EXECUTIVE SUMMARY...2015/05/26 · Executive Directors Group 20.05.2015 2 Draft self-assessment reviewed by Board Board Meeting 26.05.2015 3 Draft self-assessment evidence collated

Well-Led Governance Framework Self-Assessment Review Trust Board 26 May 2015

Corporate Governance Page 1 of 29 Commercial Division

EXECUTIVE SUMMARY

Report to Trust Board Date Tuesday 26 May 2015 Agenda Number 5.10 Agenda Item Well Led Governance Framework Self-Assessment Review Sponsor Andy Ibbs, Commercial Director Prepared by Julie Poyner, Senior Governance Manager (Compliance) Presented by Julie Poyner, Senior Governance Manager (Compliance)

1 Purpose and Key Issues

The purpose of this paper is to provide the Trust Board with a draft paper of the Well-Led Governance Review Self-Assessment paper required by Monitor.

• This Well-Led Governance Framework for Governance Review replaces the Quality Assurance Framework and the Board Governance Assurance Framework

• The Well-Led Framework has been aligned with the Care Quality Commission Well Led Inspection Question, Keogh and Francis recommendations.

• The Self-Assessment is to Red/Amber/Green rated to provide a Risk Rating .

2 Supporting Information

The report is attached. 3 Controls and Assurance

The Well-Led Framework for Governance Reviews replaces the Quality Assurance Framework and the Board Governance Framework which were externally assessed in 2012. The Executive Directors will review the evidence highlighted and provide a Risk Rating based on any gaps identified.

4 Legal and Regulatory Implications

The legal implications have been considered and none have been identified.

5 Equality and Diversity Implications

The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. No adverse or positive impacts have been identified from this report.

6 Patient, Public and Staff Engagement The Trust ensures that patients, the public and staff are involved in the decision-making process when appropriate.

7 Cost Implications

There are no cost implications.



8 Potential Risk to the Organisation There is a risk of failing to provide Monitor with a Well-Led Framework for Governance Review could lead to a delay in the Foundation Trust application process.

9 Board Prompts

• Is the Board assured that the evidence identified for the Well-Led Framework for Governance Review is sufficiently robust for External Assessment?

• Does the Board need any additional information?

10 Recommendations The Board is asked to RECEIVE the report.

11 References

• Monitor Well-Led Framework for Governance Reviews: Guidance for NHS Foundation Trusts Updated April 2015 www.gov.uk/monitor

12 Strategic Objectives

The Trust’s strategic objectives are reviewed by the Board on an annual basis. This paper supports the achievement of the following strategic objectives:

X Highest quality Flexible & multi-skilled workforce Sustainable services Efficient & effective Integrated health & social care Local provider of choice

13 Principal Risks

The Trust’s principal risks have been identified through the Trust’s risk management processes. They are updated as they are identified by the Risk Management Committee. This paper supports the mitigation of the following principal risks:

X Financial planning & management X Clinical records management Strategic & business planning X Leadership & management Workforce numbers X Unsafe behaviour Workforce skills X External demands

X Procedural management Partnership arrangements X Equipment & facilities arrangements Communication



WELL-LED GOVERNANCE REVIEW SELF-ASSESSMENT

CONTEXT

The well-led framework for governance reviews has been developed by Monitor to ensure Foundation trust board of directors maintain and get for purpose robust analyses for governance to ensure the provision of safe, sustainable and high quality care for patients.

The framework represents a ‘core’ reference for NHS foundation trusts to structure reviews of their governance. The depth and breadth of these areas for investigation can be shaped through the Trust’s self-assessment and initiate review team’s findings at the start of the process.

The framework is built along the lines of the Quality Governance Framework, with 4 domains and 10 high level questions and a body of good practice outcomes and evidence base that organisations and reviewers can use to assess governance. The evidence base should be used to guide trusts’ and assessors’ views in considering whether the processes and a well organisational archive in these areas are fit for purpose. The framework also sets out the suggested review process and what to take into account when choosing an external reviewer.

Under the ‘Risk Assessment Framework’ and in line with their Code of Governance, Monitor respects that NHS foundation trusts carry out an external review of their governance every three years. Provided they incorporate the domains and principal areas of enquiry in the framework, NHS foundation trusts are free to tailor the approach to fit their own organisational circumstances. It is expected that any findings from a governance review will be acted upon.

