COUNCIL OF GOVERNORS - Sheffield Children's Hospital · Enc F_COG Directors Report June.docx 89 12.42/19 STAFF SURVEY 2018 - CORPORATE ACTION PLAN AND PROGRESS UPDATE (ENC G) 93 Enc

COUNCIL OF GOVERNORSSchedule Tuesday 16 July 2019, 6:00 PM — 8:00 PM BSTVenue HELENA DAVIES LECTURE THEATRE, STEPHENSON

WINGOrganiser Claire Coles

Agenda

1. AGENDA 1

07~19 Agenda July 2019.doc 2

2. GOVERNOR ONLY PRE-MEET 4

3. 33/19 WELCOME AND INTRODUCTIONS 5

4. 34/19 APOLOGIES FOR ABSENCE AND DECLARATIONS OF INTEREST 6

5. 35/19 TO RECEIVE AND AGREE THE MINUTES OF THE COUNCILMEETING HELD 14 MAY 2019 (ENC A)

7

Enc A_Draft minutes from May 2019 CoG V2.doc 8

6. 36/19 TO REVIEW THE ACTION LOG (ENC B) 16

Enc B_Actions Log_July 2019.doc 17

7. 37/19 OUTCOMES FORM CQC INSPECTION 2019 (PRESENTATION) 21

8. 38/19 CONNECTING TOGETHER - IM&T STRATEGY (ENC C) 22

Enc C_Cover - IM&T Strategy - CoG Overview July 19.doc 23 Enc C_Connecting Together - Overview to Council of Governors.pptx 24 Enc C_Connecting Together - IM&T Strategy.pdf 34

9. 39/19 QUARTERLY REPORTS FROM BOARD COMMITTEES- QUALITY COMMITTEE (ENC Di)- FINANCE AND RESOURCES COMMITTEE (ENC Dii)- RISK AND AUDIT COMMITTEE (ENC Diii)- CHARITIES COMMITTEE (ENC Div)

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Enc D_i_Quality Committee assurance report July 2019.doc 63 Enc D_ii_Finance and Resources cover sheet July 2019.doc 66 Enc D_ii_FRC Governors report- updated template for review.docx 70 Enc D_iii_Risk and Audit assurance report July 2019.doc 72 Enc D_iv_Charities Committee assurance report July 2019 V2.doc 74

10. 40/19 CHAIRS REPORT (ENC E)- FEEDBACK FROM BACK TO THE FLOORS (ENC Ei)

76

Enc E_Quarterly Report from the Chair - June 19 (1).docx 77 Enc E_i_BTTF report.doc 80 Enc E_i_back to the floor feedback report Nov 2018 to April 2019.pdf 83

11. 41/19 DIRECTORS REPORT (ENC F) 88

Enc F_COG Directors Report June.docx 89

12. 42/19 STAFF SURVEY 2018 - CORPORATE ACTION PLAN ANDPROGRESS UPDATE (ENC G)

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Enc G_Report to Council of Govenors - staff survey update - July2019.doc

94

13. 43/19 KEY MESSAGES (ENC H) 101

Enc H_Governor Key Messages July 2019.docx 102

14. 44/19 IN THIS TOGETHER (PRESENTATION) 107

15. 45/19 GOVERNOR DEVELOPMENT PLAN (ENC I) 108

Enc I_Governor development plan Cover Sheet_2019.doc 109 Enc I_SCH Governor action plan.docx 110

16. 46/19 DISCUSSION OF FUTURE TOPICS (VERBAL) 113

17. DATE OF NEXT MEETING: ANNUAL MEMBERS MEETING 17SEPTEMBER 2019 13:00 LECTURE THEATE

114

1. AGENDA

Council of Governors Meeting Tuesday 16 July 2019 18:15 – 20:00 (Governor only pre meet 18:00) Helena Davies Lecture Theatre, Stephenson Wing

Please access the hospital via Damer Street (opposite Starbucks) and take lift to F Floor

AGENDA

Time Item Topic Purpose Paper

18:00 GOVERNOR ONLY PRE-MEET

To review agenda items FOR COMMENT

18:15 PRELIMINARIES

33/19 Welcome & Introductions

34/19 Apologies for absence and declarations of interest

35/19 To receive and agree the minutes of the Council meeting held 14 May 2019 Enc A

36/19 To review the actions log Enc B

18:20 QUALITY & SAFETY PRIORITIES

37/19 Outcomes from CQC Inspection 2019 (Sally Shearer) FOR INFORMATION Presentation

38/19 Connecting Together – IM&T Strategy (Kevin Connolly) FOR INFORMATION Enc C

STRATEGIC ISSUES

None scheduled.

ASSURANCE AND HOLDING TO ACCOUNT

39/19 Quarterly Reports from Board Committees: o Quality Committee (Patricia Mitchell) o Finance and Resources Committee (Andy Baker) o Risk and Audit Committee (John Cowling) o Charities Committee (Sarah Jones)

FOR INFORMATION / APPROVAL

Enc D i Enc D ii Enc D iii Enc D iv

40/19 Chair’s Report (Sarah Jones) o Feedback from Back to the Floors

FOR COMMENT Enc E Enc E i

41/19 Directors’ Report (and Governor questions on matters not otherwise covered on the agenda) (John Somers)

FOR COMMENT Enc F

42/19 Staff Survey 2018 – Corporate Action Plan and Progress Update (Nick Parker)

FOR INFORMATION Enc G

ENGAGING WITH THE PUBLIC

43/19 Key Messages (Lea Fountain) FOR INFORMATION Enc H

19:30 COUNCIL MATTERS - GOVERNORS ONLY

44/19 In This Together (Emily Hopkinson/Matthew Kane) FOR INFORMATION Presentation

45/19 Governor Development Plan (Matthew Kane) FOR INFORMATION Enc I

FUTURE AGENDA ITEMS

46/19 Discussion of future topics FOR DISCUSSION Verbal

20:00 CLOSE MEETING

Dates of next meetings:

COUNCIL OF GOVERNORS 1. AGENDA Page 2 of 114

Annual Members Meeting; 17 September 2019 at 13:00 in the Lecture Theatre

Full Council Meeting: 12 November 2019 at 18:15 in the Lecture Theatre

COUNCIL OF GOVERNORS 1. AGENDA Page 3 of 114

2. GOVERNOR ONLY PRE-MEET

3. 33/19 WELCOME ANDINTRODUCTIONS

4. 34/19 APOLOGIES FOR ABSENCEAND DECLARATIONS OF INTEREST

5. 35/19 TO RECEIVE AND AGREE THEMINUTES OF THE COUNCIL MEETINGHELD 14 MAY 2019 (ENC A)

Enc A

Minutes of the Public Meeting of the Council of Governors

held on 14 May 2019, The Helena Davies Lecture Theatre, Stephenson Wing, Sheffield Children’s Hospital

Member of the Council of Governors present:

Sarah Jones Chair Nikki Bates Partner Governor – Sheffield CCG Jackie Cole Partner Governor – YAS Charlotte Elder Partner Governor – University of Sheffield Andrew Garner Staff Governor – Nursing & Midwifery Jack Hiscock Staff Governor – Non-Clinical Kathryn Holden Staff Governor – Other Clinical Vincent Keddie Public Governor – Sheffield Rebecca Kent Public Governor- Rest of South Yorkshire Carrie Mackenzie Staff Governor – Medical & Dental Ismail Mir Public Governor – Rest of England and Wales Emma Packham Public Governor – Sheffield Robert Peace Public Governor- Rest of England and Wales Bethan Plant Partner Governor- Sheffield Helen Smith Public Governor - Sheffield Dan White Partner Governor – Sheffield Futures

Also present: Ruth Brown Director of Strategy and Operations Jane Clawson Interim Director of HR & OD Claire Coles Corporate Affairs Officer – Minutes John Cowling Non-Executive Director Lea Fountain Associate Director Communications Scott Green Non-Executive Director Matthew Kane Associate Director of Corporate Affairs Jeff Perring Medical Director Sally Shearer Director of Nursing & Quality Mark Smith Chief Finance Officer John Somers Chief Executive

Apologies: Andy Baker Non-Executive Director Ruth Barley Partner Governor- Sheffield Hallam University

Heather Bellamy Public Governor – Sheffield Sam Broadbent Public Governor - Sheffield Samantha Burns Staff Governor – Nursing & Midwifery Peter Lauener Non-Executive Director Patricia Mitchell Non-Executive Director Debbie Mander Patient/Carer Governor- Carer Phil Parkes Public Governor- Sheffield

COUNCIL OF GOVERNORS 5. 35/19 TO RECEIVE AND AGREE... Page 8 of 114

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16/19 Welcome & Introductions

The Chair welcomed Governors, members of the Board of Directors and staff to the meeting. Mr White was welcomed to his first meeting as Partner Governor.

17/19 Apologies for absence

Apologies were received as noted above.

17/19 Declarations of interest

Ms Jones declared an interest in agenda item 27/19, and would leave the meeting at that point, Mr Cowling, Senior Independent Director, would chair this item.

New Governors were asked to complete any outstanding declarations of interest.

Governors

18/19 Minutes of the previous meetings

The minutes of the meeting held in public on 12 February 2019 were presented for consideration. The minutes were accepted as a true and accurate record of the meeting.

19/19 To review the actions log

The actions arising report was reviewed and updates against actions noted.

QUALITY & SAFETY PRIORITIES

20/19 Quality Report and CQC Update

Mrs Shearer, Director of Nursing and Quality, presented an overview of the Quality Report and provided an update on the indicator testing. The following points and comments were noted:

i. An overview of the content of the report was provided and the Council was assured that a full consultation process had taken place on the Quality Report with partners such as Sheffield Clinical Commissioning Group, the Overview and Scrutiny Committee at Sheffield City Council, Sheffield Healthwatch, the Trust’s Parent Register and Youth Forum. Comments provided had been incorporated into the final report.

ii. The final external audit report was awaited relating to indicator testing, this would be included within the audit opinion to governors.

iii. The Council was assured that although the Trust received a relatively high number of complaints, this was due to the specialist nature of care provided, as well as the low tolerance culture for complaints. The Trust also tended to direct families to the complaints procedure rather than resolve issues in the first instance. Training to equip frontline staff with the skills to have appropriate conversations with families to resolve issues at the first point of contact would be undertaken. It was unclear if this was outwith nationally however from past experiences staff felt complaints numbers to be high in comparison to other trusts of a similar size. The Council was informed that two clear themes emerged from complaints relating to values and behaviours, and communications with families regarding access to treatment.

iv. The Council noted the format of the report was quite prescriptive, and the Interim Director of HR and OD agreed to circulate a separate report to governors relating to the five worst performing actions from the staff survey to understand how improvements had been made to these areas.

v. The Council received a presentation on initial high level feedback from the recent CQC inspections. Formal reports were awaited and would be published in July.

IDPOD


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The report and presentation were noted.

21/19 Culture, Behaviour and Values

Ms Clawson, Interim Director of HR and OD, gave a presentation on work taking place within the Trust in relation to culture, behaviour and trust values. The following points were noted:

i. As part of the work to refresh the Trust’s strategy a number of underpinning strategies had been developed. The Trust’s values had been considered as part of the work to develop a culture and behaviour strategy, and agreed these were still current, however it was recognised a culture change was required within the organisation to further embed these.

ii. Work undertaken to develop the strategy was outlined, and a strategy on a page handout was circulated to governors for information.

iii. There were many opportunities in which to embed these behaviours and values within the organisation, this included testing embededness within back to the floor visits, as well as consideration given to how the values linked to the results of staff survey.

The presentation was noted.

STRATEGIC ISSUES

22/19 Feedback from the February Joint Strategy Session

Ms Brown, Director of Strategy and Operations, presented a report for information. The following points were noted:

i. Some good feedback had been provided at the joint governor session, and the Trust was keen to involve governors in transformation projects. A separate clinical summit focusing on partnership working had looked at the same topic to provide a balance of discussions, as well as looking at how the Trust was positioning itself. Feedback from these sessions would be shared at a future meeting to look at themes and actions.

ii. The narrative on children and young people priorities for the Shaping Sheffield plan was circulated for governor comments.

iii. Mr Hiscock, staff governor, raised concern regarding the transformation programme summary document presented to governors at the meeting for information. This document was also available electronically. This was an internal document to share with colleagues to inform those areas without access to the digital format. Governors were assured that the cost to produce this document was low and that only a minimum number of copies had been produced. Hard copies had been provided to governors, as this was in line with governors receiving meeting papers hard copies. The useful feedback was noted.

iv. A governor stand was proposed for the next clinical summit, to enable governors to engage with their constituents. Governors noted that the transformation team was available to use for getting information out to constituents.

v. Governors were informed that the Take My Place campaign was showing positive results, and that the Was Not Brought figures had reduced significantly over the past two months since this initiative had been in place, this positive trend needed to be sustained. The next phase of the campaign was to undertake a specific targeted approach, to specific population groups and roll out the campaign GP practices. Staff

Planner


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governors reported the positive impact this initiative was having on clinics.

The Council noted the report.

ASSURANCE AND HOLDING TO ACCOUNT

23/19 Quarterly Reports from Board Committees:

The Council received a summary of work undertaken by Board Committees which provided details of the breadth and scope of issues dealt with by Non-executive Directors.

Quality Committee

i. The assurance report from the last three meetings was noted, and key areas of work over the quarter were highlighted to the Council.

ii. Ms Holden, staff governor, highlighted concern in relation to how staff were feeling within the CAMHS service following launch of the “It starts with me” transformation programme. Governors were assured that similar feedback had been highlighted to the Quality Committee, and that the voice from staff had been heard and listened to, however noted it was sometimes difficult for staff to hear difficult messages at the start of any major transformation change. This was helpful feedback and an update would be provided in due course. Governors were further reassured that all staff were accountable for their actions, and this also to the collective leadership behaviours and the Trust’s culture of a safe environment to raise such issues.

Finance and Resources Committee

iii. The assurance report from the last three meetings was noted, and key areas of work over the quarter were highlighted to the Council.

iv. Dr Elder, partner governor, noted caution in relation to the discharge summary pilot, and previous engagement challenges when similar action was undertaken to improve rates. Governors were assured that the pilot was supported by a standard operating procedure and IT system to make sure the pilot worked. It was recognised that completing a discharge summary was the right thing to do as part of a patient’s care, however noted potential impact delays that discharge might have on complaints.

Risk and Audit Committee

v. There had been one meeting during the quarter, and the key areas highlighted within the assurance report were noted.

vi. Governors were alerted to the upcoming reappointment of external auditors, which was a duty of the Council. Consideration would be given to whether to go through a tender process, which would be brought to the next meeting following internal discussions.

Charities Committee

vii. The assurance report from the second meeting of the committee was noted. The Trust was reliant on charity funding for a number of upcoming capital projects, and the committee had been established to seek assurance on the charity’s performance to deliver its fundraising plans.

viii. The Council was assured that it was not unusual for major capital builds to be solely reliant on charity funding due to the financial situation and cash flow within the NHS, this was becoming more apparent due to the national availability of funding within the NHS. Governors were informed that projects would go ahead and the Trust would


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explore other sources of funding available to make these happen.

The quarterly assurance reports were noted.

24/19 Chair’s Report

Ms Jones, Chair, presented the report. The following points were noted:

i. The new style report was noted, this was developing the Chair’s monthly reporting to Board into a more formal quarterly summary on key issues, topics, and partner discussions.

The update was noted.

25/19 Directors’ Report

Mr Somers, Chief Executive presented the report. The following points were noted:

i. The Trust had achieved all its quality performance targets. The Trust was number one nationally for A&E performance, this was by design as a quality driven organisation, which had been acknowledged in Parliament.

ii. Details of the financial position were presented to the Council. The Council was informed that the Trust had not achieved its control total, however over performance of the ICS had offset the trust’s year-end position and enabled it to receive bonus funding. This showed the financial benefit of working together as a system. The position was a complex message to communicate to staff. How this position would be reported within the annual accounts, and underlying financial position, was outlined to governors.

iii. The position for next year and savings target would be equally as challenging. Governors were informed there would be additional focus on the Trust to achieve its control total for 2019/20, and was assured that the Trust planned to develop a longer term plan to bring it back into surplus.

iv. Governors were reminded the financial position remained confidential until the position was formally reported in the annual report at the Annual Members Meeting in September. A confidential internal management message would be communicated to divisions, and governors would be kept informed of the situation

v. Governors noted the Trust’s position had been ‘off set’ by the ICS and that the Trust had not ‘borrowed’ in achieving the year-end position.

vi. Dr Mackenzie, staff governor, raised an issue highlighted within the divisional management board in relation to vacancy control processes and vacancy freeze. Governors were informed there was no vacancy freeze, and there had been investment of over £1m to front line nursing staff. The business cases for recent corporate capacity had been scrutinised and been through a robust process, these posts recognised the pressure points and additional capacity required to support system working.

vii. Mr Garner, staff governor, highlighted concerns received from domestic staff in relation to capacity to undertake deep cleans. The Trust’s domestic resource was compared to a neighbouring trust’s. Mr Garner would discuss the pressure points within domestic services with Ms Clawson and Mrs Shearer together with the Head of Support Services.

viii. The governor feedback was noted.



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ENGAGING WITH THE PUBLIC

26/19 Key Messages

Ms Fountain, Associate Director of Communications, presented the key messages for information, for sharing with constituents. Additional updates were noted:

i. A number of national staff days were highlighted to the Council, celebration events had taken place to celebrate these particular staff groups, which had been highlighted on social media.

ii. A number of activities relating to mental health awareness week were highlighted to the Council.

iii. Mr Mir, public governor, highlighted mental health issues relating to drug use within schools, with a lack of discussion within schools in addressing this issue. Healthy Minds in schools had undertaken training with teachers in over 100 schools in Sheffield on first level intervention support. Mrs Shearer agreed to investigate what support school nursing was providing to this issue. From a policing perspective Mr Green informed the Council that all schools were linked into community support officers. Mental health, drugs and domestic violence were all interlinked, and it was positive to keep talking about the issues. Ms Fountain would pick this up in terms of a public campaign. Mr Mir, Mr Green and Mr White would discuss the issue outside of the meeting in terms of support and interventions by partner organisations already in place. Mr Mir was thanked for raising the issue.

The key messages were noted.

DNQ

ADComms

COUNCIL MATTERS

27/19 Recommendations from the Recruitment and Remuneration Committee

Ms Jones, Chair, and Mr Cowling, Non-executive and Senior Independent Director presented the report. The following points were noted:

Ms Jones left the meeting at this point and Mr Cowling chaired this discussion.

Appraisal and re-appointment of the Chair

i. The Chair’s personal statement, letter, consideration of the balance of the Board and independence of the Board had all been considered by Board and the Governor Recruitment and Remuneration Committee, with a recommendation for reappointment.

ii. Governors noted that the Chair was a trustee of the charity, and that it was important to have this overlap in providing assurance to Board.

iii. The Chair’s length of tenure had been considered on her appointment to Chair, noting she had been a non-executive since 2008, and the Remuneration and Recruitment Committee had at that point been aware of the implications this might have on the length of tenure.

iv. Mr Cowling reminded governors of key factors in the Chair’s independence in relation to: not having an office at the Trust, judgment on robustness in challenging colleagues and setting of stretch objectives for the Chief Executive. Ms Jones summary appraisal and self-assessment was consistent with feedback from others.

v. The Council voted unanimously to approve the reappointment of reappoint Sarah


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Jones as Chair for a second term commencing 1 September 2019 to 31 August 2022.

Ms Jones rejoined the meeting.

Outcomes of Performance Evaluation of Non-executive Directors

vi. A 360 degree feedback assessment had been undertaken, and governors had participated in the reviews. Objectives for the year had been reviewed and considered by the Remuneration and Recruitment Committee. Mr Peace’s observations provided additional assurance.

vii. No questions were received and the report was noted.

Reappointment of Non-executive Directors

viii. The Council voted unanimously to approve the reappointments of Andy Baker and

Peter Lauener as non-executive directors for a second term commencing 1 September 2019 to 31 August 2022.

Appointment of Non-executive Director

ix. Governors were thanked for their support to the recruitment process, in the long-listing, shortlisting and interview process. From a field of 21 applications there was one standout candidate who met the criteria set out and was a fit with the Board and executives.

x. The individual recommended for appointment was Richard Chillery. Mr Chillery was currently the operations director at Harrogate and District NHS Foundation Trust. His background was a family therapist and psychologist. His expertise was in the area of paediatric mental health and CAMHS leadership. Governors approved this appointment subject to references and Fit and Proper Person checks.

xi. Consideration would be given to how one other suitable candidate might work within the trust.

xii. The Council approved the recommendation to appoint Mr Richard Chillery commencing 1 June 2019 for an initial three-year term. The appointment will be subject to Fit and Proper Person checks.

28/19 Annual Report – Governor Section

Mr Kane, Associate Director of Corporate Affairs, presented a report for information. The following points were noted:

i. The governor section of the annual report was highlighted to governors for comments.

The Council approved the governor section of the Annual Report for 2018/19.

29/19 Self-certification

Mr Kane, Associate Director of Corporate Affairs, presented the report. The following points were noted:

i. The Trust was required to self-certify against its provider licence on an annual basis.

ii. Ms Packham, public governor, had provided comments relating to governor training. Following discussion Ms Packham felt satisfied that training plans were in place to develop and involve new governors in their roles to carry out their statutory duties. Governors were reminded that initial focus had been given to updating the constitution and composition of governors. This condition would be qualified within the statement.

AD-CA


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30/19 Appointment of Lead Governor

Mr Peace left the meeting for this item.


i. Mr Peace had expressed his interest in standing again for the role of lead governor. This was an annual position.

ii. The Council unanimously approved Mr Peace for a second term as lead governor.

The Council approved the lead governor appointment.

31/19 Review of Register of Interests


i. Governors were asked to review their entry on the register, this would be published on the Trust’s website. Any revisions would be provided to the Corporate Affairs team.

The register was approved.

32/19 Discussion of future topics

i. Governors requested an update on IT systems at a future meeting.

ii. Governors supported the change in format of the meetings, in holding a pre-meet before the meeting proper.

