Screening. A review of Non Pay Budgets will be undertaken by the Head of Financial Management during the month and any virements required to smooth the variances will be undertaken as part of the Month 4 closedown. There has been an adverse movement in Bad Debt Provision during the month (£0.3m). This is in relation to Non-NHS debt over 90 days, which is expected to be recovered during June. 3.4 Cost Improvements Plan The Trust has a SQIP target of £5.0m for 2016/17. As at month 3 there is an under achievement against the planned schemes but mitigations have been found to offset this resulting in an over achievement of £0.02m. The year end forecast is currently a 0.8% under achievement of £0.04m by year end. Further detail of the SQIP position can be found in Appendix 2.

4.0 Statement of Financial Position Appendix 3 sets out the Statement of Financial Position.

4.1 Cash At the end of June the cash balance was £0.5m ahead of plan (actual: £16.6m, plan £16.1m). The Trust continues to actively manage working capital in line with the Working Capital Framework. During this month the Head of Management Accounts undertook a “deep-dive” of all accruals in conjunction with the Management Accounting and Treasury teams to ensure the nature of them were both accurate and robust. In addition, the Treasury team continues to chase outstanding debt and promote prompt invoicing of income. A detailed report highlighting the Trust’s Working Capital position was reported to the July Quality Business Committee. Further detail can be found in Appendix 4 attached.



5. Capital Plans and Expenditure

The Trust’s capital plan for 2016-17 totals £5,893k. Year-to-date spend is £708k against a plan of £876k, an under-spend of £168k. This is principally caused by variance against plan in respect of mobile working. Further detail can be found in Appendix 5 attached.

6. Risks The main risk carried forward from the previous financial year is the delivery of activity targets in the sexual health service. The activity targets have been recast in consultation with the service to reflect 2015/16 outturn. We will continue to closely monitor performance with the service.

7. Summary

Board Members are asked to note the month 3 position against the financial targets. Chris Sands Director of Finance, Information and Strategy



1 2 3 4 5 6 7 8 9 10 11 12

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

Actual Plan Variance Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Outturn Plan

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

OPERATINGIncome

Clinical Income -45,808 -45,662 -146 -14,814 -15,052 -15,942 -15,208 -14,825 -15,130 -15,178 -15,176 -14,797 -15,199 -15,100 -15,139 -181,560 -181,560

Other NHS Income -1,441 -1,302 -139 -500 -455 -486 -488 -488 -488 -488 -488 -488 -488 -488 -488 -5,833 -5,149

Education and Training -181 -198 17 -53 -55 -73 -60 -60 -60 -60 -60 -60 -60 -60 -60 -721 -725

Other Income -601 -657 56 -209 -190 -202 -192 -192 -192 -192 -192 -192 -192 -192 -192 -2,329 -2,557

INCOME TOTAL -48,031 -47,819 -212 -15,576 -15,752 -16,703 -15,948 -15,565 -15,870 -15,918 -15,916 -15,537 -15,939 -15,840 -15,879 -190,443 -189,991

Operating ExpensesEmployee Benefit Expenses 32,358 32,372 -14 10,775 10,839 10,744 10,863 10,891 10,893 10,784 10,806 10,936 10,903 10,863 11,012 130,309 130,254

Drugs 325 338 -13 97 114 114 98 98 98 98 98 98 98 98 98 1,207 1,356

Clinical Supplies and Services 2,434 2,405 29 782 846 806 825 825 825 825 825 825 915 825 825 9,949 9,367

Other Costs 9,099 9,004 95 3,066 2,828 3,205 3,273 3,311 3,415 3,165 3,328 3,223 3,192 3,237 3,142 38,385 38,078

OPERATING EXPENSES TOTAL 44,216 44,119 97 14,720 14,627 14,869 15,059 15,125 15,231 14,872 15,057 15,082 15,108 15,023 15,077 179,850 179,055

OPERATING (PROFIT) / LOSS EBITDA -3,815 -3,700 -115 -856 -1,125 -1,834 -889 -440 -639 -1,046 -859 -455 -831 -817 -802 -10,593 -10,936

NON OPERATINGLoss / (Profit) on Asset Disposal 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Impairment of non-current assets 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Depreciation / Amortisation 954 988 -34 317 320 317 306 306 306 306 306 306 306 306 306 3,708 3,946

Interest (Receivable) / Payable -15 -17 2 -3 -7 -5 -5 -4 -4 -5 -4 -4 -5 -4 -4 -54 -70

Public Dividend Capital 624 625 -1 208 208 208 195 195 195 195 195 195 195 195 195 2,379 2,500

NON OPERATING TOTAL 1,563 1,596 -33 522 521 520 496 497 497 496 497 497 496 497 497 6,033 6,376

RETAINED (SURPLUS) / DEFICIT -2,252 -2,104 -148 -334 -604 -1,314 -393 57 -142 -550 -362 42 -335 -320 -305 -4,560 -4,560

ADJUSTMENTS TO RETAINED SURPLUSDonated Asset Income 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Donated Asset Depreciation 33 0 33 11 11 11 11 11 11 11 11 11 10 10 10 129 120

Impairment of non-current assets 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

TOTAL ADJUSTMENTS 33 0 33 11 11 11 11 11 11 11 11 11 10 10 10 129 120

ADJUSTED RETAINED (SURPLUS) / DEFICIT -2,219 -2,104 -115 -323 -593 -1,303 -382 68 -131 -539 -351 53 -325 -310 -295 -4,431 -4,440

STATEMENT OF INCOME & EXPENDITUREJUNE 2016

Category

Year to Date Monthly Actual / Forecast

As at 30 June 2016



Appendix 2

R/NR Plan Actual Variance Risk Rating

Plan Out-turn Actual Variance Risk Rating

FYE Forecast

£'s % £'s %

Total SQIP 16/17 £979,726 19.6% £1,000,816 20.0% £21,090 2% £5,000,000 £4,957,800 -£42,200 -0.8% £4,690,500Recurrent SQIP R £906,483 £855,849 -£50,634 -6% £4,735,500 £4,630,500 -£105,000 -2.2% £4,690,500Non Recurrent SQIP NR £73,242 £144,967 £71,725 98% £264,500 £327,300 £62,800 24% £0

R/NR Plan Actual Variance Risk Rating

Plan Out-turn Actual Variance Risk Rating

FYE Forecast

£'s % £'s %

Integrated Community Based Services15/16 Schemes – (Bolsover Ward and Management Post) R £8,250 25.0% £8,250 25.0% £0 0% £33,000 £33,000 £0 0% £33,000OPMH/LD Medical Contract R £12,500 25.0% £12,500 25.0% £0 0% £50,000 £50,000 £0 0% £50,000Management cost savings R £42,500 25.0% £42,500 25.0% £0 0% £170,000 £170,000 £0 0% £170,000Inpatient Budget Consolidation R £22,500 25.0% £22,500 25.0% £0 0% £90,000 £90,000 £0 0% £90,000Babington seasonal bed flex NR £31,333 33.3% £9,369 10.0% -£21,964 -70% £94,000 £94,000 £0 0% £0Buxton (Fenton Ward) seasonal bed flex NR £12,000 33.3% £6,000 16.7% -£6,000 -50% £36,000 £36,000 £0 0% £0Medical Staffing Review R £26,333 33.3% £0 0.0% -£26,333 -100% £79,000 £79,000 £0 0% £79,000MARS - ICBS R £28,025 25.0% £28,025 25.0% £0 0% £112,100 £112,100 £0 0% £112,100Health, Wellbeing and InclusionChildren’s Reconfiguration School Nursing - County R £75,000 25.0% £75,000 25.0% £0 0% £300,000 £300,000 £0 0% £300,000Children’s Reconfiguration Health Visiting - County R £12,500 25.0% £12,500 25.0% £0 0% £50,000 £50,000 £0 0% £50,000Sexual Health NHS reconfiguration R £25,000 25.0% £25,000 25.0% £0 0% £100,000 £100,000 £0 0% £100,000Staff vacant posts - apprentice R £5,000 25.0% £5,000 25.0% £0 0% £20,000 £20,000 £0 0% £20,000Planned Care and Outpatient ServicesSavings through procurement – Dentistry & Podiatry R £10,000 25.0% £10,000 25.0% £0 0% £40,000 £40,000 £0 0% £40,000MARS – Planned Care R £5,425 25.0% £5,425 25.0% £0 0% £21,700 £21,700 £0 0% £21,700Integrated Facilities ManagementReduction in accommodation expenses - St Marys Ct R £28,250 25.0% £28,250 25.0% £0 0% £113,000 £113,000 £0 0% £113,000Reduction in cost of utilities; increased income from solar R £12,500 25.0% £12,500 25.0% £0 0% £50,000 £50,000 £0 0% £50,000Increased Income from Room rental R £12,500 25.0% £7,750 15.5% -£4,750 -38% £50,000 £50,000 £0 0% £50,000Catering income R £12,500 25.0% £0 0.0% -£12,500 -100% £50,000 £0 -£50,000 -100% £0IFM Catering Income Mitigations R £0 0.0% £9,949 0.0% £9,949 0% £0 £50,000 £50,000 0% £50,000IFM Procurement - e auction R £12,500 25.0% £0 0.0% -£12,500 -100% £50,000 £45,000 -£5,000 -10% £50,000MARS – IFM R £80,275 25.0% £80,275 25.0% £0 0% £321,100 £321,100 £0 0% £321,100EstatesEstates posts and contracts R £33,750 25.0% £33,750 25.0% £0 0% £135,000 £135,000 £0 0% £135,000MARS - Estates R £12,625 25.0% £12,625 25.0% £0 0% £50,500 £50,500 £0 0% £50,500Corporate15/16 Non recurrent schemes - recurrent effect R £100,000 25.0% £100,000 25.0% £0 0% £400,000 £400,000 £0 0% £400,000Corporate SQIP Target R £84,250 25.0% £84,250 25.0% £0 0% £337,000 £337,000 £0 0% £337,000ALPS (annual leave purchase scheme) NR £9,909 18.2% £9,298 17.1% -£611 -6% £54,500 £54,500 £0 0% £5,000Non Pay Inflation Reserve release R £125,000 25.0% £125,000 25.0% £0 0% £500,000 £500,000 £0 0% £500,000MARS - Strategy R £7,600 25.0% £7,600 25.0% £0 0% £30,400 £30,400 £0 0% £30,400MARS - POE R £12,450 25.0% £12,450 25.0% £0 0% £49,800 £49,800 £0 0% £49,800Capital Charges Review - Asset Lives R £0 0.0% £0 0.0% £0 0% £140,000 £140,000 £0 0% £140,000Agile Working R £25,000 25.0% £0 0.0% -£25,000 -100% £100,000 £100,000 £0 0% £100,000Digitilisation Opportunities R £0 0.0% £0 0.0% £0 0% £50,000 £50,000 £0 0% £50,000Telecoms Review NR £20,000 25.0% £7,500 9.4% -£12,500 -63% £80,000 £30,000 -£50,000 -63% £0OtherPharmacy Services Review R £0 0.0% £0 0.0% £0 0% £50,000 £50,000 £0 0% £100,000Babington Office Moves R £0 0.0% £2,500 8.3% £2,500 0% £30,000 £30,000 £0 0% £30,000Primary Care Contribution R £24,250 25.0% £24,250 25.0% £0 0% £97,000 £97,000 £0 0% £97,000Capital Charges Valuation R £0 0.0% £18,000 7.2% £18,000 0% £250,000 £250,000 £0 0% £250,000VOIP Implementation R £0 0.0% £0 0.0% £0 0% £100,000 £100,000 £0 0% £100,000Mitigation Reserve Reduction R £50,000 25.0% £50,000 25.0% £0 0% £200,000 £200,000 £0 0% £200,000

Total £979,726 £888,016 -£91,710 £4,484,100 £4,429,100 -£55,000 £4,274,600

OtherHR - Travel Renegotiation Review R £0 0.0% £0 0.0% £0 0% £100,000 £0 -£100,000 -100% £0Procurement - Utilities R £0 0.0% £0 0.0% £0 0% £50,000 £50,000 £0 0% £50,000LD review R £0 0.0% £0 0.0% £0 0% £200,000 £200,000 £0 0% £200,000Connecting for Health - Stroke Services review R £0 0.0% £0 0.0% £0 0% £65,900 £65,900 £0 0% £65,900Connecting for Health - Pul Rehab North review R £0 0.0% £0 0.0% £0 0% £100,000 £100,000 £0 0% £100,000

Total £0 £0 £0 £515,900 £415,900 -£100,000 £415,900

R/NR

Corporate Vacancy Management NR £0 - £112,800 - £112,800 0% £0 £112,800 £112,800 £0Total £0 £112,800 £112,800 £0 £112,800 £112,800

£979,726 £1,000,816 £21,090 £5,000,000 £4,957,800 -£42,200 £4,690,500

Scheme R/NR

Scheme

Scheme

MITIGATIONS

SQIP Monitoring 2016/17 June 2016

Summary of Overall SQIP Monitoring 2016/17

TO BE CONFIRMED SCHEMES

Year to Date Annual

Plan % of Annual

Actual % of Annual

Year to Date Annual

Plan % of Annual

Actual % of Annual

SQIP Schemes 2016/17



Appendix 3

1 2 3 4 5 6 7 8 9 10 11 122015-16 Annual Annual

Year Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Outturn PlanEnd Actual Plan Variance Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Outturn

£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s

ASSETSNon Current

Tangible Assets 82,396 82,237 81,875 362 82,701 82,411 82,237 82,482 82,525 82,684 82,807 82,926 79,326 79,855 80,573 81,692 82,788

Intangible Assets 1,604 1,483 1,245 238 1,564 1,524 1,483 1,218 1,191 1,164 1,137 1,110 1,083 1,056 1,029 1,002 1,002

Total Non Current Assets 84,000 83,720 83,120 600 84,265 83,935 83,720 83,700 83,716 83,848 83,944 84,036 80,409 80,911 81,602 82,694 83,790

CurrentInventories 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NHS Trade Receivabes 2,017 2,576 2,042 534 2,427 2,433 2,576 2,041 2,021 2,037 2,038 2,038 2,020 2,038 2,033 2,036 2,036

Non NHS Trade Receivabes 1,963 766 2,390 (1,624) 991 2,284 766 1,380 1,380 1,380 1,370 1,370 1,370 1,360 1,360 1,360 2,360

PDC Dividend Receivable 141 141 141 0 141 141 141 0 0 0 0 0 0 0 0 0 0

Bad Debt Provision (176) (236) (180) (56) (311) (203) (236) (186) (176) (166) (155) (150) (150) (150) (150) (150) (150)

Capital Receivables 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Accrued Income 2,258 3,046 2,443 603 4,856 2,767 3,046 2,223 1,973 1,823 2,623 2,798 2,498 2,248 2,348 2,398 1,798

Prepayments 945 2,330 745 1,585 1,326 1,195 2,330 595 795 545 845 795 995 835 1,165 1,225 1,225

Other Receivables 858 826 1,228 (402) 790 809 826 865 843 1,086 818 915 969 828 628 803 1,003

Land Held For Sale 0 0 0 0 0 0 0 0 0 0 0 0 4,100 4,100 4,100 0 0

Cash and Cash Equivalents 16,974 16,631 16,346 285 13,654 14,768 16,631 18,620 19,471 17,563 16,936 17,419 17,838 15,420 15,600 17,901 16,802

Total Current Assets 24,980 26,080 25,155 925 23,874 24,194 26,080 25,538 26,307 24,268 24,475 25,185 29,640 26,679 27,084 25,573 25,074

TOTAL ASSETS 108,980 109,800 108,275 1,525 108,139 108,129 109,800 109,238 110,023 108,116 108,419 109,221 110,049 107,590 108,686 108,267 108,864

LIABILITIESCurrent

Trade Payables (8,193) (3,985) (3,861) (124) (5,750) (4,930) (3,985) (3,870) (3,873) (3,874) (3,871) (3,872) (3,873) (3,873) (3,869) (3,569) (3,869)

Other Payables (3,754) (4,050) (4,085) 35 (4,147) (4,175) (4,050) (4,173) (4,118) (4,157) (4,094) (4,089) (4,136) (4,121) (4,224) (4,482) (5,482)

Public Dividend Capital Payable 0 (625) (588) (37) (208) (417) (625) (820) (1,015) 0 (195) (390) (585) (780) (975) 0 0

Capital Payables (853) (449) (253) (196) (558) (703) (449) (153) (361) (569) (153) (361) (569) (153) (653) (153) (153)

Accrued Expenditure (3,036) (5,515) (4,380) (1,135) (3,739) (3,742) (5,515) (4,744) (5,294) (4,066) (4,090) (4,190) (4,240) (1,740) (1,780) (2,345) (2,345)

Annual Leave Accrual (535) (537) (535) (2) (535) (535) (537) (535) (535) (535) (535) (535) (535) (535) (535) (495) (495)

Deferred Income, Current (570) (487) (426) (61) (844) (794) (487) (378) (330) (282) (234) (186) (138) (90) (42) 0 0

Provisions, Current (465) (353) (384) 31 (454) (336) (353) (384) (384) (389) (389) (389) (394) (394) (394) (399) (399)

Other Liabilities 0 0 0 0 0 0 0 0 0 0 0 0 (1,383) (1,383) (1,383) 0 0

Total Current Liabilities (17,406) (16,001) (14,512) (1,489) (16,235) (15,632) (16,001) (15,057) (15,910) (13,872) (13,561) (14,012) (14,470) (11,686) (12,472) (11,443) (12,743)

Non CurrentDeferred Income, Non Current 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Provisions, Non Current (20) (30) (105) 75 (30) (30) (30) (30) (30) (30) (105) (105) (105) (105) (105) (105) (105)

Total Non Current Liabilities (20) (30) (105) 75 (30) (30) (30) (30) (30) (30) (105) (105) (105) (105) (105) (105) (105)

TOTAL LIABILITIES (17,426) (16,031) (14,617) (1,414) (16,265) (15,662) (16,031) (15,087) (15,940) (13,902) (13,666) (14,117) (14,575) (11,791) (12,577) (11,548) (12,848)

TOTAL ASSET EMPLOYED 91,554 93,769 93,658 111 91,874 92,467 93,769 94,151 94,083 94,214 94,753 95,104 95,474 95,799 96,109 96,719 96,016

TAXPAYERS' EQUITYPublic Dividend Capital 243 243 243 0 243 243 243 243 243 243 243 243 243 243 243 243 243

Retained Earnings 69,759 71,974 71,863 111 70,079 70,672 71,974 72,356 72,288 72,419 72,958 73,309 73,256 73,581 73,891 74,186 73,483

Revaluation Reserve 21,552 21,552 21,552 0 21,552 21,552 21,552 21,552 21,552 21,552 21,552 21,552 21,975 21,975 21,975 22,290 22,290

TOTAL TAXPAYERS EQUITY 91,554 93,769 93,658 111 91,874 92,467 93,769 94,151 94,083 94,214 94,753 95,104 95,474 95,799 96,109 96,719 96,016

Year to DateAs at 30 June 2016

Monthly Actual / Forecast

STATEMENT OF FINANCIAL POSITION 2016-1730 JUNE 2016

9 of 11



Appendix 41 2 3 4 5 6 7 8 9 10 11 12

Annual Annual Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Outturn Plan

Actual Plan Variance Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Outturn£'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s £'000s

SURPLUS / (DEFICIT) 2,219 2,104 115 323 593 1,303 382 (68) 131 539 351 (53) 325 310 295 4,431 3,251

Less Non Operating Income / ExpenditureFinance Income / Charges (15) (11) (4) (3) (7) (5) (5) (4) (4) (5) (4) (4) (5) (4) (4) (54) (50)

Depreciation and Amortisation 987 1,017 (30) 328 331 328 317 317 317 317 317 317 316 316 316 3,837 3,824

PDC Dividend Expense 624 624 0 208 208 208 195 195 195 195 195 195 195 195 195 2,379 2,350

Impairment Losses 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

OPERATING CASHFLOWS BEFORE MOVEMENTS IN WORKING CAPITAL 3,815 3,734 81 856 1,125 1,834 889 440 639 1,046 859 455 831 817 802 10,593 9,375

Inventories 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

NHS Trade Receivabes (561) (25) (536) (412) (6) (143) 534 20 (16) (1) 0 18 (18) 5 (3) (22) (19)

Non NHS Trade Receivabes 1,257 (423) 1,680 1,107 (1,401) 1,551 (664) (10) (10) (1) (5) 0 10 0 0 577 (423)

Accrued Income (788) (197) (591) (2,598) 2,089 (279) 823 250 150 (800) (175) 300 250 (100) (50) (140) 460

Prepayments (1,385) 200 (1,585) (381) 131 (1,135) 1,735 (200) 250 (300) 50 (200) 160 (330) (60) (280) (280)

Other Receivables 32 (370) 402 68 (19) (17) (39) 22 (243) 268 (97) (54) 141 200 (175) 55 (145)

Trade Payables (4,208) (4,557) 349 (2,443) (820) (945) (115) 3 1 (3) 1 1 0 (4) (300) (4,624) (2,922)

Other Payables 296 331 (35) 393 28 (125) 123 (55) 39 (63) (5) 47 (15) 103 258 728 (1,038)

Accrued Expenditure 2,479 1,344 1,135 703 3 1,773 (771) 550 (1,228) 24 100 50 (2,500) 40 565 (691) (691)

Annual Leave Accrual 2 0 2 0 0 2 (2) 0 0 0 0 0 0 0 (40) (40) (40)

Deferred Income, Current & Non Current (83) (144) 61 274 (50) (307) (109) (48) (48) (48) (48) (48) (48) (48) (42) (570) (570)

Provisions, Current & Non Current (102) 4 (106) (1) (118) 17 31 0 5 75 0 5 0 0 5 19 19

Increase / (Decrease) in working capital (3,061) (3,837) 776 (3,290) (163) 392 1,546 532 (1,100) (849) (179) 119 (2,020) (134) 158 (4,988) (5,649)

NET CASHFLOW FROM OPERATIONS 754 (103) 857 (2,434) 962 2,226 2,435 972 (461) 197 680 574 (1,189) 683 960 5,605 3,726

Property, Plant & Equipment Expenditure (708) (877) 169 (594) 0 (114) (296) (333) (449) (413) (409) (367) (818) (1,007) (1,093) (5,893) (5,893)

Proceeds on Disposal of Property, Plant & Equipment 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4,100 4,100 4,100

(Increase) / Decrease in Capital Receivables 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Increase / (Decrease) in Capital Payables (404) 200 (604) (295) 145 (254) (296) 208 208 (416) 208 208 (416) 500 (500) (700) 100

NET CASHFLOW FROM INVESTING ACTIVITIES (1,112) (677) (435) (889) 145 (368) (592) (125) (241) (829) (201) (159) (1,234) (507) 2,507 (2,493) (1,693)

PDC Dividends Paid 0 0 0 0 0 0 0 0 (1,210) 0 0 0 0 0 (1,170) (2,380) (2,352)

PDC Received 0 141 (141) 0 0 0 141 0 0 0 0 0 0 0 0 141 141

Interest Received on Cash and Cash Equivalents 15 11 4 3 7 5 5 4 4 5 4 4 5 4 4 54 50

NET CASHFLOW FROM FINANCING ACTIVITIES 15 152 (137) 3 7 5 146 4 (1,206) 5 4 4 5 4 (1,166) (2,185) (2,161)

NET CASH INFLOW / (OUTFLOW) (343) (628) 285 (3,320) 1,114 1,863 1,989 851 (1,908) (627) 483 419 (2,418) 180 2,301 927 (128)

Opening Cash Balance 16,974 16,974 0 16,974 13,654 14,768 16,631 18,620 19,471 17,563 16,936 17,419 17,838 15,420 15,600 16,974 16,974

Net Cash Inflow / (Outflow) (343) (628) 285 (3,320) 1,114 1,863 1,989 851 (1,908) (627) 483 419 (2,418) 180 2,301 927 (128)

CLOSING CASH BALANCE 16,631 16,346 285 13,654 14,768 16,631 18,620 19,471 17,563 16,936 17,419 17,838 15,420 15,600 17,901 17,901 16,846

OPERATING ACTIVITIES

INVESTING ACTIVITES

FINANCING ACTIVITES

CASHFLOW STATEMENT 2015/1630 JUNE 2016

As at 30 June 2016Monthly Actual / ForecastYear to Date



Appendix 5

1 2 3 4 5 6 7 8 9 10 11 12Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

Actual Actual Actual Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast Forecast£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

A5047 Walton Hospital Site Development Estates 765.0 12.2 4.3 179.1 191.3 191.3 186.8 765.0A5050 Heanor Site Development Estates 1,958.0 -15.3 1.7 26.7 100.0 100.0 150.0 150.0 350.0 500.0 594.9 1,958.0A5105 Buxton Site Development Feasibility Fees Estates 10.0 10.0 10.0A5107 Ilkeston Hospital Upgrade Main Reception & Entrance Estates 65.0 25.0 40.0 65.0A5057 Belper Provision of Health Facilities Estates 208.0 69.3 69.3 69.4 208.0A5103 London Road Community Hospital Microscopy Lab & Accommodation Estates 90.0 36.5 -0.4 67.2 103.3 -13.3 A5108 Ripley Hospital Upgrade Security - Lighting/CCTV Estates 9.0 9.0 9.0

Purchase of Castle Street Medical Practice Estates 510.0 510.0 -10.0 500.0 10.0

A5473 IM&T - Mobile working IM&T 750.0 51.8 -51.8 62.5 62.5 62.5 62.5 85.0 85.0 110.0 110.0 110.0 750.0A5432 IM&T - Desktop renewal and local infrastructure IM&T 450.0 -12.5 38.5 13.0 37.5 37.5 37.5 37.5 37.5 37.5 37.5 75.0 73.5 450.0A5433 IM&T - System procurement IM&T 75.0 25.0 25.0 25.0 75.0A5434 IM&T - LAN/WAN Infrastructure IM&T 85.0 3.7 28.3 28.3 24.7 85.0A5435 IM&T - PAS Replacement IM&T 225.0 2.9 7.2 13.0 17.0 17.0 17.0 17.0 17.0 17.0 30.0 30.0 39.9 225.0

Equipment Equipment 343.0 68.6 68.6 68.6 68.6 68.6 343.0

A5106 Theatre - Air Handling Unit/Upgrade Ventilation Plant Backlog 50.0 50.0 50.0

CONT Contingency Contingency 300.0 100.0 100.0 87.5 287.5 12.5

MISC Expenditure relating to all other Axxxx schemes Other 8.0 1.1 0.1 9.2 -9.2

Capital Programme Expenditure 5,893.0 593.6 0.6 113.7 296.1 333.3 448.3 413.8 408.1 367.1 818.7 1,006.2 1,093.5 5,893.0 -0.0

CAPITAL PROGRAMME 2016-1730 JUNE 2016

Scheme Number Scheme Description Category 2016-17

PlanPlan v

ForecastFull Year Forecast



Summary Report from Audit and Assurance CommitteeReport To: Board

Date: 28 July 2016

Name of Reporting Committee / Group: Audit and Assurance Committee

Date of Meeting: 22 July 2016

Presenter: Nigel Smith, Non-Executive Director

Author: David Boddy, Corporate Governance Manager

This paper is for Assurance

Key Issues discussed at meeting:Include:

Brief summary of issue Decision made/action to be taken Agenda number and title of paper Risks identified

Board Assurance Framework Reference and Level of Assurance Agreed

92/16 Training for Audit and Assurance Committee members - The Committee considered if additional training or development is required in relation to the Audit and Assurance Committee.