There is no mandatory timetable and NHS foundation trusts are free to schedule when the reviews take place within the three-year window. An NHS foundation trust may decide to undertake a review on an annual basis, selecting two of the domains. Foundation trusts may also choose to add specific areas of governance that they have concerns about.

Foundation trusts should inform their Monitor Relationship Manager of when they have scheduled a governance review and the organisation chosen to carry the review out.

Following the governance review the Trust Chairman must write to Monitor within 60 days of the submission of the review to the Trust Board, either:

• Advising Monitor that the review has been completed and that there are no material governance concerns; or • Advising of any material governance concerns that have arisen from the review and providing an action plan in response to those

concerns. This should be considered as in line with the exception reporting requirements in the Risk Assessment Framework. Monitor will consider the material governance concerns identified and the Trust’s response and what, if any, steps are appropriate.

The findings of a governance review will be classified via a Green/Amber-Red/Red approach as used in the Quality Governance Framework.



It was agreed at the March 2015 Trust Board meeting that a self-assessment would be undertaken as preparation for the foundation trust application process. This would replace the Board Governance Assurance Framework, which was independently assessed in June 2012, and the Quality Governance Framework, which was independently assessed in July 2012.

METHODOLOGY

Process for the self-assessment

Ref. Action Committee 1 Draft self-assessment reviewed by Executive Team Executive Directors Group 20.05.2015

2 Draft self-assessment reviewed by Board Board Meeting 26.05.2015

3 Draft self-assessment evidence collated May 2015

4 Draft self-assessment with supporting evidence list presented to Executive Team June Board Briefing

5 Draft self-assessment with supporting evidence list presented to Board for approval Board Meeting July

6 Action plan monitored by Board at each meeting From July onwards

Scoring criteria

Green: • Meets or exceeds expectations • Many elements of good practice and there are no major omissions. Amber/Green: • Partially meets expectations but confident in management’s capacity to deliver green performance within a reasonable timeframe. • Some elements of good practice, some minor omissions and robust action plans to address perceived gaps with proven track record of

delivery. Amber/Red: • Partially meets expectations, bit with some concerns on capacity to deliver within a reasonable timeframe. • Some elements of good practice, has no major omissions. Actions plans to address perceived gaps are in an early stage of development

with limited evidence of track record of delivery. Red: • Does not meet expectations • Major omission in governance identified. Significant volume of action plans required with concerns on management’s capacity to deliver.



OVERALL SUMMARY

Domain Question RAG Summary assessment

Domain 1 Strategy and

Planning

Q1: Does the Board have a credible strategy to provide high quality, sustainable services to patients and is there a robust plan to deliver?

Q2:Is the Board sufficiently aware of potential risks to the quality, sustainability and delivery of current and future services?

Domain 2 Capability and

culture

Q3: Does the Board have the skills and capability to lead the organisation?

Q4: Does the Board shape an open, transparent and quality-focused culture?

Q5: Does the Board help support continuous learning and development across the organisation?

Domain 3 Process and

structure

Q6: Are there clear roles and accountabilities in relation to Board governance (including quality governance)?

Q7: Are there clearly defined, well-understood processes for escalating and resolving issues and managing performance?

Q8: Does the Board actively engage patients, staff, governors and other key stakeholders on quality, operational and financial performance?

Domain 4 Measurement

Q9: Is appropriate information on organisational and operational performance being analysed and challenged?

Q10: Is the Board assured of the robustness of information?



DOMAIN 1 – STRATEGY AND PLANNING

Key to Links ** Code Care Quality Commission Well Led

Begins W

Francis Report Recommendations on Mid Staffordshire

Begins F

Keogh Ambitions Begins A Q1: Does the Board have a credible strategy to provide high quality, sustainable services to patients and is there a robust plan to deliver?

Monitor Prompts Actions Evidence Links **

There is a clear statement of vision and values, driven by quality and safety. It has been translated into a credible strategy and well-defined objectives that are regularly reviewed to ensure that they remain achievable and relevant.

• The Trust is currently revising its Integrated Business Plan detailing the Trust’s Vision, Values and Six Strategic Objectives. This IBP will set out the vision and strategic intent and demonstrates that the Trust has assessed the market position and future potential having considered the risks facing the organisation over the next five years. of good practice

• Trust IBP • IBP Appendices • Board presentation of IBP

W1a F2

• The Vision, Value and Strategic Objectives were developed in early 2015 to align to advancing the strategic vision. These are displayed on the Trust Website for the public to see as well as the staff of NDHCT

• Screenshots of Trust Web Pages for Vision, Value and Strategic Objectives

W1d W1e

• The Board reviews the vision and strategic objectives using the SWOT and PESTLE methodology at a Board Briefing session on an annual basis.