Planner

The meeting was closed at 20:15

Date and Time of the Next Meeting

The next full meeting would take place on the 16 July 2019.


6. 36/19 TO REVIEW THE ACTION LOG(ENC B)

Enc B

Actions Arising Report – updated following 14 May 2019 CoG meeting

Action ref:

Date Action raised

Action Action with

Target date to

complete

Progress / evidence that completed

40/17 IM&T Overview

11/07/17

A briefing on eDMS would take place at a future meeting.

CIO May July 2019

Item deferred to July.

An update on all trust IT systems is provided under agenda item 38/19.

Action closed.

08/19 iv) Quarterly Report from Board Committees

12/02/19

Further updates relating to estates and the people agenda would be reported to the next meeting.

FRC Chair May 2019

Highlighted on the FRC assurance report.

On agenda 39/19 Enc Dii.

Action closed.

12/19 v) Governor Engagement Report

12/02/19

Governors raised concerns that an action had been closed on the action log however they did not feel this action 37/18 had been sufficiently closed. A further update against this had been provided at the November meeting under minute 50/19, in that a mock case study was being planned to test security procedures, the Director of Nursing would be asked to provide a further update to robustly close down this action.

DNQ May 2019

Update provided 1/5/19:

Work has taken place around ward security.

An abduction exercise has taken place, this was successful in that the abductor did not manage to exit the building.

Daytime security guards are now in place.

Additional training of staff, due to mental health patients escaping has increased staff awareness.

Ward staff are more vigilant around tailgating.

There is evidence of staff challenging visitors.

Action closed.

13/19 iv) Reflections on matters discussed in meeting

12/02/19

Following discussion on the practicalities of day to day basic IT issues, the Deputy Chair would raise clinic booking issues highlighted by Dr Mackenzie, staff governor, with the Chief Information Officer from a Quality Committee perspective.

Deputy Chair

May 2019

DSO taking forward a similar action from the Finance and Resources Committee. Action linked to FRC 26/19 vi). DSO to follow up with Dr Mackenzie.

Update provided to FRC 17/04/19, minute ref:

FRC was informed that the DSO and CIO were in discussions with the staff governor regarding bookings and reallocation of clinics. Therefore this action would be closed.

COUNCIL OF GOVERNORS 6. 36/19 TO REVIEW THE ACTION... Page 17 of 114

Action closed.

06/18 Trust Strategy ‘Caring Together’

20/03/18

An update on the work to give a patient’s experience within the hospital would be brought to a future meeting.

DNQ May July 2019

Item deferred to July.

This work would be showcased at the Annual Members Meeting.

07/19 iii) Overview of Back to the Floors

12/02/19

The BTTF form would be updated to capture values and behaviours, care experience feedback, and make the form more user friendly.

Corp. Affairs

May July 2019

Discussions are ongoing, and updated report would be brought to the July meeting as part of the next overview of back to the floors.

On agenda 40/19.

Action closed.

14/18 Future Agenda Items (iii)

20/03/18 The Council requested a report on the work of the Education Board.

DHROD July 2019

An update was included within the Quality Committee assurance report. On agenda 39/19 Enc Di).

Action closed.

20/19 iv) Quality Report and CQC Update

14/05/19

IDPOD to circulate a separate report to governors relating to the five worst performing actions from the staff survey to understand how improvements had been made to these areas.

IDPOD July 2019

To be covered in staff survey update.

On agenda 42/19 Enc G.

Action closed.

29/19 ii) Self-certification

14/05/19

The governor training condition would be qualified within the statement.

AD-CA May 2019

Action completed.

Action closed.

32/19 i) Discussion of future topics

14/05/19 Governors requested an update on IT systems at a future meeting.

CIO TBC On agenda 38/19.

Action closed.

Completed Actions updated following 14 May 2019 CoG meeting

Action ref:

Date Action raised

Action Action with Target date to

complete


14/18 Future Agenda Items (xxii)

20/03/18

The Chair would raise the bad state of repair of the diabetes clinic with the CEO and how similar issues can be escalated.

Chair May 2018

Minute Ref: 18/18

Medicine Division would propose a longer term solution.

Action Carried Forward.

Minute Ref: 04/19.

An update position would be sought.

Update provided 02/05/19:

Short term improvement works have been completed. Divisional leadership are taking forward a longer term solution, with options to


be referred to CFO, and this will be considered as part of the strategic estates discussions and review.

Action closed.

54/18 vii) Quarterly Reports from Board Committees

13/11/18

An update on culture and behaviour would be brought to a future meeting.

DHROD May 2019

Action closed.

Minute Ref: 21/19.

06/19 iv) Review of Constitution

12/02/19

AD-CA to work with communications team, youth forum and key stakeholders to explore options to ensure the patient demographic was represented and patient voice and young person voice was heard.

AD-CA May 2019

This has been achieved in a number of ways:

Firstly, the partner governor seat held by Healthwatch will be taken up by Young Healthwatch and discussion with them about their representative are ongoing.

Secondly we agreed to provide a standing invitation to Council meetings to the members of the Trust’s Youth Forum and this has been warmly received.

A number of young people have responded to the Trust’s publicity for the forthcoming elections and we are confident that amongst the new cohort of governors the young person’s voice will be heard.

Action closed.

10/19 i) Key Messages

12/02/19

Nominations for a governor’s Star Award would be circulated in due course, and governors were invited to vote for their choice.

Governors Feb 2019

Action closed.

Nominations made.

11/19 i) Council of Governors Work Programme

12/02/19

The work programme was a live document and governors were invited to suggest items in shaping the strategic agenda discussions.

Governors May 2019

Action closed.

No further items received.

11/19 ii) Council of Governors Work Programme

12/02/19

An invitation would be extended to the Youth Forum to attend meetings on a regular basis.

Corp. Affairs May 2019

Invitation made to Youth Forum.

Action closed.

12/19 i) Governor Engagement Report

12/02/19

A report on Chair and Non-executive appraisals would be brought back to the May meeting following

Chair May 2019

Action closed.

Minute Ref: 28/19.


completion of appraisals.


12/02/19

Governor volunteers to sit on committees were sought.

Governors Feb 2019

Action closed.

Post meeting note identifying governor reps under. Minute Ref 12/19.

12/19 vi) Governor Engagement Report

12/02/19

AD-CA to make a check of the rules around staff governor observers on committees.

AD-CA May 2019

Action closed.

Post meeting note identifying governor reps under. Minute Ref 12/19.


12/02/19

Expressions of interest were sought from governors to attend a national conference on 9 May.

Governors Feb 2019

None received.

Action closed.


12/02/19

Governors were asked to volunteer to be involved in a security exercise, to test internal security controls in early March.

Governors Feb 2019

Action closed.

Ms Kent, public governor, participated in the internal security exercise.

Actions Scheduled updated following 14 May 2019 CoG meeting

Action ref:

Date Action raised

Action Action with Target date to

complete


50/18 to review the actions log: 43/18 vii) Reflection on matters discussed in meeting

13/11/18

Ms Burns would discuss the in-house nurse counsellor initiative with the DHROD.

Ms Burns TBC

22/19 i) Feedback from the February Joint Strategy Session

14/05/19

Feedback from these sessions would be shared at a future meeting to look at themes and actions.

DSO TBC

26/19 iii) Key Messages

14/05/19

Mrs Shearer agreed to investigate what support school nursing was providing to mental health issues relating to drug use within schools.

DNQ TBC

26/19 iii) Key Messages

14/05/19

Ms Fountain would pick up mental health issues relating to drug use within schools, in terms of a public campaign.

AD-Comms TBC


7. 37/19 OUTCOMES FORM CQCINSPECTION 2019 (PRESENTATION)

8. 38/19 CONNECTING TOGETHER -IM&T STRATEGY (ENC C)

EXECUTIVE SUMMARY

Title Connecting Together – IM&T Strategy

Report to

Council of Governors Date 16 July 2019

Executive Sponsor

Ruth Brown, Director of Strategy & Operations

Author

Kevin Connolly, Chief Information Officer

Purpose of report

To provide an overview of ‘Connecting Together’ IM&T strategy, approved by Trust Board in June 2019.

Please tick as appropriate

Approval

Assurance

Information √

Executive summary –the key messages and issues

All key content for the ‘Connecting Together’ IM&T strategy was agreed through the Trust’s IM&T Strategy Board, Trust Executive Group and Finance & Resources Committee. This was also covered in dedicated Open Staff Forum sessions held across Trust sites, Jan - Feb 19. Feedback from those was very supportive and agreed that the emphasis on ‘Connecting Together’ had resonance. Where business cases have been approved and/or plans have clear milestone commitments, these are identified within the strategy. Communications Plan is being finalised for launch through July 2019 - includes commencement of recruitment to Chief Clinical Information Officer (CCIO) role and establishment of a unified Clinical Advisory Group, to be chaired by the CCIO when appointed. Involvement of Staff Governors would be much welcomed, if capacity allows.

How this report impacts on current risks or highlights new risks

IM&T Strategy is specifically covered by BAF (9), current score: 5 x 3 = 15. A number of IT operational risks are included on the corporate risk register, which were reviewed with the Risk & Audit Committee in March 2019.

Recommendations and next steps

The Council of Governors is asked to note the IM&T strategy. A full version of the strategy document will also be circulated to Governors separately.

COUNCIL OF GOVERNORS 8. 38/19 CONNECTING TOGETHER... Page 23 of 114

Connecting TogetherIM&T Strategy Overview

Kevin Connolly – Chief Information OfficerJuly 2019

COUNCIL OF GOVERNORS 8. 38/19 CONNECTING TOGETHER - IM&T... Page 24 of 114

Strategic Focus

Connecting Together IM&T Strategy (2019 – 2022), approved by Trust Board in June 2019.

- Primary focus is on the inter-relationships between our IT infrastructure, electronic record systems and

information reporting - and how they impact on our clinical services integration, data integrity,

operational efficiency and performance against key indicators.

- Also recognises that IT is now an essential utility, which staff, patient and families all increasingly expect to

consume ubiquitously, seamlessly, securely, cost effectively and without interruption.

- Delivery programmes seek balance between internal and external perspective and expectations.

- Evident from user surveys and engagement sessions with staff groups over the past year that largest

frustrations (in relation to IM&T systems and services) centre around their day to day experience with our

IT infrastructure and operational support processes. A more formalised IT operational model is a clear

necessity moving forwards, less reliant on specific individuals and with reporting against target response

and resolution times for support issues.

- It is also essential that we incorporate national interoperability standards and digital maturity roadmaps

into our forward planning, noting that these:

• commonly translate into mandated NHS contract standards and CQC framework

• tend to be applied as mandated entry commitments for any future bids against national allocations,

which will be a vital source of funding.

• are increasingly essential to working with health and social care partners, delivering activities across

our organisational boundaries.


Delivering the IM&T Vision

Delivery of Connecting Together objectives will be managed through three core strategic

programmes, plus five enabler themes which cover across all three programmes:

Connecting Together requires inherent consistency across our service planning and investment

decision making in each programme. As examples, this explicitly requires that:

We align to a commonality of infrastructure technologies across the Integrated Care System and

with NHS Digital, to ensure we operate efficiently and so that clinical staff can work seamlessly

across sites and care settings;

We include internal and external interoperability requirements as essential criteria in

specifications for all new digital record solutions to be introduced into the Trust.

We recognise the value of rich, structured clinical data in our digital record systems, not just to

share across settings, but also to utilise in our quality and performance indicators and our

development of predictive analytics.


Technical Infrastructure

Programme Delivery:

• End User Computing – desktop standard, mobile devices, VDI,

Single Sign-on, follow-me printing, Skype messaging & virtual

clinics, agile working aligned to Estates strategy.

• Networks and Storage – HSCN migration, GovRoam, remove

Novell, increasing Cloud adoption, eliminate all single points of

failure, disaster recovery and business continuity testing.

• Cyber Security – formal 3 year Cyber Plan in place

• Licensing – Infrastructure as a Service, plan move to Office 365.

• Service Management – formalise the operating model, ITIL

processes, extend 24x7x365 user support, equitable service

across Trust sites, self-help and self service, enabling process

automation across corporate support services.

Design Requirements:

• Seamless – ease of access to networks,

applications and data, process

automation, user experience with Service

Desk.

• Resilient – Infrastructure is now an

essential utility, near 100% availability,

supported 24x7x365.

• Mobility – ubiquitous connectivity needs,

across external sites also. Essential to

effective use of Estate.

• Security – national data standards, Cyber

Essentials accreditation, continual

vulnerability assessment.

• Sustainable – operating model and

architecture must anticipate continual

growth in user, asset and data volumes,

common technologies across ICS.


Digital Care Records


• Integrated – Digital Care Records will

be provided through a collection of

capabilities, not a single system.

• Real Time Data – establish systems

and processes that enable default

position where clinical data is input by

clinical staff in (near) real time.

• Clinical Workflow – system access

and configuration must not disrupt

overall workflow productivity, nor

dilute the quality of care interactions

with patients and families.

• Interoperability Standards – shifting

focus from sharing documents to

seamless exchange of structured data

between systems across care settings.

• Multi-Platform – systems are

accessible securely via mobile devices

and across wider geography, not just

via fixed desktop computers

connected to the Trust network.

Programme Delivery:

• Digital Outpatients – referral grading, outcoming, digital

dictation and voice recognition, virtual clinics, interoperability and

‘transfers of care’ (TOC) standards for sharing with GPs.

• Digital Wards – redesign electronic discharge and incorporate

TOC interoperability requirements, clinical handover, electronic

observations, real time ward whiteboards.

• CAMHS – SystmOne EPR.

• Diagnostics – electronic prescribing, order communications,

Genomics, LIMS replacement, digital pathology.

• Community – migration off QSM, SystmOne EPR optimisation.

• Shared Care Records – unified view of records within the Trust,

external integration with: national Child Protection system;

Sheffield ACP solution, Yorkshire & Humber LHCR ‘system of

systems’ integration. Patient Portal requirement.


Business Intelligence


• Data Quality

- Robust standards for data capture and coding

(‘none shall pass’ approach for reporting)

- Adopt a ‘Right First Time’ culture

- Regular clinical validation and audit

• Single Version of the Truth

- Defined business logic and data definitions for

information reporting

- Self Service provision of reports to support an

information culture and data driven decision

making, as illustrated below:

Programme Delivery:

• Integrated Performance Reporting - triangulation across

activity, finance, workforce and quality domains; predictive

planning as well as retrospective performance reporting;

extended use of benchmarking data

• Data Warehouse – extend coverage to eDMS and SystmOne.

• Data Quality Assurance – sustain data quality maturity across

acute services, raise Community and CAMHS to same level.

• Clinical Coding – continue clinical engagement and audit,

sustain audit standards, manage migration to SNOMED.

• Automated Reporting and Distribution – including self

service provision so reports can be re-compiled dynamically,

accelerating reporting timetables, releasing more time for

analysis and performance management.

• Population Health – active involvement in ACP and ICS

agenda, aggregation of data across health and social care

settings.


Collaboration and Partnerships


• Resilience

- Need to support services and users 24x7x365

- Capacity to manage major outages or security

incidents

- Access to specialist skills, e.g. cyber security,

development of business intelligence tools, IT

procurement, EPR deployment.

• Best Value

- Maintain cost benchmarking for core services.

- Reduced reliance on agency staff to deliver

capital projects.

• Best Practice

- Team Up, within NHS and through

development of commercial partnerships, to

identify and deliver transformation

opportunities across our IM&T services.

• Standardisation

- Shared procurement where possible, product

standardisation as default.

- Shared knowledge base to drive continual

performance improvement.

- Enables all models for furthering corporate

service integration.

Key Themes:

• Aggregated Procurement – whilst individual organisations

all have their own internal procurement services, all partners

recognise the opportunity and share the intent for aggregated

purchasing wherever possible. This is one of the initial 5 key

priorities for the newly established ICS Infrastructure

Programme Board.

• Commercial Relationships – we must nurture and invest in

mutually beneficial strategic relationships with our key

suppliers, to influence their development roadmaps and

anticipate our opportunities.

• Shared Services – sustainability and resilience objectives

demand that the Trust must more positively seek shared

service and partnering opportunities going forwards.

Provision of a 24x7x365 ICT Service Desk and rapid access to

specialist cyber security expertise are clear examples.

• Accountable Care Partnership and Integrated Care System

– Trust must be an active participant, shaping and influencing

to ensure alignment to wider Trust objectives and achieving

best outcomes for our patients and staff.


Underpinning Enablers

Engagement and Transformation:

• Chief Clinical Information Officer -

recruitment in summer 2019. Senior leadership

and representation, ensuring clinicians are

central to decisions guiding safe and efficient

design, deployment and use of IM&T

solutions.

• IM&T Clinical Advisory Group – ensure this

is regular and active multi-disciplinary forum,

chaired by CCIO, influencing prioritisation

decisions and advising on change

management requirements for project

implementation.

• Communications and Service Improvement

– essential support for all project delivery,

ensuring key link between project

management focus on delivery of outputs and

business requirement for delivery of benefits.

• External Representation – we must commit

time and focus to support development of

Place and System IM&T programmes, to

ensure these align to Trust clinical strategy and

Trust clinical design requirements for new

digital care record solutions.

Workforce objectives:

• IM&T Service Management – formalised IM&T support model,

with all staff trained and working to industry ITIL processes.

• Subject Matter Experts – continue to develop multi-disciplinary

networks of active clinical SMEs, representing clinical services

and provide support to the Chief Clinical Information Officer.

• Clinical Safety Officers – build a cohort of accredited clinical

safety leads (national training programme applies), to ensure all

new electronic patient record systems are rigorously tested prior

to their introduction into live clinical environment.

• Data Protection Officer – extend resource to function, for

proactive information risk management and GDPR compliance.

• ‘Grow Our Own’ principle for IM&T workforce development and

sustainability, success of which has been demonstrated in Clinical

Coding over past 2 years. Initiatives to include: Digital Academy

placements for clinical leads, internal secondment opportunities,

graduate and apprenticeship schemes.


Governance

Connecting Together programme governance structure is illustrated below. This incorporates clinical leadership

internally, as well as external alignment with ACP and ICS.

This IM&T governance will also need to remain aligned with the work streams established for the Trust’s

transformation programme, to ensure coherence and avoid duplication. The link between the ‘Digital Outpatients

EPR’ programme and the wider Trust Modernising Outpatients Programme is an example of this.

Business cases for investment funding and project approvals will also need to be managed consistent with Standing

Financial Instructions.


Financial Context

- The two most significant risks to delivery of our Connecting Together objectives are:

• Programme and project affordability, both in capital and revenue expenditure terms

• IM&T and wider Trust capacity to implement major change management projects simultaneously

- These two issues are inter-linked to a significant degree.

- Affordable schemes require access to non-recurrent funding (typically capital) to provide the necessary

project budgets. Unfortunately, due to overall staffing capacity constraints, it is also not possible to deliver

the desired projects through substantive resources, even if the projects were to take longer.

- The Trust’s regular capital allocation for IM&T is currently circa £780K per annum, although this budget

will struggle to fund much more than necessary end of life replacement of existing IT assets (network and

server infrastructure, desktop and laptops).

- Hence it is essential that the Trust continues to seek external funding sources wherever possible. Over the

past two years we have been successful with national cyber security funding (£2.2M in 2017/18) and

‘Health System Led Investment’ provider digitisation monies (£1.2M in 2018/19).

- Further external bid opportunities are anticipated in 2019/20, albeit subject to match funding (Digital

Wards and Electronic Prescribing projects), business cases required by December 2019.

- Commitment to Connecting Together objectives will be a critical factor in these external bids, most

notably in relation to interoperability specifications, record sharing (structured clinical data, not just access

to documents) and alignment towards digital systems standardisation across regional footprints.


CONNECTING TOGETHER

IM&T STRATEGY

2019 - 2022

JUNE 2019

Document control

Title IM&T Strategy 2019 - 2022

Status Final Version

Date Issued June 2019

Author Kevin Connolly, Chief Information Officer


Connecting Together, IM&T Strategy 2019 - 2022

TABLE OF CONTENTS

1. INTRODUCTION ....................................................................................................3 2. STRATEGIC DRIVERS ..........................................................................................4

2.1 STRATEGIC DRIVERS .........................................................................................4 2.2 TRUST CONTEXT ...............................................................................................4 2.3 NATIONAL CONTEXT ..........................................................................................5 2.4 SOUTH YORKSHIRE & BASSETLAW INTEGRATED CARE SYSTEM ...........................6 2.5 SHEFFIELD ACCOUNTABLE CARE PARTNERSHIP .................................................6

3. IM&T VISION AND OBJECTIVES .........................................................................7

3.1 APPROACH .......................................................................................................7 3.2 VISION ........................................................... ERROR! BOOKMARK NOT DEFINED.

4. DELIVERING THE STRATEGIC VISION ...............................................................8 5. DIGITAL CARE RECORDS PROGRAMME ..........................................................9

5.1 OVERVIEW ........................................................................................................9 5.2 DESIGN OBJECTIVES .........................................................................................9 5.3 “TRANSFERS OF CARE” INTEROPERABILITY STANDARDS ................................... 10 5.4 DIGITAL OUTPATIENTS .................................................................................... 10 5.5 DIGITAL WARDS .............................................................................................. 11 5.6 MENTAL HEALTH SERVICES ............................................................................. 12 5.7 COMMUNITY SERVICES.................................................................................... 12 5.8 ORDER COMMUNICATIONS .............................................................................. 13 5.9 LABORATORY SERVICES .................................................................................. 13 5.10 ELECTRONIC PRESCRIBING ............................................................................. 14 5.11 CHILD PROTECTION INFORMATION SHARING ..................................................... 14 5.12 SHARED CARE RECORDS – SHEFFIELD ACP .................................................... 15 5.13 REGIONAL HEALTH CARE RECORDS – YORKSHIRE & HUMBER ........................... 15

6. ICT INFRASTRUCTURE PROGRAMME ............................................................. 17 7. BUSINESS INTELLIGENCE PROGRAMME ....................................................... 20 8. ENABLERS ......................................................................................................... 22

8.1 OVERVIEW ...................................................................................................... 22 8.2 COLLABORATION & PARTNERSHIPS .................................................................. 22 8.3 WORKFORCE .................................................................................................. 23 8.4 ENGAGEMENT & TRANSFORMATION ................................................................. 25 8.5 GOVERNANCE ................................................................................................. 26

9. FUNDING ASSUMPTIONS .................................................................................. 27



INTRODUCTION PAGE 3

1. INTRODUCTION

1.1 INTRODUCTION

1.1.1 The Trust’s IM&T Strategy for the period 2019 to 2022 and has been developed to:

- formally recognise key national and regional drivers;

- incorporate appropriate response to current service user feedback;

- enable the organisation to meet our clinical strategy goals and associated corporate objectives;

- support Divisional priorities, as established through business planning and the Trust transformation programme;

- facilitate future IM&T developments to support improvements in patient care and patient experience;

- and identify requirements for further development of IM&T operational services so they are organised and ready to meet future demand.