The Committee agreed that they were content with the current training arrangements

94/16 Clinical Effectiveness and Audit Update – The Committee were updated regarding:- Audit outcomes from the 2015/2016 programme.- Progress with the new 2016/17 Clinical Effectiveness and Audit Programme, including the benefits from the reduction of audits from 145 (in 2015/16) to a more realistic target of 29- Developments in the team- The audits will pick out themes as well as links to the Board Assurance Framework (BAF). A level of assurance will be provided for each audit.

There is a challenge engaging with some staff owing to the big changes taking place in the organisation that affect staff motivation.

The Committee expressed concern regarding the amber and red RAG rated progress of specific audits. The red rated Pressure Ulcer audits have been escalated to the Chief Nurse.

The Committee were pleased with the progress being made but took Limited Assurance from the work, subject to the outputs from the 2016/17 audit programme.

95/16 Sustainability and Transformation Plan (STP) Governance Arrangements - Governance arrangements being proposed for the have been discussed by Chairs and Chief Executives of all partner

Paper for Decision

Limited Assurance1.6

Paper for Information

202�AAC�Summary�Report.docxOverall�Page�61�of�210Page�1�of�4


organisations in advance of the STP submission.

The Sustainability and Transformation Plan (STP) was submitted to NHS England on 30th June 2016. The system will be discussing this plan with NHS England and NHS Improvement at a meeting arranged for 25th July 2016.

The Committee considered in detail the potential governance risks and opportunities from both a system perspective, and a DCHS perspective. It was agreed that the governance arrangements should be consistent nationally across all 44 STPs. The Committee received the paper for information.

96/16 Assurance Framework Presentation: Quality People Committee (QPC) - The Committee reviewed the current Strategic Risks and discussed in detail the further changes made to the Board Assurance Framework (BAF) at the July QPC meeting. An up to date Risk Summary highlighted the Quality People risks.

Risk 2.1 (workforce supply shortages, upskilling staff in a Community setting):

The risk score has been increased. QPC had debated splitting the risk into two components (supply shortage owing to the impact of the education system, negative impact from future uncertainty on the recruitment to existing jobs). It was decided to keep a single risk. Audit Committee recommended that the Key Performance Indicators (KPI) reflect both of the components

Risk 2.4 (high volume of system change) - the risk score has been increased.

A new sixth risk has been added (negative impact on staff due to uncertain operating environment) which ties into 2.4. It was recommended that a KPI is included that relates to the quality of care

The Committee praised the usefulness of the Risk Profile – it provides a good visual aid regarding risk appetite and timescales. It was recommended that the Risk Profile is positioned at the beginning of each section of the BAF.

97/16 Board Assurance Framework (BAF) Quarterly Review – Q1The report reviewed the level of risk assigned to each strategic risk. This week all three Quality Committees had met and reviewed their sections of the BAF. As a result, new work has been identified to update each area – a reflection on the fast moving environment.

The Committee considered the large scope of the BAF and the value that it provides. The Committee asked if there was a more efficient alternative process. It was agreed that the Risk Profile (with comments) might provide committees with a helpful summary.

Significant Assurance4.3




The Committee asked that the process be reviewed to see if there is an efficient way to increase the regularity that the BAF outputs are reviewed.

99/16 Compliance with Governance Arrangements - The Committee discussed in detail:

The appropriateness of some Raising Concerns cases Work underway to monitor the number of declarations of

hospitality

101/16 Internal Audit Annual Report/Effectiveness of Internal Audit - The report completed the previous work regarding the Interim Head of Internal Audit Opinion. The report provided:

Further detail to support the Opinion and a summary of the delivery of internal audit service for the 2015/16 financial year;

A review of the 360 Assurance performance against contract A summary of the 360 Assurance value added services.

102/16 Internal Audit Progress Report -. The update highlighted two Main Reviews:

Bank and Agency Staffing - Significant Assurance in relation to the design of the control framework but Limited Assurance in relation to controls in place to review activity being undertaken outside of the agreed framework. The Committee was updated regarding the controls that DCHS now have in place – work will be undertaken to assure ourselves that this is now working.

Clinical Audit – advisory review Pay Expenditure – Additional Testing - Significant Assurance

104/16 External Audit Progress Report - The Committee took Significant Assurance from the work of the external auditors.

106/16 NHS Improvement (NHSI) Self-certification – Quarter 1The Committee discussed the assurance with respect to the Self-certification return for Quarter 1.

The Committee took Significant Assurance from the report and agreed to recommend to the Board to approve the Quarter 1 return, subject to one minor amendment.

107/16 Single Oversight Framework Consultation - The Committee discussed the recent NHS Improvement issue regarding its approach to overseeing providers using a Single Oversight Framework. The proposals are now out for consultation.

The Committee discussed the first draft of the Trust’s response in advance of a Board discussion. The committee considered the comments well measured and approved them subject to:

Inclusion of an offer to work with NHSI regarding the






Paper for Decision



Community FT metrics Some minor amendments to the wording

Board Assurance Framework Risk References:1.6 Risk to the provision of safe, effective care due to a lack of consistent employment of clinical governance standard. 4.1 Risk due to not having strong corporate governance systems in place resulting in Trust vision not being delivered 4.2 Risk due to not meeting regulatory, contractual or legal obligations resulting in sanctions.4.3 Not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptlyPolicies ApprovedNone. Issues to be escalated to Board or a CommitteeNone.



Summary Report from Quality Service CommitteeReport To: Board

Date: 28 July 2016

Name of Reporting Committee / Group: Quality Service Committee


Presenter: Chris Bentley, Non-Executive Director

Author: David Boddy, Corporate Governance Manager


Key Issues discussed at meeting: Board Assurance Framework Reference and Level of Assurance Agreed

215/16 Patient Story - The Patient Story discussed the impact of the challenges that a Young Carer may face and the key role of the School Nurse. The story demonstrated how the Young Carer was identified and the action taken to ensure her health and emotional needs were met.

DCHS Charitable Funds Committee has invested in a year-long project to develop a sustainable approach to Family Centred Care, which implements the Care Act 2014 which places the needs of carers alongside those of our service users. A Young Carers Event is taking place in July and a pledge will be made for School Nurses to work more closely with the Education services.

The Committee discussed the importance of appropriate information sharing. This includes the best practice care whereby School Nurses attend GP safeguarding meetings because they may be sharing the same families. Owing to resource constraints, this does not always happen. This will be raised at the Named and Designated Nurses meeting.

The Committee discussed the challenges regarding recruitment to the position of School Nurse owing to the necessity of holding a degree as an entry requirement.


220/16 Quality Service Committee - Looking ForwardThe Committee discussed and approved recommendations to help improve the QSC agenda which continues to be very busy:

Shape and content for the agenda A schedule of deep dive reports that remains flexible and

responsive when important issues arise. Work underway to create an integrated performance

management report for the Board may also have an impact on the QSC agenda. The Committee agreed that the performance

Paper for Decision

203�QSC�Summary�Report.docxOverall�Page�65�of�210Page�1�of�7


report may identify issues that have not yet been discussed by QSC. It was therefore recommended that, until the report is in place, a referral is made to QBC so that when QBC review the current performance report (which is a regular QBC agenda item) and identify a Quality Service related performance issue, this is referred to QSC for further investigation.

To help improve efficiency, amendments will be made to the membership. The Committee also received guidance to improve the quality of papers and clear definition of levels of assurance to be included in the papers.

222/16 Board Assurance Framework (BAF) Quarterly Review (Q1) - The Committee discussed the updated version of the report which has been rationalised from 12 risks to 5. Following feedback, a sixth risk had been added with respect to Patient Safety. The report is still evolving, particularly with respect to links with the Key Performance Indicators, target risk scores and also links with Strategic Priorities. In relation to dates for achieving target risk scores, the evolving complexity of the whole system meant thata 2 year timescale was thought to be realistic for some of the risks.

The Committee recommended a number of amendments to the new version of the report.


223/16 Quality Performance Report - The Committee noted that: Rehab wards reported their best ever Harm Free Care (HFC)

score at 97.4% OMPH wards reported their best ever Harm Free Care (HFC)

score at 100% There were no pressure ulcers developed in June which have

been confirmed as Avoidable There continue to be no Medication incidents which have

caused significant harm The inpatient falls continue to reduce in number

There have been positive communication benefits for staff in the community by using DCHS smart phones. The smart phones will be rolled out to Derby and also to High Peak.

Significant Assurance1.1, 1.2, 1.3, 1.4, 1.5

Limited Assurance with respect to the performance of Falls and also Pressure Ulcers in the Community.1.1, 1.2, 1.3, 1.4, 1.5

224/16 Risk Management Report - The Committee reviewed the monthly update of corporate risks, including two new risks. There were no Never Events in June.

Risk Management Policy and Risk Management StrategyThe Committee approved the policy and the strategy.


Paper for Decision

225/16 Quality Assurance and Compliance Report – The paper provided a focus on actions regarding local Key Lines of Enquiry (KLOE) plans and also progress regarding the CQC verbal feedback

Significant Assurance1.5, 2.5



action plan.The Committee requested completion dates for the mitigation of red RAG rated findings from the most recent KLOE triangulations.

226/16 Medicines Management Annual Report – The report presented a review of the variety of medicines management functions undertaken across DCHS throughout 2015/16, and informed members of the future direction of medicines management within the Trust.

The Committee recommended that the report should include an additional paragraph titled “Challenges and Constraints” to capture a number of concerns that were raised during the year:

The Committee requested a deep dive report in October regarding Non-Medical Prescribing.


227/16 General Practice Quarterly Update - Highlights from the report included:

Challenges relating to the budget setting processes and practices for general practices joining DCHS.

An update on workforce recruitment The Care Quality Commission (CQC) have inspected Creswell

and Langwith and Ripley practices Progress with work towards a Quality Governance Dashboard Work is underway towards reviewing, refreshing and making

consistent policies and procedures The General Practice Strategy Group is now holding meetings.

It is important that Finance attend these meetings DCHS have asked to attend General Practice Federation

meetings

The Committee took Limited Assurance owing to the work in hand regarding policies and procedures.


228/16 Divisional Operational Quality Report - WJ highlighted developments and issues from each division including:

Completion of the procurement of blood glucose machines A Trust action plan has been created on how DCHS will deliver

the national Health and Wellbeing CQUINs, including the challenging flu target for 2016/17

Quality Always – full accreditation for Linacre Ward, Amberley Core Unit, Spencer Ward and Melbourne Ward

Positive feedback from a Healthwatch visit in June to the dental service at Coleman Street

Significant Assurance1.5, 4.1

229/16 Patient Engagement and Experience Group:PEEG Summary Exception Report - Highlights included:

Dignity in Care – this subgroup will be disbanded and PEEG will receive reports directly on a quarterly basis




Equality and Diversity FFT exercise - actions were identified to better understand the poorer experience of BME service users

Duty of Candour Evaluation Report - assurance was limited because of lack of progress with identifying how we can learn from the experiences of patients who have been harmed and who have been involved in the Duty of Candour process. A plan will be agreed to investigate further.

Annual PEEG Report 2015/16 - The Committee took Significant Assurance from the work of the group during 2015/16.

More detail was requested for QSC about the 23 patient groups and the work that they are doing. Review of the Lessons Learned Process – the Committee considered and approved proposals derived from a separate working session, for improvement of the Lessons Learned Process, mainly with a focus on the functioning of the Learning the Lessons Group.

The proposals included: Strengthening mechanisms for initial local learning Replace Learning the Lessons Group with Lessons Learned

Panel – the panel will meet monthly and their work will be reviewed after 6 months. QSC requested sight of the monthly summary report for the first three months.

The Committee agreed that the benchmark of lessons learned is the degree of ownership by frontline staff.

The Committee agreed to implement the proposals and to review their working in 6 months.


Paper for Decision

230/16 Safeguarding Governance:Annual Safeguarding Governance Group Review 2015/16 - The Committee took Significant Assurance from the work of the group during 2015/16.

Safeguarding Service Annual Report – The Committee took Significant Assurance and approved the report subject to amendments to the section titled “Moving Forward/ Action Plan”.

Safeguarding Governance Group Summary Report - The Committee took Significant Assurance from the work of the group.

Significant Assurance1.3, 1.5, 4.2



231/16 Clinical Effectiveness Group Quarterly Summary Report The Committee took Significant Assurance from the work of the group.


232/16 Equality Diversity and Inclusion Leadership Forum (incl HC4A) Summary Exception Report – Highlights included:

The work of the Accessible Information Standard Working Group




Progress to make the Equalities Strategy more tangible

233/16 Clinical Safety Group Summary Exception Report - The group escalated to QSC a distressing issue raised through the Infection Prevention and Control Report following two cases within the community setting that involved patients on end of life care who had extensive haemorrhage at the time of death resulting in large volumes of blood damaging flooring, furnishings and mattresses. The families were unprepared for the volume of cleaning required and unable to dispose of the mattress and furnishings at the tip due to the blood contamination. This scenario created additional distress for the family/carers and distress for the staff members who felt unable to provide an adequate response to the queries raised by the family.

These incidents are not isolated. Unfortunately none of the local authority environmental health departments around Derbyshire now provide a cleaning or disposal service that would address this scenario. All councils advised that families would have to pay for a private company to clean and dispose of any items.

This activity will be raised within the “Better Care, Closer to Home” consultation exercise. WJ will also ask Jayne Needham to make enquiries from an environmental health perspective.


234/16 Legal Issues Report - The Committee reviewed the arrangements in place for managing Claims and Coroner’s inquests/investigations during Quarter 1. One inquest took place during the quarter:

CI/2011/WE – During 2010 DCHS’ Tissue Viability Team provided a service to patients at Chesterfield Royal Hospital Foundation Trust (CRHFT) via a Service Level Agreement. The DCHS Tissue Viabillity Nurse dressed the wound of an inpatient at CRHFT who had undergone abdominal surgery for cancer. When the wound was re-dressed there was a discrepancy in the number of pieces of foam removed from the wound. The wound was reviewed by the Tissue Viability Nurse (TVN) who could not see or feel the other piece of foam. In April 2011, as the wound was not healing a scan was performed and a piece of foam was identified within the wound and removed. The wound then healed and chemotherapy was commenced but the patient developed an infection and subsequently died. The cause of death was 1a Carcinomatosis 1b Colorectal Carcinoma (resected). Three DCHS witnesses gave evidence at the inquest and a conclusion of natural causes with a short narrative addendum was given by the Coroner.


236/16 Gaining Assurance - Clinical Records Audit (CRA) results – the paper reviewed the DCHS Clinical Records Audit, its background, current position, and role in providing assurance to the organisation.

Limited Assurance1.2, 2.2



The Committee discussed and agreed that the CRA does not, on its own, provide total assurance. However, it is an important part of the Assurance Framework “jigsaw”. Where the tool provides challenging results then this is a trigger for matrons to investigate locally and check the impact on the care of patients. The outcome from these investigations is the assurance provided by the process.

Understanding of the role of CRA might be clearer if the word “audit” is removed from the title and replaced with “review”.

The Committee discussed what the CRA audit tool can do and noted that there are areas of work where the generic nature of the CRA is not completely appropriate. For example the Sexual Health service have developed a bespoke version that is intended to be more relevant. A baseline audit in August will test the Sexual Health results.

The Committee noted the good progress that had been made with the CRA but agreed that over-reliance on such a tool would cause concern. The Committee discussed the proposed developments to support managers to utilise the tool, with local ownership and accountability. The Committee took Limited Assurance from the report, subject to the outcome of this work.

QSC will monitor progress via the Clinical Effectiveness Group summary reports and an update will be provided to QSC in March 2017 through the Actions Matrix.

237/16 Progress Report Following Triangulation Visit to the Diagnostic and Treatment Centre - There is a portfolio review underway which will affect a number of the actions on the plan. It is likely that this commissioner led review will deliver a different set of specialties and in a different way. The review will be completed by October 2016. The work and timescales fit well with the work towards the Sustainability and Transformation Plan initiative.

The Committee were informed that staff received the news of the portfolio review very positively.

The Committee discussed the progress of work to complete the amber RAG rated actions and were also informed about satisfactory completion of a number of the green rated actions. There is evidence of triangulation regarding satisfactory completion of actions.


238/16 Medical Devices Interim Report - The Committee was updated regarding the controls in place which help govern the Medical Devices used across DCHS.

The Committee was also updated that, temporarily, additional non-recurrent workforce are being applied to lead and support the Medical




Devices work.

Maintenance of Surgical Power Equipment - Actions are being taken to ensure surgical power equipment is maintained in an efficient state, in efficient working order and in good repair. The paper also discussed options for the future maintenance of power equipment that are currently being considered and will be put in place by September 2016.


Board Assurance Framework Risks:1.1 To management capacity and overall service continuity from the process of bidding for and acquiring new services and/or the requirement to retender for existing services1.2 To comprehensive patient information due to discontinuity between systems employed1.3 To the provision of safe, effective elective care due to lack of clinical leadership and expertise1.4 That DCHS does not provide patient centred care due to a lack of engagement and involvement of service users and stakeholders1.5 That our Clinical Governance initiatives do not deliver the outcomes necessary to support our Strategy1.6 Provision of safe, effective care due to a lack of consistent employment of clinical governance standards2.1 Not being able to provide high quality care due to staff not having the appropriate skills and competencies resulting in poor patient outcomes2.2 To patients, service-users and employees due to staff performance and behaviours not being monitored and improved resulting in an adverse impact on the provision of high quality care and organisational reputation2.5 That the Trust fails to build cultural competence and the required level of awareness and understanding across the organisation to operate inclusively and deliver equity of access and outcomes for staff and service users4.1 To the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered4.2 To the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions4.3 To the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly.

Policies ApprovedNone.

Issues to be escalated to Board or a CommitteeMatters Referred to Other CommitteesQuality Always – funding to continue to assure best quality of service. A referral will be made to the Executives meeting for discussion

Until the new performance report is in place, a referral is made to QBC so that when QBC review the current performance report (which is a regular QBC agenda item) and identify a Quality Service related performance issue, this is referred to QSC for further investigation.



Summary Report from Quality People CommitteeReport To: Board

Date: 28 July 2016

Name of Reporting Committee / Group: Quality People Committee


Presenter: Chris Bentley, Non-Executive Director

Author: Deborah Brennan, Legal Services Manager



113/16 Staff Story – Quality Always Leadership Development Centre – the story discussed personal experience of the Quality Always Leadership Development Process and reflected on the learning with the staff member stating that she felt more confident with her leadership role.

115/16 Board Assurance Framework Quarterly 1 Review - The Committee reviewed the Quality People section of the new Board Assurance Framework (BAF) with new risks listed. Members reviewed the risk rating, target and timescale for achieving the target.

It was agreed to review the wording of risk 2.1 and to add a new risk at 2.6 regarding staff engagement and wellbeing.

The Committee took Significant Assurance from the BAF Q1

116/16 – Strategic Workforce Report - AR provided QPC with an insight into national and local workforce updates including:

ESR Enhacements delay Junior Doctors’ Contract Health Care People Management Awards (HPMA) - DCHS

were shortlisted for three awards this year and won two. The Committee congratulated all staff involved in the awards.

21C consultationFlu campaign 2016/17 – this was discussed at length by the Committee as this now forms part of the national CQUIN and DCHS have been given a target of 75% of staff vaccinated. A number of different actions are taking place to increase uptake this year. In addition, the Chief Nurse is liaising with commissioners to clarify whether there is any room for negotiation on the 75% target as CQUIN targets are supposed

2.1Significant Assurance

4.3 Significant Assurance

2.4 Limited Assurance

204�QPC�Summary�Report.docxOverall�Page�72�of�210Page�1�of�6


to be stretching but achievable and this seems beyond that.

There was concern that other Providers had been able to agree lower targets with commissioners, and that DCHS might pursue this unfair settlement.

The Committee took Significant Assurance from all areas of the report for which we have in plans in place but Limited Assurance on the flu campaign due to the requirement for the Trust achieving the 75% target.

117/16 – People Performance Report and Deep Dive Reports - JG updated the Committee regarding DCHS workforce metrics, information analysis and associated trends and targets. Highlights included:

Staff appraisal completions at 91.3% for June, which has not seen the dramatic downward trend in performance like other years, and suggests that the process is embedded in the Trust and is not a year-end process.

Essential Learning compliance was slightly lower in June which was largely due to the timing of induction, which went over into July, thus leaving many new starters non-compliant at the end of their first month in post.

Sickness Absence reduced slightly in June to 4.35% and long term sickness has reduced significantly. The overall 12 month cumulative trend with sickness however, is that it is increasing and the Committee discussed whether this was specific to certain teams and how this could be addressed and the following actions are being taken: Case management regarding long term sickness

continues between the Head of People Services and the Chief Operating Officer on a monthly basis to allow staff to return to work as quickly as possible.

JB is now in post as the Staff Wellbeing Lead and is working on the wellbeing strategy so that we can better understand reasons for absence and address these.

Introduction of the Social Movement with a focus on mental health.

Further analysis needed to enable meaningful targets to reverse current trends to be set

The Committee went on to review and discuss the following Deep Dive reports:

Protected Characteristics Recruitment Staff in Post Workforce Planning and Development

The Committee took Significant Assurance from the reports with the exception of the sickness and absence figures, where Limited Assurance was taken.

2.1, 2.2, 2.3, 2.4, 2.5 Limited Assurance



118/16 - Responding to Changing Operating Environment: Our Responsive Workforce ModelJG updated the Committee on our Responsive Workforce Model, specifically aiming to highlight concerns about our ability to achieve our challenging NHSI agency expenditure target and plans for this winter with the highlights being:

DCHS have been issued with an agency staff target spend of £1.46M for 2016/17 by NHS Improvements; this is inclusive of all agency workforce (including primary care), not just nursing as was the case last year.

This figure is lower than the overall spend in 2015/16, which was £1.6M and so will be a challenge.

A plan is in place to address this and targeted recruitment events have taken place to recruit staff to the bank and the Responsive Workforce Team.

The Committee discussed the Trust’s likelihood of achieving the £1.46M spend on agency staff and agreed that this should be placed on the risk register as a financial risk.

The Committee took Limited Assurance because although there are robust plans in place, they expressed concern that these would not achieve the target figure.

119/16 - Equalities Update Report - QPC were updated on the progress that has been made towards achievement of the Trust’s key equalities priorities with highlights including:

Staff Survey Results – these show a similar picture to the previous year and a discussion took place on some areas.

Outcome of 360 Assurance 2nd follow-up review report. Completion of Equality Impact Statements (EIS) which is

patchy and requires further work.

Significant Assurance was taken from the report, except for EIS.

120/16 - Learning & Development UpdateThe Committee were updated on key learning and education workstreams:

MCA/DoLS and Consent – we have now achieved 100% of front-line staff trained on MCA/DoLs, and consent is embedded.

The revised Clinical Essentials day commences on 4 October 2016.

Traineeships – DCHS have supported four who now work on the bank and there are plans to support more in the Autumn of 2016.

Four students have been taken on through the Learning Disability Internship Programme, and this is going well

Post-Graduate Diploma/Masters (Fast Track) at University of Derby Nursing – DCHS has agreed to fund five adult field students to start securing our own future nursing workforce in

2.1 Limited Assurance

1.4, 2.5, 4.2 Limited Assurance




light of funding changes at HEE. ELearning – DCHS have joined the York and Humber

ELearning club which provides the Trust with access to a catalogue of elearning. RM asked if all the elearning packages aligned so that we are assured that staff transferring into DCHS are appropriately trained to which DW confirmed.

Essential learning day – proposed by WFPD group that this no longer features Information Governance as this will be via elearning for the majority of staff with only a few receiving face to face sessions within teams. QPC accepted this proposal.

The Committee took Significant Assurance from the update.

121/16 Health and Safety Update - An update was provided on the following:

Staff injury incidents – figures show a 257% increase on near misses and 5% increase on minor injuries from the previous year. Some of this is as a result of increased reporting and the introduction of the incident reporting cards.

Two RIDDOR reported incidents were received in Quarter 1 with actions taken.

The Committee discussed incidents involving violence and aggression and links to the staff survey results which showed an increase and it was explained that this is built into the new Health and Safety Managers training.

The members further discussed what the team are doing to tackle under-reporting of incidents and whether there is a trend between this and other factors, like sickness and absence. This will be included in future reports.

The Committee took Significant Assurance from the update.

122/16 Staffing for Quality and Efficiencies Report - The Committee reviewed the new format and content of the report.

The Committee took Significant Assurance from the report.

123/16 Staff Survey Organisational Action Plan - AR presented the action plan which the Committee discussed.

The Committee took Significant Assurance from the actions in place.

124/16 Disciplinary Casework Review – The report showed the progress from the 360 Assurance’s final review following their audit which commenced in 2014. Actions have included the following:

Review of the Trust’s Disciplinary Policy and clarification of roles.