• Board Briefing Agenda • Presentation on Vision and Strategic Objectives W1c

• The Trust’s strategic objectives are reviewed by the Board on an annual basis. All Board papers identify how they support the achievement of the individual strategic objectives:

• Example Board Papers W1f

The vision, values and strategy have been developed through a

• The development of the IBP includes the various consultations with staff and the key external stakeholders

• Trust IBP • IBP Distribution List • Web Pages

W1c W1e F2



structured planning process with regular engagement from internal and external stakeholders, including people who use the service, staff, commissioners and others.

• The IBP is condensed to a ‘Strategy on a Page’ which is shared with stakeholders and displayed prominently throughout the Trust

• Strategy on a Page from previous IBP W1a

• The Trust Quality Accounts details the Trust vision and Strategy and is consulted upon widely

• Quality Accounts 2014/15 • Webpages • Quality Accounts Distribution Plan

W1c F17

F247 • The Quality Improvement Strategy 2012-15 details the

Trusts vision and how it will improve the safety and effectiveness of care. Progress against the Quality Improvement Strategy is measured by quality performance dashboards on a monthly basis. Audits, patient surveys and the Quality Account are also used to measured outcomes.

• The Quality Improvement Strategy 2012/15 • Patient Experience Strategy 2012/15 • Clinical Effectiveness Strategy 2012/15

W1f F244

The challenges to achieving the strategy, including relevant local health economy

• The Board is sufficiently aware of any changes in the internal and external environment that impacts on the delivery of strategic plans. The Board will monitor all influences and adjust accordingly. A one year operational plan was produced to support the IBP, produced due to the impact of strategic commissioning intentions for 2014/15

• One Year Operational Plan 2015/16 •

W2a W2d W5a F127

• There are regular Board Briefings at which strategic challenges are discussed.

• Programme and subjects covered, of Board Briefings W5b

• The Performance of the Trust is reviewed at the Executive Directors Group and Trust Board. This report is the outcome of the external reporting the Trust is required to undertake. Shortfalls or reduction in achievements are identified and actioned.

• Trust Integrated Performance Report • Example Divisional Performance Report • Contract Discussions • IPAM Meeting Minutes • Mortality Review Group Meeting Minutes and

KPIs

W5b F140 K1

• The Cost Improvement Plans and related efficiency savings are monitored by the Finance Committee, a sub-committee of the Trust Board

• Finance Committee Agenda • Finance Committee Minutes • Exampled Cost Improvement Project Plan

W5b

• The IBP has been developed to take into account the strategy of both the Northern, Eastern and Western Devon Clinical Commissioning Group and the NHS

• NEW Commissioning Group Strategy • IBP (Section 2.2)

W2d F125



Futures work related to the Devon healthcare economy. • The Board undertake a SWOT and PESTLE analysis on

an annual basis to understand the implications of local and national factors that need to be considered when developing the Trust’s strategy.

• Annual SWOT and PESTLE analysis • Board Paper • Board Agenda

W2d

Strategic Objectives are supported by quantifiable and measureable outcomes which are cascaded through the organisation.

• The Board has actively encourages the development of performance dashboards which are incorporated into the Integrated Performance Report, all divisions./departments actively monitor performance against targets ensure timely adjustment for any shortfalls

• Integrated Performance Report • Board Minutes • Action Plans for improvement of performance • Performance Review Meeting report & Minutes • Clinical Effectiveness Tools • Clinical Audit Exception Reports • Customer Relations Report

F139 F141

• Adjustments are made in accordance with the contract requirements • Contract Agreements with Commissioning F124

• The local health economy influences plans and trajectories and adjustments are made in accordance • Community Hospital realignment plans W5f

• This is in the process of development. A new Board Assurance Framework will demonstrate delivery against strategic objectives, and the IPR will have a new front sheet identifying perofmrnace against KPIs, linked to Strategic Objectives.