1.1.2 Strategic drivers are summarised at Section 2. High level Vision is then articulated at Section 3. Delivery programmes and governance structure are described through Sections 4-8. Finally, funding assumptions and the extent of affordability challenge are then set out at Section 9.

1.2 CONNECTING TOGETHER

1.2.1 The Trust’s ‘Caring Together’ clinical strategy, establishes 5 core aims for how we will achieve our purpose of providing a healthier future for children and young people.

1.2.2 This ‘Connecting Together’ strategy defines IM&T technical solution requirements, operational service objectives and key investment priorities intended to contribute to each of these 5 core aims, through 2019 – 2022.

1.2.3 ‘Connecting Together’ primarily focuses on the inter-relationships and required cohesion between how we deliver our IT infrastructure, electronic patient record systems and information reporting - and how they impact on our clinical services integration, data integrity, operational efficiency and performance against key indicators.

1.2.4 ‘Connecting Together’ also recognises IT as an essential utility, which staff, patient and families all increasingly expect to consume ubiquitously, seamlessly, securely, cost effectively and with uninterrupted supply.



STRATEGIC DRIVERS PAGE 4

2. STRATEGIC DRIVERS

2.1 STRATEGIC DRIVERS

2.1.1 This section provides an overview of internal and external drivers that influence our IM&T strategic objectives and plans. Balance is sought between internal and external perspective and expectation.

2.1.2 Day to day, operational discussion understandably focuses on live internal issues and ensuring alignment to planned service developments in the Trust. However, it is essential that we do incorporate national interoperability standards and digital maturity roadmaps into our forward planning.

2.1.3 Not least, these commonly translate into later mandated NHS contract standards and incorporated into the CQC regulatory framework. They also tend to be applied as mandated entry commitments for any future bids against national allocations, which will be a vital source of funding to deliver Connecting Together objectives. They are also increasingly essential to working with health and social care partners, delivering activities across our organisational boundaries.

2.2 TRUST CONTEXT

Electronic Patient Records

2.2.1 Although we continue to have an almost even split between digital and paper based record management processes, our current position does offer a number of viable product enhancements and expansion through existing suppliers, to advance our digital maturity and electronic record coverage.

2.2.2 Most of our current clinical record systems can be considered as ‘strategic’ (i.e. not legacy) in that there are no plans to actively seek their replacement within the term of this strategy. This includes Medway Patient Administration System, Bluespier Theatres, Intersystems Integration Engine, Kainos Evolve eDMS, ICE Results Reporting, Agfa Radiology, SystmOne EPR for Community and CAMHS.

2.2.3 The key areas where we must very obviously prioritise system functionality provision relate to Order Communication, Inpatients (observations, alerting, real time bed management and alerting), Electronic Prescribing and internal record sharing across our acute, community and mental health care settings. The solution we adopt for unified records is likely to be sourced through a wider project involving all partners in the Sheffield Accountable Care Partnership. We also have a looming deadline to replace our Laboratory Information Management System (LIMS) within the next 18 months.

2.2.4 Each of these current gaps are described in later sections.




User Perception

2.2.5 As we do advance our digital records programmes, this highlights ever greater reliance on our IT services, required to support increasing user base, additional devices and more critical urgency for resolution when things do go wrong.

2.2.6 It has been evident from a series of user surveys and engagement sessions with staff groups over the past year that their largest frustrations (in relation to IM&T systems and services) centre around their day to day experience with our IT infrastructure and operational support processes. This has not been limited to staff feedback. As example, patients and families have also been critical about the reliability of bedside patient entertainment units which are connected through the Trust IT network.

2.2.7 This is despite broad acknowledgement that significant investments have been made and notable projects delivered in the same period, including full WiFi coverage, desktop migration to Windows 10 and sizeable roll-out of hybrid laptops and tablet devices to enable mobile working.

2.2.8 A more formalised IT operational model is a clear necessity moving forwards, less reliant on specific individuals and with establishment of clear expectations for target response and resolution times for support issues.

2.2.9 This need will only be further reinforced as we progress our roadmap to extend digital record coverage. A significant step change in IT process maturity and service level guarantees will become pre-requisite.

2.3 NATIONAL CONTEXT

2.3.1 New external drivers are now identified on an almost monthly basis, especially as shared care clinical strategies are being developed across organisations, at Place, System and/or national network level.

2.3.2 With this section, the key ones are identified, albeit mostly without accompanying descriptive narrative, simply for brevity. These include:

- Lord Carter: “Operational productivity and performance in English NHS acute hospitals: Unwarranted variations” (2015) – included firm recommendation for Electronic Prescribing adoption across NHS.

- Clinical Digital Maturity Index, initially launched in 2015, provides benchmark comparison to assess Trusts’ progress on their digital capability, tracked and monitored over time.

- CQC Safe Data Safe Care standards and National Data Guardian recommendations for data security – subsequently incorporated into the NHS Data Security & Protection Toolkit self-assessment requirements.

- Cyber Essentials Plus - all NHS organisations are required to achieve this certification by 2021.




- NHS Long Term Plan, Jan 2019 – dedicated chapter for Digital Transformation, confirms commitment to national interoperability standards, regional record sharing programmes (one is in place across Yorkshire & Humber), launch of the NHS App with patient access to care plans due by 2021, heightened cyber security focus, requirement for Trusts to be fully digitised by 2024.

- Dr Eric Topol review commissioned by Health Education England, published Feb 2019: focused on building a ‘digital ready workforce’.

2.4 SOUTH YORKSHIRE & BASSETLAW INTEGRATED CARE SYSTEM

2.4.1 The ICS stated vision is to develop a fully integrated digital service across South Yorkshire and Bassetlaw, to support objectives of the Long Term Plan and improve care and services for our patients in SYB.

2.4.2 Specific aims are:

- A citizen in South Yorkshire and Bassetlaw will be able to access and use digital technology and information to improve or maintain their own health and wellbeing and expect any person or organisation involved in their healthcare to do the same.

- Enabling People and Patient Empowerment

- Supporting Clinical and Strategic Decisions

- Delivering System Integration and Operational Efficiency

- Developing Local Health Tech Skills & Innovation

2.4.3 The Trust is an active participant within the ICS Digital agenda, and the Trust Chief Information Officer is the lead Director for the ‘Technical Infrastructure’ programme within this.

2.5 SHEFFIELD ACCOUNTABLE CARE PARTNERSHIP

2.5.1 The key priority for Sheffield ACP is for a unified record system, as described later at Section 5.12.

2.5.2 Other areas of focus are to ensure reciprocal connectivity for staff working across partner sites, enabling appropriate data sharing protocols for shared care, and progressing the agenda to develop Population Health capability for service planning and needs analyses.

2.5.1 Again, the Trust is an active participant, supporting delivery and ensuring that Trust clinical strategy and corporate objectives are well aligned.



IM&T OBJECTIVES PAGE 7

3. IM&T OBJECTIVES

3.1 APPROACH

3.1.1 Connecting Together objectives have been established through consideration of all strategic drivers set out in the previous section and by then testing proposed positions and design requirements with stakeholder groups across the Trust, seeking resonance and agreement.

3.1.2 This process has hence included user surveys and open staff forums, meetings with specific departments and also liaison with counterparts in other partner organisations within South Yorkshire & Bassetlaw Integrated Care System.

3.1.3 Outputs have then been reviewed and confirmed through the Trust’s governance structure, including: IM&T Strategy Board, Trust Executive Group and Finance & Resources Committee.

3.2 OBJECTIVES

3.2.1 Connecting Together firmly aligns with our local clinical strategy, addresses issues raised through engagement with our staff and enables greater clinical and corporate services integration across the Trust.

3.2.2 Connecting Together also confirms our commitment to NHS interoperability standards, regional record sharing and roadmaps towards being paperless at the point of care.

3.2.3 Connecting Together is committed to ensuring delivery of:

- Digital care records maturity achieved through a collection of integrated capabilities, not a single system;

- Shifting focus from sharing documents to seamless exchange of structured data between systems across care settings;

- New system access and configuration which does not unduly disrupt overall productivity, nor dilute the quality of care interactions with patients and families;

- IT infrastructure which is managed and supported as an essential utility; - Cyber Essential accreditation.

3.2.4 To enable this we must:

- Increase IM&T management and technical capacity, including access to specialist skills;

- Actively seek collaboration and partnerships, including shared procurement and product standardisation by default;

- Continue to build multi-disciplinary networks of subject matter experts representing clinical services, providing support to a new Chief Clinical Information Officer (to be appointed).



DELIVERING THE STRATEGIC VISION PAGE 8

4. DELIVERING THE STRATEGIC VISION

4.1.1 Delivery of our ‘Connecting Together’ objectives will be managed through three core strategic programmes, plus five enabler themes which cover across all three programmes:

4.1.2 It is essential that all described elements of the strategy are recognised as being integral to each other.

4.1.3 Connecting Together requires inherent consistency across our service planning, investment decision making and work prioritisation within each programme.

4.1.4 As examples, this explicitly requires that:

- We align to a commonality of infrastructure technologies across the Integrated Care System and wider NHS, to operate efficiently and enable clinical staff to work seamlessly across sites and care settings.

- We include internal and external interoperability requirements as

essential criteria in specifications for all new digital record solutions to be introduced into the Trust.

- We recognise the value of rich, structured clinical data in our digital

record systems, not just to share across settings, but also to utilise in our quality and performance indicators and our development of predictive analytics.



DIGITAL CARE RECORDS PROGRAMME PAGE 9

5. DIGITAL CARE RECORDS PROGRAMME

5.1 OVERVIEW

5.1.1 This section provides high level description and current status for the main digital record capabilities and maturity that we intend to progress within the strategy period, subject to funding. Where projects have formal funding approval – or plan milestones are already established – these are confirmed in the narrative.

5.1.2 Where practical these are grouped into work streams that are aligned to our Clinical Divisions - and any existing governance structures in place with external partners.

5.2 DESIGN OBJECTIVES

5.2.1 In order to ensure consistency of approach across each of these work streams, a number of over-arching design requirements have been approved through the IM&T Strategy Board. These are:

Integrated

Digital Care Records will be provided through a collection of capabilities, not a single system.

Real Time Data

We will establish systems and processes that enable default position where clinical data is input by clinical staff in (near) real time.

Clinical Workflow

System access and configuration must not unduly disrupt overall workflow productivity, nor dilute the quality of care interactions with patients and families.

Interoperability

Shifting focus from sharing documents to seamless exchange of structured data between systems across care settings

Sustainable

Systems are accessible securely via mobile devices and across wider geography, not just via fixed desktop computers on the Trust network.




5.3 “TRANSFERS OF CARE” INTEROPERABILITY STANDARDS

5.3.1 As we consider design and selection of new digital record systems, we must incorporate new Professional Record Standards Body (PRSB) published standards. These seek to ensure that Trusts are able to electronically transmit structured clinical data to GPs, with formats defined in the NHS England Standard Contract.

5.3.2 These standards are referred to as ‘Transfer of Care’ requirements - Inpatient, Emergency and Mental Health Discharge Summaries, plus Outpatient clinical letters, are all in scope.

5.3.3 We have assessed that we will be able to meet our obligations for Inpatient and Emergency Discharge Summaries through Medway PAS, albeit requiring some adaptation of our current messaging to GPs. Similarly, Mental Health is covered following migration onto SystmOne.

5.3.4 However, our current processes for Outpatient letters must be urgently addressed, ref: https://www.england.nhs.uk/wp-content/uploads/2018/05/8-nhs-standard-contract-technical-guidance-may-2018.pdf)

5.3.5 It is identified that these requirements will need to be fully incorporated into Digital Dictation configuration and associated workflows (covered in ‘Digital Outpatients’ work referred to below).

5.4 DIGITAL OUTPATIENTS

5.4.1 This grouping of projects consolidates a number of inter-related system developments, each building upon our successful implementation of the Kainos Evolve eDMS through 2016 - 2018. All schemes are also mapped to the Trust’s ‘Modernising Outpatients’ transformation work stream.

5.4.2 Part funding (£575K capital) was secured through NHS England funding in Q3 2018/19 and we have met all significant implementation milestone commitments – and target savings – thus far.

5.4.3 In turn, these projects are:

- Electronic Referral Grading (completed March 2019)

- Electronic Forms Capture, including Outcoming (to complete July 2019)

- Clinical Genetics Migration to Medway & eDMS (live at end March 2019)

- Single Sign-on (Imprivata procured, implementation delayed to Q3 19/20)

- Digital Dictation (initial upgrade of Big Hand software due end June 2019, re-procurement of a long term solution planned through Q3 19/20. This needs to include NHS ‘transfers of care’ interoperability standards, as described earlier).


https://www.england.nhs.uk/wp-content/uploads/2018/05/8-nhs-standard-contract-technical-guidance-may-2018.pdf

https://www.england.nhs.uk/wp-content/uploads/2018/05/8-nhs-standard-contract-technical-guidance-may-2018.pdf



5.5 DIGITAL WARDS

5.5.1 eDMS implementation, has effectively ensured that ‘digital records’ are available for clinicians at all outpatient clinics. All clinical noting completed during clinic is either then keyed into structured eDMS ‘e-forms’ (e.g. outcome forms, elective booking forms), or handwritten notes are scanned into eDMS within 2 working days following clinic.

5.5.2 Whilst this has delivered significant clinical efficiency and patient safety benefits across outpatient services, the same approach is not practical on our inpatient wards, where records must be captured and made available in real time. Also, whereas eDMS users are primarily doctors, it is commonly quoted that circa 80% of inpatient records are maintained by nursing staff.

5.5.3 Through a focused Digital Wards work stream we will establish solutions to fully integrate admission, clinical handover, electronic observations, alerts and inter-team communications, with all key information also made available on electronic ward whiteboards.

5.5.4 The potential benefits are significant and this is hence a key priority for to pursue through external funding sources. Indeed, it is intended that the project will be supported by NHS England ‘Health System Led Investments’ funding, as described later in this document (Section 9).

5.5.5 The vision for Digital Wards is one in which:

- Observations including vital signs and fluids will be collected electronically, at the bedside, on mobile devices removing the need for paper records.

- Assessment and screening tools will be available electronically with reminders to use them where appropriate (e.g. VTE assessment in post-pubertal surgical patients).

- Automated alerting systems will be based upon the Trust’s tailored requirements for these observations, e.g. potential sepsis alerts helping to reduce missed early opportunities to intervene.

- Discharge summaries will be easier to create in a timely fashion as the necessary information will already be on the system, with tools to help with summary creation.

- Team to team referrals will be electronic, with accurate records of who referred, when and to whom removing any ambiguity around the referral. The clinical team member receiving the referral should have access to the patient’s full clinical record at the point of referral allowing better judgements to be made about urgency.

- Handovers will be recorded electronically and will be presented alongside relevant current clinical information rather than team members having to rush around collating the latest patient observations before handover.




5.6 MENTAL HEALTH SERVICES

5.6.1 Our Inpatient and Community CAMHS teams went live on SystmOne on 1st April 2019. This means we now have a single electronic patient record for Mental Health, Community and Children’s Services within the Trust. This record also links in with the local and national GPs using SystmOne.

5.6.2 Through a linked implementation of the SystmOne “EPR Core” module this also provides GPs and other services on SystmOne with real time Acute A&E and Inpatient admission and discharge updates. [On 4th April 2019 we established a live transaction feed from the Trust’s Medway PAS.]

5.6.3 Implementation of CAMHS EPR now enables on-call Mental Health clinicians to access the patient history securely from any location using portable devices and secure data connections.

5.6.4 Access has also been enabled at Northern General Hospital for clinicians providing out-of-hours care to CAMHS patients 16 years and above, i.e. should they attend the Emergency Department.

5.6.5 We have also implemented a data feed into our Data Warehouse which will support more consistent reporting of statutory and management information. The single electronic patient record will also provide for faster and more accurate clinical audit capability, which in turn will support improvements in the completeness and consistency of clinical documentation.

5.6.6 The ‘project’ is scheduled to close in July 2019, with a dedicated Operational Group put in place to oversee ongoing system enhancements and support to users. A formal Benefits Realisation Report is due by February 2020.

5.7 COMMUNITY SERVICES

5.7.1 This work stream will focus wider than 0-19 services hosted within the CWAMH clinical division, so will also include out of hospital services hosted from Ryegate, LAACH, Helena and Safeguarding teams.

5.7.2 The majority of these services are on – or plan to move onto – SystmOne, although some services will also maintain records on Medway and eDMS due to clinical overlap with acute services.

5.7.3 Speech and Language Therapy are scheduled to formally re-launch their use of SystmOne in July 2019, supported by mobile working investment and a detailed re-mapping of all operational process, associated documentation review and staff re-training. We have also rolled out over 80 new hybrid laptop devices, selected through a clinically led evaluation process.

5.7.4 This is intended as an exemplar deployment, and lessons learned will inform how we approach equivalent work to optimise mobile working across other community services already on SystmOne. A model business case has been developed which is repeatable and is cost neutral so long as business change is embedded to deliver targeted efficiency benefits.




5.8 ORDER COMMUNICATIONS

5.8.1 We are a major outlier here, as the only Trust locally still to implement electronic ordering for diagnostic tests (Pathology and Radiology in particular), whether ordered by internal clinicians or direct access ordering from GPs. This gap in our digital maturity constrains our processes for demand management, leads to unnecessary duplicate test requests and offers little by way of financial monitoring.

5.8.2 Paper based requesting is also laden with data quality issues and inefficiencies, which in turn have potential to impact on patient safety. For example, due to issues with legibility and accuracy of handwritten request forms this can result in a trade off with the bare minimum of data provided and the laboratories taking registration risks to avoid rejecting samples. Results reported are also only as accurate as the data initially provided on the request form and therefore can be delivered to the wrong location, wrong doctor and in some cases to the wrong patient due to inaccurate completion of request forms.

5.8.3 The IM&T Strategy Board have requested that a business case for Order Communications purchase and implementation is submitted for approval by end September 2019.

5.9 LABORATORY SERVICES

5.9.1 The largest single risk within the Trust’s current digital records system portfolio relates to our ‘Telepath 2000’ Laboratory Information Management System (LIMS), which has been confirmed as end of life for some time. Although in 2018 the prime contract supplier (DXC) extended support for a final 2 years, the product will cease to be supported from October 2020.

5.9.2 The risk to the system however, is still high, because there is only one other NHS site (Birmingham - who are in the process of replacement) in the UK still using this solution, which makes its continuation in the UK market extremely vulnerable.

5.9.3 Plans for procurement and implementation of a replacement system are further complicated as they must align with potential changes in laboratory services provision, e.g. through potential partnership models with Sheffield Teaching Hospitals NHS Trust or even more complex consolidation across South Yorkshire & Bassetlaw Integrated Care System.

5.9.4 Whilst these potential options are being explored, there is also parallel work at SYB ICS level to establish a likely roadmap and investment proposal for a move to Digital Pathology.

5.9.5 This technology involves electronic transmission of pathological images from one location to another, for the purpose of interpretation and diagnosis. Whole slide imaging is a relatively new technology that allows the digitisation of an entire glass slide, producing a digital image for review.




5.9.6 This is comparable with PACS technology that has been ubiquitous across Radiology services for over 10 year services.

5.9.7 Together, these present a complex set of interdependencies which will require collaborative agreement on priorities and sequencing of planned deployments. Financial support for Digital Pathology is being pursued via national sources, including Cancer Alliance funding, with business cases and procurement to be managed at regional level (SYB ICS).

5.10 ELECTRONIC PRESCRIBING

5.10.1 Electronic Prescribing and Medicines Administration (EPMA) provides well established patient safety functionality to increase medicines safety and improve discharge processes. Lord Carter firmly recommended its introduction in his report: “Operational productivity and performance in English NHS acute hospitals: Unwarranted variations”.

5.10.2 In spring 2018 the Secretary of State for Health and Social Care announced that dedicated central funding would be made available to accelerate the rollout of Electronic Prescribing and Medicines Administration (EPMA). In July 2018 NHS Improvement then published a prospectus explaining how this funding can be accessed.

5.10.3 There are a number of qualification criteria for this funding, which we do meet. We are now included in a planned 3rd (and final) wave of applicants, which requires full business case submission and completion of procurement activities by January 2020.

5.10.4 The specific paediatric nature of our organisation means that we need to ensure that we implement a system that best meets specialist paediatric functionality, in particular relating to dosage measurement.

5.10.5 We are currently undertaking informal market testing and a detailed Output Based Specification will be completed by end June 2019.

5.11 CHILD PROTECTION INFORMATION SHARING

5.11.1 The national Child Protection Information Sharing (CP-IS) project ensures that when a child is known to social services - and is a Looked After Child or on a Child Protection Plan – an alert and basic information about the plan will be available to NHS users with relevant access.

5.11.2 CP-IS applies to emergency and unscheduled healthcare settings and as such access has been enabled for our Safeguarding teams since April 2019 and will be incorporated into Emergency Department processes in July 2019.

5.11.3 Through our use of CP-IS this then means that social care teams are automatically notified that the child has attended, and both parties can see details of the child's previous 25 visits to unscheduled care in England.