A case management timeline has been implemented.



2.1, 2.2, 2.3, 2.4, 2.5 Significant Assurance

2.1, 2.2, 2.5, 4.2 Significant Assurance



Training for case investigators and panel members has been reviewed and implemented.

Internal processes within the POE Directorate for case management have been strengthened.

A major reduction in timelines has been achieved

Although formal assurance has not been received from 360, the Committee took Significant Assurance from the actions taken.

125/16 360 Audit Report eRostering Review – follow up An update was provided on the 360 Assurance’s recent follow up report into DCHS’ 2014/15 eRostering Review. Progress against the implementation of actions was highlighted.

The Committee took Significant Assurance from the report.

126/16 DCHS volunteer investigation - lessons learned - The report outlined the lessons learned from an issue that arose with a DCHS Volunteer and the actions taken, which include:

Compliance with the Lampard report (2015) recommendations. Appropriate management of volunteer activity within the Trust

in clinical areas. Controls on giving volunteers access to clinical areas. Process at the Diocese of Derby and the checks that take place. Information sharing with partner organisations. Maintaining good relations with volunteers.

Significant Assurance was taken from the lessons learned and actions taken.

128/16 Staff Partnership Committee Summary Reports - An update was provided from the work of the committee during the May and June meetings and highlighted the concerns that DCHS are experiencing with our payroll provider as a result of over payments to some staff. This will be placed as a risk on the risk register.

Limited Assurance was taken due to the Payroll concerns.

129/16 Workforce Planning and Development Group Summary Report - The Committee took Significant Assurance from the Summary Report.

130/16 Staff Health Wellbeing & Safety Group Summary ReportThe Committee took Significant Assurance from the work of the group.

131/16 Equality, Diversity and Inclusion Leadership Forum - The Committee took Significant Assurance from the work of the Forum.


2.2, 2.3 Significant Assurance

2.1, 2.2, 2.4 Significant Assurance

2.1, 2.2Significant Assurance


1.4, 2.5, 4.2Significant Assurance



Board Assurance Framework Key Risks:1.4 There is a risk that DCHS does not provide patient centred care due to a lack of engagement and involvement of service users and stakeholders.2.1 There is a risk of not being able to provide high quality care due to staff not having the appropriate skills and competencies resulting in poor patient outcomes.2.2 There is a risk to patients, service-users and employees due to staff performance and behaviours not being monitored and improved resulting in an adverse impact on the provision of high quality care and organisational reputation.2.3 There is a risk that the Trust fails to develop a proactive Health and Safety culture across the organisation, resulting in the trust not achieving zero harm to staff, visitors, contractors and members of the public.2.4 There is a risk to organisational performance due to the high volume of organisational and health system change, which is likely to continue to be a feature of our health economy for several years.2.5 There is a risk that the Trust fails to build cultural competence and the required level of awareness and understanding across the organisation to operate inclusively and deliver equity of access and outcomes for staff and service users.4.2 There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions.4.3 There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly.

Policies Approved Retirement Policy Flexible Working Policy

Issues to be escalated to Board or a CommitteeHighlighted in the Summary Report are:

128/16 Concerns relating to DCHS’ payroll provider to be escalated to the Board



Summary Report from Quality Business Committee

Report To: Board

Date: 28 July 2016

Name of Reporting Committee / Group: Quality Business Committee


Presenter: Ian Lichfield

Author: Gary Roe


Key Issues discussed at meeting:

Board Assurance Framework Reference and Level of Assurance Agreed

142/16 - Board Assurance Framework (BAF) - committee discussed the Quarter 1 BAF and considered the level of risk assigned to each strategic risk taking into account provision of assurance, KPI performance and operational risk profile. The committee agreed to leave the risks as they were presented for quarter one and that additional work would be done before the next QBC on rewording any risks and adding risks where appropriate due to the changing environment the Trust are working in. The committee took significant assurance from the report 144/16 - Key Performance Indicators (KPIs) for QBC Objectives – committee discussed the proposed KPIs for each of the agreed QBC objectives for 2016/17. The committee agreed the KPIs subject to a number of amendments 145/16 - STP Finance Update – presented to give QBC members an understanding of the financial plan submitted for Derbyshire at the June 2016 checkpoint around the Sustainability and Transformation Plan (STP). Next three months will be used to work up the plan in further detail, and in particular, focus upon the actions required now to support delivery of both 2016/17 and 2017/18. It was clear that efficiencies would need to be delivered in the year in order to invest in future years. The committee took significant assurance from the report 148/16 - Transformation Update including DCHS Mileage Claims Comparison and Smartphone roll out - update on work being undertaken to reduce the burden of travel on the Trust and the direct costs associated with travel, and also to provide an update on Project Mercury (Smartphone) implementation. Committee agreed that a good metric for agile working would be the effect on travel compared to productivity. The committee

4.3 Significant Assurance 3.1 Significant Assurance 3.7, 3.9 Limited Assurance

205�QBC�Summary�Report�inc�ToROverall�Page�78�of�210Page�1�of�9


requested that two relatively small teams could be compared to illustrate this, with one of the compared teams being a team that have embraced agile working and the other team being a team that have not embraced agile working. The committee also discussed the need to look at a metric to see how many staff are returning to base in-between journeys rather than working agilely and the reasons why staff do this. The committee took limited assurance from the report 150/16 - QBC Performance Report - summary of DCHS’ performance against the DCHS focus area of Quality Business. Paper outlined that there are 22 green, 16 amber, 4 red, and 24 unrated indicators this month. The committee took significant assurance from the report 151/16 - Finance Report - financial performance of the Trust as at 30th June 2016. The Trust is reporting a surplus position of £2.25m at month 3, which represents a £0.15m surplus variance against the planned surplus of £2.1m. The cash position is £0.5m ahead of plan. A year end surplus of £4.56m is forecast which represents an agreed increase in line with the letter received from NHS Improvement. The Trust is forecasting that it will meet all its statutory financial duties for the year. The committee took significant assurance from the report 152/16 - Analysis of Employee Pay Run Rates - set out the Run Rates for Employee Benefit Expenses across the previous 12 months. The committee took significant assurance from the report 153/16 - Treasury Management Report - outlined a number of key performance indicators to assist the committee in understanding performance in relation to managing the Trust’s working capital. At the end of June the cash balance was £0.3m ahead of plan (actual: £16.6m, plan: £16.3m). Additional detail was provided on receivables, payables, accrued income and accrued expenditure. Committee felt that the Trust should consider using their legal right to charge interest on overdue debts from non NHS organisations. The committee took significant assurance from the report 154/16 - SQIP Report 2016/17 - 2016/17 Sustainable Quality Improvement Plan (SQIP) together with updates on progress against PMO schemes. The report highlighted where there was slippage against expected SQIP outturn and provided detail of any mitigation schemes or non-recurrent savings used to offset this. LD Review and Connecting Health schemes were yet to be sorted and therefore there was a current shortfall of £365k. The committee took significant assurance from the report 155/16 - Cost Improvement Report 2015/16 Outturn - outlined the financial outturn of the 2015/16 CIP Programme as at 31st

3.2, 3.8, 3.10 Significant Assurance 3.7, 3.8 Significant Assurance 3.7 Significant Assurance 3.10 Significant Assurance 3.7, 4.1 Significant Assurance 3.7 Limited Assurance



March 2016.Committee noted that variances that should have fallen into this year have reduced significantly in a month. The committee took limited assurance from the report 156/16 - 2015/16 Reference Costs Collection - The committee approved the proposed Reference Cost collection process and authorised the Director of Finance, Information & Strategy to sign off the Trust’s reference cost submission on behalf of the Board 158/16 - Business Development Report - provided information around External Business Environment, Business Opportunities, Contract Update and Procurement Updates. Trust had received formal notification from Derbyshire County Council that it had been awarded the Oral Health Contract, that the tender for the Intensive Home Visiting Service had been submitted today (20 July 2016) and that the Langwith and Cresswell contract had been awarded as a 10yr + 5yr contract. The committee took significant assurance from the report 160/16 - Capital & Estate Programme Group: Summary Report and Annual Review The Committee discussed and took significant assurance from the work of the Capital & Estate Programme Group, significant assurance from the Annual Review and approved the groups Terms of Reference 161/16 - Security Management Group: Summary Report, Terms of Reference for merged EPPR and Security Management Group and Annual review The Committee discussed and took significant assurance from the work of the Security Management Group, significant assurance from the Annual Review and approved the merging of the EPPR and Security management Groups and their Terms of Reference 162/16 - Informatics Strategy Quarterly Project Update - progress to date of the major elements of the strategy for the current year. Key elements including the deployment of electronic clinical records (based on TPP SystmOne), mobilisation of community staff and the development of trusted single portal to deliver information for the purposes of business intelligence. The committee took significant assurance from the report Benefits Realisation - benefits accruing from the projects within the Informatics programme. No evidence of tangible benefits within the paper and that the Trust needed to be assured that they were spending monies correctly. The committee took no assurance from the report Informatics Strategy Group Summary The Committee discussed and took significant assurance from the work of the Informatics Strategy Group

3.1, 3.2, 3.3, 3.4, 3.6, 3.7, 3.8, 3.12 Significant Assurance 3.1, 3.3, 3.4, 3.5, 3.6, 3.7, 3.9, 3.10, 3.12 Significant Assurance 3.11 Significant Assurance 3.9, 3.10 Significant Assurance 3.9, 3.10 Limited Assurance 3.9, 3.10 Significant Assurance



163/16 - Proposal for General Practice Strategy Group (GPSG) to Report into QBC and GPSG Summary Report - proposal that the recently former General Practice Strategy Group reports into the Quality Business Committee for a provisional period of six months. The committee approved the proposed reporting arrangements and the groups Terms of Reference 166/16 - QBC Terms of Reference (attached) The committee approved the Terms of Reference subject to some minor amendments BAF Key; 3.1 There is a risk to the organisation achieving strategic objectives due to a lack of integrated planning both internally, resulting in poor outcomes across the DCHS Way and, in addition externally across the whole system 3.2 There is a risk to the organisation due to not proactively managing the more competitive environment resulting in an impact on future sustainability of the Trust 3.3 There is a risk to future sustainability due to change in national policy and commissioner priorities 3.4 There is a risk to the effective and efficient provision of DCHS services due to the impact of funding cuts within Local Authorities resulting in greater activity being directed towards health services 3.5 There is a risk to the organisation due to poor estate impacting upon patient care resulting in poor outcomes 3.6 There is a risk to the organisation regarding the efficient use of resources constrained by Health Economy Plans 3.7 There is a risk to the financial stability of the organisation of not meeting future Sustainable Quality Improvement Programme over the next two years 3.8 There is a risk to the organisation due to the inability to meet contractual activity targets, resulting in financial risk 3.9 There is a risk to the organisation due to non-delivery of elements of the IM&T strategy, resulting in objectives not being achieved 3.10 There is a risk to the organisation due to lack of comprehensive data quality systems resulting in poor decisions that could affect outcomes and financial loss 3.11There is a risk to the Trust’s resilience, due to an emergency or severe disruption, resulting in an impact on patient care, inability to meet targets, loss of revenue 3.12 There is a risk to the organisation, due to failure to align and influence stakeholders resulting in poor relationships that impact on patient care 4.1 There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered 4.3 There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly Policies Approved None. Issues to be escalated to Board or a Committee QPC – 148/16 - The committee made a formal referral to QPC regarding moving the Derby City staff that had transferred to the Trust onto the DCHS Terms & Conditions in line with other staff.



Quality Business Committee Terms of Reference

July 2016

Introduction

The Quality Business Committee is one of DCHS’ key Board sub-committees. The Board sub-committees are concerned with the governance of the organisation; that is how DCHS is structured, how it is led and how it is held to account. The Committee’s remit does not extend to the management of the organisation which is the responsibility of each Directorate. The Committee has delegated authority from the Board and is chaired by a Non-Executive Director who is directly accountable to the Board. Section 4 of the Scheme of Delegation details the Board delegation to its subcommittees. Quality Business Committee will make decisions within the scope of its Terms of Reference. This will include delegated authority to approve the Sealing of documents. The Committee will support the Board in setting and ensuring that high standards of governance and behaviour are maintained in the conduct of the Trust’s business.

What

The Quality Business Committee is responsible for monitoring that relevant controls are in place and providing assurance to the Board. The Quality Business Committee will review performance of the organisation and agree actions where required. The Quality Business Committee will delegate responsibility for specific aspects of performance and management to a number of sub-committees and working groups. These are:

• Emergency Preparedness Resilience and Response and Security Management Group

• Information, Management and Technology (IM&T) Strategy Group • Capital & Estate Programme Group • Tender Oversight Group • Operational Plan Delivery Group • General Practice Strategy Group (time limited)

The Quality Business Committee will work in adherence to the DCHS vision and values.

Who

Non Executive Director Chair Non Executive Director Director of Finance, Information and Strategy Associate Director of Strategy and Commercial Development Medical Director



Chief Operating Officer Trust Secretary Attendees: The Associate Director of Transformation will regularly attend meetings. Although not a member, the Chief Executive will attend the three sub-committees of the Board (Quality Service, Quality People and Quality Business Committees) on a rotational basis All Executive Directors may be in attendance at any of the meetings. The Committee may invite other individuals as required on a time limited basis.

Quoracy Minimum of one Non-Executive Director, one Executive Director and two other committee members.

When

The Business Committee will meet not less than six times per year either in person or via conference call; additional meetings will be held as required. Members are expected to attend at least four meetings in a financial year.

Where Committee meetings will be held at DCHS premises or via conference call.

Why To take responsibility, on behalf of the Board for the Governance aspects of the Quality Business domain of the DCHS Way.

How

The Quality Business Committee will shape, influence and provide overall assurance regarding the delivery of: 1. Compliance against regulatory requirements

• Compliance with NHS Improvement’s planning and performance requirements

1. Performance Framework 2. Financial Strategy:

• Consider DCHS’ financial strategy in relation to income and expenditure, balance sheet, cashflow and Continuity of Services Rating

• Consider DCHS’ annual financial targets and performance against them before submission to the Board of Directors

• Monitor DCHS’ working capital position • Consider the ‘in year’ financial performance of the Trust and make any

subsequent comments or reports to Board

3. IM&T Strategy:



• To ensure appropriate investment and capacity across DCHS to deliver the IM&T Strategy

• To define the scope, requirements and pace of the information management and information technology agenda of DCHS in building the IM&T capacity of the organisation

• To assure the DCHS Board of delivery of the IM&T agenda 4. Estates Strategy:

• Oversee the development of the Trust’s Estates Strategy and Capital Programme and ensure it is appropriately updated for approval by the Trust Board

• Consider & review the annual capital programme prior to Board decision

• Monitor progress against delivery. • To review on a quarterly basis action plans produced by the Head of

Estates for improving performance against estate related targets • To establish reporting mechanisms that provide the Trust Board with

regular updates on all relevant issues associated with the Trust’s estates management activities

5. Procurement Strategy • To review the procurement strategy and the associated metrics for the

delivery of the strategy and annual work programme. 6. Transformation

• To review progress against health and social care economy transformation priorities

• To review progress against Trust transformational priorities • To understand the benefits realisation from transformation initiatives,

and to ehaure that an approriate return on investment is delivered. 7. Business Development Framework:

• Develop DCHS’ Investment Policy and ensuring this is maintained to fit with best practice

• To maintain an oversight of DCHS’ investments, ensuring compliance with the Trust’s policy

• Review business cases for major investments, defined as greater than £500,000 against the Trust’s strategy and test compliance with the Investment Policy in advance of a Board decision

• To ensure appropriate independent advice is sought in relation to major investments

• Review and consider the Trust’s financing strategy • Consider post project evaluation reports on significant capital

investments • Consider and review the decision making criteria for

investment/disinvestment and tender opportunities

8. Business partnering arrangements:



• Oversee the development of the Trust’s Business Partnering arrangments

• Consider forms of delivering business partnering arrangements • Provide assurance that DCHS interests will be safeguarded from

proposed partnering arrangements • Review the legal, financial and risk implications of any proposed

partnering arrangements 9. Policy Approval:

• Will have delegated authority from the Board to approve business, finance and corporate policies

10. Emergency Planning & Business Continuity (EPRR) and Security Management

• To ensure there is an appropriate Emergency Plan in place for the organisation that fulfils national and local requirements for EPRR

• To ensure there is an appropriate Security Policy in place for the organisation that fulfils national requirements from NHS Protect

Assurance: The Quality Business Committee is responsible for reviewing the effectiveness of the controls in place relevant to the risks identified within the Quality Business section of the Board Assurance Framework. The number of risks may vary during the course of the year. The Committee will review and challenge the strength of the assurances that have been provided, identify any gaps in control or assurance and will confirm if the appropriate level of risk has been identified based on the information presented to the Committee.

Sub Committees /

Groups

• Information, Management and Technology (IM&T) Group • Emergency Preparedness Resilience and Response and Security

Management Group • Capital & Estate Programme Group • Tender Oversight Group • Operational Plan Delivery Group • General Practice Strategy Group (time limited)

The above groups will provide a Summary Report from each of their meetings to the next Quality Business Committee. Each group will also provide an annual review of performance in line with their Terms of Reference, including the Key Performance Indicators.

Communication Links

The Committee will need to ensure effective communication with the Quality People Committee and Quality Service Committee. The Quality Business Committee will also have a relationship with the Audit and Assurance Committee in the context of its overall role in relation to assurance.



Reporting To

The Quality Business Committee will report formally to DCHS Board and provide assurance to both the Board and the Audit and Assurance Committee. The Chair of the Quality Business Committee will prepare a Summary Report after each meeting which will provide an overview of the meeting and will identify any issues or areas of risk that the DCHS Board or other committee will need to action/note.

Key Performance

Indicators/Key Deliverables

The Quality Business Committee will be responsible for delivering the following key controls outlined in the Board Assurance Framework:

• A system to ensure Business Planning (long term and annual plans) controls are in place

• A system to ensure estate controls are in place • A system to ensure financial controls are in place • A system to ensure IM&T controls are in place

The Quality Business Committee will also have oversight of the delivery of the following:

• IBP and annual plan targets and milestones • Financial plan • Contract / activity plan • IM&T strategy etc • Feedback from Clinical Commissioning Groups • Financial surplus • Delivery of productivity programme • Service driven estate strategy • % of tenders won / lost

Review Date July 2017



Summary Report from Council of GovernorsReport To: Board

Date: 28 July 2016

Name of Reporting Committee / Group: Council of Governors


Presenter: Prem Singh

Author: Gary Roe



77/16 – Patient Story – highlighted the impact that a Volunteer made on the patients quality of life in the context of a life limiting condition, the value and importance of the Home from Hospital Programme to support discharge from DCHS’ hospitals until required support is in place from hospital and how the existing Volunteering resource is being used to support patients after discharge.

Concerns were raised as to whether the patient was discharged to home with the right care package. Chief Nurse is going to follow up issues raised.

The story was received for information.

79/16 - Care Quality Commission (CQC) Visit - update on the recent CQC comprehensive inspection of DCHS services.

Next steps are for the CQC to produce their reports and these reports to be presented to the CQC Quality Review Panel before being presented to DCHS to check for accuracy. The CQC review panel was scheduled for 7th July, however, the draft reports have been taken off their agenda. It is expected that the Trust will receive the draft reports from the CQC around the end of August.

The paper was received for information.

80/16 - Quality and Performance Report

Quality ReportThe Council discussed:

Harm free care continues to fall below target levels in month Falls with harm across DCHS continue to reduce No medication incidents resulting in significant harm were

reported in May The Patient Experience data continues to provide a positive

story

The report was received for information.

206�CoG�Summary�Report.docxOverall�Page�87�of�210Page�1�of�3


Analysis of pressure ulcer incidents identified a cluster in Derby City and therefore additional support has been put into this area.

Linacre Ward, Melbourne Ward, Spencer Ward and the Amberly Core Unit had all been awarded Gold status from the Quality Always team.

Regulatory Performance Report Performance against the regulatory performance indicators for the month were all RAG rated green. The position for month 2 showed that the Trust had no area of risk with a red rating.

Finance Report The Trust is forecasting a surplus of £4.56m. This is supported by £2.14 million non-recurrent income, and £0.21m non recurrent efficiencies. Therefore the underlying forecast outturn surplus position of the Trust is £2.21m surplus.

81/16 - Patient Experience Annual Report - provided an overview of Patient Experience and Involvement activity at Derbyshire Community Health Services NHS Foundation Trust (DCHS) from 1 April 2015 - 31 March 2016, including a summary of:

Complaints and general feedback Friends and Family Test survey (patients and staff results

are provided which describes how likely people are to recommend our services)

Overall patient experiences Patient Involvement Volunteers Patient Experience Team priorities to strengthen processes

and systems for obtaining patient feedback and learning 2016-17

The report was received for information.

82/16 - Quality Business Committee Presentation - about the work of the Quality Business Committee. This included discussion around ;

• Context – Five year forward view• Why have a Quality Business Committee?• Committee Overview • Approach of the committee• The Quality Business Committee Agenda• 2015/16 Financial Score Card• Areas of Focus 2016/17 – From Good to Great

The content of the presentation was received by the Council

84/16 - Nominations and Remuneration Committee Summary Report

The Governors agreed to the appointment of Kaye Burnett as a Non-Executive Director on a three year term

The Governors agreed to the appointment of James Riley as an Associate Non-Executive Director on a one year term

The report was received for information and the governors agreed to the two appointments as outlined above. The meeting also took significant assurance



(James Riley has no voting rights). regarding the Chair’s and Non-Executive Directors appraisals.

86/16 Chief Executive’s Report - highlights of the report included: Updates on the development of the Sustainability and

Transformation Plan 21st Century Better Care Closer to Home consultation launch NHS Improvement 2015/16 Quarter 4 Trust Monitoring Progress with Care Quality Commission Inspection Quality Always Accreditation Transition to NHS Mail 2

The paper was received for information.

88/16 - Trust Secretary’s Report – the meeting were informed of; Council of Governors elections Annual Governors/Members Meeting

o The 2015/16 meetings will be held as one joint Annual Governors Meeting/Annual Members Meeting on 7 September 2016.

The report was received for information

Policies ApprovedNone.Issues to be escalated to Board or a CommitteeNone.



TRUST BOARDDocument Title: Quality Report

Presenter/Title: Jo Hunter, Deputy Chief NurseContents of Paper were previously discussed by:

Quality Service Committee (QSC) and a variety of other groups and forums across DCHS

Author Jo Hunter, Deputy Chief NurseContact Email and Telephone Number:

Carolyn White [email protected] Hunter [email protected]




Document is for:(more than one box can be ticked) Information X Decision Assurance X

Purpose of Paper

This report is brought to Board to provide an update on key issues across the Quality agenda.

The Staffing for Quality information and exception reports can be found in Appendix 1.

Recommendations

Board is asked to receive and discuss the report and agree the levels of assurance provided across the areas of the Quality agenda covered by this report.


1.3 There is a risk to the provision of safe, effective elective care due to lack of clinical leadership and expertise

1.5 There is a risk that our Clinical Governance initiatives do not deliver the outcomes necessary to support our Strategy

2.1 There is a risk of not being able to provide high quality care due to staff not having the appropriate skills and competencies resulting in poor patient outcomes

4.1 There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered

Financial Impact

There are no direct financial implications to this report, although some Serious Incidents may result in a claim being made with increased litigation and financial sanctions for not managing patient care and other key functions appropriately.


1.0 The National Agenda / Department of Health

1.1 Decontamination of Surgical Instruments (HTM01-01) This revised guidance (July 2016)

207�Quality�Report.docxOverall�Page�90�of�210Page�1�of�25




replaces that previously issued in March 2013 and provides guidance about the management and decontamination of reusable surgical instruments and medical devices used in acute care. https://www.gov.uk/government/publications/management-and-decontamination-of-surgical-instruments-used-in-acute-care

Implications for DCHS Whilst this guidance is aimed at Acute Trusts a review of current practice will be carried out and reported to the IP&C Committee with summary reporting via the clinical Safety Group to Quality Service Committee. Any relevant changes to policy will be approved through the same route.

1.2 Putting Children First (July 2016) This paper sets out the government’s reform programme for children’s social care in England over the next 5 years. The major impact will be on local government. https://www.gov.uk/government/publications/putting-children-first-our-vision-for-childrens-social-care

Implications for DCHS The reforms outlined will have a developing impact on Children’s Safeguarding practice. This aspect of implementation will be led by the Safeguarding Children Board which has DCHS representation. As services work more closely together looking forwards the practical implications to practice will be more fully understood.

1.3 Keep on Caring – supporting young people from care to independence This strategy (July 16) looks at how to improve services, support and advice for care leavers. It makes recommendations for local and national government, and wider sectors of society. https://www.gov.uk/government/publications/keep-on-caring-supporting-young-people-from-care-to-independence

Implications for DCHS The implementation of this strategy sits predominately with local government however it will have potential implications for the 0-19 Children’s Service and Safeguarding Team.

1.4 Changes to Cervical Screening The process of cervical screening is to be changed to allow women to benefit from more accurate tests. After a successful pilot programme and a recommendation by the UK National Screening Committee, screening samples will be tested for human papilloma virus (HPV) first. This will be rolled out across England as the primary screening test for cervical disease https://www.gov.uk/government/news/changes-to-cervical-cancer-screening.

Implications for DCHS Integrated Sexual Health Services and the three General Practices are engaged in the Cervical Screening Programme and will be made aware of further detail as the change to testing is rolled out nationally.