• F142

Staff in all areas know and understand the vision, values and strategic goals

• The Vision and Values are part of the public web pages and is available to read • Screenshots of public website

• The values are the screensaver for the Trust computer screens

• Communication department Communication plan for Trust Values

• Chief Executive Bulletin links work undertaken within the Trust with the Trust Values • Chief Executive Bulletin Issue 225: 13.04.15

• Corporate Induction • Corporate induction Powerpoint • Annual Roadshow, which reached approximately 2,000

staff • Roadshow Powerpoint from 2014. (2015 in

development)

• We undertake values-based recruitment • Evidence from recruitment department • Values-based appraisal system • E-appraisal paperwork F194 • Staff initiatives such as listening into action are aligned

with the vision and values so staff can understand what impact their work has on the strategic aims of the Trust

• Listening into Action presentation W5d



Overall conclusion Assessed risk

rating:

Ref Action Comments Lead Due date Status Annual business plans to be

developed for each Division/business unit clearly setting out how they are linked to the Trust’s strategic objectives.

The current Intranet provision for staff is undergoing change to enable a more robust system to be implemented.

Q2: Is the Board sufficiently aware of potential risks to quality, sustainability and delivery of current and future services?

Monitor Prompts Actions Evidence

There is an effective and comprehensive process in place to identify, understand, monitor and address current and future risks

• All risks, both clinical and non-clinical, are recorded on the Corporate Risk Register with a named Risk Lead and named Action Leads. Each risk has a supporting action plan with nominated action leads. Overall responsibility for managing a risk lies with the nominated risk lead. Monitoring progress of the supporting action plans is managed centrally by the risk team and reported to the Risk Management Committee. The Risk Management Committee has a role for approving exceptions and for approving the acceptance of a risk with its residual risk score

• Risk Register • Risk Management committee Terms of

Reference • Risk Management Committee Agenda • Risk Management Minutes • Example Risk Update Request Letter • Local Deep dives e.g. Deep Dive to review

patient harm events Nov 14-Jan15

W2i

• The minutes of the Risk Management committee are presented to the Audit and Assurance Committee and

• Board Agenda • Board Minutes



the Quality assurance Committee, both of these are sub-committee to the Board and minutes are presented as Board Papers monthly.

• The Board regularly discusses key risks facing the Trust and the plans to manage or mitigate them. Examples include the exception reports in the Integrated Performance Report. Strategic risks are discussed at Board Briefings

• Exception report in the Integrated Performance Report

• Cancer waiting times action plan • Action Plan to mitigate Risk • Board Briefing programme

W2i F143

• Appropriate training is provided to staff and managers on risk and assurance

• Organisation Prospectus • New Managers Risk training • Root Cause Analysis Training • Practical Risk Assessment Courses

W3b F152

Service developments and efficiency changes are developed and assessed with input from clinicians to understand their impact on the quality of care. Their impact on quality and financial sustainability is monitored effectively. Financial pressures are managed so that they do not compromise the quality of care.

• Proposed initiatives are assessed according to their potential impact on quality, via a Quality Impact Assessment. These are signed off by the Medical Director and Director of Nursing

• Examples of Quality Impact Assessments • New QIA approach W5d

• The Board has reviewed lessons learned from inquiries, internal and external reviews and considered the impact on the Trust. Actions arising from these exercises are monitored via the risk management processes.

• The Keogh and Francis report reviews to Board • Action Plans from Francis and Keogh • Supervisor of Midwives Report • NHS Saville Report • RCOG External Review • Care Quality Commission Inspection Report • Quarterly report on SIRIs

W5c F192

• Project Initiation Documents and Business Cases have clinician input for departments

• Example Business Case i.e. ICU/HDU Increased Capacity

• Board Paper • Board Meeting Minutes • Project Updates

W5a

• Initiatives or proposed projects are required to have an Impact Analysis undertaken, identifying any potential risks to the departments normal service

• Examples of Impact Analysis W5a

• Financial monitoring of project implementation is reported to the Finance Committee and monitored for any effects on potential costs/savings

• Project Updates to board i.e. EHR implementation W5b




rating:

Ref Action Comments Lead Due date Status 2.1 Implement programme of formal

post-implementation reviews for CIP projects

From BGAF

2.2 Requirement for robust Cost Improvement Programmes being signed off and realising estimated value

DOMAIN 2 – Capability and culture Q3: Does the Board have the skills and capability to lead the organisation?


The board has the experience, capacity and capability to ensure that the strategy can be delivered.

• The Board is established with all positions recruited into except for the Director of Nursing, whereby an Interim is in position. Recruitment interviews are planned for June.