5.12 SHARED CARE RECORDS – SHEFFIELD ACP

5.12.1 The Sheffield Accountable Care Partnership established a formalised Digital Delivery Board in April 2020, with priority set on developing a business case and defined requirements specification for a Shared Care Record solution.

5.12.2 This shall create a unified record that integrates patient/citizen information held about a person from across the health and care system in Sheffield, i.e. from own Trust system, Sheffield GPs, Sheffield City Council, Sheffield Health and Social Care Trust and Sheffield Teaching Hospitals. The objective is to support the integration of direct care provided by teams who span across different organisations and acre settings.

5.12.3 For our Trust, a number of opportunities have been identified to target for benefits realisation, these include: transfers from Jessop hospital, community services provided to patients whose GP’s do not use SystmOne, children under Safeguarding alerts, assessments for Looked After Children, transition planning and patients 16+ years presenting at adult Emergency Departments.

5.12.4 Within the Trust it is also acknowledged that even internally our clinical teams do not have a unified view of the Trust’s clinical records for patients who are managed across internal Acute, Community and/or CAMHS care settings. Furthermore, even within respective care settings, clinical teams have to separately log in to multiple record systems to derive a broader view of patients’ clinical records including referral information, images and test results. Whilst the ease of managing these multiple log-ins will be significantly improved through Single Sign-on implementation in 2019, this still falls short of delivering a unified internal record, which is increasingly viewed as a quality imperative.

5.12.5 Circa £1.0M capital funding is available to support this project in 2019/20; an initial Strategic Outline Case is being finalised for end June 2019 which will then be submitted for approval through ACP Executives. The detailed Output Based Specification is also well progressed and shall ready in July 2019.

5.13 REGIONAL HEALTH CARE RECORDS – YORKSHIRE & HUMBER

5.13.1 This is a high profile programme which has been supported by initial 2 year national funding in excess of £7M, to build an integrated record architecture and early adopter use cases for a regional Yorkshire & Humber ‘Local Health Care Record’ (Y&H LHCR).

5.13.2 The approach being taken is to develop a ‘System of Systems’ integration model which utilises the latest FHIR open messaging standards, avoiding the cost and vendor tie in that would be involved with purchase of a single commercial solution to be adopted across all organisations. This is also cognisant that many ‘Place’ health and care economies already have their own local shared record solutions, so these can be incorporated through integration.




5.13.3 A parallel development being progressed through the Y&H LHCR programme relates to regional procurement of Population Health capability. This includes infrastructure for data storage, data analytics application to process data and some data analytics people resource for initial analysis and reporting.

5.13.4 Also within scope is the objective to provide citizens (patients) with access to their unified record, so that a common solution is provided. This will be supplemented by take up of the new NHS App, enabling patients to access their appointments, letters and test results.

5.13.5 We are currently at the very early stage of discussions with the Y&H LHCR team as to feasibility for our inclusion in their ‘Wave 2’ take on in first half of 2020 calendar year. i.e. integration to enable our data feeds through the regional solution. Internal evaluation of this will be progressed through our IM&T Strategy Board.



ICT INFRASTRUCTURE PROGRAMME PAGE 17

6. ICT INFRASTRUCTURE PROGRAMME

6.1.1 It has been evident from a series of user surveys and engagement sessions with staff groups over the past year that their largest frustrations (in relation to IM&T systems and services) centre around their day to day experience with our IT infrastructure and operational support processes.

6.1.2 This is despite staff acknowledgement that significant investments have been made and notable projects delivered in the same period, including full WiFi coverage, desktop migration to Windows 10 and sizeable roll-out of hybrid laptops and tablet devices to enable mobile working.

6.1.3 A more formalised IT operational model is a clear necessity moving forwards, less reliant on specific individuals and with establishment of clear expectations for target response and resolution times for support issues.

6.1.4 This need will only be further reinforced as we progress our roadmap to extend digital record coverage. A significant step change in IT process maturity and service level guarantees will become pre-requisite.

6.1.5 Hosted applications are expected to be always available, without unplanned downtime and with an appropriate level of 24x7x365 support provided to users. Access to IT services is increasingly expected to be enabled from any place, at any time and from any device. Whilst these desired positions must be balanced against IT security and data privacy considerations, which staff do accept, it is well recognised that expectations are ever increasing.

6.1.6 From a resourcing perspective, whilst service demand will inevitably increase year on year, IM&T budgets (pay and non-pay, revenue and capital) can not keep pace with this. Hence, it is imperative that IT services generate significant operational efficiencies to best absorb growth in demand and expectation. This is in addition to enabling service transformation and financial savings across most other areas of the Trust.




6.1.7 Pursuit of these opportunities is often constrained by more than just budgetary provision however. IT infrastructure investments that may have served the Trust very well over a long period previously now present as ‘technical debt’. They now hold us back, limiting our options for new technology innovation and they add complexity and risk. It is never as simple as just ‘swapping them out’, given the need for data migration, complex integration with other niche systems etc…

6.1.8 Taking account of all these factors, and reflecting stakeholder feedback from user surveys and ‘open staff forum’ engagement sessions across Trust sites, the following objectives have been agreed upon for the Technical Infrastructure programme:

Seamless

Ease of access to networks, applications and data, comparable to how we now use IT in our personal lives.

Improved user experience with IT Service Desk.

Greater adoption of paperless workflows, including process automation.

Resilience

Infrastructure to be considered an essential utility, near 100% availability requirement, appropriately supported 24x7x365.

Mobility

Ubiquitous connectivity needs, across external sites also. Essential to effective use of Estate and agile working.

Security

Attainment of all 10 national data security standards.

Cyber Essentials accreditation, continual vulnerability assessment.

Sustainable

IT operating model and architecture must anticipate continual growth in user,

asset and data volumes.

Alignment to common technologies across the ICS.

6.1.9 Whilst this requires an ongoing programme to support continual extension of IT operational services (additional users, systems, devices, organisational reliance etc…), key priorities identified to demonstrate delivery of these objectives are:

End User Computing - desktop standardisation; wider coverage of mobile devices; Virtual Desktop Infrastructure performance; Imprivata Single Sign-on implementation; follow-me printing; finalise migration to NHS Mail; roll-out Skype messaging; introduction of technology to facilitate virtual outpatient clinics; and agile working initiatives aligned to Estates strategy.




Network and Storage – Health & Social Care Network (migration from N3); GovRoam connectivity across external sites within SYB ICS (with priority for those where the Trust provides peripheral outpatient clinics); remove Novell; increase Cloud adoption; eliminate single points of failure within the physical network and technical team supporting it; independent review of disaster recovery processes and business continuity testing.

Cyber Security – formal 3 year Programme, fully funded, approved in November 2017. This covers 17 specific project initiatives but is not widely shared outside the Trust’s senior management levels due to its content, i.e. examining areas of potential vulnerability and risk exposure, along with timing of plans to address these.

Licensing – openly seeking opportunities to move to “Infrastructure as a Service” (IaaS) where as a Trust we ‘consume’ IT as a utility. This has clear advantages whereby we are only charged for what we use and we can smooth out peaks and troughs of capital investment. This approach also benefits our disaster recovery and business continuity position as expert suppliers are responsible for operating systems, underlying storage, servers, security, backups etc…. Developing the business case for a move to Office 365 subscription licensing is a high priority in 2019.

Service Management – formalise the IT operating model and embed ITIL processes (later described at ‘Enablers’ section); help desk system replacement; extend 24x7x365 user support; equitable service levels across Trust sites; self-help and self service; lead on the delivery of paperless processes to streamline activities and enhance user experience whilst not relaxing on necessary audit controls; also seeking to enable process automation across corporate support services (for example, current ‘Day 1 Ready’ project being delivered between HR, IT and Estates).

6.1.10 Together, these project priorities shall all support the intent to ensure that IT operational services are delivered more professionally, more openly and subject to appropriate independent audit assessment.

6.1.11 Within the IT help desk system replacement, we shall also ensure that performance reporting is an essential aspect of the project, so that we measure and publish how well IT services operate.

6.1.12 Where possible we shall also remove the reliance on individual IT staff so that problems can be resolved consistently and more quickly.

6.1.13 Availability of self-help and on-line video tutorials will be a priority so we can enable staff to resolve many problems themselves (with support available if they can’t). This is after all how we all expect IT support services to operate in our personal lives.



BUSINESS INTELLIGENCE PROGRAMME PAGE 20

7. BUSINESS INTELLIGENCE PROGRAMME

7.1.1 The following objectives have been identified, to be taken forward through a focused Business Intelligence programme:

Data Quality

Robust standards for data capture and coding (‘none shall pass’ approach for reporting)

Adopt a ‘Right First Time’ culture

Regular clinical validation and audit

‘Single Version of the Truth’

Defined business logic and data definitions for information reporting

Self Service provision of reports to support an information culture and data driven decision making

7.1.2 As we progress through the Strategy roadmap to extend digital care record coverage this will of course bring accompanying challenges for parallel development of our information reporting capability.

7.1.3 Over the past 12 months the Trust has introduced a new Integrated Performance Report, used at both Trust-wide and Divisional level and fully aligned with Corporate Objectives. This includes qualitative and quantitative clinical and corporate performance metrics, alongside financial and workforce information to achieve a broader and more balanced insight.

7.1.4 With each implementation of new or enhanced digital record systems, or step change in mature use of existing ones, this delivers extended data sets (both breadth and depth).

7.1.5 There is hence significant opportunity to be derived from a more sophisticated approach to Business Intelligence and performance reporting, with a much greater focus on data driven insight enabling evidence based decision making, predictive modelling and proactive performance management. It is a must that this is built upon confidence with regards to data quality and ‘single version of the truth’ reporting, assured by robust validation processes and appropriate audit opinion.



BUSINESS INTELLIGENCE PROGRAMME PAGE 21

7.1.6 Key work streams identified to support delivery of these objectives are:

Integrated Performance Reporting - triangulation across activity, finance, workforce and quality domains; predictive planning as well as retrospective performance reporting; extended use of benchmarking data.

Data Warehouse – extending coverage to fully incorporate eDMS and SystmOne data sets, plus all future digital record system delivery (e.g. following Digital Wards implementation).

Data Quality Assurance – sustain data quality maturity across all acute services (where benchmark reports for Commissioning Data Sets show the Trust is typically best performer in the region), must prioritise to raise Community and CAMHS data to same level.

Clinical Coding – continue clinical engagement and audit programme which has been a well-recognised success over the past 3 years, sustaining formal audit standards and attainment scores, managing migration to SNOMED.

Automated Reporting and Distribution – including self-service provision so reports can be re-compiled dynamically, accelerating reporting timetables, releasing more time for analysis and performance management.

Analytical Insight – training and support so that staff are confident and proficient in the use of any new data warehousing or self-service reporting facilities made available to them (so includes staff in the information management function as well as information recipients across the organisation).

Population Health – active involvement in the ACP and ICS agenda, aggregation of data across health and social care settings to inform wider service planning and commissioning.



ENABLERS PAGE 22

8. ENABLERS

8.1 OVERVIEW

8.1.1 The above listed ‘enablers’ have each been identified as needing specific attention and senior oversight through the term of the Strategy.

8.1.2 Each are certainly essential for successful project selection, implementation and subsequent benefits realisation. Equally, they are essential to ensuring ongoing alignment of plans for systems/service development to keep pace with anticipated changes in requirements.

8.2 COLLABORATION & PARTNERSHIPS

8.2.1 Our approach to collaboration and partnership working, both internal and external, is central to our delivery of Connecting Together objectives. Through stakeholder review we have established the following objectives that can be better progressed through collaboration and partnerships:

Resilience

Increasing requirement to support services and users 24x7x365

IM&T management and technical capacity to manage major outages or security incidents

Access to specialist IM&T skills, e.g. cyber security, development of business intelligence tools, IT procurement, EPR deployment.

Best Value

Maintain cost benchmarking for core IM&T services.

Reduced reliance on agency staff to deliver IM&T capital projects.

Best Practice

Team Up, across our Divisions, within SYB ICS and through development of commercial partnerships, to identify and deliver transformation opportunities across our IM&T services.

Standardisation

Shared procurement where possible, product standardisation as default.

Shared knowledge base to drive continual performance improvement.

Enable all models for furthering corporate service integration.



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8.2.2 Key themes identified to support delivery of these objectives are:

Aggregated Procurement - whilst individual organisations all have their own internal procurement services, all partners recognise the potential and share the intent for aggregated purchasing wherever possible. This is one of the initial five priorities for the recently established ICS Infrastructure Programme Board.

Commercial Relationships – we must nurture and invest in mutually beneficial strategic relationships with our key suppliers, to influence their development roadmaps and anticipate our opportunities.

Shared Services – sustainability and resilience objectives demand that the Trust must more positively seek shared service and partnering opportunities going forwards. Provision of a 24x7x365 ICT Service Desk and rapid access to specialist cyber security expertise are clear examples.

Accountable Care Partnership and Integrated Care System – we must be an active participant, shaping and influencing to ensure alignment to wider Trust objectives and clinical strategy, thereby achieving best outcomes for our patients and staff.

8.3 WORKFORCE

8.3.1 Our confirmed IM&T strategic workforce objectives, in respect of Connecting Together delivery, are:

Subject Matter Experts

Continue to develop multi-disciplinary networks of active clinical SMEs, representing clinical services and provide support to the Chief Clinical Information Officer.

Clinical Safety Officers

Build a cohort of accredited clinical safety leads to ensure all new electronic patient record systems are rigorously tested prior to their introduction into live clinical environment.

Data Protection

Extend resource to function, for proactive information risk management and GDPR compliance.

Grow Our Own

Key principle for IM&T workforce development and sustainability, success of which has been demonstrated in Clinical Coding over past 2 years.

Initiatives to include: Digital Academy placements for clinical leads, internal secondment opportunities, graduate and apprenticeship schemes.

IM&T Service Management

Formalised IM&T support model, with all staff trained and working to industry ITIL processes.



ENABLERS PAGE 24

8.3.2 Prominent clinical leadership is a must. We will continue to develop an active network (internal and external liaison) of well informed and representative multi-disciplinary clinical leads, suitably immersed in each of the strategic projects.

8.3.3 This will require dedicated time for project workload, to be balanced against clinical commitments and hence will need to be factored into project resource planning and budgets. This has been well demonstrated through recent projects to implement eDMS and CAMHS EPR.

8.3.4 Patient safety is of paramount importance when implementing new clinical record systems and new working practices. We shall secure a larger cohort of formally accredited ‘Clinical Safety Officers’, who will each complete the relevant national training programme. These roles shall provide advice (and instruction where necessary) for projects teams developing initial system specifications. They will then also undertake formal risk assessments as an essential approval gateway prior to go-live on any relevant systems.

8.3.5 Similarly, all changes to IM&T systems and data flows must be subject to data privacy risk assessments. These requirements were of course much reinforced in the 2018 EU General Data Protection Regulation (GDPR) and subsequent update to the Data Protection Act... It is clear that we must plan to extend resource to be provided to the Data Protection Officer function, which is also a formal Internal Audit recommendation.

8.3.6 In respect of IM&T recruitment, it is the firm intent of our senior management team to see local Graduate and Apprenticeship schemes introduced, supported by HR and developed in partnership with local education organisations. This ‘grow our own’ principle can be a vital enabler for a sustainable IM&T workforce plan, and has been shown to work extremely well in the past in areas such as Clinical Coding.

8.3.7 ‘ITIL’ is a recognised industry standard model for running IT operational support services and also typically translated into formal IT audit standards. Where ITIL processes are currently implemented within the IT department, these are often informally enforced and not hard coded into the IT help desk and automated workflow systems. This will need to be addressed through replacement of the existing IT help desk system, which has confirmed funding through the Cyber Programme approved in November 2017.

8.3.8 Ahead of this help desk system replacement we will ensure that staff throughout the IT function are provided with accredited ITIL training, so that this will inform decisions regarding new system design and associated process changes.



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8.4 ENGAGEMENT & TRANSFORMATION

8.4.1 The following priorities have been identified to optimise the benefits from Connecting Together delivery and to ensure the strategy’s continued alignment with the Trust’s clinical strategy:

Chief Clinical Information Officer

CCIO Recruitment planned July/August 2019.

Senior leadership and representation, ensuring clinicians are central to decisions guiding safe and efficient design, deployment and use of IM&T solutions.

IM&T Clinical Advisory Group

Ensure this is regular and active multi-disciplinary forum, chaired by CCIO, influencing prioritisation decisions and advising on change management requirements for project implementation.

Consolidate existing clinical reference groups that currently oversee developments for acute, community and CAMHS systems separately.

Communications and Service Improvement

Essential support for all project delivery, ensuring key link between project management focus on delivery of outputs and business requirement for delivery of benefits.

External Representation

We must commit time and focus to support development of Place and System IM&T programmes, to ensure these align to Trust clinical strategy and incorporate our clinical design requirements for new digital care record solutions.

8.4.2 Working with the senior IM&T team and through the IM&T governance structure, the CCIO will champion the development of a clinically appropriate information culture across the organisation.

8.4.3 The CCIO will also chair the IM&T Clinical Advisory Group, along with developing a network of informatics champions and subject matter experts within the clinical and nursing professional groups.

8.4.4 An effective engagement strategy also requires commitment to maintaining a high quality communications plan. Initial communications activities will accompany the launch of the Strategy and will thereafter be maintained through the Clinical Advisory Group and relevant Programme and Project Boards.

8.4.5 This must also factor in awareness of relevant external developments, including those occurring within Sheffield Accountable Care Partnership, South Yorkshire & Bassetlaw Integrated Care System and the Yorkshire & Humber Local Health Care Record programmes.



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8.5 GOVERNANCE

8.5.1 Connecting Together programme governance structure is illustrated below, consistent with recent EPR business cases approved through Trust Executive Group. This promotes clinical leadership internally and incorporates necessary alignment with external programmes also.

8.5.2 This structure will be also be reflected in the management of the agenda for the IM&T Strategy Board, programme reporting (including budget and expenditure reports) and communications plan.

8.5.3 This IM&T governance will also need to remain aligned with the work streams established for the Trust’s transformation programme, to ensure coherence and avoid duplication. The link between the ‘Digital Outpatients EPR’ programme and the wider Trust Modernising Outpatients Programme is an example of this.

8.5.4 Business cases for investment funding and project approvals will also need to be managed consistent with the Trust’s Standing Financial Instructions. We must also be cognisant of all necessary external bid submission processes and award criteria where national allocations are being sought for specific projects.



FUNDING ASSUMPTIONS PAGE 27

9. FUNDING ASSUMPTIONS

9.1.1 At the point of launching this strategy, the two most significant risks to delivery of our Connecting Together objectives are:

Programme and project affordability, both in capital and revenue expenditure terms, regardless of expectations regarding ultimate return on investment.

IM&T and wider Trust capacity to implement major change management projects simultaneously.

9.1.2 These two issues are inter-linked to a significant degree.

9.1.3 It is increasingly common that investment priorities can develop unarguable value for money appraisals, but these same schemes have to then be subsequently delayed or cannot proceed due to the affordability of non-recurrent funding (typically capital) to provide the necessary project budget.

9.1.4 Unfortunately, due to overall staffing capacity constraints, it is also not possible to deliver the desired projects through substantive resources, even if the projects were to take longer.

9.1.5 The Trust’s regular capital allocation for IM&T is currently circa £780K per annum, although it is understood that within this budget we will struggle to fund much more than necessary end of life replacement of existing IT assets (network and server infrastructure, desktop and laptops).

9.1.6 Additionally there is the ever increasing challenge to ensure the Trust is fully licensed for all operating software, much of which had historically been covered through NHS-wide enterprise agreements. In the past these ‘true up’ investments have been funded through internal capital allocations, but they then repeat as per vendor product lifecycles. As example, we are rapidly approaching the end of life for core Microsoft products such as:

SQL Server 2008R2 (expires July 2019)

Server 2008R2 (expires January 2020)

Office 2010 (expires October 2020)

9.1.7 Cloud based (revenue funded) solutions such as Office 365, Azure and/or Amazon Web Services smooth out investment cycles not only for software licensing, but also for associated hardware requirements. They also provide for automatic upgrade paths funded within the subscription.

9.1.8 Any such changes will certainly be subject to formal business cases which address the financial affordability challenges, but there is little doubt this will be the ‘best value’ way forward for long term licensing of our core operating software.



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9.1.9 In this overall context it is essential that the Trust continues to seek external funding sources wherever possible. Over the past two years we have been successful with national cyber security funding (£2.2M in 2017/18) and ‘Health System Led Investment’ provider digitisation monies (£1.2M in 2018/19).

9.1.10 Further external bid opportunities are anticipated in 2019/20, albeit subject to match funding commitment over contract terms.

9.1.11 Circa £1.0M capital funding is currently earmarked for the planned Digital Wards project, sourced through ‘Health System Led Investment’ provider digitisation funding. Capital funding for the Trust to implement Electronic Prescribing is also available through dedicated national allocation.

9.1.12 Each of these is subject to submission of full business cases which have been approved within the Trust and then ratified by the ICS Digital Board. The business case for Digital Wards is due by December 2019 and the one for Electronic Prescribing must be submitted by no later than January 2020.

9.1.13 In order to be successful with such bids, our commitment to Connecting Together objectives will be a critical factor, most notably in relation to our commitment to interoperability specifications, record sharing (structured clinical data, not just access to documents) and alignment towards digital systems standardisation across regional footprints.


9. 39/19 QUARTERLY REPORTS FROMBOARD COMMITTEES- QUALITY COMMITTEE (ENC Di)- FINANCE AND RESOURCESCOMMITTEE (ENC Dii)- RISK AND AUDIT COMMITTEE (ENCDiii)- CHARITIES COMMITTEE (ENC Div)

EXECUTIVE SUMMARY

Title Quarterly Report from the Quality Committee

Report to


Author

Ms Patricia Mitchell, Non-executive Director, Chair of the Quality Committee

Purpose of report

To present to the Council of Governors the key issues arising from the 13 May and 17 June 2019 Quality Committee meetings.