2.0 Care Quality Commission (CQC)

2.1 The Safer Management of Controlled Drugs The report for 2015 highlights local and national initiatives to promote the safe use of controlled drugs and to reduce harm from their misuse. The report also includes an overview of data for 2015 on prescribing of controlled drugs across England in the primary care sector and identifies any trends in prescribing, and highlights key changes to legislation. http://www.cqc.org.uk/content/safer-management-controlled-drugs

Implications for DCHS Controlled drugs (CDs) are used across DCHS and their safe use is a Patient Safety issue. There are regular CD audits undertaken with improvement plans discussed


https://www.gov.uk/government/publications/management-and-decontamination-of-surgical-instruments-used-in-acute-care

https://www.gov.uk/government/publications/management-and-decontamination-of-surgical-instruments-used-in-acute-care

https://www.gov.uk/government/publications/putting-children-first-our-vision-for-childrens-social-care

https://www.gov.uk/government/publications/putting-children-first-our-vision-for-childrens-social-care

https://www.gov.uk/government/publications/keep-on-caring-supporting-young-people-from-care-to-independence

https://www.gov.uk/government/publications/keep-on-caring-supporting-young-people-from-care-to-independence

https://www.gov.uk/government/news/changes-to-cervical-cancer-screening

https://www.gov.uk/government/news/changes-to-cervical-cancer-screening

http://www.cqc.org.uk/content/safer-management-controlled-drugs


and managed at a team level with oversight by the Head of Medicines Management. The three recommendations made in this report focus on NHS England, CCGs and local authorities with commissioning responsibilities.

2.2 Not seen, not heard This report provides the overview of 50 local inspections undertaken across services for ’Looked After Children’ in England in 2015/16 http://www.cqc.org.uk/content/not-seen-not-heard.

Implications for DCHS DCHS Integrated Sexual Health Services were inspected as part of this review in respect of the Derby City service when the Inspectors visited Derby City Council. There were two recommendations made both of which were immediately actioned:

DCHS membership of the Derby City Child Sexual Exploitation Group DCHS membership of the Derby City Safeguarding Boards

3.0 Local Agenda

3.1 Better Care Closer to Home everyone in North Derbyshire is being encouraged to have their say on a public consultation which is due to launch on 29 June and finish on 5 October 2016. The staff briefings and question and answer sessions continue to be well attended and the Executive and senior Management Team from DCHS are now supporting a series of public meetings.

4.0Staffing for Quality (see Appendix 1)

From April 2016 NHS Improvements issued further guidance around bank and agency spend. We now have to report all types of agency spend across DCHS not just nursing as was previously the case. Alongside this, rather than reporting as a % of our budget we have been given a financial ceiling rate for DCHS for 2016/17 this is £1.46 million noting that in 2015/16 our actual spend was £1.6million making this target challenging to achieve. A plan of action identifying a forecast spend based on the outturn for 20116/17 is in place with monthly reporting against this. Focused actions looking at how we can address learning from the work we have undertaken in nursing and spread this across other areas is currently taking place. Expenditure against our trajectory will be monitored monthly as part of the financial performance report.

If we were to stop using all agency this would result in gaps to service and risk around safety and quality of service delivery therefore alternatives need to be in place through a flexible and responsive workforce model.

During 2015/16 DCHS continued to attain required staffing levels within our inpatient areas and remained within our ceiling for Agency spend noting we were the best performing organisation in the East Midlands. However we recognise that the arrangements around staffing levels and agency are


http://www.cqc.org.uk/content/not-seen-not-heard

http://www.cqc.org.uk/content/not-seen-not-heard


changing with financial targets becoming more challenging and to address this position we are therefore undertaking the following steps:

• To support the understanding of staffing levels discussions with Allocate have reconvened to consider if this information can be advised into DCHS BI dashboard

• POE AND Finance colleagues developed returns to NHSI collaboratively based on 2015/16 trend

• Monthly data is submitted around staffing levels to unify from e roster and financial data is submitted to NHS Improvement by our finance team

• A review has taken place and a recovery plan submitted via QPC July 2016 to improve flexibility and responsiveness of our workforce

• Continue to review our staffing requirements in light of changing patient acuity and national requirements for care

• More robust confirm and challenge via the new group from the merged Responsive Workforce Group and Workforce Planning


What are the Governor involvement implications?

The Chief Nurse presents a paper covering the Quality Agenda reflected in this report to the Council of Governors. Governors may be involved in some of the pieces of work reported in this paper.


Individual items within this report will have implications for Equality and Diversity. It is always possible to present the information in more accessible formats should this be required.

What are the Patient, Public, Staff, Member and Stakeholder involvement implications?

The report covers Clinical Quality which impacts on Patients, Public, staff and in many cases will have stakeholder implications.

Risk Register

Is the issue on the current Risk Register?

No(Delete as appropriate)


N/A



Appendix 1 Staffing for QualityAshgreen – Hillside

Ash Green – Valley ViewReported as site due to responding to patient admission and dependencies that is managed by staff working across site



Reported as site due to responding to patient admission and dependencies that is managed by staff working across site



Ash Green Site

Ash green has 2 wards on site, Hillside offering assessment and treatment and Valley View offering social short breaks

There is currently one ward manager at Ashgreen who covers across both wards

Due to the acuity of patients fluctuating staff are working across the site to meet patient need and bed occupancy giving consideration to skill mix required at any given time

Due to the high levels of patient acuity on Hillside this area has qualified nurses at all times and they cover valley view when required ensuring best use of staffing across the service

There has been no bank and agency use as staff work flexibly to cover demand207�Quality�Report.docx

Overall�Page�96�of�210Page�7�of�25


Babington Hospital - Baron Ward

Bed occupancy has fluctuated dependant on demand .There has been some high patient acuity requiring increased staffing

Where shifts have not been filled by bank some agency support has been required .Occupancy is averaged out so there are times when it looks as if there is overstaffing but this relates to when extra support is needed for 1-1 /increased acuity and is mainly a requirement for HCA to support this demand for closer observation. Some of the support is also available due to short notice demands such as sickness cover.



Bolsover Hospital - Hudson Ward

There have been fluctuations in patient acuity with patients requiring extra support and some 1-1 support .Bed occupancy is generally less than over previous months.

Where possible these shifts have been filled with bank but some agency has been required to support observational and care requirements and to cover last minute unavailability due to sickness.207�Quality�Report.docx



Cavendish Hospital - Fenton Ward

There has only been a very small amount of bank used in this area and no agency use

Staff in this area work long days

Bed numbers reduced this month



Cavendish – Spencer Ward

Staffing levels are dependent on patient acuity which can fluctuate Bank has been used to enable flex of staffing levels as required

There has been some HCA bank and a very small amount of agency to support additional observational/care requirements



Cavendish Hospital Site

Due to variations in specialism on the wards at Cavendish hospital staff do not work across the wards but this graph shows staffing on site for emergency planning only



Clay Cross Hospital - Alton Ward

There is some staff vacancy within the area at present requiring some support from bank, agency use has also been required to support gaps from these vacancies and unavailability mainly for registered nurses.

Support is available from responsive workforce in this area.



Ilkeston Hospital - Heanor Ward

There has been some bank and agency use due to vacancies which are open to recruitment and flex in beds to meet demand. This is HCA only.



Ilkeston Hospital - Hopewell Ward

Staff utilised across site to meet demand. Responsive workforce are providing additional cover on this ward due to vacancy . There has been some bank and agency use for HCA only



Ilkeston Hospital Site

All grades of staff work across site to provide appropriate cover especially at night the wards alternate cover to ensure one RN on each ward and an extra person across the wards

Extra staffing has been provided to meet the higher acuity of patients mainly HCA at night



Newholme Hospital - Riverside Ward

The skill mix on this ward fluctuates dependant on patient acuity and service demand .There is some use of bank and no agency use where it looks as though there is over staffing this is due to 1-1 support required.

There are often HCA required as opposed to RN



Newholme Hospital - Rowsley Ward

Due to fluctuations in bed numbers due to demand some bank and agency use has been required and is assessed dependant on acuity. There is support from responsive workforce due to RN vacancies on this ward

Extra staffing has been used at night to ensure safety and to meet increased observational requirements



Newholme Hospital site

Due to variations in specialism on the wards at Newholme hospital staff do not work across the wards but this graph shows staffing on site for emergency planning only



Ripley Hospital – Butterley Ward

Due to acuity extra HCA support has been required which has been met through bank and agency



St Oswald’s Hospital – Okeover Ward

There has been an increase in shifts sent to bank and agency this is due to fluctuations in bed numbers and high patient acuity and some vacancies that have been recruited to but awaiting start dates.

There is support from responsive workforce



Walton Hospital - Linacre Ward

There are currently some HCA vacancies which are open to recruitment and maternity leave. Bank HCA were used to cover some of these shifts following review of acuity and occupancy. Some HCA Agency required.

Staff continue to flex staff across both wards to meet service and patient need

There are some RMN vacancies open to recruitment 207�Quality�Report.docx



Walton Hospital – Melbourne Ward

Due to vacancies which are open to recruitment and unavailability due to maternity leave bank staff were used to cover some of these shifts following review of acuity and occupancy. Melbourne have a number of high acuity patients. Some HCA Agency use required when unable to cover from Bank.

Staff continue to flex staff across both wards



Walton Hospital Site

All Grades of Staff flex across both wards to maintain Staffing levels. Bank is used due to patient acuity/ vacancies – however-this is HCA bank/agency only and not for RN’s. Nights when required flex 3 RN to cover both wards there is always one RN on each ward. Staff flexed across site to ensure numbers at required level with HCA.

RN vacancies open to recruitment but these are hard to fill posts with rolling advert.



Whitworth Hospital – Oker Ward

Some bank use following planned increase in bed occupancy and fluctuations in acuity

There has been a small amount of agency use



TRUST BOARD Document Title: Single Oversight Framework Consultation

Presenter/Title: Chris Sands, Director of Finance, Information and Strategy Contents of Paper were previously discussed by: July 2016 Audit and Assurance Committee

Author/Title: Chris Sands, Director of Finance, Information and Strategy Contact Email and Telephone Number: [email protected]

Date of Meeting: 28July 2016 Agenda Item No: 208/16



Document is for: (more than one box can be ticked) Information Decision X Assurance

Purpose of Paper

NHS Improvement has recently issued its approach to overseeing providers using a Single Oversight Framework. The proposals are now out for consultation. This paper sets out the proposed Trust response.

Recommendations

The Board is asked to approve the response.


N/A

Financial Impact

None


The response was discussed in detail by the Audit and Assurance Committee at its July 2016 meeting, and some minor adjustments made. An update on the discussion is provided in the Audit and Assurance Committee summary report. Appendix 1 includes the proposed response to the consultation.. Appendix 2 sets out the Trust performance at month 2 against the proposed financial metrics in the Oversight Framework. Appendix 3 sets out the Trust performance at month 2 against the proposed financial and operational performance measures

208�Single�Oversight�FrameworkOverall�Page�115�of�210Page�1�of�43




The Single Oversight Framework replaces the current regulatory approach. Governors will need to hold the Board to account for the new framework introduced


There are no specific requirements in the proposed framework around Equality and Diversity..


This is a consultation response. All other stakeholders are able to respond.

Risk Register



N/A (Delete as appropriate)



APPENDIX 1: DRAFT RESPONSE TO CONSULTATION

Consultation question 1: What should we consider in seeking to ensure NHS Improvement and CQC’s frameworks are as aligned as possible? There needs to be a consistent approach to regulation from all parties, and there needs to be clarity from all parties as to what the measure for assessing compliance should be. Ideally, we would like to see a framework which avoids inconsistency of view from regulators. In a time of limited resources, regulators need to ensure that their collective ask of providers is joined up so that they can get the assurances they require, but be minded that this needs to be cost effective for the taxpayer and providers. Quality of Care It would make sense to use the CQC’s most recent assessment of providers as the basis for the quality score. The CQC and other interested parties continue to have dialogue between inspections and have regular surveillance meetings. These surveillance meetings bring together intelligence from a variety of sources to triangulate whether there are existing or emerging concerns around the quality of care within a provider. We believe that NHSI need to continue to be a clear contributor to these meetings. By using a combination of the formal assessments, together with the surveillance meeting, NHSI should be able to develop a consistent view with the CQC around the Quality of Care within an organisation, and use this as the basis of the compliance assessment. Therefore we believe that the processes in place at the CQC should be relied on by NHSI to inform the Quality of Care assessment by NHSI Finance Through the regular financial returns, and relationship management process, NHSI will have a good understanding of the financial position of each provider. There is a danger of duplication of effort by the CQC if they plan to introduce their own assessment of financial performance. Therefore we believe that the processes in place at NHSI should be relied on by the CQC to inform the financial assessment by CQC Leadership and Improvement Capability Through their assessments, CQC will provide a view as to the capability of leadership within an organisation. NHSI will use the well led framework to assess organisations. We believe that going forward, the regulators need to use a consistent assessment framework for this area (which may be the well led framework, which providers will self-assess against). Through the CQC assessment, or through governance concerns raised in the normal course of business, this will be assessed by either NHSI or CQC dependent upon the issue raised. Therefore we believe that the processes in place need to be aligned to ensure that there is a consistent approach to regulation in this area.



Consultation question 2:

(i) Do you agree with our proposed approach to the oversight of providers?

In principal, the approach appears sensible and consistent with previous regimes. However, we are concerned that the metrics proposed will significantly restrict the freedom of a foundation trust to operate in the best interests of local residents and the health system. In particular, the measures proposed around finance, where control totals are being introduced, will restrict foundation trusts from managing their finances flexibly over a number of years to maximise the benefit to local patients. The proposed approach is much more prescriptive than we would expect from a regulator.

(ii) Do you consider that regular reporting should be on a weekly/ monthly or quarterly basis? Are there circumstances where oversight should be more or less frequent than these intervals?

We believe that reporting should be proportional to risk. Organisations that are performing well should benefit from earned autonomy. Regular reporting provides a burden on providers, and creates an opportunity cost. Therefore any information request by regulators needs to be considered in the context of:

• Risk of organisation breaching the oversight framework • The value to the regulator of the information being requested • The cost to the provider of supplying that information

(iii) Do you have any further comments on our overall approach? The consultation is being run at a time when organisations are developing local Sustainability and Transformation Plans, and the governance arrangements for the systems these plans cover. There needs to be alignment of the regulation of both providers (by NHSI), commissioners (by NHS England) and systems (by NHSI and NHS England) to ensure that the right incentives are in the system, and to avoid disincentives to working together for the benefit of patients. Consultation question 3:

(i) Do you agree with our proposed approach to overseeing quality of care?

The approach appears sensible. As per our response to question 1, we believe that NHSI and CQC need to work closely together on their approaches to oversee quality to ensure they are consistent, can rely upon each other’s findings, and don’t duplicate effort and cost to providers.

(ii) Given our and CQC’s respective roles in the NHS, are there other approaches we



could consider?

See above

(iii) Are there other ways in which we could use this framework to identify where providers may need support to meet 7 day services requirements?

The delivery of 7 day services will to some extent be dependent upon additional resources being invested by commissioners. Therefore providers are not solely responsible for the delivery of this indicator. Our view is that consideration needs to be made as to joining up the performance management of this issue at STP, commissioner and provider level, as the three are inter-related. (iv) Do you have any further comments on our proposed approach to overseeing quality of care? No Consultation question 4:

(i) Do you agree with our proposed approach to overseeing finance and use of resources?

We agree in principle with the proposed approach, but have some specific concerns which are set out in the answer to the questions below.

(ii) Do you agree with the chosen metrics?

The financial efficiency section includes “Change in cost per weighted activity unit”. Currently, community and mental health trusts have not been included in the Carter work. Our assumption, therefore is that this metric will be not applicable to these sectors, until the sectors are engaged in this work The agency spend metric is difference from provider cap. The proportion of agency spend per provider varies widely across the country, as does the level of the provider cap. For regulatory purposes, we do not believe it is fair to include a metric which may result in an organisation not achieving their cap, and being rated a 4, when their proportion spend may be much lower than an organisation which is meeting their cap, but is spending a much higher proportion of spend on agency. Therefore for regulatory purposes, we believe that there needs to be a de minimus level, such as 3%, whereby providers are automatically rated as level 1. Where spend raises above this level, the metrics should apply. This approaches would therefore not disadvantage strong performers on agency spend.

(iii) Do you agree with the proposal to weight the metrics equally, or should some, e.g. distance from control totals and change in cost/WAU receive a higher weighting?

We believe that the financial sustainability measures should carry the highest rating, as these are the true measures of organsiations ability to have sufficient cash to operate as a going concern, and true indicators of whether an organisation is moving into financial distress. As mention above, the financial controls measures are not necessarily good indicators of financial performance. The metrics will be inconsistent across all providers, dependent upon their starting position.



(iv) Are there any other metrics you consider we should use?

The previous ratings used by Monitor were good indicators of financial standing of organisations.

(v) Do you agree with our proposed approach to phasing in three of the metrics (change in cost/weighted activity unit, agency controls, capital expenditure controls) above?

This is a sensible approach on the basis of:

• Cost / Weighted Activity Unit – not yet applied to mental health and community providers. We have concerns around introducing this measure in Mental Health and Community Trusts until assurance can be provided that these sectors have good data quality driving their reference cost submissions.

• Capital controls – capital control rules and targets have yet to be issued

• Agency – see comments above regarding our concerns with this metric

(vi) Do you have any further comments on overseeing finance and use of resources? One of the benefits for becoming a foundation trust was that boards would be able to operate autonomously, within a light touch regulatory framework. The introduction of the “financial controls” section in the financial ratings metrics signals that these benefits will not be available both in the short and the medium term. Whilst we accept that in the short term there needs to be controls put in place to support the national position, if this continues into the medium term, it will restrict well run organisations from being innovative with their finances, and may restrict some of the plans being developed in local Sustainability and Transformation Plans. For example, the introduction of capital controls will “lock” cash in the balance sheet. This cash could be used to invest to deliver efficiencies in the future. We would therefore ask that clarity should be provided as to whether the use of financial controls is intended to be a short or medium term set of metrics In addition, the scoring of 1 – 4 is the opposite way around from the previous Monitor framework. Our view is that the scoring needs to be turned around to be consistent with the previous regime. Otherwise it is likely to cause confusion for the stakeholders of the provider who are used to viewing “4” as low risk of financial issues, and “1” as high risk of financial issues. Consultation question 5 :

(i) Do you agree with our proposed approach to overseeing operational performance?

We agree in principle with the proposed approach

(ii) Do you agree with the metrics proposed in Appendix 3?

Yes



(iii) Are there other metrics or approaches we should also consider?

The metrics proposed are limited in relation to a community trust provider. We would be happy to work with NHSI to develop appropriate metrics for Community Trusts. (iv) Do you have any further comments on overseeing operational performance? The delivery of operational metrics will, to some extent, be dependent upon all parts of the system working together. NHSI will need to consider how the regulation of individual providers will work alongside the development of Sustainability and Transformation Plans. The regulation of both needs to be aligned to create the right incentives for commissioners and providers. Consultation question 6: What should we consider to identify potential issues and/or potential support needs in the area of Strategic change? Our understanding is that NHSI will be involved in the governance of STP plans at a local level. Through this local involvement, NHSI will be able to assess for all providers in the STP their relationships, their plans and how far plans have been implemented. However, this may be quite subjective, and therefore there needs to be the development of some KPIs to assess the progress the system is making with the STP plan. Each local system will want to develop their own KPIs dependent upon their local challenges. Our view is that the STP should be allowed to develop local trajectories at both a strategic and operational level, and that the STP, and the providers within this, are assessed with the progress being made against these local measures. We do not support national top down measures in this area, which may divert attention away from local needs. We also believe that there needs to be consistency of approach between NHSI and NHS England. Regulators need to ensure a system is in place which promotes local commissioners and providers working together for the better of the system. The commissioner and provider regulatory system need to be aligned to support this approach. Consultation question 7:

(i) Do you agree with our proposed approach to overseeing providers’ leadership and improvement capability?

Yes

(ii) Are there other factors we should incorporate to identify where providers may require support?

No (iii) Do you have any further comments on overseeing leadership and Improvement capability?



Whatever process is introduced needs to ensure that there is consistency between the view of NHSI and CQC, and that there is the avoidance of duplication. The two national bodies need to work closely together on this area. Consultation question 8:

(i) Do you agree with our proposed approach to segmentation?

Yes (ii) Do you have any further comments on segmentation? We welcome the concept of earned autonomy, and would be interested to understand further details of what this practically will be. Consultation question 9 Do you agree with our proposed approach to supporting providers? We agree. However, we recognise that NHSI will be undertaking a wide range of improvement work across organisations, that would provide value to other organisations. We believe that it is really important to ensure that the learning from targeted and mandated work is shared across the whole sector, as this learning will help prevent some organisations from slipping into levels 3 and 4. We would therefore like to see a set of case studies, checklists etc. as a central resource available for all providers to access.



APPENDIX 2 Single Oversight Framework Consultation Finance Metrics – Month 2 and Forecast Outturn

Area Metric Definition Year to date Year End Outturn Value Score Value Score

Financial Sustainability

Capital Service Capacity Degree to which the provider’s generated income covers its financial obligations.

4.76 1 4.48 1

Financial Sustainability

Liquidity (Days) Days of operating costs held in cash or cash-equivalent forms, including wholly committed lines of credit available for drawdown

17.75 1 29.03 1

Financial Efficiency

EBITDA Margin EBITDA / Total Revenue 6.32

1 5.62 1

Financial Efficiency

Change in Cost per Weighted Activity Unit

Assessing provider efficiency by measuring its average cost increase for an average episode of care (smaller is better)

N/A N/A N/A N/A

Financial Controls

Capital Controls Distance above capital control total N/A N/A N/A N/A

Financial Controls

Distance from Control Total or Financial Plan

Providers with control totals: YTD actual surplus/deficit vs YTD Trajectory Providers without control totals : YTD actual I&E surplus in comparison to the YTD plan I&E surplus

112.2% 1 0 1

Financial Controls

Agency Spend Distance from provider’s cap 97.7% 4 30% 3

Overall Rating 8/5 2 (1.6) 7/5 1 (1.4)



APPENDIX 3 – OPERATIONAL PERFORMANCE MEASURES

DCHS Board Performance Report 2016/17 15/16 Month

Month May Outturn Current Current Trend Plan

3.Organisational health IndicatorsOperational Performance

A&E maximum waiting time of 4 hours from arrival to admission/transfer/discharge - 96.96% 99.98% 96%Maximum time of 18 weeks from point of referral to treatment (RTT) in aggregate – patients on an incomplete pathway

- 97.34% 97.44% 92%

All cancers – maximum 62-day wait for first treatment from:Urgent GP referral for suspected cancer - - - -NHS cancer screening service referral - - - -Maximum 6-week wait for diagnostic procedures - 100% 100% 99%

Acute and specialist providers

Year to date

Single Oversight Framework Template



Single Oversight Framework Consultation June 2016



About NHS Improvement

NHS Improvement is responsible for overseeing NHS foundation trusts, NHS trusts

and independent providers. We offer the support these providers need to give

patients consistently safe, high quality, compassionate care within local health

systems that are financially sustainable. By holding providers to account and, where

necessary, intervening, we help the NHS to meet its short-term challenges and

secure its future.

NHS Improvement is the operational name for the organisation that brings together

Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting

and Learning System, the Advancing Change team and the Intensive Support

Teams.



Contents

1. Context .......................................................................................................................... 4

2. This consultation ............................................................................................................ 4

3. Summary of our proposed approach to overseeing providers ......................................... 7

3.1. Other considerations ......................................................................................... 9

4. Monitoring providers ..................................................................................................... 10

5. Identifying potential concerns ....................................................................................... 12

5.1. Quality of care ................................................................................................. 12

5.2. Finance and use of resources ......................................................................... 13

5.3. Operational performance ................................................................................ 16

5.4. Strategic change ............................................................................................. 17

5.5. Leadership and improvement capability ......................................................... 18

6. Segmentation and the segmentation process ............................................................... 19

6.1. Segmentation process .................................................................................... 21

7. Our support of providers ............................................................................................... 22

8. Summary of consultation questions .............................................................................. 24

Appendix 1: Summary of triggers of potential concern ........................................................ 26

Appendix 2: Proposed quality of care monitoring metrics .................................................... 28

Appendix 3: Proposed operational performance metrics ..................................................... 31



4

1. Context

In recent years, the NHS has achieved improvements in care and delivered

efficiencies during a time of increasing financial pressure caused by slowing growth

in the NHS budget and rising demand. The need to respond effectively to this

continuing increase in demand during a period of limited funding growth was the key

impetus for the NHS Five Year Forward View (5YFV).

Part of the national response to the ambitious and stretching tasks highlighted in the

5YFV was to create NHS Improvement, reflecting that NHS trusts and foundation

trusts face similar challenges. On 1 April 2016, NHS Improvement became the

operational name that brings together Monitor, the NHS Trust Development Authority

(TDA), Patient Safety, the Advancing Change Team and Intensive Support Teams.

The specific legal duties and powers of Monitor and TDA persist.1 We will build on

the best of what these organisations did but with a change of emphasis to one

primarily focused on helping NHS trusts and foundation trusts to improve. We will

provide strategic leadership, oversight and practical support for the trust sector.

We will support NHS trusts and foundation trusts2 to give patients consistently safe,

effective, compassionate care within local health systems that are financially and

clinically sustainable. We will work alongside providers, building deep and lasting

relationships, harnessing and spreading good practice, connecting people, and

enabling sector-led improvement and innovation. We will stimulate an improvement

movement in the provider sector, helping providers build improvement capability, so

they are equipped and empowered to help themselves and, crucially, each other.

Our aim is to help providers attain, and maintain, Care Quality Commission (CQC)

ratings of ‘Good’ or ‘Outstanding’.

The challenges facing the system require a joined-up approach and increased

partnership between national bodies. We are committed to working more closely with

the CQC, NHS England and other partners, at national, regional and local levels.

2. This consultation

This document sets out the approach NHS Improvement proposes to take in

overseeing providers using a Single Oversight Framework for both NHS trusts and

1 NHS Improvement will be clear on which duties and powers of Monitor and the TDA it is exercising at both Board and executive level. Non executive positions are joint and the executive decision- making structure accommodates appropriately constituted committees to enable the exercise of respective functions.

2 For the purposes of this document and our framework, we will use the term ‘providers’ to mean NHS trusts and NHS foundation trusts. This document does not apply to Independent Sector Providers: The Risk Assessment Framework for Independent Providers (available at https://www.gov.uk/government/publications/risk-assessment-framework-independent-sector-providers-of-nhs-services) covers our statutory duty to assess financial risk at those organisations where they provide Commissioner Requested Services (CRS).


https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf


5

foundation trusts and shaping the support we provide. It describes our proposed

approach to:

the main areas of focus of our oversight

how we will collect the information we require from providers

how we will identify potential concerns with a provider’s performance

how we will segment the provider sector according to the level of challenge

each provider faces.