• Trust Web pages – Executive and Non-Executive Director profiles

• Individual responsibilities of Executive and Non-Executive Directors for Sub Committees of the Board

• The staff survey provides a measurement of staff opinion of the Leadership provided by the Trust Board

• Staff Survey Results • Spring 2015 PULSE

• The Trusts consistent performance against national targets

• Benchmarking data • Dr Foster data (Integrated Performance Report) • Mortality Review KPIs

• The challenge to Monitor regarding the CCG decision on TCS • Monitor Press Release on complaint

• The Board undertakes an annual self-assessment of its • However, we last did this around January 2014



capabilities • Quality Accounts and Financial Accounts measure the

capability of the Board to achieve target • Quality Accounts 2014/15 • Year End Financial Accounts

• The Terms of Reference for each of the Board sub-committees are reviewed annually after submission of the Compliance report, which identifies whether the committee has undertaken its key responsibilities

• Audit & Assurance Committee Terms of Reference

• Audit & Assurance Compliance Report • Quality Assurance Committee Terms of

Reference • Quality Assurance committee Compliance

Report • Risk Management Committee Terms of

Reference • Risk Management Committee Compliance

Report • Board Minutes approved Compliance Report

• The Board support the Excellence in Leadership Programme, identifying and supporting managers and clinicians to become excellent leaders in the NHS

• Excellence in Leadership letters • Course Dates • NHS Leadership Academy Particpants

The leadership is knowledgeable about quality issues and priorities, understands what the challenges are and takes action to address them.

• The Board members attend Board Briefing days allowing more in-depth discussions regarding issues affecting the achievement of strategies. Papers and presentations are provided to ensure full understanding is made of progress against plans and any shortfalls. This will include an understanding of the metrics used and some benchmarking data

• Integrated Performance Report Presentation Feb Board Briefing

• A&E Performance & Patient Flow Plan Feb Board Briefing presentation

• Safety Thermometer Report Feb Board Briefing Paper

W2f W3c F143 F144 F262

• The Integrated Performance Report presented to Board is challenged where any shortfalls are identified and actions implemented

• Integrated Performance Report board Paper • Trust Board Minutes W2f

• The Care Quality Commission Chief Inspector of Hospitals Inspection report and subsequent action plan. This action plan is monitored through Executive Directors Group and Trust Board to ensure it is on track.

• CQC Chief Inspector of Hospitals Inspection Report

• CQC Action Plan • Trust Board Agenda • Trust Board Minutes

F13 F176 K4

• The Quality Assurance Committee meetings have been changed from Bi-Monthly to monthly to ensure robust

• QAC Meeting Dates • QAC Meeting Agenda (Open and Confidential)



challenge is in place for all of the reports presented. Papers are prioritised and meetings lengthened if required.

• QAC Minutes (Open and Confidential)

• The Sub Committees to the Board are each chaired by a Non-executive Director and all have other non-Executive Directors as members, along with some of the more important committees.

• QAC Terms of Reference • RMC Terms of Reference • A&A Terms of Reference • H&S Committee Terms of Reference • Workforce and Organisational Committee Terms

of Reference • Finance Committee Terms of Reference

W3d

• A more robust system has been implemented to ensure the NICE guidelines and technology has been implemented across the Trust

• Job Description of HCY • NICE Implementation report • NICE Database reports

Overall conclusion Assessed risk rating:

Ref Action Comments Lead Due date Status 3.1 Review the effectiveness of SID

role From BGAF

3.2 Establish independent evaluation of Board effectiveness

From BGAF

3.3 Establish process to evaluate effectiveness of Chairman by SID

From BGAF

3.4 The Board should commit to an annual self-assessment of its effectiveness and of its capability and capacity to meet the demands of good quality governance.

From QGF

3.5 A full understanding of Governance throughout the Trust is required

Care Quality Commission recommendation



Q4: Does the Board shape an open, transparent and quality-focused culture?


Leaders at every level prioritise safe, high quality, compassionate care and promote equality and diversity?

• There is a programme of Statutory Training that all members of the staff have to attend according to the role they hold. More robust management of staff attending training has been introduced to ensure the safety of all staff and patients.