Approval

Assurance √

Information


The Committee has a full and varied work plan each month. From the committee discussions a number of areas of focus were highlighted for reporting to Trust Board from the May and June meetings, for assurance:

CAMHS Transformation Committee A subcommittee established to oversee the introduction of the CAMHS transformation programme had agreed their terms of reference, and agreed to explore possibilities to engage a parent / carer representative to sit on the committee. A role profile had been developed and suggestions for suitable candidates would be followed up.

Update on Operational Management of Central Transition Database The Committee is overseeing the introduction of a central database to manage transition plans as patients move from children’s to adult services. This was an action from the 2018 CQC inspection.

Work has taken place to identify patients on a transition plan, and validate information for patients aged 17+ with open referrals in the system. A central database is now in place for all patients aged 14, however work is still taking place with the output team to make actions within eDMS more explicit to consider whether a transition plan was required, this was to be in place by the end of June. This course of action was driving the culture change required, to stop the current functionality and process being bypassed. Timely reporting from the system was also being implemented.

The Committee was assured that the CQC had been content with the positive progress made.

Report from the Education Board

The committee received a six monthly highlight report which focussed on two key concerns of the board in relation to student nurse practice placements and Health Education England, which provided funding for doctor and nurse education. Four conditions had been imposed on the Trust. The committee was assured that actions were being taken to address these conditions by Health Education England which related to:

1) Failure of appropriate IT induction and access to facilities for doctors and nurses in training

2) Lack of engagement of the Surgical Division in the appointment of a Royal College of Surgery Clinical Tutor

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3) Lack of representation of Education at the Trust’s Management Board (in other Trust’s the Director of Medical Education has a seat at Management Board)

4) Failure to pay Educational Supervisors.

Whilst there was an accountable governance structure in place within the Trust for managing doctor and nurse training, capacity to support education across the organisation would be reviewed and reported within the next update.

The committee noted that the Trust would be increasing its student nurse placements to 90, this highlighted the increasing complexity in coordinating placements and capacity to do this was a concern. The outcome of a bid for funding to support placements was awaited. Work was taking place with finance to identify funding for a placement facilitator post.

A review to understand the nurse education model within the organisation and utilisation of education within areas was taking place.

Integrated Legal and Governance Annual Report

The Committee received the annual report, this reports details relating to patient safety including; complaints, risks, serious incidents and never events, root cause analysis investigations, duty of candour, outcomes from the clinical audit programme, as well as clinical audit projects undertaken by divisions. The report highlighted an increase in activity over the year against these key areas.

An organisational change process was being planned for the department, and the capacity of the team would be considered as part of this process. It was not expected to see any change to capacity until after the organisational change.

A proposal on how performance against key metrics would be improved would be brought back to the Committee following commencement of the organisational change process.

Annual Update on Contract Products

The Committee received a presentation on the annual update relating to quality aspects within the contract schedules it holds with commissioners. The Deputy Director of Strategy and Operations provided an overview of the various aspects of its commissioner contracts and gave the assurance that they are being delivered in an effective, economic and efficient way.

Learning from deaths The Committee received the annual report from the mortality review panel, which included the learning from deaths report. The trust is required to publish this report on its website.

The related learning from deaths policy was also approved by the committee.

The committee was assured that learning from deaths would be disseminated in a number of different ways to achieve the 90 days target. Any additional resource requirements to ensure these targets are met would be taken through the Executive Team.

Discharge summaries

Discharge summary performance had been monitored over a number of months through the integrated performance dashboard as it was below target, and fluctuated over the year between 70 to 80 percent against a target of 100 per cent. Non-executives had been keen to see this performance improve from a patient’s care plan perspective. A “no discharge summary, no discharge” pilot of two areas had been implemented once winter seasonal pressures were over. The results of the pilot were brought to the May meeting of the Committee, which were reported as good, with the process embedding well into everyday practice within these areas. The Committee supported the continuation of the project to the wider Trust, and recommended to the Executive Team that this was rolled out further. Performance would continue to be monitored through the integrated performance report.

The committee received the following reports for information:

Monthly Integrated Performance Report

Quality Impact Assessments exception report

Final Quality Accounts report 2018/19


The following terms of reference for the Committee’s sub groups were approved by the committee;

CAMHS Transformation Subcommittee Drugs and Therapeutics Committee

The committee approved three policies during the reporting period, these were;

Child death reviews and learning from deaths policy

The transition from children’s to adult services policy

Policy for quality impact assessments

How this report impacts on current risks or highlights new risks Links to the Board Assurance Framework, BAF 1:

Failure to effectively deliver healthcare impacts on the safety and quality of patient experience, regulatory compliance and loss of confidence of the wider community


The Council of Governors is asked to note the assurance report from the Quality Committee meetings held on 13 May and 17 June 2019.

Glossary: CAMHS – Child and Adolescent Mental Health Service CQC – Care Quality Commission eDMS – Electronic document management system / patient records system


EXECUTIVE SUMMARY

Title Quarterly Report from the Finance and Resources Committee

Report to


Executive Sponsor

Author

Mr A Baker, Non-executive Director, Chair of the Finance and Resources Committee

Purpose of report

To present to the Council of Governors the key issues arising from the 15 May and 19 June 2019 meeting of the Finance and Resources Committee.


Approval

Assurance √

Information


Due to the phasing of the various meetings, there have only been two Finance and Resources Committee (FRC) meetings since we last met (The July FRC meeting takes place next Wednesday 24th).

Of these two Committee meetings, one was a standard FRC and one was an extended FRC to focus on our resource agenda. This is our usual meeting rhythm with every third meeting a longer session to allow more time on our ‘people’ agenda, to ensure that this has due focus on the largely finance, performance and transformation agendas of the Committee.

The Committee also welcomed to the sessions, Vince Keddie, as our first FRC Governor observer. Vince now attends the FRC on an ongoing basis and is also available to support any questions the governors may have on this committee or any specific agenda items covered.

As normal, the FRC took a mixture of monthly, recurring and routine papers for assurance, combined with ‘deep dives’ into some areas we want to understand better, and finally some items that require committee approval. In summary:

Monthly recurring routine reports

The following reports are received by the Finance and Resources Committee each month:

Monthly Integrated Performance Report

Update from the Recovery and Transformation Board

Monthly Headline Finance Report, including Escalations from the Cash Management Committee

From the committee’s Consideration of these agenda items the following key points were escalated to the Board of Directors for the quarter:

Monthly Integrated Performance Report (IPR)


A significant number of medical guidelines had expired between April and May and a wider review into both the specific process to ensure these guidelines were always in date and the allocation of Trust time to ensure such actions were closed to appropriate deadlines was escalated. The Executive team are currently reviewing changes to both.

The committee reviewed the investigation report following a recent information governance serious incident and received assurance that all actions had been completed.

A 6% decline in PDR compliance in comparison to the previous year despite a focused effort to improve performance. Further investigation would take place to understand how this related to the annual cycle process. Further investigation would also take place to get a better insight into how IT functionality of the e-learning system impacted on mandatory and statutory training compliance.

Update from the Recovery and Transformation board

We have taken updates on the Recovery & Transformation board will evolve its structure and plans for 1920, taking the opportunity to reflect on areas in 1819 that worked well/less well.

Monthly Headline Finance Report

The Trust was reporting its month 2 (May), cumulative position £45k ahead of its target (the control total). The profile of the target leaves much to do in the latter stages of the year and as such, the Trust is required to provide assurance to the regulator, NHS Improvement, on its Cost Improvement Plans (CIP) due to their concern relating to delivery of the control total by year-end. Plans had been requested from divisions, and the Chief Finance Officer was following up outstanding plans with those divisions.

The Trust had highlighted to the ICS that it would require system support to achieve its control total, this was a risk, as it had not yet been agreed how the system would provide support, however the Committee was informed the system was aware their support was needed.

The Trust reported its cash position was adverse £1.5m to forecast at month 2, this was due to non-payment by a key supplier. The Cash Committee would look to resolve this issue, and it was expected the Trust would get back on plan through management of its payments.

Specific ‘deep dive’ agenda items covered at FRC May 2019 to June 2019

2019/20 Transformation Plans

The Committee received the plans for the forthcoming year for each workstream. Longer term plans would be developed for the next phase of the programme. The Committee was assured that workstreams were taking forward these plans at pace.

The Committee would undertake deep dives by workstream during the course of the year to challenge and add value. The first of these deep dives took place in June to review the scope of the workforce transformation workstream, within the people section of the meeting.

The Committee was assured that the CAMHS transformation subcommittee, established to oversee the implementation phase of the CAMHS improvement programme, would move into the recovery and transformation programme in the longer term. The Quality Committee was overseeing the initial phase of this subcommittee.

Waiting Times

The Committee received an update on all internal waiting times across the Trust (not just those reported externally), and endorsed the recommendation to develop the IPR to report this performance going forward. There was an ambition to incorporate this full set of waiting times within our external reporting, in line with best practice, in due course.


Centre for Child Health Technology

The Committee received an update on the project to develop, in partnership with other stakeholders, a centre for child health technology as part of the Olympic Legacy Park. This project is uncommitted and very much in discovery phase. The update included potential funding proposals. The Committee tentatively supported continuing to progress conversations to gain better clarity on the business case and governance arrangements, but noted some of the challenges Trust wide on capacity for such projects.

Finance and Resources Committee Annual (Self Appraisal) Report

The committee reviewed its annual report and committee effectiveness and agreed a number of areas of improvement during 2019/20, these included consideration of (i) how the committee spends more time with key functions (ii) how to build in more reflection time.

The committee agreed to move two of its meetings in the year to Moorfoot, and hold a session with finance and HR teams to showcase areas. It was also agreed to develop a back to the floor programme for NEDs to attend divisional board meetings to raise the committee’s visibility within the organisation.

Our People Agenda (extended meeting- June 2019)

The extended June meeting focused on our equality, diversity & inclusion agenda, and undertook a deep dive into the recovery and transformation workforce workstream.

Recovery and Transformation worforce workstream – deep dive

The committee had a useful discussion providing support to the risks and challenges faced by this workstream to take forward change over the next three years, and highlighted the cultural challenge around mind set within divisions in relation to this. We also discussed the sufficiency of resourcing currently available to drive this change and if more should be added.

The committee also discussed the internal resource bank model currently in use to replace agency staff. The committee asked to see some metrics to measure the impact on welfare and performance of this resource bank.

Workforce equality and diversity

The committee had a good conversation in relation to equality, diversity and inclusion and supported the direction of travel to develop networks, however the challenge in engaging with staff groups was highlighted. Alternative ways to engage with key protected characteristic groups would be explored, and it was agreed to ask staff governors to offer support to champion some of these groups.

The committee approved the terms of reference for the equalities forum subject to agreeing representation.


Risk that we do not maintain financial stability due to failure to deliver our financial plan or the negative impact of movement to a system-wide financial planning regime, resulting in requirements for additional CIPs or reduction in level and standard of services.

Failure to ensure that the Trust has a motivated, suitably trained and engaged workforce impacts on operational performance, transformational change and achievement of strategic objectives.

Failure to ensure that the Trust recruits staff in the right numbers and with the appropriate breadth of skills and competencies to deliver high quality services now and in the future.

Risk that insufficient leadership capacity and capability prevents necessary transformational change

Failure to ensure that the required IT infrastructure and strategy is in place to deliver clinical services and support clinical strategy and transformation impacts on the Trust's ability to deliver services, improve quality and transform services.

Failure to develop our leadership, management and governance arrangements to ensure


delivery of sustainable high quality person-centred care, support learning and innovation, and promote an open and fair culture prevents the Trust from demonstrating it is a Well Led organisation

Operational capacity constraints and failure to deliver transformation impact on our ability to deliver planned activity and manage demand impacting on operational efficiency, service quality and financial performance.

Failure to manage the Trust’s cash position would result in the Trust not being able to satisfy its obligations in respect of pay and non-pay costs.


i. Governors are asked to note key issues arising from the Finance and Resources Committee held on 15 May and 19 June 2019

ii. Staff governors are asked to champion and engage with protected characteristic groups to support the development of equality, diversity and inclusion networks with any feedback or questions in the first instance being directed to Jane Clawson ([email protected])

Glossary: CAMHS – Child and Adolescent Mental Health Service CIP – Cost Improvement Programme CIT – Capital Investment Team ICS – Integrated Care System IPR – Integrated Performance Report NED – Non-executive Director PDR – Performance development review / appraisal


mailto:[email protected]

Finance and Resource Committee Quarterly Report to Council of Governors Dated: 16th July 2019

Finance and Resource Committee Overview- Q1 2019/20 Document Purpose: For Assurance

Meetings: FRC 15th May 2019, Extended FRC (to include people agenda) 19th June 2019

Attendees All attendees were present for both sessions with no apologies received.

Key Agenda items covered

Recurring items 1. Monthly Integrated Performance report 2. Update from Recovery & Transformation

board 3. Monthly finance Report

Deep Dives 1. 2019/20 Transformation Plans 2. Waiting Times across the Trust 3. Centre for Child Health Technology 4. Committee (self) appraisal report 5. Transformation Workforce workstream 6. Workforce Equality & Diversity

Financial Headlines

1. The Trust reported its month 2 (as at end of May) cumulative financial position as being marginally ahead (£45k) of its target at that stage. However, the profile of the target leaves much to do in the latter stages of the year. As such, the Trust is required to provide assurance to NHS improvement on its Cost Improvement Plans (CIP’s) to achieve this. The Chief Finance Officer is following up on these plans with the divisions.

2. The Trust has highlighted to the ICS that achievement of 1920 targets is also dependent on system support and discussions are underway on how this will be delivered. Until this is confirmed, a risk exists.

3. Our cash position at month 2 was adverse £1.5m to target, due to non-payment by a key supplier. This was escalated.

The following items were escalated from the FRC to the board during Q1 for either escalation or awareness:

The following items were escalated to the board during Q1: 1. Policies & Guidelines: A number of medical guidelines had expired April-May and a wider review into a both a specific process to ensure these

guidelines were always in date and the allocation of Trust time to ensure such actions were closed to appropriate deadlines was escalated. The Executive team are reviewing both.

2. Serious incident review: The Committee had reviewed the investigation report following a recent information governance serious incident and received assurance that all learning and close out actions had been completed.

3. PDR’s : A 6% decline in PDR completions vs the same time last year was noted, despite a focused effort to improve performance. A review would take place to understand how this related to the annual performance cycle.

4. Mandatory Training: A review will take place on how much IT and system issues obstruct the completion of mandatory training modules. 5. Recovery & Transformation: The Recovery & Transformation programme has taken the opportunity to evolve its structure and plans for 1920,

reflecting on what worked well/ less well in the 1819 programme. We have agreed to undertake ongoing FRC deep dives into workstreams to provide further support and challenge. The first of these was the Workforce workstream. We also received assurance that the CAMHS transformation subcommittee, established to oversee the implementation phase of the CAMHS improvement programme, would move into the recovery and transformation programme in the longer term. In the interim the Quality committee has oversight of this sub committee.

COUNCIL OF GOVERNORS 9. 39/19 QUARTERLY REPORTS FROM BOARD CO... Page 70 of 114

6. Waiting Times: The committee took an update on all internal waiting times across the Trust (not just those reported externally) and endorsed the

recommendation to evolve the IPR to report on these going forward and in due course, build out our external reporting to include all waiting times, in line with best practise.

7. Centre for Child Health: The committee took an update on the project to develop, with other stakeholders, a centre for child health technology as part of the Olympic Park. The project is in discovery phase on both purpose and funding and the committee gave tentative support for this phase to continue, subject to better clarity on the business case and governance arrangements and noted the resource capacity challenges Trust wide for such projects.

8. Workforce deep dive: The deep dive of the of the workforce workstream was productive though highlighted the cultural challenge around mind set to achieve our ambitions and the need to review appropriate resource allocation to this activity. We also discussed the internal resource bank model in use to replace agency staff and asked to see some metrics to measure the impact on welfare and performance of this resource bank.

9. Workforce equality & diversity: We supported the proposal in establishing our equality, diversity and inclusion agenda and the desire to develop networks, however the challenge in engaging with staff groups was highlighted. We approved the terms of reference for the equalities forum.

Escalations/ Requests for support to/from the COG

1. Governors are asked to note the key issues documented in this report 2. Governors are also asked to note that from Q1 Vince Keddie attends the FRC as a Governor lead; and is also available to support any related

questions. 3. Staff Governors are asked to help champion and engage on the development of equality, diversity and inclusion networks with any feedback or

questions in the first instance being directed to Jane Clawson.

Summary from the Chair

This report covers two FRC sessions, one of which was extended to cover our people agenda. I’m comfortable the meetings covered in suitable depth and with sufficient rigour the key Finance, Resource and Transformation topics most pertinent to the Trust across Q1. As part of our committee effectiveness review we have agreed some committee improvements for 1920, specifically (i) how to spend more time with the relevant FRC functions; we plan to move at least two of our FRC committees to Moorfoot to do this (ii) to build more reflection time into our agenda (iii) to schedule NED visits to divisional board meetings.

Report Author Andy Baker, NED Chair, Finance and Resources Committee In support Vince Keddie, Governor attendee

COUNCIL OF GOVERNORS 9. 39/19 QUARTERLY REPORTS FROM BOARD CO... Page 71 of 114

EXECUTIVE SUMMARY

Title Risk and Audit Committee

Report to

Council of Governors

Date 16 July 2019

Executive Sponsor

Author

Mr J Cowling, Non-executive Director, Chair of the Risk and Audit Committee

Purpose of report

To present to the Council of Governors the key issues arising from the 20 May 2019 Risk and Audit Committee.


Approval

Assurance √

Information

Executive summary –the key messages and issues There had been one meeting during the reporting quarter. The meeting was mainly given over to reviewing the annual report and annual accounts process, and the following reports were noted by the Committee for information / assurance:

Local Counter Fraud Specialist Annual Report 2018/19

Internal Audit Progress Report

Head of Internal Audit Annual Report

Quality Report

Draft Assurance on 2018/19 Quality Report

Annual Report and Finance Statements

Draft ISA 260 Audit Highlights Memorandum

Annual board Self-Certification Declarations

Review of the Committee’s Effectiveness

Following discussions the following points were highlighted to the Board of Directors:

The Committee received the annual report from the Local Counter Fraud Specialist, which highlighted the achievements and findings of fraud activity. Actions rated amber from a recent self-assessment were scrutinised by the Committee. The Committee was assured that no fraud activity was going to full criminal follow through.

Board Self-Certification Declarations had been reviewed by the Council of Governors, and the Committee supported the statement relating to Governor training, in that the Trust had plans in place to improve training following changes to governor composition. The Committee felt that training was in the wider sense to support governors to better understand the business of the organisation. The committee recommended approval of the self-certification declarations to Board.

The committee took significant assurance from the work of internal audit and their report but noted the areas for improvement for next year around core controls.


The committee took assurance from the work of external audit over the financial statements and the “clean” audit opinion. The committee also took assurance from the external auditors over the value for money work and noted the auditors considered that the Trust’s work on CIP had improved significantly.

The following reports were reviewed to support the Committee’s recommendation of the 2018/19 Annual Report and Financial Statements for approval by Board, and will be published at the Annual Members Meeting in September.

Quality Report 2018/19 – The 2018/19 quality accounts were reviewed by external audit as part of consideration of this annual report and their opinion was noted.

Annual Report 2018/19 and Annual Governance Statement (subject to a small number of suggested editorial amendments) - the Chief Executive provided a detailed overview of the content of the report. Further consideration would take place in relation to including people focused stories within future reports.

Financial Statements (subject to a small number of final amendments) – The Committee noted the tight timescales in producing the financial statements and reports. The content of the ISA 260 was noted with management responses to recommendations required.

External Audit will formally present their findings and opinion at the Annual Members Meeting.

The committee approved two policies on behalf of the Board:

CP33 Risk Policy

RM01 Policy for the Management and Investigation of Incidents and Serious Incidents, subject to updating of some minor changes.


Link to the Board Assurance Framework:



The Council of Governors is asked to: 1. NOTE the items for escalation from the meeting held on 20 May 2019

Glossary: CIP – cost improvement programme ISA – International standard on auditing


EXECUTIVE SUMMARY

Title Charities Committee Assurance Report

Report to

Council of Governors Date 14 May 2019

Author

Ms Sarah Jones, Chair of the Charities Committee

Purpose of report

To present to the Council of Governors the key issues arising from the 17 June 2019 Charities Committee.


Approval

Assurance √

Information


The committee met on 17 June 2019, and considered the following recurring routine reports:

Charity Quarterly Financial Performance Report

The Children’s Hospital Charity Fundraising Campaigns Position and income projection

Review of Funds Held by Sheffield Hospitals Charity

From the committee’s discussions it was agreed that the following would be highlighted to the Board of Directors:

Quarterly Update on Charity Financial Performance

o The committee recognised the importance of capital funding provided through The Children’s Hospital Charity (TCHC) and reviewed the quarterly financial report. It was highlighted to the Committee that forecasts showed a potential short-fall by year-end, however the Committee was assured that reserves could be used to meet plans.

o Discussions would be arranged with trustees to explore how charity donations were reported within the trust’s accounts.

o A risk register in relation to funding plans would be brought to a future meeting to understand how these fitted with the trust’s corporate risks.

The Children’s Hospital Charity fundraising campaigns position and income projections

o The committee was assured on the charity’s fundraising campaigns position and revised income projections. In addition to this there were positive discussions in relation to exploring options for joint working, improving the charity visibility throughout the Trust. In relation to this a number of mock up marketing displays were currently out for consultation, and the committee recommended that these were considered further from a parent perspective. A market research plan of


income strands and canvasing of families would be developed to consider the charity’s branding further.

o The trust’s strategy in relation to its SheffieldChildren’s@ model within the Integrated Care System (ICS) would be taken to trustees to keep them informed of the trust’s strategic direction.

Review of Funds Held by Sheffield Hospital Charity (SHC)

o Work was taking place with divisions to identify bids against a number of funds held by SHC. These would be collated for further consideration.