The purpose of this framework is to identify where providers may benefit from, or

require, improvement support across a range of areas (see below). This will inform

the way we work with each provider. This framework does not detail the

improvement support we will provide as in each case this will be individually tailored

to address what a provider needs help with. We ask a number of specific questions

on our proposed approach through the document, and these are collected together

in Section 8 and at the survey website (see below for link).

We are still considering our approach to oversight in a number of areas, including

how well a provider is managing strategic change, and we are using this exercise to

invite views on how we should proceed.

The Single Oversight Framework will replace Monitor’s risk assessment framework

and TDA’s Accountability Framework. It is a ‘Single’ Oversight Framework because it

applies to both NHS trusts and foundation trusts. As far as possible, we will combine

and build on the previous approaches of Monitor and TDA, but adapt them to reflect

and enable our primary improvement role. Any changes from these frameworks are

intended to be as much as possible incremental in nature. The changes we are

making are intended to reflect the challenges providers face and initiatives to support

them. All other related policies and statements, unless indicated, remain

unchanged.

The Single Oversight Framework set out in this document reflects the continuing

statutory duties and powers of Monitor with respect to NHS foundation trusts and of

TDA with respect to NHS trusts (whereby the TDA exercised functions via directions

from the Secretary of State).

Alignment with CQC

CQC sets out what good and outstanding care looks like, asking five key questions

of all care services: Are they safe, are they effective, are they caring, are they

responsive to people’s needs, and are they well-led? These questions will be

supplemented by a forthcoming assessment of the use of resources being jointly

developed by CQC and NHS Improvement.



6

NHS Improvement will support providers in attaining and/or maintaining a CQC

‘good’ or ‘outstanding’ rating, covering the areas listed above. We will do this by

focusing on five themes. As set out in the next section, these five themes are linked

to CQC’s key questions, but are not identical to those questions. This is because:

CQC’s questions do not yet incorporate use of resources; we have a particular role

in supporting improvement in performance against the NHS Constitution standards

for patients; and because our approach to improvement incorporates the strategic

changes within local health economies that will be needed to assure high-quality

services in the longer term.

We will continue to work with CQC to align our approaches more fully as we move

towards a single combined assessment of quality and use of resources. We

welcome views on this as part of the consultation.

Lord Carter’s report, Operational productivity and performance in English NHS acute

hospitals: Unwarranted variations3, recommended the development of an integrated

performance framework to ensure there is a single set of metrics and approach to

reporting, reducing the reporting burden in order to allow providers to focus on

improving quality and efficiency. In line with this recommendation, we are working

with the CQC and with the provider sector to ensure that we draw on a single,

shared set of metrics both to review performance and to decide where to target

support or oversight.

Responding to the consultation

We are looking forward to collecting the views of providers and stakeholders on our

proposals. We ask all interested parties and stakeholders to respond to the

consultation by 5pm on 4 August 2016. To do so please use the survey link:

https://www.surveymonkey.co.uk/r/JBCFCMY. If you have trouble accessing this

please email us at [email protected]. During the

consultation period we will run engagement events to (i) get views, answer queries

and clarify points; and (ii) get more detailed input from the sector on certain areas.

Confidentiality

Please let us know if your response is in confidence. Your name and/or that of your

organisation will then not be given in our published summary of responses.

If you would like just part of your response (instead of or as well as your identity) to

be confidential, please make this obvious by marking those parts we should keep

confidential.

3 Available at

www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_productivity_A.pdf


https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_productivity_A.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_productivity_A.pdf

https://www.surveymonkey.co.uk/r/JBCFCMY


http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_productivity_A.pdf

http://www.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_productivity_A.pdf


7

We will do our best to meet all requests for confidentiality, but because we are a

public body subject to freedom of information legislation we cannot guarantee that

we will not be obliged to release your response (including potentially your identity) or

part of it even if you say it is confidential.

3. Summary of our proposed approach to overseeing providers

NHS Improvement will use the new oversight framework to identify where providers

need support in any of five areas (which we will refer to as themes):

Quality of care: we will use CQC’s most recent assessments of whether a

provider’s care is Safe, Caring, Effective and Responsive, in combination

with in-year information where available. We will also include delivery of the

four priority standards for 7 day hospital services.

Finance and use of resources: we will oversee a provider’s financial

efficiency and progress in meeting its financial control total. We are co-

developing this approach with CQC.

Operational performance: we will support providers in improving and

sustaining performance against NHS Constitution and other standards. These

will include A&E waiting times, referral to treatment times, cancer treatment

times, ambulance response times, and access to mental health services.

Strategic change: working with system partners we will consider how well

providers are delivering the strategic changes set out in the 5YFV, with a

particular focus on their contribution to Sustainability and Transformation

Plans (STPs), new care models, and, where relevant, implementation of

devolution.

Leadership and improvement capability: building on the joint CQC and

NHSI well-led framework, we will develop a shared system view with CQC on

what good governance and leadership looks like, including organisations’

ability to learn and improve.

By focusing on these five themes we will support providers to improve to attain

and/or maintain a CQC ‘good’ or ‘outstanding’ rating. Quality of care, finance and

use of resources, and operational performance relate directly to sector outcomes.

Leadership and improvement capability is crucial in ensuring that providers can

deliver sustainable improvement. Strategic change recognises that organisational

accountability and system-wide collaboration are mutually supportive.

We welcome the sector’s views on how we can most effectively align NHS

Improvement’s approach to support and oversight with CQC’s framework for

assessing providers.

Consultation question 1: What should we consider in seeking to ensure NHS

Improvement and CQC’s frameworks are as aligned as possible?



8

The Single Oversight Framework

NHS Improvement’s Single Oversight Framework is intended to:

provide one framework to oversee providers, irrespective of their legal form

help us identify problems, and risks of problems, as they emerge

pinpoint the source of the problem, allowing us to tailor our support packages

to the specific needs of providers and local health systems. These packages

will draw on expertise from across the sector as well as within NHS

Improvement.

NHS Improvement will need to be flexible in how it carries out its role. For example,

we may need to respond quickly and proactively to unexpected issues in individual

providers or sets of providers, or to policy changes at a national level. We may,

therefore, from time to time, adjust our approach, for example:

add/remove some metrics from our oversight of providers

increase the frequency of our data collection

act sooner than the general threshold set in the framework.

We propose to segment the provider sector according to the scale of issues faced by

individual providers. This will be informed by data monitoring and, importantly,

judgement based on an understanding of providers’ circumstances. Figure 1 sets out

our proposed approach.

Improvement

Confidential

Figure 1: Summary of our approach

1

Is the provider triggering a

concern against any of the

oversight themes/measures?

Has NHSI found, on reviewing

information & evidence, the

need to provide support?

1

yes

Mandated support

required

Yes, with

major/complex

concerns (inc.

special measures)

Yes, with

serious

concerns

Further

investigation/

minor concerns

Targeted

support offered

Universal

support offered

Monitoring

Identifying

concerns

Judgement &

Segmentation

Relationship/

support

no

1

2

34 Across

five

themes

Bre

ach

Co

nce

rn

2

Critical issues No concernsSerious

issues

Emerging

concerns / minor

issues



9

The segment a provider is in will determine the nature of the support we provide.

While this will be tailored to the circumstances of providers, we have identified three

broad categories of support for providers – universal offers, targeted offers and

mandated – which will link to the segment they are in – see section 7.

Segmentation does not in itself constitute an assessment of provider performance.

NHS Improvement teams will work with providers to determine the appropriate,

tailored, support package for each, including directly provided support and support

facilitated by, for example, other parts of the sector.

The legal basis for actions in respect of NHS trusts and NHS foundation trusts

remains unchanged. This means that, for example, a foundation trust will only be in

segments 3 or 4 where it has been found to have been in breach or suspected

breach of its licence. Mandated support for foundation trusts4 continues to follow

existing policy set out in the Enforcement Guidance.5

3.1. Other considerations

The NHS Provider Licence

The statutory obligations of Monitor and TDA continue within NHS Improvement.

Therefore, NHS Improvement must ensure the operation of a licensing regime over

all eligible NHS providers. The NHS provider licence6 forms the legal basis for

Monitor’s oversight of foundation trusts and can be found here. While NHS trusts

are exempt from the requirement to apply for and hold the Monitor provider licence

itself, Directions from the Secretary of State require TDA to ensure that NHS trusts

comply with conditions equivalent to the licence as it deems appropriate. This

includes giving directions to an NHS trust where necessary to ensure compliance.

The Single Oversight Framework applies equally to NHS foundation trusts and NHS

trusts, and we aim to treat all providers in comparable circumstances similarly unless

there is sound reason not to. Consequently NHS Improvement will base our

oversight of all providers – NHS trusts and foundation trusts – on the conditions of

the NHS provider licence.7

4 Based on s.105, s.106 or s.111 of the Health and Social Care Act 2012

5 We will look to update the Enforcement Guidance in due course and consult as appropriate

6 https://www.gov.uk/government/publications/the-nhs-provider-licence

7 For the most part, this is likely to entail holding providers to account against the standards in condition FT4 – the NHS foundation trust governance condition, but our scope extends to the entire NHS provider licence (see www.gov.uk/government/publications/the-nhs-provider-licence). For completeness it should be noted that NHSI has functions and powers in addition to those stemming from the Monitor provider licence in relation to both NHS Trusts and Foundation Trusts and the Single Oversight Framework does not cover these additional matters.


https://www.gov.uk/government/publications/the-nhs-provider-licence

https://www.gov.uk/government/publications/the-nhs-provider-licence

http://www.gov.uk/government/publications/the-nhs-provider-licence


10

4. Monitoring providers

We will use information from our data monitoring processes to identify where

providers are triggering a potential concern in one or more of the five themes (which

indicates they are not in segment 1 and may benefit from support) and judgement,

based on consistent principles, to determine whether or not they are in breach of

licence – or the equivalent for NHS trusts – and, if so, whether the issues are serious

or very serious/complex.

We will collect information on providers (see Figure 2) – either directly or from third

parties. We will seek to ensure that the collection burden is proportionate and, where

possible we will use nationally available information.8 We will collect, for example:

regular financial and operational information

annual plans

third-party information

any ad-hoc or exceptional information that can be used to oversee providers

according to the five themes.

CONFIDENTIAL

Quality of care

Finance & Use of

Resources

Operational

performance

Strategic change

Leadership &

improvement

capability

Monthly returns

Monthly/quarterly(in some

cases weekly) operational

performance information

(see Appendix 3)

Annual plans One-off financial events (eg

sudden drops in income/

increases in costs)

Transactions/mergers

Delivery of Sustainability and

Transformation Plans (STPs)

Progress of any new care

models, devolution plans

Sustainability and

Transformation

Plans (STPs)

In-year quality information

to identify any areas

for improvement

(see Appendix 2)

Third-party information with

governance implications1

Organisational health indicators

- staff absenteeism

- staff churn

- board vacancies

Staff & patient surveys

Third-party information

with governance

implications1

Findings of well-led reviews

Third-party information with

governance implications1

In-yearAnnual/ less

frequentlyAd hoc

Annual quality information

Any sudden &

unforeseen factors

driving a significant

failure to deliver

Any sudden & unforeseen

factors driving a significant

failure to deliver

1 eg reports from Quality Surveillance Groups (QSGs), GMC, Ombudsman, CCGs, Healthwatch England, auditors, Health

& Safety Executive, Patient groups, complaints, whistleblowers, Medical Royal Colleges

Figure 2: Summary of information requirements for monitoring

Results of CQC inspections

CQC warning notices, fines,

civil or criminal actions and information

on other relevant matters

Collection will be:

8 Eg in reviewing performance against national targets and standards.



11

in-year: following a regular in-year monitoring cycle (see Figure 3), using

weekly/monthly/quarterly/six-monthly collections as appropriate

annual: using annual provider submissions (eg Annual Plans, Annual

Statements on Quality) or other annually published data (eg staff surveys)

ad-hoc/by exception: NHS Improvement will be as agile as possible in

responding to issues identified at providers. Where material events occur, or

we receive information that triggers our concerns outside the regular

monitoring cycle, we will consider these in our view as to whether there are

potential concerns at the provider and the steps we need to take.

Improvement

Confidential

Figure 3: NHS Improvement’s oversight cycle

3

Monitoring Support Identifying

potential

concerns

Segmentation

Core set of data from

all providers

Weekly /Monthly/

quarterly frequency

depending on

information source

Providers with critical

issues may be

monitored more

frequently

Focus is on actual

performance and,

where possible,

early warning

Performance assessed

against each theme:

- quality of care

- finance/use of resources

- operational performance

- strategic change

- leadership and

improvement capability

Where may a provider

need support?

Where providers are

triggering concerns we will:

− consider evidence (via

existing knowledge

and/or informal/formal

investigation)

− assess issues providers

are facing

− consider the level and

intensity of support

providers need

− Place providers in the

relevant segment

How serious and complex

are the issues a provider

faces?

Support will be driven by

what we know:

- background to issue

- actions taken to date

- plans prepared/

delivered

- provider capability

Support is either via:

- universal tools

- targeted support offered

to address specific

areas, for providers to

accept voluntarily

- mandated by NHSI due

to seriousness and

complexity of the issue

(or a combination)

Support is tailored and

proportionate to a

provider’s circumstances

During 2016/17, we will use the existing Monitor and TDA oversight templates to

collect information. We will give notice of changes to the collection as we develop

our processes to gather information from providers.


(i) Do you agree with our proposed approach to the oversight of

providers?

(ii) Do you consider that regular reporting should be on a weekly/ monthly

or quarterly basis? Are there circumstances where oversight should be

more or less frequent than these intervals?

(iii) Do you have any further comments on our overall approach?



12

5. Identifying potential concerns

We will use the information we collect on provider performance to identify where

providers need support. Our oversight focuses on identifying ‘triggers’ of potential

concern in each theme.

Our approach in each theme is set out below and summarised in Appendix 1.

Where providers are triggering any of these potential concerns, we will consider the

circumstances surrounding the triggers to determine the nature of any support

required. Practically, we are likely to consider:

the extent to which the provider is triggering a potential concern

any associated circumstances the provider is facing

the degree to which the provider understands what is driving the issue

the provider’s capability and the credibility of plans it has developed to

address the issue

the extent to which the provider is delivering against a recovery trajectory.

We will engage with providers on an ongoing basis. When providers trigger potential

concern, we will consider whether the level of interaction needs to change to monitor

the issue and the provider’s response to it. How we propose to identify potential

concerns against each theme is set out below.

5.1. Quality of care

Where CQC’s assessment identifies a provider as ‘inadequate’ or ‘requires

improvement’ against any of the Safe, Caring, Effective or Responsive key

questions, this will represent a potential concern and we will consider what support is

appropriate for the provider.

We will supplement CQC’s inspection findings with warning notices, any civil or

criminal actions or changes to registration conditions to ensure that we use the most

up to date CQC views of quality and also that their views on quality at providers yet

to be inspected can be incorporated.

In a continuation of TDA’s approach, we will use a number of additional in-year

quality-related metrics to identify emerging issues and/or scope for improvement at

providers – see Appendix 2. If necessary, we will use this information to identify any

improvement needs and support needed.

In addition we will oversee delivery of 7 day hospital services across providers in

order to identify where organisations need support. This will include assessing

whether providers are delivering against an agreed trajectory to meet the four priority

standards for 7 day hospital services. We may, in time, extend this to monitoring

other 7 day services standards and metrics where appropriate.



13

5.2. Finance and use of resources

We will oversee and support providers in improving financial sustainability, efficiency

and controls relating to high profile policy imperatives such as agency staffing,

capital expenditure and the overall financial performance of the sector. We are, with

CQC, co-developing the approach to overseeing providers’ use of resources. This

builds on the approaches taken by Monitor and TDA, which aimed to identify

financial distress rapidly, while introducing a greater focus on efficiency as

recommended by the Carter Review. As the Model Hospital develops, we may

include further efficiency metrics in the Single Oversight Framework.

We propose to use financial metrics to oversee financial performance (see Table 1)

by:

scoring providers 4 (poorest) to 1 (best) against each metric (see Figure 4)

using provider performance average across all the metrics to arrive at an

overall view of the provider.9

Identifying potential financial concerns

Providers scoring 4 or 3 against this overall financial assessment will trigger a

potential concern, as will providers scoring a 4 (ie significant underperformance)

against any of the individual metrics.10

9 Scores are rounded to the nearest whole number. Where a provider’s score is exactly in between two whole numbers, it is rounded to the lowest whole number (eg both 2.2’ and 2.5 are rounded down to 2). This follows Monitor’s prior approach where financial scores were rounded positively, ie towards the ‘best’ score for providers, which in the Single Oversight Framework is lower.

10 The best overall score a provider scoring ‘4’ for any of the individual metrics can obtain is a ‘3’


(i) Do you agree with our proposed approach to overseeing quality of

care?

(ii) Given our and CQC’s respective roles in the NHS, are there other

approaches we could consider?

(iii) Are there other ways in which we could use this framework to

identify where providers may need support to meet 7 day services

requirements?

(iv) Do you have any further comments on our proposed approach to

overseeing quality of care?



14

Table 1: Finance and Use of Resources Metrics

Metric Rationale/considerations

Capital Service Capacity

Assess how much financial headroom providers have over interest or other capital charges (eg PFI payments).

Liquidity Assess providers’ short-term financial position, ie their ability to pay staff and suppliers in the immediate term.

Distance from control total or financial plan

As part of our role in providing sector-wide financial oversight, we are working with providers to agree control totals that will help the sector achieve financial balance. We will track providers’ positions against these through the year.

EBITDA11 margin Assess providers’ operating efficiency independent of capital structure or other factors.

Cost/Weighted Activity Unit - efficiency metrics

(to be run in shadow form in 2016/17 – we will track but not incorporate in the financial rating)

We are introducing a proposed efficiency metric, cost per weighted activity unit (WAU), developed as part of the Carter Review. This estimates provider efficiency by measuring the average cost of an average episode of care, taking into account different types of treatments (HRGs) and modes of delivery (eg elective, outpatient).

The metric relates to a provider’s efficiency improvement and will exclude factors that affect costs but are outside its control. Because reference costs are reported annually, we will use different, more frequently reported, activity and cost datasets to calculate in-year costs per WAU12

Capital Controls

(as above, to be run in shadow form in 2016/17)

NHS Improvement has a responsibility to ensure that capital expenditure remains within the system’s means and we will track providers’ positions against their set capital limits over the year.

Agency spend

(as above, to be run in shadow form in 2016/17)

Monitor and TDA introduced controls on agency spend in 2015 in response to the sharp increases in agency costs seen since 2012. We will continue to track agency spending at providers. Where we have potential concerns, we will consider how best to support the provider in addressing them.

Broader value for money considerations

In addition to using the metrics above, we may investigate whether there is, more

broadly, sufficient evidence to suggest inefficient and/or uneconomical spending at a

provider. Such spending may indicate that a provider is failing to operate effective

11

Earnings Before Interest, Tax, Depreciation and Amortisation 12

The data in these datasets are already provided by providers. There is therefore no new additional reporting burden associated with the calculations.



15

systems and/or processes for financial management and control, and not operating

economically, efficiently and effectively.

Such evidence would come from, for example, published national benchmarking. We

will notify the sector when appropriate benchmarks become available nationally. We

may also look at whether a provider is delivering good practice with respect to value

for money, for instance regarding management consultancy spend. In the absence of

appropriate benchmarks we may still consider investigating a provider if there is

material evidence to suggest it is delivering poor value for money.

CONFIDENTIAL

Area Metric DefinitionScore

1 2 3 41

Financial

sustainability

Capital service capacityDegree to which the provider’s generated

income covers its financial obligations>2.5x 1.75-2.5x

1.25-

1.75x< 1.25x

Liquidity (days)

Days of operating costs held in cash or

cash-equivalent forms, including wholly

committed lines of credit available for

drawdown

>0 (7)-0 (14)-(7) <(14)

Financial

efficiency

EBITDA margin EBITDA/total revenue ≥5% 3-5% 0-3% ≤0%

Change in Cost per

Weighted Activity Unit2

Assessing provider efficiency by

measuring its average cost increase for an

average episode of care (smaller is better)

≤1.1%1.1%-

2.1%

2.1%-

3.1%>3.1%

Financial

controls

Capital controls2 Distance above capital control total <5% 0-5% 5-15% ≥15%

Distance from Control

Total or financial plan

Providers with control totals: Ytd actual

surplus/deficit vs. Ytd trajectory

Providers without control totals : Ytd

actual I&E surplus in comparison to the

Ytd plan I&E surplus2

≥0% (1)-0% (2)-(1)% ≤(2)%

Agency spend2 Distance from provider’s cap ≤0% 0%-25% 25-50% >50%

1 Scoring a ‘4’ on any metric will cap the overall rating to at most 3, triggering a concern.

2 To be used on a shadow basis - ie monitored not evaluated - in 2016/17.

Figure 4: Financial rating metrics

Note: brackets indicate negative numbers

Phasing in the new metrics

We propose to use three of these metrics – change in cost/weighted activity unit,

capital controls and agency spend – in ‘shadow’ form during 2016/17. As a result, we

will not use those in calculating providers’ average financial score during 2016/17,

nor will scoring a 4 against the thresholds for these metrics lead to an override. This

will allow us to assess the quality of data underpinning them and calibrate them

across providers. We can then consider how best to introduce them formally in

2017/18. For 2016/17 our oversight for the purpose of identifying a potential financial

concern will be based on the remaining four metrics in Figure 4.



16

5.3. Operational performance

We will track providers’ performance against, and support improvements in, a

number of NHS Constitution standards and other metrics. Rather than require

providers to make bespoke data submissions, wherever possible we will use

nationally collected and evaluated datasets. Appendix 3 lists the metrics we propose

to use and their collection frequency across acute, mental health, ambulance and

community providers. We may revise this list – introducing new metrics or varying

the collection frequency – as necessary and appropriate, particularly as the Model

Hospital work develops. We will consider whether a potential concern has been

triggered if:

for a provider with one or more agreed Sustainability and Transformation

Fund trajectories against any of the metrics in Appendix 3: it fails to meet any

trajectory for at least two consecutive months

for a provider with no agreed Sustainability and Transformation Fund

trajectory against any metrics: it fails to meet a relevant target or standard in

Appendix 3 for at least two consecutive months

where other factors (eg a significant deterioration in a single month, or

multiple potential concerns across other standards and/or other themes)

indicate we need to get involved before two months have elapsed.

We will then consider the nature of the issues and use this to identify the appropriate

segment for the provider (see below) and develop the support offer.


(i) Do you agree with our proposed approach to overseeing finance and use

of resources?


(iii) Do you agree with the proposal to weight the metrics equally, or should

some, eg distance from control totals and change in cost/WAU receive a

higher weighting?


(v) Do you agree with our proposed approach to phasing in three of the

metrics (change in cost/weighted activity unit, agency controls, capital

expenditure controls) above?

(vi) Do you have any further comments on overseeing finance and use of

resources?



17

5.4. Strategic change

The 5YFV sets out the agenda for the change necessary to support a sustainable

NHS. We will consider the extent to which providers are working with local partners

to address local challenges and improve services for patients. This will include their

contribution to developing, agreeing and delivering Sustainability and Transformation

Plans (STPs) as well as in some cases the implementation of new care models and

implementation of devolution.

To begin with we will use our forthcoming STP assurance process and associated

reviews of STPs as our principal approach to oversight of this theme across

providers. We are working with NHS England to develop a consistent approach and

are likely to consider:

providers’ relationships with local partners

their plans (including STPs they are involved in)

how far these plans have been implemented.

We have published draft guidance on how we expect well-led providers to work with

partners and collaborate locally to improve the quality and sustainability of services

for patients.13 In this guidance we set out the expectation that providers should be

engaging constructively with local partners to

build a shared understanding of local challenges and patient needs

design and agree solutions

implement improvements.

It will be important in our oversight and our support offer to acknowledge the

interplay between individual provider outcomes and delivery of aggregate outcomes

13 Available at

www.improvement.nhs.uk/uploads/documents/Guidance_on_good_governance_in_a_LHE_context_final.pdf

Consultation question 5 :




(iv) Do you have any further comments on overseeing operational

performance?


http://www.improvement.nhs.uk/uploads/documents/Guidance_on_good_governance_in_a_LHE_context_final.pdf

http://www.improvement.nhs.uk/uploads/documents/Guidance_on_good_governance_in_a_LHE_context_final.pdf


18

across a local health economy. As we are still developing our approach under this

theme, we invite input from the service on what other information we should collect

and how we could identify where a provider may need support in this area. We will

look to hold engagement events on this theme during the consultation period.

5.5. Leadership and improvement capability

Shared standards of governance were set out in the NHS foundation trust

governance condition (FT4), TDA Accountability Framework as well as TDA general

objective (which covers much of the same ground as FT4). We expect providers to

demonstrate three main characteristics as part of this theme:

1. Effective boards and governance: We will use a number of information sources

to oversee provider leadership as used previously by Monitor and TDA, including:

information from third parties

staff/patient surveys

organisational metrics

information on agency spend

CQC ‘well-led’ assessments.

We will also draw on the existing well-led framework and associated tools to

identify any potential concerns with the governance and leadership of a provider.

Many providers have already used this framework to assess their governance.

2. Continuous improvement capability: We are working with CQC to consider how

the current shared well-led framework needs to evolve to better reflect the theme

of improvement.

3. Use of data: Effective use of information is an important element of good

governance. Well-led providers should collect, use and, where required, submit

robust data. Where we have reason to believe this is not the case, we will

consider the degree to which providers need support to do so in this area.

Consultation question 6: What should we consider to identify potential

issues and/or potential support needs in the area of Strategic change?



19

Our approach in 2016/17

We will review our approach to leadership and well-led, working with the CQC. In the

meantime, we propose using the same information previously collected by Monitor

and TDA, augmented by other information where available, to identify potential

leadership concerns at individual providers. These can provide early warnings of

issues that have yet to manifest themselves in, for example, quality issues or

financial underperformance, as well as evidence of serious governance failings.