• Trust Training Needs Analysis • Monthly Training Reports to Managers • E Appraisal documentation

F155 F185

• CQC report highlighted a number of areas in which Trust could demonstrate the prioritisation of safe, high quality and compassionate care

• CQC report F20

• All staff have to attend a Corporate Induction programme, providing them with the knowledge they will need to commence employment with NDHCT, and the values we expect them to uphold

• Corporate Induction Dates • Corporate Induction agenda W3f

• Appraisals and Supervision ensure all members of staff are in the right roles and have the right skills and knowledge for their role

• Doctors Appraisal System • Monthly Appraisal Reports • Supervision Policy

W3f F185

• The Trust recognises its responsibility for Equality and Diversity and has much support and guidance on the Trust’s Intranet for Staff. Equality is part of the Trust’s vision.

• Quality and Diversity Intranet Pages • The Trust Vision W3g

• During the Appraisal process, goals are aligned with the vision and values of the organisation

• E Appraisal guidance • E Appraisal documentation W3g

Candour, openness, honesty and transparency and challenges to poor practice are the norm. Behaviour and performance inconsistent with the values is identified and dealt with swiftly and effectively, regardless of seniority.

• Each member of the Trust Board make a declaration of interest for openness • Board Paper, Interest for Openness Jan 2015

W3d F178 F182

• The Trust entirely promotes the staff to be open and honest and will support all staff when an accusation has been made or they are expected to appear as a witness.

• Being Open and Duty of Candour Policy • Duty of Candour Film on Bob • Duty of Candour slides for various training events

W3i F173

• The Duty of Candour has been introduced as a Fundamental Standard by the CQC and the Trust has implemented the principles throughout its processes where complaints, investigations or claims are made.

• Serious Incident Requiring Investigation documentation

• Example SIRI’s where Duty of Candour has been undertaken

W3i F174 F180 F181



• Claims Policy • The Patient Experience Group meets monthly to discuss

all aspects of Patient Experience to enable improvement to be made to any service

• Patient Experience Group meeting minutes

• We are a consistently high reporter of incidents. Staff survey demonstrates that staff recognise the Trust encourages openness and is fair

• Intelligent Monitoring Report • Staff Survey

• Any incidents of improper behaviour or unsuitable acts are investigated by the HR team, whether they are made by other members of staff, patients, the public or regulatory authorities. Members of the Board are actively involved in these investigations

• Summary of Bideford Hospital Investigation • Holsworthy HR Investigation • Response to the CQC regarding staff member

without professional registration

W3g F183

• The Trust requested the RCOG into the Maternity Department to review the processes and Multi- Disciplinary team working when a series of Serious Incidents were identified.

• RCOG Report • Action plan in response to RCOG Report

The Leadership actively shapes the culture through effective engagement with staff, people who use the services, their representatives and stakeholders . Leaders model and encourage co-operative, supportive relationships among staff so that they feel respected, valued and supported.

• The Trust is a Listening into Action Trust and has run the first wave of initiatives that will be fed back to the staff through the ‘Pass it on events’. This has provided staff with opportunities to generate improvement ideas and contribute to the business of the organisation

• List of Key Projects • Action plans of projects • Email to all staff from CEO 14.04.15

W3h

• Both non-executive and executive directors participate in patient safety walkabouts, which incorporate interviews with staff members in all locations and all services

• Patient Safety Walkabout Dates • Sample Patient Safety Walkabout reports W3d

• The Corporate Communication Strategy 2013/14-2016/17 sets out how effective communications will build the reputation of the Trust through the provision of trusted, timely and high quality information to the public, patients, partners, voluntary groups and stakeholders.

• Corporate Communication Strategy

• Patients stories are actively sought and routinely presented to both the Trust Board and the Quality Assurance Committee in a variety of ways, e.g. patient attending, DVD or report, providing an identified source of patient experience.

• Patient Story • Board Minutes • Quality Assurance Committee Minutes • Patient Stories DVD

W4a



• The Executive Directors review the responses to the Complaints received within the Trust which ensures they are fully appraised of the complaints that are made.

• Complaints policy • Example Response Letters • Patient Experience Report • Paper to Trust Board and minutes

F109

• The Trust actively discusses commissioning requirements with the NEW Devon Commissioning group to enable a contract to be drawn up for services in the forthcoming year

• Contract negotiation report • Contract for 2015/16

F128 F129 F130

Mechanisms are in place to support staff and promote their positive wellbeing

• A new initiative of Health and Wellbeing is being implemented across the Trust led by a Health and Wellbeing Advocate. This intention is to be put in place some of the actions set out in the Health and Wellbeing Strategy.