Specific ‘deep dive’ agenda items covered by the committee at the meeting included:

Charity access agreement

o The committee supported the recommendation to develop a memorandum of understanding for closer working between the two organisations which set out an agreed access protocol, the current draft would be developed further.

The June meeting mainly focused on The Children’s Hospital Charity, however other charities which fundraised on behalf of the trust would be invited to the next meeting to discuss their fundraising plans and explore how the trust could also support them better.

The committee’s terms of reference had been updated into the corporate format, these were approved.


Link to Board Assurance Framework:

Failure to engage effectively with partner organisations and the local community threatens the ability of the Trust to deliver its strategic ambition


The Council of Governors is asked to:

NOTE key issues arising from the Charities Committee held on 17 June 2019.

Glossary: ICS – Integrated Care System SHC – Sheffield Hospitals Charity TCHC – The Children’s Hospital Charity


10. 40/19 CHAIRS REPORT (ENC E)- FEEDBACK FROM BACK TO THEFLOORS (ENC Ei)

EXECUTIVE SUMMARY

Title Quarterly Report from the Chair and Briefing on Emerging Issues

Report to


Author

Ms S Jones, Chair

Purpose of report

To present an update to the Board on Chair’s activities


Approval

Assurance

Information √


To present the quarterly report summarising the activity of the Chair, Board and Council of Governors that has progressed over the last quarter. The Chair will update on any recent activity at the meeting. The six month back to the floor programme report is appended for information.


N/A.


The Council of Governors is asked to NOTE:

i) the update report ii) back to the floor report iii) additional verbal updates from the Chair on progress.

COUNCIL OF GOVERNORS 10. 40/19 CHAIRS REPORT (ENC E)... Page 77 of 114

Quarterly Report from the Chair The following report summarises the activity of the Chair, Board and Council of Governors covering the various activities that we have progressed over the last quarter. Council of Governors A committee of the Council of Governors met several times to run the appointment process for an additional Non Executive Director. Twenty-one applications were received and a shortlist of five candidates were interviewed. Mr Richard Chillery was appointed with effect from 1 June 2019. Richard has a background in clinical paediatrics and is the operations director at Harrogate and District NHS Foundation Trust. We look forward to welcoming him. This additional NED now brings the Board of Directors in line with NHSI guidance regarding the balance of non-executives to executive directors. The annual performance reviews of all non-executive directors have taken place and been reported back to the Governors. The Governors have discussed and agreed to second terms being granted for Mr Peter Lauener and Mr Andy Baker. Furthermore, they have reappointed me for a second term as chair. These all become effective as of 1 September 2019 to 31 August 2022. Governor elections Following the closure of nominations on Monday 10 June 2019, elections are being held for the vacant seats on the Trust's Council of Governors. A total of 31 members will contest the 10 vacant seats across five areas - a record number of nominations for the Trust - with all five areas contested. In Sheffield, 14 candidates will contest the five seats on offer, four candidates will contest the two Rest of South Yorkshire seats and four candidates will contest the newly created North Derbyshire seat. In the two staff classes that are up, three candidates will contest the single Non-clinical role while six will contest the new Other Clinical Healthcare seat. This is the first round of Trust elections since Board of Directors and Council of Governors agreed to change the constitution to reduce the number of uncontested and unfilled seats we were experiencing. It also follows two engagement sessions in May for staff and the public at which the Chair, CEO, Associate Director Corporate Affairs and several existing governors all presented. Voting packs/emails were sent out on 2 July and the results will be known on 26 July. New governors will join the Council at the AGM in September. The system used for voting is Single Transferable Vote, a preference-based system where voters rank candidates 1, 2, and so on. If a voter's first preference is elected, or knocked out during an earlier voting round, their vote moves to their second preference and so on. Board The Board has appointed two new Executive Directors who commenced in their new posts on 1 July 2019. Mr John Williams was appointed as Executive Director of Finance and Mr Nick Parker was appointed as the Executive Director of People and Organisational Development.


On behalf of the Board, our thanks to Mark Smith who has served the Trust exceedingly well over the past two years as Chief Finance Officer. We are pleased that Mark will remain with the Trust and wish him well in his new role as Associate Director for Finance. Thanks also to Jane Clawson who has acted up as interim director of human resources and organisational development since Steve Ned’s departure in March and now returns to her substantive role. Recognising that we will have three new Board directors as of July, a programme of further Board Development has been agreed. This will incorporate some in-house development with another externally facilitated day in October. Board Committee membership has been reviewed and changes will be recommended to the Board for approval. As usual, non-executives have been proactive in chairing Consultant interview panels, and sitting on Mental Health Act Review Panels. Board members have also undertaken Back to the Floor visits, details of which are appended to this report (Appendix A) for information and comment. In Partnership The Chair and Chief Executive have been proactive in the various Integrated Care System (ICS) and Accountable Care System (ACS) meetings in the quarter. Interim governance arrangements for the ICS have now been agreed and became effective from 1 April 2019. New governance arrangements at the ACP level are now being discussed and will be agreed shortly. The Chair and Chief Executive have also contributed to the review being conducted for the Clinical Commissioning Group (CCG). The Chair has also supported partners by acting as the external assessor for Sheffield Teaching Hospital in their recruitment of a non-executive director, and as the South Yorkshire and Bassetlaw representative on the external stakeholder panel for Chesterfield Royal Hospital in their recruitment process for a new Chief Executive. Following a recent Board debate, strategic partnership discussions have been arranged with both Sheffield Health & Social Care Trust and Sheffield Teaching Hospital Trusts. The Chair also attended a committee in common meeting of the ICS on 1 July. Back to the Floor programme The six month report on the back to the floor programme is appended to the report for information (Enclosure Ei). July 2019


EXECUTIVE SUMMARY

Title Feedback From Back To The Floor Visits: February 2019 To June 2019

Report to


Author

Claire Coles, Corporate Affairs Officer

Purpose of report

To provide assurance that management actions identified from Back to the Floor visits are being taken forward.


Approval

Assurance √

Information

Executive summary – the key messages and issues

This paper presents a summary of feedback from back to the floor visits undertaken February 2019 to June 2019.

A number of professional visits by the Executive Director of Nursing and Quality and Executive Medical Director are also included within the report, in Appendix A.

Matters relating to staff

Visits to services positively indicated that staff are aware of how to raise concerns highlighted by patients and are aware of Trust policy and their responsibilities under Duty of Candour. Staff also felt that communications had improved and they are kept well informed about what was happening around the Trust.

Evaluation of feedback identified that staff are proud of what they do and the service they provide. The report highlights one change that staff would like to see made in their place of work that would help them do their job better or feel more valued, and what they feel most proud of in their roles.

Matters relating to patients

Positive feedback had been received from patients and their families of the services visited. Staff were dedicated, welcoming and enthusiastic, whilst quick to resolve any issues identified during visits. Any issues or concerns identified during these visits were fed back to the relevant executive director.

Matters relating to the environment

One area of concern identified by the visit to outpatients nursing team was the frequently crowded waiting area, with insufficient seating areas with access to visible screens.

Other / general observations and comments

It was evident from visits that teams worked well together, and were proud of the service they provided. Talking to staff during the visits also showed that they were well placed to identify improvements within their own service, but should be kept informed of other service changes that impacted on their service to ensure necessary cover was provided.

Visits had been positive and showed positive teams, who were passionate about their work and enthusiastic about improving services for patients.


Teams however felt there should be more recognition for some of the work that they performed, and a Board spotlight presentation for the Quality and Audit Team would be scheduled for 2020.

Actions highlighted from the visits: 1. Responses to actions highlighted by the staffside visit are included with the feedback report. 2. Issues relating to the medical team in relation to communications and understanding the

complex needs of the child had been fed back to the Medical Director and Director of Nursing and Quality.

3. Action to look at signage to Ward 4 and longer working hours in pharmacy. 4. Hearing aid loop to be looked at for theatre seminar room and the lecture theatre. 5. Schedule a board spotlight presentation in 2020 for Quality and Audit team. 6. Raise updating of clinical guidelines with divisions at their deep dive presentations to Quality

Committee. 7. Additional patient and family waiting space needed in outpatients, which includes access to

visible appointment screens. At the June Board meeting Non-executives and Executives undertook a coordinated site visit of Becton Centre. Useful feedback received highlighted some areas to look into including time wasted by staff travelling between sites, communication of recruitment plans due to upcoming retirements within the team, better use of space across the centre. Actions identified from these visits: 8. Consider scope to develop or better use space / facilities within the estate. 9. Pick up family support / accommodation for Tier 4 with NHS England 10. CEO and Chair would respond to Becton school pupils letter regarding recycling. 11. IDHR to pick up the good news story regarding achievement of Mental Health Gold Charter

Mark with communications team. 12. Cross site mental health training plan required. 13. Look at the implications of the change in law regarding place of safety for young people and

implications for the 136 suite. The back to the floor visit feedback form has also been revised to make it more user friendly and align it to the Trust values, attached at Appendix B.


Link to Board Assurance Framework



Risk that insufficient leadership capacity and capability prevents necessary transformational change

Risk to clinical service viability due to failure to meet nationally defined standards or unfavourable changes to the commissioning of services

Failure to engage with our clinicians prevents the development / implementation of an effective clinical strategy that responds to the needs of patients and other health and social care partners and prevents us from capitalising on the use of research, innovation and technology

Failure to develop our leadership, management and governance arrangements to ensure delivery of sustainable high quality person-centred care, support learning and innovation, and promote an open and fair culture prevents the Trust from demonstrating it is a Well Led organisation

Operational capacity constraints and failure to deliver transformation impact on our ability to deliver planned activity and manage demand impacting on operational efficiency, service quality and financial performance.



Governors are asked to:

i) Review the report. ii) Recommend any management actions or identify any themes for sign off by the relevant

Executive, for inclusion in an action plan. iii) Monitor action plans. iv) Note the revised feedback form.


13 February 2019 Centenary House Peter Lauener

14 February 2019 Chaplaincy Patricia Mitchell

15 February 2019 Outpatients booking team and Hub Ruth Brown

18 February 2019 PACTPatricia Mitchell

Rebecca Kent

07 March 2019 Safeguarding Nurses

Sarah Jones

Patricia Mitchell

Peter Lauener

11 April 2019 Staff Side Patricia Mitchell

15 April 2019 Looked After Children Team Jeff Perring Professional visit

01 May 2019 Ward 4 Patricia Mitchell

03 May 2019 Quality and Assurance Team Patricia Mitchell

03 May 2019 Speech and Language Therapy Jane Clawson

07 May 2019Catering / Porters / Domestic

ServicesPatricia Mitchell

08 May 2019 Outpatients Patricia Mitchell

17 May 2019 Outpatients Nursing Ruth Brown

07 June 2019 AAU Sarah Jones

14 June 2019 Becton Ruth Brown

25 June 2019 Becton site

Executive Directors

and Non-executive

Directors

Professional

Visits

Back to the Floor visits:

February 2019 to June 2019

Board member/

GovernorDate Service Area


Matters relating to staff Matters relating to patients Matters relating to the environment Other general issues to report / Comments Management Actions

14/02/2019 Chaplaincy Patricia Mitchell

One change:

While completely understanding of the Trust’s

financial position we would love to be able to fund

a group for siblings of long time sick children and a

Mums and babies group. PM to look for funding

opportunities outside the Trust.

Most proud of:

The way in which they can help patients and their

families cope with what they are going through

which is not just bereavement which is incredibly

important but other issues too. This is a very wide

reaching service which staff feel priviledged to

deliver and which includes all Trust staff in its

remit.

I met two families that Kathy and

her colleagues are supporting and

they mentioned issues specific to

them which were fed back to the

DNQ.

Kathy and her colleagues, Cathy and Claire clearly provide a much needed service

through their work with patients, their families and carers and support to Trust staff.

The team provides support 24/7.

The team has the lowest resource versus number of beds when benchmarked with

the Trust's peer group. Investment of just £20,000 would enable it to extend its reach

and, for example, run groups for Mum's and babies and a service for siblings of long

time sick children.

The team visit all 6 Wards once a week although more time is spent on the oncology

and PICU Wards.

The team relies on the work of volunteers of 25 hours a week to reach patients and

their families.

We visited two families that Chaplaincy are currently helping and I saw what a great

service is provide, firstly to one Mum of a one year old baby boy with complex needs

and Mum herself also had medical needs. She was very isolated and has been at the

Trust for 10 months so the visits from Chaplaincy are a lifeline and she clearly really

appreciated the support. The other family was of a 5 month old baby girl born

prematurely whose twin sister had died and they were also very grateful for the

support.

The team also support staff in many different ways and one example was in helping

staff cope with de banding by reframing their thoughts to turn a negative situation into

a positive one of potential opportunity.

Between July 2016 to February 2019 there have been 10,616 separate interactions

with staff which averages out at over 300 sessions per month.

This was an inspirational visit and the reach of the team with only a 1.4 wte staff

working 24/7 was a privilege to see in action

Specific issues from two families were fed back to the Director of Nursing

18/02/2019 PACT and PACT HousePatricia Mitchell

Rebecca Kent

One change:

Beryl was waiting for sometime for her line

manager to be confirmed but this is now resolved.

A new tream member is joining shortly which will

free Beryl’s time to spend more time with families.

Most proud of:

Beryl and Nicola do an amazing job and they make

a huge difference to patients and their families

going through the most difficult time.

The funds that PACT have raised have made

a huge difference to the quality of space in

the separate new outpatients and daycare

centre with a bright welcoming waiting room,

friendly consulting rooms and new treatment

rooms. The facilities are uplifting and family

friendly. Beryl even does a sandwich order

and collection for parents paid for by PACT!

The team also run PACT House where

parents and family can stay a few doors from

the Acute site in a welcoming and relaxing

space which is homely, cosy and has

everything anyone could need. The care and

thought that has gone into its design is very

evident.

There is a large sitting room and a

bereavement group meets there each month.

PACT offer holiday homes in Filey and

Berwick to allow famnilies to have a break

and enjoy some leisure time with other

families who are going through the same

stressful time.

The team also provide emotional as well as

practical support to families and both

Rebecca and I were so moved by their work

and the holistic approach to all they do. We

felt very proud that they work with our Trust

and make such a difference to all the people

they work with.

01/03/2019 SafeguardingPatricia Mitchell

Peter Lauener

One change:

There have been isues with staffing levels and

sickness which has meant that, on occasions the

daily ward rounds have not taken place as time has

been needed for training. The team is small (6.6

WTE) but with sick leave and a vacancy the team

has been very stretched. However this should now

improve as the vacancy has been filled with a new

Band 7 starting in July.

Most proud of:

The team have a very good presence throughout

the acute site and this was very evident on the

ward rounds we saw. The SARC service is very

unusual as it provides a hospital based service

rather than a police station base which means that

sensitive interviews and examinations are based at

the Trust. There are full recording facilities as well

as secure storage of very sensitive data. The team

are very proud of the excellent feedback they

receive from the vulnerable service users. The

service gets 1-2 referrals a week and they come

from all over South Yorkshire and as far as

Grimsby and Hull because there is no comparable

facility elsewhere. We were delighted to hear (the

night after our visit) that the team won a Star

award.

Peter and I were very impressed by

this service and the dedication of

the team. They made us very

welcome and were enthusiastic

about explaining their work and

transparent about the need for

continuous training and proper

management of information when

we observed two lapses in this

area, both dealt with openly and

immediately with incident forms

completed and learning

immediately implemented.

We attended a medical morning handover meeting with Caroline and then a tour of

the Wards when any safeguarding issues were discussed. It was apparent that the

team are well known to staff and their visits are very much welcomed.

Although not included in our morning BTTF the team visit ED who have requested

that they visit them in an afternoon as that is when they are busier and any issues are

likely to have arisen. They say that they tend to be quieter in the mornings and any

issues that have arisen overnight would be handed over to the nurse and consultant

in charge of the department and they would come and seek advice. Anything urgent

they would e-mail the tream on our generic e-mail account which is checked every

morning or leave a voice mail on the confidential answer machine so that the team

could sort first thing or know to attend ED first thing in the morning.

The Paediatric Liaison Nurse (PLN) also attends ED and shares information between

the acute and community service as well as attending the safeguarding huddles and

shares referrals to her and concerns from both acute and community.

Sheffield are now "live" with the Child Protection Information Sharing Service (CP-IS)

this database is a nationally held base, where all children who are on a child

protection plan, or who are looked after by the local authority, are held. This supports

practitioners to make a more informed choice about the plan of care for children who

are at a greater safeguarding risk. It also identifies children who are "hospital

shopping", avoiding services or who have frequently attended health services.

Safeguarding Nurses and ED reception staff have access to it.The named social

worker for the child is informed when a child attends out of hours or unscheduled

care anywhere in the country.

Feedback from Back to the Floor visits: February 2019 to June 2019

Date Service AreaBoard member/

Governor

FEEDBACK

COUNCIL OF GOVERNORS 10. 40/19 CHAIRS REPORT (ENC E) - FEEDBACK F... Page 84 of 114



Governor

FEEDBACK

07/04/2019 Staffside Patricia Mitchell

One change:

See below but generally greater involvment in

several areas would be helpful.

Proud of:

Overall good relationship with the Board, HR and

Management and much better that at many other

Trusts.

Staffside work closely with the Freedom to Speak up Guardian.

The team perform many different roles in supporting staff and sit on the Health and

Wellbeing Group and the Staff Survey Working Group. It supports staff in formal

grievance, sickness and disciplinary hearings and signposts them for example when

they need financial advice. The Chair attends JNCC meetings. On the whole Staffside

have a much better relationship with the Board, HR and management than is the case

in many other Trusts.

However there are areas that could be improved. There are no staff on the Staff

Survey Working Group. This has been discussed with Jane Clawson. There are

issues with the effectivenss of middle management and we discussed the issue of

training as there can be implementation problems at all levels. This has been

identified as something that needs work within the Trust.

In terms of staff involvement the Clinical Summits were discussed and the fact that

staff were not sure if they should attend.

The team were not involved in the Strategy setting for the People and Culture

Strategies. These are very outline at this stage.

The team are supportive of and understand the need for the Trust to implement

transformation that will deliver better and more efficient services but would like input

into some of the proposed changes as staff often have good ideas and know what will

and will not work. The WLI was given as one example.

There are several issues around Comms and one example was not being able to

send out Comms re e learning but there is a meeting in place to discuss this. Another

was around getting the right message across from the staff perspective and the

example was given of the flu jab Comms which focussed on achieving the CQINN

rather than staff wellbeing.

Post visit note. All concerns identified were fed back to the appropriate executive.

All concerns identified had been fed back to the relevant Executive Director and responses are:

1) staff on the staff survey working group. staffside raised previously and feels that the group is management heavy rather than involving front line staff. IDHR agreed

with this as a change going forward have said that we will change this as part of a review of our governance arrangements to support implementation of the people

strategy and specifically the staff engagement theme. My view that I have shared with staffside chair is that the group should be representative of all staff groups and

across all levels of staff. We have asked each division/directorate to ensure any action planning to address their results includes staff at all levels and across all

disciplines - not be written by managers without staff input.

2) training for middle managers and cascade of information. There is a recognition that information does not always flow effectively and there is a reliance on staff

reading email communication. There has been a review of how information flows, and the newly created Management Board includes a presentation to middle

managers re matters discussed and decided by Exec Directors since the previous management board, and a soon to be launched Leadership Forum (first meeting 10

July) that is an information sharing meeting as well as incorporating a development session for all leaders across the Trust.

We will continue to look at how we cascade messages and the recently introduced Team Brief is an example of how we are trying to share messages in a simple,

effective way via usual team meetings.

2) training for middle managers and cascade of information. There is a recognition that information does not always flow effectively and there is a reliance on staff

reading email communication. There has been a review of how information flows, and the newly created Management Board includes a presentation to middle

managers re matters discussed and decided by Exec Directors since the previous management board, and a soon to be launched Leadership Forum (first meeting 10

July) that is an information sharing meeting as well as incorporating a development session for all leaders across the Trust.

We will continue to look at how we cascade messages and the recently introduced Team Brief is an example of how we are trying to share messages in a simple,

effective way via usual team meetings.

3) Staff side involvement in people strategy and culture and behaviours strategy. Staff Side were not included in the development of the core themes of either strategy,

albeit IDHR did consult directly with Sue as staff side chair on themes that she would like to see in a people strategy. We missed a good opportunity to engage staff

side with this work and have apologised to them that on reflection, and they should have been involved at an earlier stage. They have since seen both strategies and

we have had some discussion at JNCC. Staffside have been invited to be part of the implementation and be involved in more detailed actions going forward.

4) Comms and urgent emails. There are controls that the Comms Team use to minimise all user emails which don't always fit with the urgency needed to highlight

that e-learning is not working. Whilst this isn't part of the staff side chair's role (more the substantive role in L&OD) I am supportive of this being raised with Comms

to resolve and believe Head of L&OD has had a positive conversation to this effect.

5) Flu uptake and CQUIN. The reflection acout staff being encouraged to have the flu jab to achieve a final payment (ie CQUIN) is correct but unfair. This has been

shared with the staffside chair. The whole campaign to achieve 75% of front line workers vaccinated was focussed on protecting yourself and so protecting others,

particularly patients and colleagues. The remark refers to was an isolated email from the manager who was instrumental in delivering this successful uptake and it

was sent on the final day flu jabs could be counted when we were a handful of flu jabs away from our 75% target and so the financial reward.

01/05/2019 Ward 4 Patricia Mitchell

Comms much improved and the Ward produces

its own Newsletter.

One change:

There is a staff shortage on the Ward as there are

staff on secondment to OPAT and Ward 6 which

can impact on office days for admin and more

education hours would be beneficial. Steps are

being taken to address this and the Ward is

looking to train more support workers.

Most proud of:

Very proud of the teamwork and there is a good

atmosphere on entering the Ward. Staff are

dedicated, flexible, motivated and very pro active

about training and sharing good practice.

Ward 4 is a 20 bed general medical Ward looking after children 0-16. Staff are fully

aware of how to raise concerns and this was helped by the mock CQC inspections.

Their mandatory training and PDR rates are excellent at 93% and almost 100%.

Staff are very clear about recording risks and incidents and know how to escalate as

well as linking risks and incidents.