6. Segmentation and the segmentation process

Segmentation helps NHS Improvement determine the nature of the appropriate

support relationship with a provider (see Section 7). It does not give an overall

assessment of a provider’s performance, for which the CQC’s rating is the

benchmark; nor does it determine the specifics of the support package needed,

which is tailored by teams working with the provider in question. We propose

segmenting the sector into four, depending on the extent of any issues identified in

the oversight process.


(i) Do you agree with our proposed approach to overseeing providers’

leadership and improvement capability?

(ii) Are there other factors we should incorporate to identify where

providers may require support?

(iii) Do you have any further comments on overseeing leadership and

Improvement capability?



20

Improvement

Confidential

Scope of data

requested

Monitoring

frequency

Supporting

others

Higher

frequency1 Monthly

n.a. n.a.

Segments for providers

Mandated support

(required)

Targeted support

(offered)3

Universal support

(offered)

Lower

frequency2

Lead role in

transactions, New

Care Models,

success regime

Monthly

Only if acknow-

ledged leader in

an area

Support

Across

5 themes

1234

Serious issuesCritical issuesEmerging

concerns / minor

issues

No evident

concerns

Bre

ach

1 Where necessary

2 Where appropriate

Con

ce

rn

Figure 5: Segmenting the provider sector

3 Or requested by providers

Segment Description

1 No potential concerns identified across our five themes – lowest level

of oversight

2 Triggering criteria of concern in one or more of the five themes – but

not in breach of licence (or equivalent for NHS trusts) and/or formal licence action not needed

3 Serious issues – the provider is in actual/suspected breach of the

licence (or equivalent for NHS trusts)

4 Critical issues - the provider is in actual/suspected breach of its licence (or equivalent for NHS trusts) with very serious/complex issues (eg including providers requiring major intervention on multiple issues to return to sustainable performance).



21

6.1. Segmentation process

The segment a provider is placed in will reflect, in our judgement, the seriousness

and complexity of the issues it faces. We will base our decision on the appropriate

segment for a provider by:

considering all available information on providers – both obtained directly and

from third parties

identifying those providers with one or more triggers of potential concern

using our judgement, based on relationship knowledge and/or the findings of

formal or informal investigations, consideration of the scale of the issues

faced by a provider and whether it is in breach or suspected breach of licence

conditions.

Providers will then be segmented as follows:

no potential concerns identified (per section 5 of this document): segment 1

provider in licence breach (or equivalent for NHS trusts): segment 3 or 4

depending on the seriousness and/or complexity of the issues faced

provider not in breach but still triggering a potential concern: segment 2.

Segmentation needs to be as timely and rigorous as possible, without becoming a

bureaucratic or complex process. We plan to carry out a segmentation exercise

before going live with this new framework, identifying which segment a provider is in

at the time the framework goes live. Subsequently, where our in-year, annual or ad-

hoc monitoring of a provider flags a potential concern, we will review the provider’s

situation and consider whether we need to change its allocated segment.

In parallel with the development of the framework, we will consider providers’

incentives to be in segment 1. While some conditions are fixed across the sector (eg

control totals) others could vary from segment to segment in accordance with the

principle of earned autonomy.



(ii) Do you have any further comments on segmentation?



22

7. Our support of providers

While outside the scope of the Single Oversight Framework itself, our teams will co-

ordinate and oversee tailored support for providers, to support sustainable

improvement. Segmentation informs the oversight and support relationship we have

with each provider, but does not determine the support package, which will be

tailored to a provider’s particular situation.

The support offered will be provider specific but we envisage that it will fall into three

categories:

universal support offer – tools that providers can draw on if they wish to

improve specific aspects of performance. Optional for providers to draw on.

targeted support offer – support to help providers with specific areas – eg

intensive support teams to help in emergency care or agency spend.

Programmes of targeted support will be agreed with providers. This support is

offered to providers – its use is voluntary.

mandated support – where a provider has complex issues, we may prepare

a directed series of improvement actions to help it, eg appoint an

improvement director, or agree a recovery trajectory and support providers to

deliver this. In these serious and critical cases, providers are required to

comply with NHS Improvement’s actions/expectations.

Table 2 below outlines how these types of support link to the segment a trust is in.



23

Table 2: Support offer by segment

Segment Relationship with provider

1 No concerns

Universal support

eg tools, guidance, benchmark information

made available for providers to access

2 Emerging issues/ minor concerns

Universal support (as for segment 1) Targeted support as agreed with the provider

to address issues and move the provider to segment 1

either offered to provider (and accepted voluntarily) or requested by provider

3 Serious issues

Universal support (as for segment 1) Targeted support as agreed with the provider (as for segment 2) Mandated support as determined by NHS Improvement

to address specific issues, move the provider to segment 2 or 1

compliance required

4 Critical issues

Universal support (as for segment 1) Targeted support as agreed with the provider (as for segment 2) Mandated support as determined by NHS Improvement

to minimise the time the provider is in segment 4

compliance required

Consultation question 9 : Do you agree with our proposed approach to

supporting providers?



24

8. Summary of consultation questions


What should we consider in seeking to ensure NHS Improvement and CQC’s

frameworks are as aligned as possible?


(i) Do you agree with our proposed approach to the oversight of providers?

(ii) Do you consider that regular reporting should be on a weekly/ monthly or

quarterly basis? Are there circumstances where oversight should be more or

less frequent than these intervals?

(iii) Do you have any further comments on our overall approach?


(i) Do you agree with our proposed approach to overseeing quality of care?

(ii) Given our and CQC’s respective roles in the NHS, are there other

approaches we could consider?

(iii) Are there other ways in which we could use this framework to identify where

providers may need support to meet 7 day services requirements?

(iv) Do you have any further comments on our proposed approach to overseeing

quality of care?


(i) Do you agree with our proposed approach to overseeing finance and use of

resources?


(iii) Do you agree with the proposal to weight the metrics equally, or should

some, eg distance from control totals and change in cost/WAU receive a

higher weighting?


(v) Do you agree with our proposed approach to phasing in three of the metrics

(change in cost/weighted activity unit, agency controls, capital expenditure

controls) above?

(vi) Do you have any further comments on overseeing finance and use of

resources?



25





(iv) Do you have any further comments on overseeing operational performance?

Consultation question 6: What should we consider to identify potential issues and/or

potential support needs in the area of Strategic change?


(i) Do you agree with our proposed approach to overseeing providers’

leadership and improvement capability?

(ii) Are there other factors we should incorporate to identify where providers

may require support?

(iii) Do you have any further comments on overseeing leadership and

Improvement capability?



(ii) Do you have any further comments on segmentation?


Do you agree with our proposed approach to supporting providers?



26

Appendix 1: Summary of triggers of potential concern

Theme Information used Triggers

Quality of care

CQC information

Other quality information to inform our view of a provider (see Appendix 2)

7 day services

CQC ‘inadequate’ or ‘requires improvement’ assessment versus one or more of: - ‘Safe’ - ‘Caring’ - ‘Effective’ - ‘Responsive’

CQC warning notices

Any other material concerns identified through CQC’s monitoring process, eg civil or criminal cases raised

Concerns arising from trends in our Quality Indicators (Appendix 2)

Delivering against an agreed trajectory for the 4 priority standards for 7 day hospital services

Finance Sustainability o Capital Service

Cover o Liquidity

Efficiency o EBITDA14 margin o Efficiency metrics

Controls o Delivery of control

totals or against plan

o Capital expenditure controls

o Agency spend

Value for money information

Poor levels of overall financial performance (average score of 3 or 4) Very poor performance (score of 4) in any individual metric Potential value for money concerns

14

Earnings Before Interest, Tax, Depreciation and Amortisation



27

Operational performance

NHS Constitution standards Other national targets and standards

For providers with STF trajectories in any metric: failure to meet the trajectory for this metric in more than two consecutive months For providers without STF trajectories: Failure to meet any standard in more than two consecutive months

Strategic Change

Review of Sustainability and Transformation Plans (STPs) and other relevant matters

Material concerns with a provider’s delivery against the transformation agenda, including New Care Models and devolution

Leadership and Improvement capability

Findings of governance or well-led review undertaken against the current well-led framework Third party information, eg Healthwatch, MPs, whistleblowers, Coroners’ reports Organisational Health Indicators Operational efficiency metrics CQC well-led assessments

Material concerns CQC ‘inadequate’ or ‘requires improvement’ assessment against ‘Well-led’.



28

Appendix 2: Proposed quality of care monitoring metrics

Quality indicators for quality surveillance and oversight The 42 proposed indicators below are those previously used in either TDA’s Assurance Framework, Monitor’s Risk Assessment Framework or NHS England’s quality dashboard. The latter mirrors the CQC Intelligent Monitoring Tool. The primary focus and CQC domain for these indicators are shown. Proposed indicators

Measure Type Frequency Source

Organisational Health Indicators – all providers

Staff sickness(2) Organisational

Health Monthly/Quarterly

HSCIC (publicly available)

Staff turnover(2) Organisational

Health Monthly/Quarterly

HSCIC (publicly available)

Executive team turnover (3) Organisational

Health Monthly FT return/O&E

NHS Staff Survey Organisational

Health Annual

CQC (publicly available)

Proportion of Temporary Staff (4) Organisational

Health Quarterly FT return

Aggressive Cost Reduction Plans (4) Organisational

Health Quarterly FT return

Written Complaints - rate Caring Quarterly HSCIC (publicly

available)

Staff Friends and Family Test Percentage Recommended - Care

Caring Quarterly NHSE (publicly

available)

Never events Safe Monthly NHSE (publicly

available)

Never events - incidence rate Safe Monthly NHSE (publicly

available)

Serious Incidents rate Safe Monthly StEIS

National Reporting and Learning System (NRLS) medication errors: Percentage of harmful events

Safe Monthly (1)

NRLS (publicly

available)

Proportion of reported patient safety incidents that are harmful

Safe Monthly NRLS (publicly

available)

Potential under-reporting of patient safety incidents


available)

Central Alerting System (CAS) alerts outstanding


available)

Acute providers Mixed Sex Accommodation

Breaches Caring Monthly

NHSE (publicly available)

Inpatient Scores from Friends and Family Test - % positive

Caring Monthly NHSE (publicly

available)

A&E Scores from Friends and Family Test - % positive


available)



29

Measure Type Frequency Source Emergency c-section rate Safe Monthly HES

CQC Inpatient / MH and Community Survey

Organisational Health

Annual CQC (publicly

available)

Maternity Scores from Friends and Family Test - % positive


available)

Percentage of Harm Free Care Safe Monthly NHSE (publicly

available)

Percentage of new Harms Safe Monthly NHSE (publicly

available)

VTE Risk Assessment Safe Quarterly NHSE (publicly

available)

Clostridium Difficile - variance from plan

Safe Monthly PHE (publicly

available)

Clostridium Difficile - infection rate Safe Monthly PHE (publicly

available)

MRSA bacteraemias Safe Monthly PHE (publicly

available)

Hospital Standardised Mortality Ratio (DFI)

Effective Quarterly DFI

Hospital Standardised Mortality Ratio - Weekend (DFI)

Effective Quarterly DFI

Summary Hospital Mortality Indicator Effective Quarterly HSCIC (publicly

available)

Emergency re-admissions within 30 days following an elective or emergency spell at the Provider

Effective Monthly HES

Community providers




available)

Community Scores from Friends and Family Test - % positive


available)


available)


available)

Mental health providers




available)

Mental Health Scores from Friends and Family Test - % positive


available)

Admissions to adult facilities of patients who are under 16 years of age

Safe Monthly HSCIC (publicly

available)


available)


available)



30

Measure Type Frequency Source Care Programme Approach (CPA)

follow up - Proportion of discharges from hospital followed up within 7 days - MHMDS

Effective Monthly HSCIC (publicly

available)

% clients in settled accommodation Effective Monthly HSCIC (publicly

available)

% clients in employment Effective Monthly HSCIC (publicly

available)

Ambulance providers Ambulance see and treat from

Friends and Family Test - % positive Caring Monthly

NHSE (publicly available)

Return of Spontaneous Circulation (ROSC) in Utstein group

Effective Monthly NHSE (publicly

available)

Stroke 60 mins Effective Monthly NHSE (publicly

available)

Stroke Care Effective Monthly NHSE (publicly

available)

ST Segment Elevation Myocardial Infarction (STeMI) 150 Mins

Effective Monthly NHSE (publicly

available)

Notes

1. If we use published data NRLS data would be six monthly and publicly available.

2. Historically TDA used ESR and Monitor used HSCIC for these data, hence the difference in frequency in 2016-17

3. These data are readily available for NHS providers. 4. The data for NHS trusts has to be confirmed.



31

Appendix 3: Proposed operational performance metrics

Standard Frequency Standard15

Acute and specialist providers16

A&E maximum waiting time of 4 hours from arrival to admission/transfer/discharge

Monthly 95%

Maximum time of 18 weeks from point of referral to

treatment (RTT) in aggregate – patients on an

incomplete pathway

Monthly 92%

All cancers – maximum 62-day wait for first treatment from:

- Urgent GP referral for suspected cancer - NHS cancer screening service referral

Monthly 85% 90%

Maximum 6-week wait for diagnostic procedures Monthly 99%

Ambulance providers17

Maximum 8-minute response for Red 1 calls Monthly 75%

Maximum 8-minute response for Red 2 calls Monthly 75%

Maximum 19-minute response for all Category A calls Monthly 95%

Mental health providers18

Patients admitted to inpatient services who are given access to crisis resolution / home treatment teams in line with best practice standards (UNIFY2 and MHSDS)

Quarterly 95%

15

Minimum % of patients for whom standard must be met 16

NHS Improvement is following the development of indicators to assess the expansion and oversight of liaison mental health services in acute hospitals, including routine analysis of (i) numbers of emergency admissions of people with a diagnosis of dementia; and (ii) length of stay for people admitted with a diagnosis of dementia. These may be incorporated in future iterations of this framework.

17 We will balance this oversight with the impact of dispatch on disposition and other pilots affecting performance reporting currently underway across ambulance providers

18 In addition to the Mental Health indicators here, NHS Improvement is following the development of indicators to assess: (i) Access and waiting times for children and young people eating disorder services; (ii) Providers’ collection of data on waiting times (decision to admit to time of admission, decision to home-treat to time of home-treatment commencement), Delayed Transfers of Care and Out of area placements(OATS); and (iii) Systems to measure, analyse and improve response times for urgent and emergency mental health care for people of all ages. These may be incorporated in future iterations of this framework.



32

Standard Frequency Standard15

People with a first episode of psychosis should commence treatment with a NICE-recommended package of care within 2 weeks of referral (UNIFY2 and MHSDS)

Quarterly 50%

Ensure that cardio-metabolic assessment and treatment for people with psychosis is delivered routinely in the following service areas19:

a) Inpatient wards

b) Early intervention in psychosis services

c) Community mental health services (people on Care Programme Approach)

Quarterly

90%

90%

60%

Complete and valid submissions of metrics in the monthly Mental Health Services Data Set submissions to the HSCIC:

identifier metrics20

priority metrics21

Monthly Monthly

95% 85%

IAPT / Talking Therapies Proportion of people completing treatment who move to recovery (from IAPT MDS) Waiting time to begin treatment (from IAPT MDS) - within 6 weeks - within 18 weeks

Quarterly Quarterly Quarterly

50%

75% 95%

Community providers

Any relevant mental health or acute metrics above

19

Board declaration 20

Comprising: NHS number, Date of birth, Postcode, Current gender, Registered GP org code,Commissioner org Code

21 Comprising: Ethnicity, Employment status (for adults), School attendance (for CYP), Accommodation status, ICD10 coding. By 2016/17 year-end



33

NHS Improvement is the operational name for the organisation that brings together Monitor, NHS Trust Development Authority, Patient Safety, the National Reporting and Learning System, the Advancing Change team and the Intensive Support Teams.

This publication can be made available in a number of other formats on request.

© NHS Improvement (June 2016) Publication code: C 01/16

Contact us

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T: 020 3747 0000 E: [email protected] W: improvement.nhs.uk



TRUST BOARD Document Title: Board Assurance Framework (BAF) Quarter 1

Presenter/Title: Kirsteen Farrar, Trust Secretary Contents of Paper were previously discussed by: 22 July 2016 - Audit and Assurance Committee

Author/Title: Melanie Curd – Deputy Trust Secretary Contact Email and Telephone Number: [email protected]




Document is for: (more than one box can be ticked) Information x Decision x Assurance x

Purpose of Paper

The purpose of the paper is to present the Board Assurance Framework (BAF) for Quarter 1 for approval.

Recommendations

The Board is asked to approve the Board Assurance Framework for Quarter 1.


4.3 - There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly

Financial Impact

There is no direct financial impact linked to this report.


Following a Board Development Session in November 2015, the Executive and Non-Executive Directors have been developing a new version of the BAF for 2016/17. This is the first quarter it has formally been presented to the Quality Committees and Audit and Assurance Committee and it has generated a good discussion. On review at the meetings:

• The wording of 2.1 within the Quality People section has been amended to reflect the workforce supply issues as well as the training issues, the score was increased to 15 making this a high risk. The score of risk 2.4 was increased to 16, also making this a high risk and a new risk was added at 2.6

• All three Quality Committees agreed further development of the BAF is required to reflect the challenges arising from the local health economy and the Derbyshire Sustainability and Transformation Plan. This work will be undertaken during Quarter 2

209�Board�Assurance�Framework�Overall�Page�158�of�210Page�1�of�37


• The Audit and Assurance Committee reviewed the BAF in its entirety and agreed there was further work required on the BAF and also requested the process to review the BAF was flexible enough to meet the rapidly changing environment we are working within

The new BAF risk score summary is attached to support the development of our risk appetite by monitoring how long it takes to achieve our target risk scores. The target risk scores and the timescales have been discussed by the appropriate Quality Committee and Audit and Assurance Committee meetings during July. In summary, there are 28 strategic risks on the BAF. Five high risks; two within Quality People and three within the Quality Business section. The remaining risks on the BAF are all medium risks with the exception of 4.4 regarding Mental Health Act Compliance which is a low risk. In addition, the Summary View is attached which details all areas of limited assurance which have been received by the Committees and Board during the quarter. The Board is asked to approve the Board Assurance Framework for Quarter 1.


What are the Governor involvement implications?

The Governors receive the BAF on a quarterly basis as part of the Board papers.


There are specific risks on the BAF in relation to Equality and Diversity.

What are the Patient, Public, Staff, Member and Stakeholder involvement implications?

The BAF is a public document and in the public domain.

Risk Register

Is the issue on the current Risk Register? N/A If yes, what is the Risk Number?


All operational risks are aligned to the BAF risks. This allows an operational profile to be established. These have been updated on the BAF as of 30 June 2016.



BAF No Risk Description

Q1 Risk

Score

Target Risk

Score

Timeframe to achieve Target

Risk Score

Movement

Q2 Q3 Q4

1.1 There is a risk to management capacity and overall service continuity from the process of bidding for and acquiring new services and/or the requirement to retender for existing services

12 8 (2x4) April 2018

1.2 There is a risk to comprehensive patient information due to discontinuity between systems employed 12 8

(2x4) April 2018

1.3 There is a risk to the provision of safe, effective care due to a lack of consistent clinical leadership and expertise 10 5

(1x5) April 2018

1.4 There is a risk that DCHS does not provide patient centred care due to a lack of engagement and involvement of service users and stakeholders 8 8 N/A

1.5 There is a risk that our Clinical Governance initiatives do not deliver the outcomes necessary to support our Strategy 8 4

(1x4) April 2018

1.6 There is a risk to the provision of safe, effective care due to a lack of consistent employment of clinical governance standards 10 10 N/A

2.1

There is a risk to providing high quality care due to national and local workforce supply shortages and the challenges of developing the workforce to have the appropriate skills and competencies to provide the future models of care

15 8 (2x4) April 2018

2.2

There is a risk to patients, service-users and employees due to staff performance and behaviours not being monitored and improved resulting in an adverse impact on the provision of high quality care and organisational reputation

6 6 N/A

2.3 There is a risk that the Trust fails to develop a proactive Health and Safety culture across the organisation, resulting in the trust not achieving zero harm to staff, visitors, contractors and members of the public.

9 6 (2x3) April 2017

2.4 There is a risk to organisational performance due to the high volume of organisational and health system change, which is likely to continue to be a feature of our health economy for several years

16 12 (4x3) April 2018

2.5

There is a risk that the Trust fails to build cultural competence and the required level of awareness and understanding across the organisation to operate inclusively and deliver equity of access and outcomes for staff and service users

9 6 (2x3) April 2017

2.6 There is a risk to the personal engagement, morale, and health and wellbeing of our staff due to the uncertain operating environment DCHS is working in

TBC




Q1 Risk

Score

Target Risk

Score


Risk Score

Movement

Q2 Q3 Q4

3.1

There is a risk to the organisation achieving strategic objectives due to a lack of integrated planning both internally (through business planning) and externally (through the Sustainability and Transformation Plan) resulting in poor outcomes for patients and poor use of resources

8 8 N/A

3.2 There is a risk to the organisation due to not proactively managing the more competitive environment resulting in an impact on the future sustainability of the Trust

10 10 N/A

3.3 There is a risk to future sustainability due to change in national policy and commissioner priorities 15 10

(2x5)

3.4 There is a risk to the effective and efficient provision of DCHS services due to the impact of funding cuts within Local Authorities resulting in greater activity being directed towards health services

16 12 (3x4)

3.5 There is a risk to the organisation due to poor estate impacting upon patient care resulting in poor outcomes 8 8 N/A

3.6 There is a risk to the organisation regarding the efficient use of resources constrained by Health Economy Plans 9 9 N/A

3.7 There is a risk to the financial stability of the organisation of not meeting future Sustainable Quality Improvement Programme over the next two years

15 10 (2x5)

3.8 There is a risk to the organisation that activity levels will exceed contractual activity targets, resulting in financial risk 12 8 (2x4)

3.9 There is a risk to the organisation due to non-delivery of elements of the IM&T strategy, resulting in objectives not being achieved 12 8 (2x4)

3.10 There is a risk to the organisation due to lack of comprehensive data quality systems resulting in poor decisions that could affect outcomes and financial loss

12 8 (2x4)

3.11 There is a risk to the Trust’s resilience, due to an emergency or severe disruption, resulting in an impact on patient care, inability to meet targets, loss of revenue

10 10 N/A

3.12 There is a risk to the organisation, due to failure to align and influence stakeholders resulting in poor relationships that impact on patient care 8 8 N/A

4.1 There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered 10 8 April 2018




Q1 Risk

Score

Target Risk

Score


Risk Score

Movement

Q2 Q3 Q4

4.2 There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions 10 8 April 2018

4.3 There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly

8 8 N/A

4.4 There is a risk to the organisation due to non-compliance of administration of the MHA 1983 resulting in poor patient outcomes and breaches in legislation

4 4 N/A



DCHS NHS Foundation Trust Board Assurance Framework QUALITY SERVICE - Quarter 1 2016-17

Objective: To deliver high quality and sustainable services that echo the values and aspirations of the communities that we serve

Lead Committee: Quality Service Committee, chaired by Chris Bentley, Non-Executive Director Lead Executive Director: Carolyn White, Director of Quality/ Chief Nurse Strategic Priorities 2016/17

1. Ensure delivery of safe and clinically effective services 2. Ensuring a positive patient experience and meaningful engagement 3. Develop comprehensive and effective systems of quality improvement and assurance

Summary of Quality Service BAF Risks by Lead Executive Director:

There continues to be a high level of support being provided to new service areas including sexual Health and primary Care to ensure that these services meet contractual targets and expected quality standards. Support and advice is being provided from the quality directorate to both areas. In particular sexual health continues to present the trust with a number of operational quality and performance challenges. There has been a decision to halt the roll out of TPP system 1 to inpatient areas which will help to moderate the risk associated with this activity until a better or adapted system has been identified. It does not mitigate the risk completely as we now have different parts of the clinical team accessing a TPP record whilst some staff are recording on paper patient records which are then scanned into the electronic record. This is both cumbersome and time consuming but essential in maintaining a comprehensive record of care. The first four teams to achieve Gold Accreditation standard as part of the quality Always quality improvement process have been identified. Presentations from these teams identified the positive benefits of this initiative to staff and patient outcomes and the positive links with clinical leadership development. The trust is participating in a process of public consultation led by CCG partners over the future provision of clinical care for older people. As part of the process the trust is attending a range of public consultation meetings. We will monitor carefully any impact this may have on our FFT over the coming months. The CQC have completed the first part of their comprehensive inspection of our community services. Verbal feedback was on the whole positive



with confirmation of the trusts achievements in embedding personalised care planning, mental health act and DOLs awareness and very positive feedback from patients and carers. End of life care and community learning disability services were singled out as providing exemplary services. Full reporting on the inspection is due in quarter 2.