They get great feedback from patients and families and there were very

complimentary comments on the "tree". The " you said we did" board demonstrated

their responsiveness.

Things that would help them included longer working hours in Pharmacy and

signage. The Ward been waiting since October for the new signage and it is

confusing as I had to ask to find my way there. Parents have complained about this,

not surprisingly.

Issues relating to the medical team in relation to communications and understanding the complex needs of the child had been fed back to the Medical Director and

Director of Nursing and Quality.

Action to look at signage and longer working hours in pharmacy.

03/05/2019 Quality and Audit Patricia Mitchell

One change:

Better recognition of this service and the good

work being done in evolving and changing

practices. More triangulation.

Most proud of:

The team are proud of their resilience, flexibility

and commitment to the Trust which is at the heart

of the service.

We discussed the teams’ structure and how they work together and the system for

implementing clinical guideline updates. We know there has been a backlog with

these and that they have got "stuck" in Divisions. This was discussed with the AD for

medicine when he presented his Division's deep dive to the Quality Committee and

they are committed to a cultural improvement around this issue. This will be raised

with the other Divisions when they present their deep dives to the Quality Committee.

The levels of audit programme was explained and that very few of the locally

undertaken audits are abandoned. We also discussed the specialised services

dashboard and that the "no data submitted" issue has been resolved. We agreed that

it would be useful to have the number of indicators that are good in the report for a

better perspective. CQUINS are now managed by the Transformation team and they

will not be included in future reports as they are not monitored by this team and there

is a separate CQUIN report.

Historically, risk and audit have not been formally triangulated but this is beginning to

happen now which is excellent.

They hold a Clinical Audit Awareness week every year and we talked about the good

work that can come from this such as changing hand cleansing gel to make it

useable my patients with psoriasis.

In discussion with the team they agreed that more recognition of their work would be

useful. We discussed a possible spotlight presentation to the Board to highlight some

examples of their work such as the Roma Slovak population report which won a

National Quality Improvement Network Award. The Board calendar will be set for this

year but I will raise it as a possibility for next year.

On the whole there is good engagement with clinicians as they understand the value

of what the team do. When I was talking to Keith he raised the fact that there is no

hearing aid loop in either the Theatre Seminar Room or the Lecture Theatre and I will

raise this with Estates and HR.

1. Hearing aid loop to be looked at for theatre seminar room and the lecture theatre.

2. Schedule a board spotlight presentation in 2020.

3. Raise updating of clinical guidelines with divisions at their deep dive presentations to Quality Committee.

4. More recognition of their would across the trust was suggested.

07/05/2019 Hotel Services Patricia Mitchell

One change:

For Domestic staff to be included in is service

changes so they can arrange cover. For example

they were not aware that eye clinics would operate

on Saturday’s and that their service would

therefore be needed.

Proud:

Throughout all the services visited; Domestic

services, porter services and the kitchen and

dining room, all staff were very proud of their work

and demonstated real commitment and dedication.

It was really impressive.

I visited with the three supervisors in Domestic Services. They manage 74 wte on the

acute site and they really impressed with their dedication and commitment. They

have all been at the Trust for many years but were still so enthusiastic!! They

explained training, audit and how they manage rota's.

There are things which can be difficult to manage, in particular when they are not

consulted on service changes such as Saturday clinics. They are very proud of the

service and they often receive compliments from patients and their families. PDR and

MT rates are good and their staff know how to raise issues and complaints. They do a

great job!

During the visit to the porter service we went on a walk around the Wards and

discussed the test abduction which was very impressive with the Ward being locked

down in 2 seconds and the whole acute site within 80 seconds. On a subsequent

visit to Outpatients they praised the porters for their security work and support.

The porters do a varied and valuable job. They are trained in restraint of MHA

patients as well as more obvious restraint. They have a long reach from supporting

the families of patients going to the mortuary to reporting safeguarding issues. The

procedure for lock down was explained and I was very much assured that the Trust is

a much safer place through their work.

The kitchen feeds our patients and breast feeding Mums and cares for special dietary

requirements. The kitchen makes its own yoghurt, sausage rolls and cakes and holds

an award from Food for Life and uses sustainable products. It consults with the Youth

Forum and holds a 5 star award for Environmental Health.

The Dining Room provides a delivery service to the Wards at lunch and tea as well as

providing meals to families from 8-2.30 and 3.30-7. Again, this service receives

praise from families for supporting them during their stressful time in the Trust.

I spoke to parents of a patient who

had no concerns about the nursing

which they said was excellent but

had several issues with the medical

team around communication and

understanding the complex needs

of their child who had severe

learning difficulties and autism.

These were fed back to the Medical

Director and the Director of Nursing

for action. They would be very

happy to share their experience

with the Board and feed into the

work that the Trust is currently

undertaking around these issues.




Governor

FEEDBACK

08/05/2019 Outpatients Nursing Patricia Mitchell

Yes and comms have improved greatly.

One change:

Acceleration of the pace of improvement of

Ryegate and Centenary House facilities.

Most Proud of:

Excellent team work.

The waiting area around the Hub is

frequently very crowded with parents and

patients standing against the walls by PALS

as there are insufficient seats and they need

to be able to see the screens. Space has

been taken by retail outlets, the pharmacy

and the Charity which is good in many ways

but there is a concern that the Charity wants

to expand its current space which will result

in a loss of seating. There will be increased

pressure on patient space with the growth in

the blood service as the Trust is taking over

this service from GP’s.

The Outpatients Nurse Manager manages 60 nursing staff within 24 specialities.

Outpatients is a very busy service and can see over 350 patients in a day including

services at Centenary House, Ryegate and the Northern General. The MT and PDR

rates are very good, which is excellent given the number and range of staff. Staff are

very aware of how to report concerns and of the Duty of Candour. The work being

done in the Learning and Development team was mentioned as being very good and

particularly the roll out of Mind Tools. Also mentioned was the excellent work of the

security team who are helpful and effective and the work of the volunteers.

The team are working with the Microsystems team to look at patient flow and where

there are bottlenecks and there are improved communications within the Division

where there is good support from the AD of the Medicine Division. There was concern

expressed at the slow progress of plans to make improvements to Ryegate and

Centenary House which have been escalated and are on the risk register.

We walked around the clinics and it was very busy with many people standing. There

are plans to open up the outside courtyard to provide extra space and a lovely area

but there is the issue of no appointments boards there which is being looked at.

Additional patient and family waiting space is needed, which includes access to visible appointment screens.


Becton site visit

Service Board member Comments Action

Community CAMHS Mark Smith and Andy Baker

Noted time wasted by staff travelling across sites.

Noted tough with focus on the service however complimentary of support from Executives, which was

good / positive.

Estates, Kitchens and ODNPatricia Mitchell and John

Cowling

Kitchen large, dining room chairs had metal legs which were ocassionally used inappropriately.

Space / facilities not well used within the large estate. / scope to develop and or use better.

ODN worked well with MD and DSO. Success story nationally recognised.

Consider scope to develop or better use space / facilities within the estate.

Induction TourJohn Williams and Richard

Chillery

Effective use and staffing of section 136 capacity

Recycling project

Ruby LodgeCraig Radford and Scott

Green

Unclear if there was a recruitment plan due to upcoming retirements.

Nursing gaps - regularly recruit nurses, however different approach process for recruitment of nurses at

Becton.

Noted no cross fertilisation across lodges, feel like separate self contained units, unaware of focus

elsewhere.

National service however no parent accommodation available and current space not well utilised.

Action to pick up family support with NHSE.

SchoolJane Clawson and Peter

Lauener

Pupils at the school had passed letters for the CEO regarding recycling.

Rental of space / facilities for school in comparison to other trusts / benchmarking financial information

would be passed on to CFO.

Good achievement of Mental Health Gold Charter Mark - first school of any kind to achieve this.

CEO / Chair would respond to the letters regarding recycling.

IDHR to pick up the good news story with communications.

Emerald Lodge/136 Suite Sarah Jones and Claire Coles

Cross site training between CAMHS and main site previously undertaken, would be good to roll out

again due to staff turnover since completed.

Mental health training to main site staff.

Size of 136 suite was impressive. Only commissioned for 12 patients over the year. Need to understand

the implications for any received over the 12.

Note the law change that a police station is not a place of safety for a young person, and the implications

of this on the 136 suite.

136 is for young people 16, 17, 18. Need to understand where younger people are accommodated on

the main site.

Cross site training plan required.

Look at the implications of the change in law regarding place of safety for

young people and implications for the 136 suite.

0-19 ServiceJohn Somers and Sarah

Jones

Very resilient team

Getting better at agile working - helped by IT

Team-working

System not joined up - other providers sometimes not accepting

responsibility

Input of ED safeguarding data very time consuming

High caseload


11. 41/19 DIRECTORS REPORT (ENC F)

1

EXECUTIVE SUMMARY

Title Directors’ Report

Report to


Executive Sponsor

Mr J Somers, Chief Executive

Purpose of report

To present a quarterly update from Executive Directors


Approval

Assurance

Information √

Executive summary –the key messages and issues Chief Executive’s Report – June 2019

1. Integrated Performance Report

The Integrated Performance Report (including quality, activity, workforce and performance) including a high level dashboard is structured around the organisation’s five strategic aims. This includes an Executive Summary of Trust wide performance against the five strategic aims.

All data relates to May 2019 unless otherwise specified (e.g. sickness absence which is reported one month in arrears).

Key Achievements

The Trust continued to achieve all Cancer standards throughout May.

The Trust has continued to achieve the ED Waiting Time standard, with 98% of patients being seen within four hours.

The Diagnostic standard was achieved with 99% of patients being seen within six weeks.

Was Not Brought rates for first outpatient appointments continued to be within the Trust’s tolerance level of 9%.

The percentage of complaints responded to within deadline increased significantly for the second consecutive month.

Outpatient attendances at trust-level are currently above plan by 524 episodes.

Areas for Improvement

The percentage of patients on an 18-week RTT incomplete pathway was not achieved at Trust-level for the second consecutive month. The closing month-end position was 91.64% against the national standard of 92%. This is, however, an improving position on last month.

The number of incidents pending investigation which are overdue increased by 68 in comparison to April’s closing position.

Both PDR and Mandatory Training compliance continues to remain below the Trust target of 90%. PDR compliance deteriorated in-month to 75% from 81% in April and Mandatory Training compliance remained static at 87%.

The Performance Report is available on the Trust website and can be accessed on the link:

COUNCIL OF GOVERNORS 11. 41/19 DIRECTORS REPORT (EN... Page 89 of 114

2

https://www.sheffieldchildrens.nhs.uk/download/604/june/8914/june-2019-board-papers.pdf

Questions should be directed to:

Operational: Ruth Brown, Executive Director of Strategy and Operations: [email protected]

Quality: Sally Shearer, Executive Director of Nursing and Quality: [email protected]

Finance: John Williams, Executive Director of Finance: [email protected]

Workforce: Nick Parker, Executive Director of People and OD: [email protected]

2. Complaints Performance

At the previous Board meeting, colleagues requested further information about recent complaints performance.

Since the departure of the previous complaints officer in early 2018 there had been a decline in complaints response times and quality. In July 2018 a new complaints officer was appointed. Unfortunately this officer inherited poor performance that had been the result of the interim agency complaints handlers. The complaints officer has worked with the Divisions individually to improve response times, providing training on the new complaints module in Datix, action planning and lessons learnt. The complaints officer has attended complaints courses herself on questioning and communication techniques, process, procedure and information gathering as well as letter and report writing to assist in improving the quality of complaint times and responses.

Weekly complaints reports are sent to the Divisions with updates on progress and an escalation procedure for the complaints process has been implemented to ensure that responses from Divisions are received in a timely manner.

We are now beginning to see the benefits of these actions in the performance reports and hope that this can continue. There are plans to improve the quality of the complaints responses and lessons learnt. However, this is currently on hold until there is more capacity within the team.

To date, we have 12 complaints live with only one overdue. In addition, governance around complaints in divisions has improved with designated people responsible for overseeing that information flows promptly.

3. NHS Mail roll-out

The planned switch over to NHS mail over the weekend 15/16 June unfortunately had to be postponed, following a national incident affecting NHS Mail on the Friday evening. This has now been scheduled for Friday 12 July 2019.

Questions should be directed to: Kevin Connolly, Chief Information Officer: [email protected]

4. Serious incident

The Trust was involved in a serious incident on 24 May. I was grateful to all staff that were involved, including those from overnight shifts who remained at the Trust to assist. A full debrief has taken place with some areas for future consideration highlighted.

5. Changes in CWAMH

Shatha Shibib has been appointed to Clinical Director of CWAMH. Dr Vaidya has moved into an Associate Medical Director role in recognition of his work with the Clinical Commissioning Group, and will report into the Medical Director on this.

6. Interim People Plan

At the start of this month, NHS England/Improvement published the Interim People Plan for the NHS. This has been developed over the last few months and sets an agenda to tackle the range of workforce challenges in the NHS with a particular focus on the actions for this year.


https://www.sheffieldchildrens.nhs.uk/download/604/june/8914/june-2019-board-papers.pdf






3

The plan is structured into the following themes, with each theme having a number of immediate actions that need to be taken by NHS organisations to enable the people who work in the NHS to deliver the NHS Long Term Plan. Key actions for employers are around:

making the NHS the best place to work

improving our leadership culture

prioritising urgent action on nursing shortages

developing a workforce to deliver 21st century care

developing a new operating model for workforce

The plan also includes specific commitments to:

increase the number of nursing placements by 5,700

increase the number of nurse associates to 7,500

increase the number of doctors and nurses recruited internationally.

work with Mumsnet on a return to the NHS campaign

better coordinate overseas recruitment.

As part of the theme of making the NHS the best place to work, the government is bringing forward a consultation on a new pension flexibility for senior clinicians. The proposal would give senior clinicians the option to halve the rate at which their NHS pension grows, in exchange for halving their contributions to the scheme.

A board level briefing has been developed by NHS Employers and is available here: https://www.nhsemployers.org/news/2019/06/interim-people-plan.

7. NHS Confed

I attended the 2019 NHS Confederation conference in Manchester on 19 and 20 June. NHS England chief executive Simon Stevens and Mayor of Greater Manchester Andy Burnham were among the speakers.

During a CEO’s event at the Conference I specifically probed Simon Stevens on NHSE/I’s focus on children’s service and funding. I have followed this up with a letter and an offer for Simon to come and see some of the excellent work we are doing at Sheffield Children’s.

8. Child Health Day

Work is continuing to take place behind the scenes ready for the launch of the first ever Child Health Day on 9 September. This day is being developed by the Trust to create a national conversation about child health. It is also an excellent opportunity to highlight the specialist work of Sheffield Children’s and to position us as a leading advocate for children’s health.

9. Jim Bonham MBE

Jim Bonham was recognised in the Queen’s Birthday Honours, receiving an MBE on 8 June. The application for the award was developed by the Communications Team, and included messages of support from clinical colleagues and The Children’s Hospital Charity.

The honour recognises his services to the development of newborn screening. The timing of the award coincides with the 50th anniversary of the first newborn screening. A short video has been produced to recognise Prof Bonham’s honour and will be shared via media and social media.

10. Charity Football Match a Success

On 10 June, a select Sheffield Children's team took on a Hallam FC XI to raise money for a new Emergency Department for our hospital. We secured a 4-4 draw thanks to a last-gasp penalty from our mascot, Theo Bear, who scored with his first touch!


https://www.nhsemployers.org/news/2019/06/interim-people-plan

4

A huge thank you to Hallam FC whose hard work made this possible and to everyone who donated raffle prizes, supported from the stands, or played in the match.

11. Open staff meetings

The next round of open staff meetings are underway. The focus of the meetings will be on the quality strategy and the meetings used to consult with staff. Executives have encouraged staff to invite them to local team meetings as well.

12. Trust Board Meetings

All Governors are invited to attend Public Board meetings. The next meeting is scheduled to take place on Tuesday 30 July 2019, at 8.30am to 10.30am in the Boardroom, Western Bank.

You can register to attend via the Trust website here:

https://www.sheffieldchildrens.nhs.uk/about-us/board-of-directors/

The Public Board papers and minutes are also available to review on the Trust website each month, via this link:

https://www.sheffieldchildrens.nhs.uk/about-us/board-of-directors/#478-2019

13. Back to the floor visits

Governors are reminded that they can book themselves on to join service visits by accessing the booking system from the Trust website, this lists upcoming visits and also includes dates for the Trust’s internal programme of cleanliness audits and PLACE assessments. Three planned visits have all be quickly booked up, however further visits are in the process of being arranged, details of which will be shared with governors in due course.


Failure to effectively deliver healthcare impacts on the safety and quality of patient experience, regulatory compliance and loss of confidence of the wider community.

Risk that we do not maintain financial stability due to failure to deliver the financial plan resulting in requirements for additional CIPs or reduction in level and standard of services.


Failure to ensure that the Trust recruits staff in the right numbers and with the appropriate breadth of skills and competencies to deliver high quality services now and in the future.

Risk to clinical service viability due to failure to meet nationally defined standards or unfavourable changes to the commissioning of services.

Failure to engage effectively with partner organisations and the local community threatens the ability of the Trust to deliver its strategic ambition.

Capacity constraints impact on our ability to deliver planned activity and manage demand impacting on operational efficiency, service quality and financial performance.


Governors are asked to: i) Review the report ii) Ask questions and comment as appropriate


https://www.sheffieldchildrens.nhs.uk/about-us/board-of-directors/

https://www.sheffieldchildrens.nhs.uk/about-us/board-of-directors/#478-2019

12. 42/19 STAFF SURVEY 2018 -CORPORATE ACTION PLAN ANDPROGRESS UPDATE (ENC G)

EXECUTIVE SUMMARY

Title STAFF SURVEY – ACTION PLAN AND PROGRESS UPDATE

Report to


Executive Sponsor

Nick Parker, Executive Director of People and Organisational Development

Author

Jane Clawson, Deputy Director of People and Organisational Development

Purpose of report

To inform the Council of Governors of actions planned and progress arising from the 2018 staff survey results.


Approval

Assurance

Information √

Executive summary –the key messages and issues The 2018 national staff survey results were received in February 2019. The results allow the Trust to compare changes in staff feedback with 2017, and compare our results with other NHS Trusts in the category of combined acute and community trusts. Our results are considered by the CQC as part of their well-led review, by NHSI/E and by Sheffield CCG as part of commissioning review. Our response rate has improved consistently over the last 5 years to 54%. The results are presented in 10 themes. The Board have already received a high level summary which sets out our changes since last year, and a copy of the summary report. The results were not remarkably different from the previous year, and our attention this year is to focus on three key areas for improvement – quality of care, quality of appraisals and health and wellbeing. This report summarises actions that have been taken following receipt of the results and ongoing work to improve the experience and environment of our staff to aid staff retention, staff performance and ultimately improved quality of care for our patients.


Staff engagement has a proven link to the quality of patient outcomes as it is a significant factor in staff performance. Poor staff engagement results in absenteeism, under-performance and high turnover. Empowering a motivated and compassionate workforce is a key strategic objective of the Trust as part of our organisational strategy.

Recommendations and next steps The Council of Governors are asked to note and comment on the actions taken and proposed future actions to continue to improve staff engagement.

COUNCIL OF GOVERNORS 12. 42/19 STAFF SURVEY 2018 - ... Page 94 of 114

STAFF SURVEY – ACTION PLANS AND UPDATES

1.0 Background

1.1 All NHS employers take part in the national annual staff survey. This takes place between September and November each year and the results are shared directly with employers as early as January the following year, with benchmarked results (ie comparison with other NHS employers) embargoed until March.

1.2 The results act as a measure of staff engagement across the NHS, and its purpose is to arm employers with information to help build on good practice and make changes for the better in other areas. The benchmarked results allow organisations such as the Care Quality Commission to consider staff feedback as part of their well-led assessment.

1.3 Each year we invite all directly employed staff to participate. The findings to the on-line

questionnaire do not identify individuals, but can identify trends by department, staff group and protected characteristics such as age, gender, sexual orientation, ethnic background, religion and disability.

1.4 The Trust contracts with a survey provider to manage the survey on our behalf. This year,

we selected a new provider based on the suite of reporting, in that it could be manipulated by us for specific analysis, rather than a set format. Unfortunately, the provider has failed to provide more than the basic reports to date and so our planned analysis of data available is limited, despite escalation. The biggest failing is that we don’t have departmental level reports (usually available for teams of 20 or more). The reports are at divisional level only.

2.0 The results in summary 2.1 For ease of reference, Table One below summarises the 10 key themes and compares

them with our feedback from the last survey (2017). Safe environment covers two themes together in this table. Table Two below summarises the results compared with the 42 other Trusts in our comparator group – combined acute and community trusts.

Table One – summary of themes compared with 2017 survey


2.2 Table Two: Summary of themes and our place amongst 43 combined acute and community trusts (19th out of 43 overall)

3.0 Acting on the results

3.1 The Trust has a Staff Survey Working Group – made up of HR, trade unions and divisional representatives. The Group analyse the results, the free-text comments that are also provided and identify themes for action. The constitution and governance of this group is under review so it has clear reporting arrangements and includes a wider cross-section of staff to share ideas.

3.2 Analysis of the feedback identified three themes that were proposed as the areas to

concentrate on Trust wide. The rationale for this was to concentrate on fewer key themes, looked at in more depth, and to aid simple and effective communication with staff about them. The three themes are:

3.2.1 Quality of care. The feedback from staff is below average compared with other

trusts in our sector, but better than last year. As this is core to our service delivery, it is important to look to improve this as a Trust wide action.

3.2.2 Quality of appraisals. Staff feedback is that the quality is below average in our comparator group and that the quality is reduced compared with feedback from the previous year. Appraisals are a key element of staff performance and feeling valued and supported.

3.2.3 Health and wellbeing. Staff health and wellbeing is an area that has worsened nationally and we are average in our comparator group. Feedback from staff is that we are doing less to support their health and wellbeing and this is a trend over the last four years.