Board Assurance Framework Risk 1.1 Risk Register ID 2990

Risk Description Previous Quarters Risk Score Operational Risk

Profile There is a risk to management capacity and overall service continuity from the process of bidding for and acquiring new services and/or the requirement to retender for existing services. Lead Committee/Group:

L3 x C4=12

Medium

High Medium Low

1 2 0

Controls Identified Lead KPIs Quarter 1

1. Comprehensive due diligence checks including quality assessment and staffing profile

Measure Apr May Jun

2. DCHS strategy and Annual plan Incidents related to lead service area reported during tendering process or within 6 months of new service acquisition

Under development

Under development

Under development

3. Risk strategy and Register Number of risks within top X related to service delivery in lead service area

Under development

Under development

Under development

4. Central corporate team to coordinate processes Sickness absence rates within lead management team Under development

Under development

Under development

All papers presented for Assurance in Quarter 1 were received positively with the exception of

Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales):

General Practices – regarding on-going actions April - Outstanding actions from independent insight visit report April - Work to dovetail DCHS policies with the Practices April - A review to streamline overlapping Practice procedures

April - A General Practice Group is being formed and will report to QSC, an operational based Practice Managers Group is also in place

Integrated Sexual Health Services – current completion of outcomes from the plan

June - paper based system used at Wheatbridge hub complicated and confusing to CQC

June – Wheatbridge hub due to migrate to electronic results management system in June/July





Profile

There is a risk to comprehensive patient information due to discontinuity between systems employed Lead Committee/Group:

L3 x C4 = 12

Medium

High Medium Low

0 9 2


1. IMT strategy and provision of TPPsystem One across all services

Measure Apr May Jun

2. Information Governance policies

Roll out of System one in accordance with timetable Under development

Under development

Under development

3. Records audits

Information governance training 95% 94% 93%

4. Information Governance group

5. Caldicott Guardian



General Practices – regarding on-going actions

April - Outstanding actions from independent insight visit report April - Work to dovetail DCHS policies with the Practices April - A review to streamline overlapping Practice procedures


Strategic Shift Apr - Areas are remaining for improvement (a) Apr - Action plan to be presented to QSC in Aug

Community Services Waiting Times Review Jun – Prior to waiting times being reported on, the Committee needs to ascertain areas of most concern (c)

Jun – The divisions will discuss and report their top 5 concerns regarding waits; Provider Services will then analyse the waiting times and report back to QSC in September. A referral will also be made to QBC regarding the concern of QSC re waiting times and flag that they should look at the issue





Profile

There is a risk to the provision of safe, effective care due to a lack of consistent clinical leadership and expertise Lead Committee/Group:

L2 x C5 = 10

Medium

High Medium Low

0 3 0


1. NICE standards and review group Measure Apr May Jun

2. Rotating clinicians from acute services STEIS reportable incidents related to elective services Under development

Under development

Under development






Clinical Safety Group Summary Exception Report – medical devices update

April - Concerns regarding preventative maintenance of podiatric surgery equipment (a)

A check of podiatric surgery equipment has been commissioned to take place over the next few weeks. The matter is to be taken forward via Executives. A report will be provided to QSC that also includes other equipment across the services.


Integrated Sexual Health Services Update Apr – Limited assurance taken subject to: Providing the opportunity for the new senior staff to effectively manage the service; review of the action plan to ensure it matches the new model; appropriately rating the action plan; implement an effective governance system

Apr – Monthly updates to be reported to QSC





Profile

There is a risk that DCHS does not provide patient centred care due to a lack of engagement and involvement of service users and stakeholders Lead Committee/Group:

L2 x C4 = 8

Medium

High Medium Low

0 0 0


1. Patient and engagement and experience group

Measure Apr May Jun

2. EDILF

Friends and family test (target 95%) 98.3% 98.8% 96.80%

3. Stakeholder focus and engagement groups

Number of complaints upheld by ombudsman 0 0 0

4. Council of Governors

Number of complaints responded to within 40 working days 6 (67%) 8 (57%) 7 (64%)

5. Policies related to Duty of candour

Number of engagement groups (?Target) 23 involvement groups have been established across DCHS

6. Insight visits Number of serious incidents were Duty of candour applies 10 14 13

7. Consultation and engagement Processes Dignity in care achievements 79 services have the DiC award

Number of Insight visits completed with feedback 3 1 2













Profile There is a risk that our Clinical Governance initiatives do not deliver the outcomes necessary to support our Strategy Lead Committee/Group:

L2 x C4 = 8

Medium

High Medium Low

0 0 0


1. Measure Apr May Jun

2.

3.

4.

5.













Profile There is a risk to the provision of safe, effective care due to a lack of consistent employment of clinical governance standards Lead Committee/Group:

L2 x C5 = 10

Medium

High Medium Low

2 13 0


1. Measure Apr May Jun

2.

3.

4.

5.

6.






Integrated Sexual Health Services Update Apr – Limited assurance taken subject to: Providing the opportunity for the new senior staff to effectively manage the service; review of the action plan to ensure it matches the new model; appropriately rating the action plan; implement an effective governance system





DCHS NHS Foundation Trust Board Assurance Framework QUALITY PEOPLE - Quarter 1 2016-17

Objective: To build a high performance work environment that engages, involves and supports staff to reach their full potential

Lead Committee: Quality People Committee, chaired by Barbara-Anne Walker, Non-Executive Director Lead Executive Director: Amanda Rawlings, Director of People and Organisational Effectiveness Strategic Priorities 2016/17 1. Effectiveness workforce planning and development to meet our current and future patient needs. 2. Ensuring DCHS maintains its excellent staff engagement and grows this further. 3. To build cultural competence and awareness across DCHS to ensure we deliver equity of access and outcomes for staff and service users. 4. To ensure DCHS is compliant with health and safety legislation and builds a zero harm environment. Summary of Quality People BAF Risks by Lead Executive Director: Following review at the Quality People Committee in July, DCHS has 6 Quality People BAF risks, two high risks and four medium. The risk of ‘our staff not being able to provide high quality care due to national and local workforce supply shortages and the challenges of developing the workforce to have the appropriate skills and competencies to provide the future model of care resulting in poor patient outcomes’ has been re-scored to 15 in light of the expected STP plans, which will no doubt have major implications for how we will need to train and develop our staff in future. The risk of DCHS not building a zero harm environment (2.3) has received much focus drawing quarter 1. A number of key pieces of new work to mitigate this risk are now underway. For example, we have now launched easy to use paper ‘near miss’ and ‘incident reporting’ cards across the Trust to make it easier for staff with little access to IT to still log near misses and incidents. We have also launched our Health and Safety for Leaders training programme, which is receiving great feedback. This aims to equip managers to lead by example to create a zero harm environment for their teams. We are also about to go live with our Safety Culture survey, which will inform future focus around this risk. Risk 2.4 (high volume of organisational and health system change) has also been reviewed and re-scored to a 16 due to the expected changes arising from the STP work. In addition, a 6th risk has been added to reflect the impact organisational change is likely to have on our staff at an individual level in terms of their morale, engagement and wellbeing. Due to proposed system transformation plans it is envisaged that achieving the target risk scores will take longer and the timescales have been amended accordingly however this will be monitored on a quarterly basis.



All papers presented for Assurance in Quarter 1 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Clinical Safety Group Summary Exception Report – medical devices update (QSC)

Apr - Concerns regarding preventative maintenance of podiatric surgery equipment (a)

Apr - A check of podiatric surgery equipment has been commissioned to take place over the next few weeks. The matter is to be taken forward via Executives. A report will be provided to QSC that also includes other equipment across the services.

Strategic Shift(QSC) Apr - Areas are remaining for improvement (a) Apr - Action plan to be presented to QSC in Aug Integrated Sexual Health Services Update(QSC) Apr – Limited assurance taken subject to:

Providing the opportunity for the new senior staff to effectively manage the service; review of the action plan to ensure it matches the new model; appropriately rating the action plan; implement an effective governance system


People Performance Report and Priority Areas of Focus May - Trend of increasing absence resulting from sickness (a) May - QPC recommended that POE invite an independent individual to review strategy around this topic to ensure everything possible is being done

Board Assurance Framework Risk 2.1 Risk Register ID 2995 Risk Description Previous Quarters Risk Score Operational Risk

Profile There is a risk to providing high quality care due to national and local workforce supply shortages and the challenges of developing the workforce to have the appropriate skills and competencies to provide the future models of care Lead Committee/Group: Workforce Planning and Development

L3 x C5 = 15

High

High Medium Low

1 4 0

Controls Identified Lead KPIs Quarter 1 1. Regular reporting of training compliance to Ops Management, WFPDG and QPC Measure Apr May Jun 2. Revised Training needs analysis aligned to Service and strategic workforce plans Essential learning compliance 95% 94.5% 95% 3. Clinical Audits (e.g. Quality Always Assessment) Appraisal compliance 92% 93.1% 91% 4. Friends and Family Test No. of failed revalidations 1 2 2 5. Re-registration policy Care certificate attainment compliance 100% 6. Staff Survey Preceptorship compliance 7. DATIX Incidents 8. Internal Intelligence Group




Profile There is a risk to patients, service-users and employees due to staff performance and behaviours not being monitored and improved resulting in an adverse impact on the provision of high quality care and organisational reputation Lead Committee/Group: Staff Partnership Committee

L2 x C3 = 6

Medium

High Medium Low

1 0 0

Controls Identified Lead KPIs Quarter 1 1. Robust People Policies (e.g. Disciplinary, Performance Attendance) Measure Apr May Jun 2. Outcomes and actions from result of Staff Survey and Pulse checks

Av number of days an Employee Relations case takes to complete 91 91 86

3. Resolve Staff Support service Attendance % 95.12% 95.27% 95.65% 4. Feedback and action from “Raising Concerns” app Pulse Checks Staff Engagement score 74% 74% 74% 5. Friends and Family test No. of complaints from Patients that lead to employee

investigations or performance management 1 0 0

6. Revalidation / Registration and monitoring process Number of Employment Tribunals ongoing 1 1 1 7. Quality Always development centre Essential Learning compliance 95% 95.4% 95% 8. DATIX incidents Appraisal compliance 92% 93.1% 91%

All papers presented for Assurance in Quarter 1 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): People Performance Report and Priority Areas of Focus May - Trend of increasing absence resulting from sickness (a) May - QPC recommended that POE invite an independent

individual to review strategy around this topic to ensure everything possible is being done




Profile There is a risk that the Trust fails to develop a proactive Health and Safety culture across the organisation, resulting in the trust not achieving zero harm to staff, visitors, contractors and members of the public. Lead Committee/Group: Staff Health Safety and Wellbeing Group

L3 x C3 = 9

Medium

High Medium Low

0 4 0

Controls Identified Lead KPIs Quarter 1 1. Health and Safety Strategy (September 2016) Measure Apr May Jun 2. Manager Training for Health and Safety (April 2016) Safety frequency rate (no) 0 0.34 0 3. Health and Safety Training for all staff Safety severity rate (no) 3.2 3.03 2.21 4. Dedicated Health and Safety Manager in post Lost time injury cost (000) £130,870 £103,208 £90,304 5. Annual Health and Safety Self Audits Zero Harm- Riddor Reportable Injuries. 0 2 0 6. Regular reports from Occupational Health and Resolve on activity % of managers who have received Health and Safety training 97% 98% 97% 7. Policies and Operating Standards for health and safety activities. 8. Banksmen Training

All papers presented for Assurance in Quarter 1 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Clinical Safety Group Summary Exception Report – medical devices update (QSC)

Apr - Concerns regarding preventative maintenance of podiatric surgery equipment (a)

Apr - A check of podiatric surgery equipment has been commissioned to take place over the next few weeks. The matter is to be taken forward via Executives. A report will be provided to QSC that also includes other equipment across the services.


Health and Safety Update May – Low number of near misses reported May – High number of violence and aggression incidents reported

Staff Health and Wellbeing Agenda at DCHS May – Absence of any outcomes at the present time May - QPC will receive follow up reports regarding progress against the CQUIN targets



Board Assurance Framework Risk 2.4 Risk Register ID 2998 Risk Description Previous Quarters Risk Score Operational Risk Profile There is a risk to organisational performance due to the high volume of organisational and health system change, which is likely to continue to be a feature of our health economy for several years. Lead Committee/Group: Staff Partnership Committee

L4 x C4 = 16

Medium

High Medium Low

0 7 0

Controls Identified Lead KPIs Quarter 1 1. Organisational Change Policy Measure Apr May Jun 2. Dedicated POEM support to each organisational change Staff turnover 9.72% 10.82% 11.18% 3. Check and challenge of each organisational change proposal

through the Management of Change section of SPC % of staff successfully redeployed after being placed at risk of redundancy 0% 0% N/A

4. Tracking of Management of Change processes through SPC Numbers of Grievances re: org. change 0 0 1 5. Derbyshire-wide HR Policy Sub-Group agreement on cross –

organisational support during organisational change Attendance % 95.12% 95.27% 95.65%

6. Resolve staff support service Appraisal % 92% 93% 91% 7. Clinical Vision Events Essential Learning % 95% 95% 95% 8. DCHS Leadership Development Friends and Family Test 98.30% 98.80% 96.80%

All papers presented for Assurance in Quarter 1 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Integrated Sexual Health Services Update Apr – Limited assurance taken subject to:

Providing the opportunity for the new senior staff to effectively manage the service; review of the action plan to ensure it matches the new model; appropriately rating the action plan; implement an effective governance system



Deep Dive: Lessons Learnt from Organisational Change in the HWBI Division

May - Management of change remains very challenging work (a) May - A paper will be presented to the Board in June to share learning from the process



Board Assurance Framework Risk 2.5 Risk Register ID 2999 Risk Description Previous Quarters Risk Score Operational Risk Profile There is a risk that the Trust fails to build cultural competence and the required level of awareness and understanding across the organisation to operate inclusively and deliver equity of access and outcomes for staff and service users. Lead Committee/Group: Equality, Diversity & Inclusion Leadership Forum

L3 x C3 = 9

Medium

High Medium Low

1 2 0

Controls Identified Lead KPIs Quarter 1 1. Equality and Diversity Training for staff Measure Apr May Jun 2. Board Equalities Action Plan

% of actions in (1) Corporate, (2) Board and (3) Service-level Equalities Action Plans achieved

Under development

3. Corporate Equalities Action Plan % of services using TPP that are using the Equality Monitoring Questionnaire (Big 9) for service users 41.37% 38.28% 46.42%

4. Directorate / Service-level Equalities Action Plans Level of EDS2 achieved (at ‘Developing’ moving to ‘Achieving’) Achieving Achieving Achieving 5. Service User Equality Data Analysis

DCHS Workforce profile Vs Derbyshire population profile

DCHS Derbyshire 6. People Policies White 94% 96% 7. People Strategy BME 4% 4%

Disability 3% 14% Male 11% 49% Female 89% 51% LGB 0.33%-0.42% 4%-7% Christian 50% 63%

All papers presented for Assurance in Quarter 1 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): People Performance Report and Priority Areas of Focus May - Trend of increasing absence resulting from sickness (a) May - QPC recommended that POE invite an independent

individual to review strategy around this topic to ensure everything possible is being done



Board Assurance Framework Risk 2.6 Risk Register ID Risk Description Previous Quarters Risk Score Operational Risk Profile There is a risk to the personal engagement, morale, and health and wellbeing of our staff due to the uncertain operating environment DCHS is working in Lead Committee/Group:

New Risk during 2016/17 Q1

High Medium Low

Controls Identified Lead KPIs Quarter 1 Measure Apr May Jun



DCHS NHS Foundation Trust Board Assurance Framework QUALITY BUSINESS - Quarter 1 2016-17

Objective: To ensure an effective, efficient and economical organisation which

promotes productive working and which offers good value to its community and commissioners

Lead Committee: Quality Business Committee, chaired by Ian Lichfield, Non-Executive Director Lead Executive Director: Chris Sands, Director of Finance, Information and Strategy Strategic Priorities 2016/17 1. To deliver a resilient current and future financial position, and be able to demonstrate value for money in the use of resources 2. To develop the Trust’s estate and infrastructure to support patient care ensuring benefits are identified, tracked and delivered 3. To explore, implement and monitor technical innovative approaches to providing care in a better way whilst demonstrating value for money 4. To develop the Trust in line with the commercial strategy to support the health economy in delivering the 5 year forward view Summary of Quality Business BAF Risks by Lead Executive Director: The Trust has 3 red risks on the Quality Business section of the BAF. There is a risk to future sustainability due to change in national policy and commissioner priorities. The Sustainability and Transformation Plan (STP) was submitted in draft to NHS England on 30th June. This was a ”checkpoint” in the STP planning process. The emerging plans are consistent with those within the Integrated Business Plan and Operational Plan, and support out of hospital provision of services where this is in the best interests of patients. The plan will now be reviewed and leaders from Derbyshire will be meeting the national team on 25th July 2016. This will give us insight into whether our plans are supported nationally. The intention is to align national policy and commissioner priorities into the STP plan. Once plans have been fully signed off, this risk will be reviewed. There is a risk to the effective and efficient provision of DCHS services due to the impact of funding cuts within Local Authorities resulting in greater activity being directed towards health services. The Trust continues to engage with colleagues in Derbyshire County



Council and Derby City Council to understand the impact of these cuts. For the purposes of the June Checkpoint, the STP plan does not include Council financial positions. However, the Councils continue to be well engaged and the intention is to ensure that the Council position remains an integral part of system planning. This further work is required on the joined up system plan before the risk can be reduced. There is a risk to the financial stability of the organisation of not meeting future Sustainable Quality Improvement Programme over the next two years. The Trust has started the financial year positively. At Quarter 1, the Trust is on track with the SQIP programme for 2016/17, and the financial position is slightly ahead of plan. The Trust is now starting to turn its attention to the 2017/18 SQIP plan. This will need to be developed both within DCHS, but also start to align with the STP plans. The national financial position continues to be challenging, and the Trust needs to be aware of the indirect impact this could have on our own finances. Further clarity is expected in the next month around the national financial position for both 2015/16 and 2016/17. It is expected that there will be top down requirements imposed on health systems that will either directly, or indirectly, affect the Trust financially.



All papers presented for Assurance in Quarter 1 were received positively Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales):


Profile There is a risk to the organisation achieving strategic objectives due to a lack of integrated planning both internally (through business planning) and externally (through the Sustainability and Transformation Plan) resulting in poor outcomes for patients and poor use of resources Lead Committee/Group: Quality Business Committee

L2 x C4 = 8

Medium

High Medium Low

0 11 0

Controls Identified Lead KPIs Quarter 1 1. IBP 5. Performance Reports Measure Apr May Jun 2. LTFM 6. Chief Executives Report Monitor Sign Off of Plan 3. Annual Plan 7. Policies and Procedures Governance Risk Rating 0 0 4. Operational Plan Updates 8. Transformation Update Finance Risk Rating 4 4




Profile There is a risk to the organisation due to not proactively managing the more competitive environment resulting in an impact on the future sustainability of the Trust Lead Committee/Group: Board

L2 x C5 = 10

Medium

High Medium Low

0 1 0

Controls Identified Lead KPIs Quarter 1 1. Business Development Reporting Measure Apr May Jun 2. Commercial Strategy Tenders Won (Value) 0 0 0

3. Business development framework (eg investment policy / decision making tool) Tenders Lost (Value) 0 0 0 4. Competitor and market analysis Tenders Won (Number) 0 0 0 5. Tender oversight and analysis Tenders Lost (Number) 0 0 0





Profile There is a risk to future sustainability due to change in national policy and commissioner priorities Lead Committee/Group: Quality Business Committee

L3 x C5 = 15

High High Medium Low

0 2 0

Controls Identified Lead KPIs Quarter 1 1. Contract management and negotiation process Measure Apr May Jun 2. Board and Executive colleagues meetings with Commissioner Chief Officers /team/ other contacts

3. Analysis of commissioning intentions as part of planning process 4. SQIP indicate level of commissioner support 5. Tender oversight and analysis 6. Board and Executive colleagues attendance at National Meetings / National Groups





Profile There is a risk to the effective and efficient provision of DCHS services due to the impact of funding cuts within Local Authorities resulting in greater activity being directed towards health services Lead Committee/Group: Quality Business Committee

L4 x C4 = 16

High

High Medium Low

0 0 0

Controls Identified Lead KPIs Quarter 1 1. Health and Wellbeing Board Measure Apr May Jun 2. Contract Management Board Delayed Transfer of Care (Rehabilitation) 7.8% 9.5%

3. Transformation groups Delayed Transfers of Care (MH) 0.0% 3.0%

4. Better Care Fund Number of Patients waiting for a DoLS assessment Direct impact on contracts portfolio in HWBI





Profile There is a risk to the organisation due to poor estate impacting upon patient care resulting in poor outcomes Lead Committee/Group: Capital and Estate Programme Group

L2 x C4 = 8

Medium High Medium Low

0 6 1

Controls Identified Lead KPIs Quarter 1 1. Estates Planning System Measure Apr May Jun 2. Capital Planning System

Proportion of estate at B or above Under

development

3. Progress Reports against Estates Strategy Percentage of unutilised estate

4. Planned Preventative Maintenance System Percentage of non-patient facing estate Under development

5. Policies and procedures

6. Facet Survey

All papers presented for Assurance in Quarter 1 were received positively with the exception of: Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Integrated Sexual Health Services Update (QSC) Apr – Limited assurance taken subject to:

Providing the opportunity for the new senior staff to effectively manage the service; review of the action plan to ensure it matches the new model; appropriately rating the action plan; implement an effective governance system (a)





Profile There is a risk to the organisation regarding the efficient use of resources constrained by Health Economy Plans Lead Committee/Group: Capital and Estate Programme Group

L3 x C3 = 9


0 1 0

Controls Identified Lead KPIs Quarter 1 1. Capital Planning System Measure Apr May Jun 2. Progress Reports against Estates Strategy 100% Delivery of Capital Programme 11.4% 10.1%





Profile There is a risk to the financial stability of the organisation of not meeting future Sustainable Quality Improvement Programme over the next two years Lead Committee/Group: Quality Business Committee

L3 x C5 = 15

High High Medium Low

0 3 0

Controls Identified Lead KPIs Quarter 1 1. Finance Reports Measure Apr May Jun 2. SQIP Reports Recurrent SQIP Planned (£,000) 303 607 3. Performance Management System Recurrent SQIP Actual (£,000) 265.5 550.5 4. PMO Office Forecast SQIP (£,000) 5,000 4,740 5. Policies and procedures 2017/2018 SQIP Planned (£,000)







Profile There is a risk to the organisation that activity levels will exceed contractual activity targets, resulting in financial risk Lead Committee/Group: Quality Business Committee

L3 x C4 = 12


0 4 0

Controls Identified Lead KPIs Quarter 1 1. Finance Reports Measure Apr May Jun 2. Performance Reports Income - Planned (£,000) 15,541 31,298 3. Performance Management System Income - Actual (£,000) 15,576 31,328 4. Policies and Procedures Income Forecast - (£,000) 187,008 188,541 5. Planning Process Activity -Planned (no) 33,488 33,006 6. Contract Management meetings with Commissioners Activity Actual (no) 35,311 35,158







Profile There is a risk to the organisation due to non-delivery of elements of the IM&T strategy, resulting in objectives not being achieved. Lead Committee/Group: Information Management & Technology Group

L3 x C4 = 12


0 7 0

Controls Identified Lead KPIs Quarter 1 1. IM&T Reporting Measure Apr May Jun

2. IM&T Strategy Percentage of Services on an electronic system - progress against IM&T Plan (%) 63.7% 63.7%

3. IMT Group Information Sharing within the Trust Percentage 81.7% 80.3% 4. Policies and Procedures




Benefits Realisation May - Report illustrated no benefits (a) May - The report is to be revisited in order to drive through the benefits originally laid out. The background section is to be rewritten and baseline figures added so that benefits can be measured




Profile There is a risk to the organisation due to lack of comprehensive data quality systems resulting in poor decisions that could affect outcomes and financial loss Lead Committee/Group: Information Management & Technology Group

L3 x C4 = 12


0 0 0

Controls Identified Lead KPIs Quarter 1 1. Performance Reporting - Data Quality issues Measure Apr May Jun 2. Data Quality Kitemark Percentage of performance KPIs covered by kitemark 3. Policies and procedures Percentage of kitemarked KPIs 12 or above 4. IM&T Strategy CIDS services under kitemark 5. IMT Group SUS Patient Records with NHS Number 99.8% 99.9%

All papers presented for Assurance in Quarter 1 were received positively with the exception of: Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Data Quality Update Paper (AAC) Apr - TPP Project behind schedule (a) Integrated Sexual Health Services Update (QSC) Apr – Limited assurance taken subject to:






Profile There is a risk to the Trust’s resilience, due to an emergency or severe disruption, resulting in an impact on patient care, inability to meet targets, loss of revenue. Lead Committee/Group: Quality Business Committee

L2 x C5 = 10


0 1 1

Controls Identified Lead KPIs Quarter 1 1. Accountable Emergency Officer appointed Measure Apr May Jun 2. Member of the multi-agency Local Health Resilience Partnership Gold Training -Number Compliant (no) 7 7 7 3. Member of the multi-agency Local Resilience Forum Gold Training -Number Available (no) 7 7 7 4. Framework for Responding to Industrial Action in-place Gold Training (%) 100% 100% 100% 5. Quarterly reporting to the board via QBC Silver Training -Number Compliant (no) 8 8 8 6. Major Incident Plan/Business Continuity Plan Silver Training -Number Available (no) 8 8 8 7. Site Contingency Plan in-place Silver Training (%) 100% 100% 100% 8. Pandemic Influenza Contingency Plan in-place Core Standards Training (%) >90% >90% >90% 9. Internal assessment against NHS England's Core Standards for EPRR undertaken





Profile There is a risk to the organisation, due to failure to align and influence stakeholders resulting in poor relationships that impact on patient care Lead Committee/Group: Board

L2 x C4 = 8


0 0 0

Controls Identified Lead KPIs Quarter 1 1. Communications and marketing strategy Measure Apr May Jun 2. Board level lead for communications and marketing Staff and service user friends and family test 98.3% 98.8% 96.8% 4. Staff survey 5. Partnership strategy and governance 6. Tender oversight includes review of necessary partnership arrangements






DCHS NHS Foundation Trust Board Assurance Framework QUALITY GOVERNANCE - Quarter 1 2016-17

Objective: To manage and develop a successful organisation Lead Committee: Audit and Assurance Committee, chaired by Nigel Smith, Non-Executive Director Lead Executive Director: Kirsteen Farrar, Trust Secretary Strategic Priorities 2016/17 1. To ensure control systems to manage strategic risks are operating effectively 2. To ensure the Board Assurance Framework remains a live document which fully reflects the risks and opportunities facing the Trust to deliver

our vision 3. To understand the implications of new models of care and to advise the Board as to the emerging governance issues arising and the Trust’s

response Summary of Quality Governance BAF Risks by Lead Executive Director: During the Quarter, significant external assurance was received on; the Counter Fraud Annual Report 2015/16, Head of Internal Audit Opinion, Annual Internal Audit Plan, Internal and External Audit Progress Reports, Cost Improvement Report (which was presented to QBC), Auditors Report on Annual Quality Report and 360 Assurance Mental Health Act Compliance Follow-up Report. Significant internal assurance has been received for all papers during the quarter with the exception of the Strategic Shift which was presented to the Quality Service Committee in April but impacts on 4.2 There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions. This received limited assurance and the improvement actions are being monitored by QSC.





Profile There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions Lead Committee/Group: Audit & Assurance Committee

L2 x C5 = 10

Medium

High Medium Low

0 2 1

Controls Identified Lead KPIs Quarter 1 1. CQC Compliance Reporting Measure Apr May Jun 2. Monitor Self-Certification CQC Non-Compliance with Fundamental Standards resulting in Enforcement Action (no) 0 0 0 3. Performance Reporting CQC Compliance Action Outstanding (no) 0 0 0 Governance Risk Rating Continuity of Service Rating 4 4 4

All papers presented for Assurance in Quarter 1 were received positively with the exception of: Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Strategic Shift(QSC) Apr - Areas are remaining for improvement (a) Apr - Action plan to be presented to QSC in Aug

Board Assurance Framework Risk 4.1 Risk Register ID 3000 Risk Description Previous

Quarters Risk Score Operational Risk Profile

There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered Lead Committee/Group: Audit & Assurance Committee

L2 x C5 = 10


0 1 1

Controls Identified Lead KPIs Quarter 1 1. Constitution and Procedures 5. Counter Fraud Reports 9. Board Assurance Framework Measure Apr May Jun 2. Board Committee Reporting 6. External Audit Reports 10. Clinical Audit Programme Governance Rating 3. Quality Governance reporting 7. Scheme of Delegation 11. Annual Governance Statement 4. Internal Audit Reports 8. Self-Certification Reporting




Profile There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly Lead Committee/Group: Quality Service Committee Risk Register Review Meeting

L2 x C4 = 8


0 0 0

Controls Identified Lead KPIs Quarter 1 1. Risk Management Strategy Measure Apr May Jun 2. Board Assurance Framework Number of top X risks 33 32 29 3. Risk Register 4. Risk Management Policy Number of overdue risks 0 0 1 5. DATIX Risk Management System 6. Annual Governance Statement



Board Assurance Framework Risk 4.4 Risk Register ID 3003 Risk Description Previous

Quarters Risk Score Operational Risk Profile

There is a risk to the organisation due to non-compliance of administration of the MHA 1983 resulting in poor patient outcomes and breaches in legislation Lead Committee/Group: Mental Health Act Committee

L1 x C4 = 4

Low High Medium Low

0 0 1

Controls Identified Lead KPIs Quarter 1 1. AMHAM Audits Measure Apr May Jun 2. MHA Scheme of Delegation Completion of 2 AMHAM Audits per year OPMH and LD inpatient services 3. MHA Code of Conduct Unrectifiable errors on section paperwork 0 0 0 4. Regular training updates for staff Overdue actions on Code of Practice action plan 5 5 5 5. Policies and procedures



TRUST BOARDDocument Title: NHS Improvement (NHSI) Self-certification – Quarter 1

Presenter/Title: Kirsteen Farrar, Trust SecretaryContents of Paper were previously discussed by:

Executive Meeting – 14 July 2016Audit and Assurance Committee – 22 July 2016

Author/Title: Melanie Curd, Deputy Trust SecretaryContact Email and Telephone Number: 01773 525065



Has an Equality Impact Assessment been undertaken Yes No XDocument is for:(more than one box can be ticked) Information Decision X Assurance X

Purpose of Paper

The purpose of the paper is to provide assurance to enable the Board to approve the Self-certification return for Quarter 1.

Recommendations

The Board is asked to consider the Self-certification, discuss the issues and approve the Quarter 1 return.


4.2 - There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions.

Financial Impact

The Self-certification requires the Board to make a financial declaration.


DCHS became a Foundation Trust (FT) on the 1 November 2014 and as such we are required to provide in-year submissions to NHSI on a quarterly basis based upon the reporting requirements in the Risk Assessment Framework (RAF) – August 2015.

The RAF provides a framework to assess individual NHS foundation trusts’ compliance with two specific aspects of their work: ‘the continuity of services’ (CoS) and ‘governance conditions in their provider licenses’. The RAF confirms that the Governance rating will be based on:

performance against selected national access and outcomes standards outcomes of CQC inspections and assessments relating to the quality of care provided relevant information from third parties a selection of information chosen to reflect organisational health at the organisation the degree of financial sustainability risk and other aspects of risk relating to financial

210�NHS�Improvement�(NHSI)�SelOverall�Page�195�of�210Page�1�of�16


governance and efficiency any other relevant information.

Appendix 1 details what could give NHSI cause for concern and affect our Governance Rating.

The Trust has submitted six returns and feedback from NHSI confirmed our Governance Risk Rating of Green and our CoS of 4.

To comply with the governance conditions of our Licence we are required to provide a statement (the Corporate Governance Statement) detailing:

Any risks to compliance with the governance condition Actions taken or being taken to maintain future compliance

Appendix 2 details the Corporate Governance Statement, the sources of assurance and the Executive Lead for that area. It also cross references the Board Assurance Framework.

Appendix 3 provides details of the Licence conditions and the sources of assurances that we are compliant.

DCHS must report to NHSI any in-year material, actual or prospective changes which may affect our ability to comply with any aspect of our Licence. There is currently nothing to report to NHSI as an exception.

At the January 2016 Audit and Assurance Committee, it was requested that future Self-certifications include any governance issues that had been raised through the Raising Concerns Policy; there are no governance issues raised under this policy to report during Quarter 1.

In addition, the Board is required to make a declaration:

For Finance, that: The Board anticipates that the Trust will continue to maintain a Continuity of Service Risk Rating of at least 3 over the next 12 months.

The Board anticipates that the Trust's capital expenditure for the remainder of the financial year will not materially differ from the amended forecast in this financial return.

Based upon the evidence provided, it is proposed that the Board makes a positive submission, please see Appendix 4 and the Financial Performance Report for more detail.

For Governance, that: The Board is satisfied that plans in place are sufficient to ensure: ongoing compliance with all existing targets (after the application of thresholds) as set out in Appendix A of the Risk Assessment Framework; and a commitment to comply with all known targets going forward.

Based upon our internal assessment of the risks, it is likely that the Trust will be rated Green, please see the Performance Report for more detail.

Otherwise: The Board confirms that there are no matters arising in the quarter requiring an exception report to NHSI (per the Risk Assessment Framework page 22, Table 3) which have not already been reported.



There are no matters to be reported to NHSI as an exception, please see Appendix 5.

The Board is asked to agree the statements and approve the submission to NHSI.

Monitoring Information Brief Summary and References


The Governors will require the information to perform their statutory duties of holding the Board to account.

What are there Equality and Diversity implications?

Equality and Diversity (E&D) is included in the detail which constitutes the Self-certification, for example the performance metrics include Healthcare for All.

What are there Patient, Public and Stakeholder Involvement implications? The Self-certification is a publicly available document

Risk Register





APPENDIX 1 Indicators of Governance Concerns

Category Metrics Governance concern triggered by…CQC concerns Outcomes of CQC inspections and

assessments CQC warning notice changes to registration

conditions civil and/or criminal action

initiated

Access and outcomes metrics

For acute trusts, metrics including: RTT within 18 weeks A&E waits (4 hours) Cancer waits (62 days) C. difficile (national target)

For ambulance trusts: Category A response time

For mental health trusts, metrics including: CPA follow-up, EIP and IAPT tracking accommodation/employment

status (data completeness only)

For providers of community services: data completeness against selected

elements of the Community Information Data Set

breach of a single metric in three consecutive quarters or four or more metrics breached in a single quarter breaching

predetermined annual C. difficile threshold (either three quarters’ breach of the year-to-date threshold or breaching the full-year threshold at any time in the year)

breaching the A&E waiting times target in two quarters of any four-quarter period and in any additional quarter over the subsequent three quarters

Third-party reports

ad hoc reports from the General Medical Council, the Ombudsman, commissioners, Healthwatch England, auditor reports, Health & Safety Executive, patient groups, complaints, whistleblowers, medical Royal Colleges

judgement based on the severity and frequency of reports

Quality governance indicators

patient metrics, eg:o patient satisfaction

staff metrics, eg:high executive team turnover

o satisfactiono sickness/absence rateo proportion of temporarystaffo staff turnover

aggressive cost reduction plans

material reductions in satisfaction or increases in sickness or turnover rates

material increases in proportion of temporary staff

cost reductions of >5% in any given year

Financial risk and efficiency

financial sustainability risk rating inadequate planning processes value for money measure

financial sustainability risk rating indicating financial issues arising as a result of governance

inefficient/uneconomical spend compared to published benchmarks



APPENDIX 2Corporate Governance Statement 2015/16

(Risk Assessment Framework, Appendix F)

Corporate Governance Statement Assurance Frequency BAF Ref:

Lead

1) The Board is satisfied that DCHS NHS Foundation Trust applies those principles, systems and standards of good corporate governance which reasonably be regarded as appropriate for a supplier of heath care services to the NHS

BAF

AGS

External Assurance from Head of Internal Audit Opinion

External Audit Governance Report

Summary Report from AAC

Quarterly

Annual

Annual

Annual

Quarterly

4.1 Trust Secretary

2) The Board has regard to such guidance on good corporate governance as may be issued by NHSI from time to time

Reports to Board or delegated Committee

As issued by NHSI

4.1 Trust Secretary

3) The Board is satisfied that DCHS NHS Foundation Trust implements:

(a) effective board and committee structures

Review of Terms of Reference and Committee Structure

Annual 4.1 Trust Secretary

(b) clear responsibilities for its Board, for committees reporting to the Board and for staff reporting to the Board and those committees and;

(c) Clear reporting lines and accountabilities throughout its organisation

Terms of Reference

Summary Reports

Governance Structure

Annual

After each meeting

Annual

4.1 Trust Secretary

4) The Board is satisfied that DCHS NHS Foundation Trust effectively implements systems and/or processes:

(a) to ensure compliance with the Licence holder’s duty to operate efficiently, economically and effectively;

Performance, Finance and Quality Reports

Monthly All sections

Director of Finance

(b) for timely and effective scrutiny and oversight by the Board of the Licence holder’s operations;

Performance and Quality Reports Monthly All sections

Director of Operations

(c) to ensure compliance with health care standards binding on the Licence holder including but not restricted to standards specified by the Secretary of State, the Care Quality Commission, the NHS Commissioning Board and statutory regulators of health care professions;

Quality Report

Summary Report from QSC

Monthly

Monthly

Section 1.0

Chief Nurse

(d) for effective financial decision-making, management and control (including but not restricted to appropriate systems and/or processes to ensure the Licence holder’s ability to continue as a going concern);

Finance Report

Summary Report from QBC

Summary Report from AAC

Monthly

Bi-monthly

Quarterly

3.33.63.7

Director of Finance

(e) to obtain and disseminate accurate, comprehensive, timely and up to date information for Board and Committee decision-making;

Board and Committee Forward Agendas

Quarterly 4.1 Trust Secretary




Lead

(f) to identify and manage (including but not restricted to manage through forward plans) material risks to compliance with the conditions of its Licence;

Risk Report

Summary Reports from the Sub-Committees

Monthly

After each meeting

4.3 Chief Nurse

(g) to generate and monitor delivery of business plans (including any changes to such plans) and to receive internal and where appropriate external assurance on such plans and their delivery; and

Summary Reports from QBC

Board Development Sessions

Bi-monthly

As required

3.13.23.3

Director of Finance

(h) to ensure compliance with all applicable legal requirements.

Summary Report from AAC Quarterly 4.2 Trust Secretary

5) The Board is satisfied:a) that there is sufficient capability at

Board level to provide effective organisational leadership on the quality of care provided;

Outcome of Appraisal Report for Executive Team

NED Appraisal

Job Descriptions for Board members

Succession plans

Fit and Proper Persons Register

Annual 2.1 Chair

b) that the Board’s planning and decision-making processes take timely and appropriate account of quality of care considerations,

Quality Report Monthly 4.1 Chief Nurse

c) the collection of accurate, comprehensive, timely and up to date information on quality of care;

Quality Dashboard

Business Information System

Ongoing 3.10 Director of Finance

d) that the Board receives and takes into account accurate, comprehensive, timely and up to date information on quality of care;

Quality Report

Performance Report

Monthly

Monthly

3.10 Chief Nurse

e) that DCHS NHS Foundation Trust including its Board actively engages on quality of care with patients, staff and other relevant stakeholders and takes into account as appropriate views and information from these sources; and

Patient Stories

Spotlight on local Services at each Board meeting

Council of Governors Summary Report

Quality Services Committee Summary Report

Quality People Summary Report

Patient Experience Annual Report

Staff Survey Results

Quality Report

Monthly

Monthly

After each meeting

After each meeting

Bi-monthly

Annual

Annual

Annual

1.4 Chair




Lead

f) that there is clear accountability for quality of care throughout DCHS NHS Foundation Trust including but not restricted to systems and/or processes for escalating and resolving quality issues including escalating them to the Board where appropriate,

Risk Report

Quality Assurance Framework

Ward to Board Escalation Framework

Monthly 4.1 Chief Nurse

6) The Board of DCHS NHS Foundation Trust effectively implements systems to ensure it has personnel on the Board, reporting to the Board and within the rest of the licence holder’s organisation who are sufficient in number and appropriately qualified to ensure compliance with the conditions of its NHS Provider Licence

Staffing for Quality

Report on Executives to the RATS Committee

Report on NEDs to the Nominations and Remuneration Committee

Appraisal

Essential Learning

Summary report from QPC

Fit and Proper Persons Process

Monthly

Annual

Annual

Annual

Annual

Bi-monthly

On joining the Trust and annual self-declaration

2.12.22.42.5

Director of People

Key:

AAC Audit and Assurance Committee

AGS Annual Governance Statement

BAF Board Assurance Framework

NED Non-Executive Director

QBC Quality Business Committee

QPC Quality People Committee

QSC Quality Service Committee



APPENDIX 3

Provider Licence ConditionsLicense Condition Description AssuranceG1 - Provision of Information

This condition requires the Licensee to furnish to NHSI such information and documents and shall prepare or procure and furnish to NHSI reports NHSI may require under section 96(2) of the 2012 Act.

DCHS will comply with requests from NHSI for information they may require under section 96(2) of the 2012 Act.

Quarterly review meeting with NHSI

G2 – Publication of Information

This condition requires the Licensee to comply with any direction from NHSI to publish information (and the manner in which it should be published) about healthcare services.

DCHS will comply with direction from NHSI to publish information and the manner in which it should be published. For example:

Operational Plan Annual Report Quality Report

G3 – Payment of fees to NHSI

This condition requires the Licensee to pay fees to NHSI in each financial year in respect of the exercise by NHSI of its functions.

DCHS will pay fees to NHSI in respect of the exercise by NHSI of its functions.

G4 – Fit and proper persons as Governors and Directors

This condition requires that licensees do not allow unfit persons to become or continue as Governors or Directors.

“Unfit persons” are: undischarged bankrupts, individuals who have served a prison sentence of three months or longer during the previous five years, and disqualified Directors. A company may also be an unfit person.

The Constitution Code of Conduct for the Trust Board Code of Conduct for Governors Annual self-declaration for Directors Robust recruitment process for Directors include

Disclosure and Barring Service (DBS) and reference checks

DBS checks for GovernorsG5 – NHSI Guidance This condition requires licensees to have regard to any

guidance issued by NHSI for any of the purpose set out in section 96(2) of the 2012 Act.

DCHS complies with all mandatory NHSI guidance and would always consider NHSI’s best practice guidance as and when they are published.



License Condition Description AssuranceG6 - Systems for compliance with licence conditions and related obligations

This condition requires the Licensee to take reasonable precautions against the risk of failure to comply with:

The conditions of the licence Any requirements under the NHS Acts The requirement to have regard to the NHS

Constitution

Self-certification returns Internal Control mechanisms Significant assurance received from Internal Audit on

our Self-certification processes

G7 – Registration with the Care Quality Commission (CQC)

This condition reflects the obligation in the Health and Social Care Act 2012, for licensees to be registered with the CQC. This condition allows NHSI to withdraw the licence from providers whose CQC registration is cancelled and who therefore cannot continue to lawfully provide services.

CQC reports to QSC

G8 – Patient eligibility and selection criteria

This condition requires licensees to set and publish transparent patient eligibility and selection criteria and to apply these in a transparent manner. This includes criteria for determining patient eligibility for particular services, for accepting or rejecting referrals, or determining the manner in which services are provided to that person.

DCHS have transparent eligibility and selection criteria for all services as outlined within service specifications.

Where applicable and appropriate services are offered through “Choose and Book” which clearly identifies who is eligible for which services

Referral processes into DCHS have access and admission criteria clearly indicated throughout.

G9 – Application of Section 5 (Continuity of Services)

The conditions in Section 5 shall apply: Whenever the Licensee is subject to a contractual or

other legally enforceable obligation to provide a service which is a CRS

From the commencement of this licence until the Licensee becomes subject to an obligation of the type described in sub-paragraph above, if the Licensee is an NHS FT which was not subject to such an obligation on commencement of the Licence and was required to provide services or was party to an NHS contract to provide services

The mandatory services currently included within the contract are:• Community Nursing (in hours and Out of Hours

services)• Health Visiting Services• Older People’s Mental Health Inpatient Service• Learning Disabilities Services• Intermediate Care Services (including inpatient and

community services)• Continence Nursing Services• Day services / specialist rehabilitation units• Head Injury Services• Health Promotion Services



License Condition Description Assurance• Specialist Nursing Services (Heart Failure, Diabetic

Liaison, Parkinson’s, Tissue Viability, Neurotherapy)• Wheelchairs services

Under the grandfathering arrangements set out in guidance, these mandatory services will automatically become Commissioner Requested Services (CRS), and will be included on the Trust’s CRS schedule.

Discussions regarding provision of these services are held at the Contract Management Group and Contract Management Board.

P1 – Recording of information

Under this licence condition, NHSI may require licensees to record information, particularly information on their costs, in line with approved guidance NHSI will publish. The licence condition is worded in a way that any costs and other information that may be required can be collected from both licensees and their sub-contractors. This licence condition may also require licensees to record other information, such as quality and outcome data, in line with NHSI guidance and for the purpose of carrying out NHSI pricing functions.

DCHS level Income & Expenditure (I&E) report presented to Board each month with supporting narrative explaining main variances movements

I&E reports at Directorate level provided to QBC

P2 – Provision of information

Under this condition, once the information has been recorded in line with P1, NHSI can then require licensees to submit this information for the purposes of performing its functions under Chapter 4 in Part 3 of the 2012 Act.

DCHS would comply with NHSI’s requests for information.

P3 – Assurance Report on submissions to NHSI

Under this condition NHSI may require licensees to submit an assurance report confirming the accuracy of the data they have provided under P2 or submit information to third parties designated by NHSI.

DCHS would comply with NHSI’s request for an assurance report.



License Condition Description AssuranceP4 – Compliance with the National Tariff

This licence condition imposes the obligation to charge for NHS health care services in line with the National Tariff.

Patient Care Activity is charged in line with National Tariff where applicable. However for DCHS this only applies to a small proportion of our services (approx. 6% of clinical income).

For DCHS, Tariff applies to Planned Care Services (Outpatients and Day Case) and Minor Injuries Units. All other services are not covered by Tariff and payment is locally agreed.

P5 – Constructive engagement concerning local tariff modifications

This licence condition requires licensees to engage constructively with Commissioners and to try and reach a local agreement before applying to NHSI for a local modification.

DCHS will engage constructively with Commissioners to try and reach a local agreement before applying to NHSI for a local modification.

C1 – The right of patients to make choices

This condition: Requires licensees to tell their patients when they

have a choice of provider and to tell them where they can find information about the choices they have – this must be done in a way that is not misleading

Requires that information and advice that licensees provide to patients about their choice of provider does not unfairly favour one provider over another and is presented in a manner that helps patients to make well-informed choices

Prohibits licensees from offering gifts and benefits in kind for patient referrals or for the commissioning of services

Patients for elective care services and Any Qualified Provider are offered choice through the “Choose and Book” process.

C2 – Competition oversight

This condition prohibits the licensee from entering into or maintaining agreements that have the object or effect of preventing, restricting or distorting competition to the extent it is against the interests of health care users.

It also prohibits the licensee from engaging in other

Commercial Development Strategy Business Development Framework



License Condition Description Assuranceconduct which has the effect of preventing, restricting or distorting competition to the extent it is against the interests of health care users.

IC1 – Provision of integrated care

This condition requires the licensee to not do anything that could be reasonably be regarded as detrimental to enabling integrated care.

The purpose of this licence condition is to enable NHSI to step in where integrated care is not being delivered, in spite of decisions and efforts made by Commissioners.

Joined up Care and 21st Century Joined up Care work streams in the north and south of the county.

CoS1 – Continuing provision of Commissioner Requested Services (CRS)

This condition states the Licensee shall not cease to provide or materially alter the specification or means of provision of, any CRS apart from under certain conditions.

Any amendment to contract variation is done in negotiation with Commissioners.

CoS2 – Restriction on the disposal of assets

This condition states the Licensee shall establish, maintain and keep up to date an asset register which complies with paragraph 2 and 3 of this condition

The asset register shall list every relevant asset used by the Licensee for the provision of CRS

The asset register shall be established, maintained and kept up to date in a manner that would be reasonably be regarded as adequate and professional

Our asset register is held electronically on the Estates IT system and planned maintenance / servicing is carried out to meet statutory and mandatory requirements. Maintenance contracts are in place for specialist items of equipment.

Following any refurbishment or capital upgrade works any new equipment is added to the asset register and added to the planned maintenance programme.

Estates are registered to BS EN ISO 9001 Quality Assurance standard and as such all maintenance procedures are subject to audit.

CoS3 – Standards of Corporate Governance and Financial Management

This condition states the Licensee shall at all times adopt and apply systems and standards of corporate governance and financial management which reasonably would be regarded as:

Suitable for a provider of CRS Providing reasonable safeguards against the risk of

The Constitution Scheme of Delegation Corporate Governance Statement Compliance report to AAC Corporate Framework Governance structure



License Condition Description Assurancethe Licensee being unable to continue as a going concern

Risk management system Board Assurance Framework Internal Audit programme Financial Performance Report QBC Summary Report AAC Summary Report

CoS4 – Undertaking from the Ultimate Controller

This condition states the Licensee shall procure from each company or other person which the Licensee knows or reasonably ought to know is at any time its ultimate controller, a legally enforceable undertaking in favour of the Licensee, in the form specified by NHSI, that the ultimate controller

Will refrain for any action which would be likely to cause the Licensee to be in contravention of any of its obligations under the 2012 Act

Will give to the Licensee all such information to enable the Licensee to comply fully with its obligations under this licence to provide information to NHSI

Not applicable for Foundation Trusts

CoS5 – Risk Pool Levy

This condition states the Licensee shall pay NHSI any sums required to be paid in consequence of any requirement imposed on providers under section 135(2) of the 2012 Act, including sums payable by way of levy imposed under section 139(1) and any interest payable under section 143(10) by the dates by which they are required to be paid.

DCHS would comply with this requirement.

CoS6 – Co-operation in the event of financial stress

This condition states obligations will apply if NHSI has given notice in writing to the Licensee that it is concerned about the ability of the Licensee to carry on as a going concern.

QBC Summary Report AAC Summary Report Financial Performance Report Going Concerns Report



License Condition Description AssuranceCoS7 – Availability of resources

This condition states the Licensee shall at all times act in a manner calculated to secure that it has, or has access to the Required Resources.

The Licensee shall not enter into any agreement or undertake any activity which creates a material risk that the Required Resources will not be available.

Certificate of Required Resources to NHSI

FT1 – Information to update the register of NHS FT

This condition states the Licensee shall ensure NHSI has available to it written and electronic copies of:

Constitution Most recently published annual accounts and

auditors report Most recently published annual report

DCHS submitted its annual accounts and annual report by the deadlines.

A copy of our Constitution is available on NHSI’s portal and their website.

FT2 – Payment to NHSI in respect of registration and related costs

This condition states whenever NHSI determines, in accordance with section 50 of the 2006 Act that the Licensee must pay a fee to NHSI in respect of its functions under section 39 and 39A of that Act, the Licensee shall pay that fee to NHSI within 28 days of the fee being notified.

DCHS would comply with the requirement.

FT3 – Provision of Information to Advisory Panel

This condition states the Licensee shall comply with any request for information or advice made to it under section 39A (5) of the 2006 Act.

DCHS would comply with this requirement.

FT4 – NHS FT Governance Arrangements

This condition states the Licensee shall apply those principles, systems and standards of good corporate governance which reasonably would be regarded as appropriate for a supplier of healthcare services to the NHS.

The Constitution Scheme of Delegation Corporate Governance Statement Compliance report to AAC Corporate Framework Governance structure Risk management system Board Assurance Framework Internal Audit programme



APPENDIX 4

Continuity of Service Risk RatingFrom 1st October 2013, NHSI’s regulatory regime moved to a Continuity of Service rating, which replaces the Financial Risk Rating. The Risk Assessment Framework guidance does not specifically identify a quarterly declaration that needs to be made on finance. All Commissioner Requested Services (CRS) providers are required to provide financial information to NHSI during the year so that financial risk and the continued provision of CRS can be assessed. NHSI will use this information to update the continuity of services risk rating.

Under their governance condition, NHS foundation trusts will submit a corporate governance statement which requires Boards to confirm forward compliance with the governance condition for the current financial year. It is therefore proposed to declare quarterly against the following financial statements:

Statement Evidence ConclusionThe Board anticipates that the trust will continue to maintain a Continuity of Services rating of at least 3 over the next 12 months

Annual Plan Monthly Financial Report

Future 2 year plan forecasts a CoS of 4.

The Board is satisfied that the trust shall at all times remain a going concern, as defined by the relevant accounting standard in force from time to time.

Annual Plan Monthly Financial Report Treasury Management Report

Confirmation that the Trust will remain a going concern as defined by the relevant accounting standard in paper to April 2016 Audit and Assurance Committee. Rolling cashflow does not highlight any liquidity concerns.

Based upon the evidence provided, it is proposed that the Board makes a positive submission against both statements.



APPENDIX 5

Examples of Exception Reporting

(Risk Assessment Framework, page 22)



Documents

Copy of 201-Big 9 - M3-June - Presentation with RAG ... · Minutes of the DCHS Board Meeting held on Thursday 30 June 2016 Matlock Town Football Club, Causeway Lane, Matlock, DE4