3.3 In addition to Trust-wide action plan, each division had results that could be compared with

other divisions and where they could see the results for each question answered on the survey. Divisional leads were asked to identify three key themes to focus on and develop an action plan that involved staff, cut across all staff groups in the division and had measures of success built in. HR Managers were tasked with supporting divisional leads


with this work and aligning action plans under the key cultural ambitions of keep learning, feel safe, team up and leading collectively. Some action plans have been submitted to HR, and others are still in development.

4 Improving quality of care 4.1 The quality of care theme is rated using responses to the following questions:

4.1.1 Staff are satisfied with the care they give (78.3% said they were). This was higher

than last year, but below average in our comparator group. 4.1.2 Staff feel that their role makes a difference to patients (86.9% said they were). This

was lower than last year and below average in our comparator group. 4.1.3 Staff feel they could deliver the care they aspire to (60.7% said they could). This

was an improvement on last year but below average in our comparator group. 4.2 For nursing/ward based staff, there are plans in place for the Pathway to Excellence

programme to empower staff to take forward quality initiatives and improve patient care. This programme will be led by the new Deputy Director of Nursing. It is a long term plan of quality improvement and will help address nursing perception of quality of care delivered. The Director of Nursing and Quality and Deputy Director of Nursing both carry out “walk-abouts”, listening to staff and their ideas for change and feeding these back to operational nursing management. A clinical managers’ away day has been organised to focus on how quality of care is a factor in workforce retention.

4.3 There is further work to be explored with other clinical staff groups to understand their

perception of the quality of care they deliver and the Junior Doctors’ Forum will feature this topic.

4.4 All staff have a role that makes a difference to patients, and the further someone’s work is

from the patient makes it more difficult to see the connection. Many corporate department staff are based in areas where patients are not even passing through (eg Moorfoot/Northumberland Road) and have roles where they are primarily office based.

Actions underway to address this are:

A Support Services Summit has been organised for 18 July 2019. Staff in corporate departments will have opportunity to better understand their connection to Trust objectives and delivery of patient care.

Moorfoot have pictures of patients and clinical staff in work areas

Executive Directors go out to corporate areas as part of the ‘open meetings’ season to talk about clinical achievements and progress

Team meetings include discussion about clinical activity and performance as well as new developments

4.5 In addition to this, corporate staff are to be encouraged to visit their internal customers and

undertake a shadowing exercise to understand their value to services. Corporate departments are to be encouraged to discuss the value of their team objectives to deliver of patient services including a line of sight to the patient through staff support, and appraisal conversations and 121s will be directed to include reference to work outputs and how they link to patient care.

5 Improving quality of appraisals 5.1 The quality of appraisals is measured by the following feedback:

5.1.1 Staff feeling their appraisal helps they do their job is a worsening trend with 17.5%

of respondents agreeing with this. We are below average in our comparator group.


5.1.2 Staff feeling the appraisal gives them clear objectives for their work is also a worsening trend as only 32.4% of respondents felt this was the case.

5.1.3 Staff feeling that the appraisal left them feeling valued is improving year on year, but is still only 30.2% of respondents.

5.1.4 Staff reporting that Trust values were discussed in their appraisal is 33.4% - an improvement on last year and above average in our comparator group.

5.2 Our focus on achieving compliance at 90% each year may have affected the quality of

appraisals in some areas. As a comparison across divisions, the quality of appraisals is lowest in three of our clinical divisions.

5.3 The appraisal process including reporting, recording and documentation is under review

this year with a deep dive review going to Finance and Resource Committee in September 2019. How to build a quality review into this process will be considered.

There are, however, some quick actions to help improve the experience:

We have provided more appraisal training in the last 12 months than previously and the Learning and Development Team strive to meet demand, showing that appraisers and appraises want the experience to be better. The feedback from the staff survey will feed into the training delivered.

Effective conversations’ training is being promoted this year which will equip appraisers with the tools to discuss important and difficult topics more effectively.

The Mind Tools on-line training platform is receiving great feedback from managers and will be further promoted via targeted campaigns to increase uptake and guide staff to useful appraisal guidance.

In addition, a revised appraisal policy is due for consultation in July 2019 and will include reference to the importance of clear objectives and clear feedback as satisfactory completion of objectives will be linked to pay progression.

6.0 Health and Wellbeing 6.1 Staff health and wellbeing is measured by the following:

6.1.1 Do staff have flexible working opportunities? Our result is the same as last year at 55% which is above average in our compactor group.

6.1.2 Does the Trust take positive action on staff health and wellbeing? Our result is a worsening trend and only 25% of respondents were positive about this. We are lower than average in our comparator group.

6.1.3 Have staff had a work-related MSK injury in the last 12 months? We are best in our comparator group at 21.4%, but this is fewer staff that last year.

6.1.4 Have staff felt stressed at work in the last 12 months? Our results show a worsening trend with 43% of respondents this year saying they have felt stressed. We are below average in our comparator group.

6.1.5 Have staff come to work despite not feeling well enough to? Our results are the same as last year at 56% of respondents saying they had attended work not well enough to do their duties, and this is average in our comparator group.

6.2 The Trust has a health and wellbeing working group that looks at initiatives to help staff

manage their own health and wellbeing. This has led to a number of programmes to help staff manage their weight, access exercise opportunities, access emotional wellbeing support and review policies such as flexible working and stress management. The group is to undergo a refresh this year to strengthen its purpose and set appropriate governance arrangements to ensure their work meets our objectives. Our new people strategy has a key theme of health and wellbeing and commits the Trust to:


Developing communication with staff to encourage them to manage their own health and wellbeing

Reviewing and developing policies that support health and wellbeing such as stress, flexible working and acceptable behaviour at work

Ensuring our managers have the tools and training to positively influence staff health and wellbeing and introducing key performance indicators to monitor and revise our effectiveness.

The trust has seen increasing levels of sickness absence due to stress in the last two years. Research from clinical divisions highlights workload and dealing with emotional challenges of care as key reasons. Actions underway and in place focusing on mental health support are the introduction of Mental Health First Aiders, introduction of a new 24/7 employee assistance line, mental health awareness training for managers, additional emotional support sessions for staff to debrief and process emotionally challenging work. The Health and Wellbeing Group are hosting a workshop at the Caring Together Clinical Summit in September 2019 to highlight focus on mental health and launch a staff resilience workshop. Work load challenges are a regular theme, as staff report feeling the pressure to increase activity/productivity within existing resource. The transformation team and service improvement coaches are a source of support for departments to address work flow issues, and individual management support is required for specific cases.

6.3 The fast-track physio service introduced almost 2 years ago continues to extend its use. This year our aim is to be more proactive and ensure increased awareness and early intervention where an employee reports an MSK injury or is absent as a result of one. The aim is to ensure that staff and managers act quickly to access the service to aid more effective recovery and prevent or reduce absence. Raising awareness of this free service to staff is planned in this year and builds on the positive musculo-skeletal awareness week held across the Trust last year.

6.4 The Mind Tools online training platform has also been used widely by staff and managers

to access supporting resources since its launch in February 2019. Stress management tools and resources are the most popular resources accessed. There is scope to promote the platform more and its effectiveness will be measured as part of consideration of extending our licences when the 12-month pilot ends.

7.0 Divisional response 7.1 HR Managers are working with divisions on their own action plans. Highlights include:

7.1.1 Surgery and Critical Care: The division has completed a further survey (200

respondents) to understand the results. This has been positively received and provided a good source of feedback. An action plan is in place as a result focusing on staff morale, support from immediate manager and quality of appraisals.

7.1.2 Pharmacy, Genetics and Diagnostics: An action plan will be in place by the end of

June focusing on appraisal, health and wellbeing and morale. The division are completing a survey monkey focusing on appraisal to understand specific actions which staff want the division to undertake to improve the quality of their appraisals

7.1.3 Community, Wellbeing and Mental Health Services: The division is on track for an

action plan to be completed by end of June focusing on health & wellbeing, quality of care and safety. The action plan will identify areas of good practice in terms of appraisals to share with other divisions.

7.1.4 MEDicine: The division is on track for action plans to be in place by end of June.


7.2 Divisional action plans will be discussed at Staff Survey Working Group in July to identify corporate support required which will fed into Trust wide action plan and Support Services Summit. Examples of good practice will be shared at this group so other divisions can learn/adopt different approaches.

8.0 Next steps 8.1 Not all actions have timescales as they are ongoing commitments, not quick actions. The

focus for next year will be that the survey results are an output of what we want to achieve from the people strategy and culture and behaviour strategy, together with an improvement in staff engagement measured by a continually improving trend.

8.2 The Trust has endorsed the investment of a Staff Engagement Lead role to give focus to

many facets of staff engagement and to lead developments in the staff survey and other more regular ‘pulse checks’.

8.3 Communications are in place in the run up to the next survey to report on what we have

done with the results this year to help drive a further increase in our response rate and these will be shared in the next series of ‘open meetings’ and cascaded through team meetings.

9.0 Summary 9.1 The Council of Governors are asked to note the progress against our staff survey results

and comment on the proposed actions and direction. Jane Clawson Deputy Director of People and Organisational Development June 2019


13. 43/19 KEY MESSAGES (ENC H)

EXECUTIVE SUMMARY

Title

Governors’ Key Messages

Report to


Executive Sponsor

Mr N Parker, Executive Director of People and OD

Author

Ms L Fountain, Associate Director Communications

Purpose of report

To present key messages for governors to share with their constituents


Approval

Assurance

Information √


To present to Governors key messages that can be used to support Governors engage with their local constituency members and the wider public.


Link to Board Assurance Framework

Failure to engage effectively with partner organisations and the local community threatens the ability of the Trust to deliver its strategic ambition


Governors are asked to:

i) Review the report ii) Ask questions and comment as appropriate iii) Share these messages with local constituency members / the public

COUNCIL OF GOVERNORS 13. 43/19 KEY MESSAGES (ENC H) Page 102 of 114

GOVERNORS - KEY MESSAGES JULY 2019

1. CHILD HEALTH DAY

Work is continuing to take place behind the scenes ready for the launch of the first ever Child Health Day on 9 September. This day is being developed by the Trust to create a national conversation about child health. It is also an excellent opportunity to highlight the specialist work of Sheffield Children’s and position us as a leading advocate for children’s health.

Media organisations are being engaged to ensure good coverage of the day, and the Communications Team is developing a library of case studies to highlight on the day through media and social media.

National partners are being engaged, such as the Royal College of Paediatrics and Child Health, and other health organisations will be encouraged to take part nearer the time.

A website and social media accounts have already been established.

Clinical feedback has already been sought and a working group has been set up including clinical representation.

Involvement across the Trust will be encouraged. Divisions will be given suggestions on how they can get involved nearer the time, but teams will also be given freedom to interpret the day in their own way.

Note: Several key partners have not been briefed at this stage, so Governors are asked not to discuss details at this stage.

2. JIM BONHAM MBE

A professor from Sheffield Children’s Hospital is being awarded an MBE, having helped save lives across the UK and beyond through the newborn screening programme. Professor James (Jim) Bonham was a key figure in the introduction of blood spot screening tests for newborns, which help more than 1,000 babies each year by detecting and treating conditions that otherwise could be fatal.

Through his role as President Elect of the International Society of Newborn Screening, Prof Bonham is helping to support and develop similar screening programmes in more than 80 countries around the world. Currently, approximately 25 million babies each year receive this form of screening and many thousands of lives are saved as a result.

Prof Paul Dimitri, Director of Research at Sheffield Children’s, said: “Prof Jim Bonham is an inspiration for those working in the fields of paediatrics and newborn screening. He has shown dedication and determination in advancing newborn screening nationally and internationally during his 30 years in the field of inborn errors of metabolism, to ensure that thousands of babies with life debilitating and threatening diseases are detected and treated early in life. His work has no doubt saved and improved the lives of thousands of children.


“Recently Professor Bonham has been using his expertise to help progress newborn screening in developing countries, ensuring that services are established and resourced appropriately. By reaching out to other countries desperately in need of newborn screening his work will undoubtedly improve the lives of children worldwide.”

Prof Bonham was a Clinical Director at Sheffield Children’s until April 2019. He is also President Elect of the International Society of Newborn Screening and national laboratory lead for the newborn screening blood spot programme. The award for Prof Bonham comes as the blood spot newborn screening programme celebrates 50 years in operation, screening babies across the UK for potentially life threatening conditions.

A short video is available on Facebook to recognise Prof Bonham’s honour.

3. CQC

The Trust’s CQC rating is due for publication on Tuesday 16 July. Extensive communication will be taking place both inside and outside of the Trust. The support of Governors in communicating those messages will be greatly appreciated.

4. NATIONAL AND INTERNATIONAL COVERAGE

Media coverage of sleep service - The Sheffield Children’s communications team worked with NHS England to profile the Children’s Sleep Well Project in the national media. This included facilitating an interview with Prof Heather Elphick and producing a list of sleep tips for parents. The resulting story was covered by the Guardian, i Newspaper, BBC News, BBC Radio Sheffield and the National Health Executive. A further article was secured in the Mirror, with Dr Miriam Stoppard praising the scheme run by Sheffield Children’s. Daily Mail, Sheffield Start and SWNS - A 107-year-old donated his entire estate to a hospital to help fund an innovative scanner which will be used to treat his great-great-niece's brain tumour. Former army-veteran David 'Stanley' Brackenbrough left a legacy gift of £245,000 to Sheffield Children's Hospital when he died in 2017 which has been used to fund a third of the £800,000 machine. The device will enable doctors to give children like seven-year-old Isabelle Smith a more detailed diagnosis of a benign tumour she was diagnosed with at nine months old. Isabelle’s mum believes the donation was his way of 'saying thank you' for the way the hospital had looked after her all her life. The Good Times - The story of Rafi Solaiman and the care he received at Sheffield Children’s Hospital, with the support of the Sick Children’s Trust, after he had a stroke. Diabetes.co.uk - Grateful patient 8-year-old Sophielee thanks Sheffield Children’s diabetes team for supporting with her diagnosis. London Economic - A mother ran the London Marathon today for her brave daughter Poppy Bell-Minogue who has battled a degenerative brain disease – exactly six years since the day she was born. Poppy is treated at Sheffield Children’s Hospital, and her mum ran the marathon to raise money to say thank you for the care she’s received at SCH. Poppy has Maple Syrup Urine Disease and is treated by the specialist metabolic team at Sheffield Children’s Hospital. Yorkshire Post - A feature on a previous patient at Sheffield Children’s, Lucy Mountain, who has cystic fibrosis, who isn’t letting her serious health condition get in the way of her career.


The feature talks about the care Lucy received at SCH, how it’s a second home for her and how she’s supported by the hospital to still pursue her dream of becoming a make-up artist. The piece includes a quote from Noreen West, consultant paediatrician at Sheffield Children’s. Health Tech News - Sheffield Hallam University and Sheffield Children’s Hospital are working together on new virtual reality technology which can help injured children through rehabilitation. National and international news - The communications team worked with Press Association, the UK’s leading provider of multimedia content and services for news media outlets across the country, to share the story of a patient Harry Pankhurst who went viral after singing his favourite football song while he was in hospital recovering from an infection in his shunts. We secured coverage outlets both regional, national and international. Harry’s father posted the touching video of his ill son singing a football chant while at Sheffield Children’s Hospital and it went viral and received support (including videos, well wishes and merchandise) from a number of high profile sports people including Harry Kane, Hugo Lloris and Andy Murray. The father thanked the staff at Sheffield Children’s for supporting Harry throughout his life and this particular time of illness and said this new wave of support was a great boost while in the hospital. 5. AWARDS

Nursing bank - On 6 June, an ICS-level collaboration won a HPMA Excellence Award. The collaborative nursing bank management won the award for “Workforce contribution in health and social care systems”. The HMPA (the healthcare people management association) recognised the £1.2m reduction in agency costs achieved by the partnership, of which Sheffield Children’s was a key member. Sheffield Children’s is working with partner organisations to communicate the award win more widely.

Dental fast track – The dental fast track service has been shortlisted for an HSJ Award, based on an application developed by the communications team. Their judging presentation is taking place on the 10 May. The presentation was put together by the communications team to ensure to judging criteria was effectively responded to, and that the achievements of the dental team were fully communicated. The team will find out if they have been successful on 2 July.

Muscular Dystrophy - Sheffield has been officially recognised as Centres of Clinical Excellence by Muscular Dystrophy UK at an award ceremony on 2 July.

The Trust received its national awards from Rob Burley, Director of Campaigns, Care and Support.

The multidisciplinary neuromuscular clinic at Sheffield Children’s was set up 20 years ago to provide care for children across South Yorkshire, North Derbyshire and Lincolnshire with nerve and muscle conditions such as muscular dystrophy, spinal muscular atrophy. The team includes neuromuscular doctors, a specialist neuromuscular physiotherapist and a specialist neuromuscular care adviser. www.sheffieldchildrens.nhs.uk/news/sheffield-childrens-hospital-awarded-centre-of-clinical-excellence-status-by-muscular-dystrophy-uk/


http://www.sheffieldchildrens.nhs.uk/news/sheffield-childrens-hospital-awarded-centre-of-clinical-excellence-status-by-muscular-dystrophy-uk/

http://www.sheffieldchildrens.nhs.uk/news/sheffield-childrens-hospital-awarded-centre-of-clinical-excellence-status-by-muscular-dystrophy-uk/

6. THE CHILDREN’S HOSPITAL CHARITY

Update on The Children’s Hospital Charity’s Appeal The hospital received a donation of £800,000 from the charity for the redevelopment of the Child Assessment Unit, CAU. This marks the start of the new appeal to Build a Better Future, which aims to develop four key areas within the hospital; CAU, Emergency Department, Ward 6 and to build a new Helipad. The first instalment will enable the architects to finalise the plan for the space and for the building work to commence, creating a new space built and designed specifically for some of our most vulnerable children in our region. The project is due to complete by October and open before the end of the year. Artfelt have also been granted additional charity budget to soften the space with art and create distractions throughout the unit. Events The Children’s Hospital Charity’s target for 2019/20 is to raise £4,100,000. One of the key areas the charity will be focusing on is the development of events throughout the year:

13th July Theo’s Inflatable 5K

21st September Thornbridge Clay Pigeon Shoot

30th November Winter Ball


14. 44/19 IN THIS TOGETHER(PRESENTATION)

15. 45/19 GOVERNOR DEVELOPMENTPLAN (ENC I)

EXECUTIVE SUMMARY

Title Governor Development Plan

Report to


Author

Matthew Kane, Associate Director of Corporate Affairs

Purpose of report

To present to the Council the proposed governor development plan for 2019/20.


Approval √

Assurance

Information


In preparation for the CQC inspection, and in particular the CQC workshop with governors, the Trust sought to codify a number of its ideas around increasing the role and profile of governors. This builds on the recent work around constitutional amendments, fresh elections for vacant seats and a commitment within the annual self-certification to increase the training focus for governors. A copy of the plan is attached. Corporate Affairs will work with the Chair, governors and others in delivering this work.


The proposal mitigates against the risk that the Trust fails to have in place adequate arrangements for its Council of Governors and is not complying with its regulatory duties.


The Council is asked to endorse, and provide comments, on the development plan.

COUNCIL OF GOVERNORS 15. 45/19 GOVERNOR DEVELOP... Page 109 of 114

1

Sheffield Children’s – Council of Governors - Areas of focus 2019/20

Project area Project

Actions required Progress

Governor role Code of conduct New approach to local induction NHS Providers’ induction

Trust values session with Head of L&OD planned 14 May 2019 but did not take place due to sickness. Rearranged for 16 July. Present code to governors for approval in November. New local induction planned with Chair, Lead Governor and Trust Secretary. To be launched following 2019 elections. In addition to local induction, NHS Providers to host a day-long induction for new governors elected in 2019. Make open to all governors.

Working with members and member communications

The member offer Meet the Governor day

Work with Communications over Summer 2019 to develop the member offer. Currently includes high-street shopping discounts, involvement in AMM and elections, opportunity to stand as a governor. Consider a brand, i.e. The Members’ Club. Session at Acute Hospital Site Autumn 2019 where governors can ask patients two key questions:

COUNCIL OF GOVERNORS 15. 45/19 GOVERNOR DEVELOPMENT PLAN (ENC I) Page 110 of 114

2

Prospective governor sessions Consider our approach to AMM Member events

1. How would you rate your visit today? 2. What could we do better? Present the findings to COG in November 2019. Write to key businesses, community and voluntary group CEOs across Sheffield to ask whether there are people on their boards who wish to stand. Invite them to two prospective governor sessions during the nomination period to hear more about the trust, the role of the governor and the election process. Consider (if not for 2019 then for 2020) having displays stands an hour prior to the formal meeting where staff can highlight key developments and service areas. This also provides a key opportunity for governors to meet with members and inform them of the governor role. Working with the Medical Director, look to hold one member event in 2019/20 in the lecture theatre on key developments led by a member of the Trust’s consultant staff.

Complete. The Trust made contact with local companies and groups and hosted two sessions for prospective governors in May 2019. These were well attended and resulted in nominations.


3

Member newsletter

Work with communications to look at producing a member email once per quarter.

Involvement and influence

Governor effectiveness review Involvement in national processes Attendance at ICS events Develop the governor’s brand – Your voice in Your Children’s Hospital

In Winter 2019, once new governors are established in role, undertake a governor effectiveness review looking at their role, influence and support within the Trust. Present findings and action plan to future Council of Governors. Put forward governors and seek for volunteers to attend NHS Provider sessions including Governor focus conference in 2020. Seek governor representation at SYB ICS development events beginning with the first one in November 2019. Longer term, seek to elevate the role and profile of governors, through branding and review of their pages on the website.


16. 46/19 DISCUSSION OF FUTURETOPICS (VERBAL)

17. DATE OF NEXT MEETING: ANNUALMEMBERS MEETING 17 SEPTEMBER2019 13:00 LECTURE THEATE

Documents

COUNCIL OF GOVERNORS - Sheffield Children's Hospital · Enc F_COG Directors Report June.docx 89 12.42/19 STAFF SURVEY 2018 - CORPORATE ACTION PLAN AND PROGRESS UPDATE (ENC G) 93 Enc