• Health and Wellbeing Strategy • Health and Wellbeing Newsletter Dec 14 • Health and Wellbeing Newsletter Mar 15 •

W3j

• Staff feedback is sought in some areas and action plans are implemented for improvements where identified`. Staff survey demonstrated high scores for staff believing Trust took H&W seriously

• Staff survey report in relation to how staff feel about H&W

• Staff Feedback • Meetings minutes where feedback provided • Actions taken as a result of feedback

W3f

• A physio assessment, management-referral service has been made available for staff to enable staff to get appointments within seven days, supporting the well being programme.

• Staff Express 29 Nov 13 • Web Pages on Bob • Occupational Health Physiotherapy Staff

Assessment Service Management Referral Form

There is a culture of collective responsibility between teams and services

• There is strong working relationships between Board members to achieve some of the service improvements, such as the Patient Flow work where the Director of Operations, Medical Director and Director of Nursing are working together to achieve the project goals

• Patient Flow Presentation • A&E Performance & Patient Flow Plan Feb Board

Briefing presentation

• The plan of delivery for 2015/16 will be a collective participation to ensure full delivery • Summary of One year Operational Plan 2015/16

• The Care Quality Commission identified cases of good multi-disciplinary working between teams on every ward and each of the Core Services.

• CQC report

• Staff achievements are celebrated and any awards are communicated across the Trust

• Spring 2015 PULSE • Staff Express 08.04.15 • Staff Express 13.03.15

W5e



The leadership actively promotes staff empowerment to drive improvement and a culture where the benefit of raising concerns is valued

• The initiative for Listening into Action is about improving patient care by systematically focussing on and listening to what matters to staff

• Pulse-check Aug 14 • List of Key Projects W5e

• Heads of Department meetings are held monthly in the North and in the Mid/Eastern patch where the Chief Executive or other Board member cascades information on what is happening to the Trust. The staff are encouraged to feedback at this meeting on what is happening within the services.

• Date of HOD’s • Feedback of information from HOD’s to teams

W5e K8

• Any member of staff is enabled to report an incident or near miss. If the incident is deemed as serious then an investigation is made and this is usually undertaken by the staff involved in the incident. Training is provided for staff to investigate incidents

• Risk Management Training • Root Cause Analysis Training • SIRI guidance • Trust Induction

F12

• The Trust has a PALS service located in the foyer of the hospital where any patient, member of the public or member of staff can approach the staff for guidance or help

• PALS leaflet • PALS Intranet information


rating:

Ref Action Comments Lead Due date Status 4.1 Divisional Meetings should be

mapped Care Quality Commission recommendation

4.2 Meeting Minutes should be published on Bob for transparency purposes



Q5: Does the Board help support continuous learning and development across the organisation? Monitor Prompts Actions Evidence

Information and analysis are used proactively to identify opportunities to drive improvement in care

• The Trust Board are presented with papers at the monthly meeting which are challenged by the Board members for more information or further explanation if issues are raised.

• Example papers i.e. TRR 18 weeks overview (Aug 14)

• 4hour Performance Patient Flow and Capacity • Capacity Plan 2014/15 (Nov 14)

• The Board Assurance Report is presented to the Board providing an overview of the risks to the Strategic Objectives and progress made in the development of the Framework.

• Board Assurance Framework Presentation (Dec 14)

• Chairman’s report to Board (Jan 15)

• The newly published CQC Fundamental Standards have provided the Trust with an opportunity to review the compliance with the Health and Social Care act

• The CQC Fundamental Standards management process

F14 F15

• NICE technologies and guidance provide the services with an opportunity to review their processes when they are issued

• NICE database • NICE Compliance Report F18

• The Board are presented each month with an Integrated Performance Report which is discussed and challenged

• Integrated Performance Board Paper • Copy of Board Minutes

• The internal process to ensure improvements are made in line with progress, communication is made to all staff via a weekly Chief Executive Bulletin. Keeping staff appraised of developments they need to be aware of.

• Example Chief Executive Bulletin • Screenshots of Bob listing all past editions

There is strong focus on continuous learning and improvement at all levels of the organisation. Safe innovation is supported and staff have objectives focused on improvement and learning

• The Board Assurance Framework details the high level corporate objectives which translate into the Executive Directors annual personal performance objectives. These objectives are cascaded to line managed staff at annual appraisal

• Appraisal documentation • Example of Directors objectives (?)

• SIRI Investigations are identified from incidents that occur within the services. Investigation leads and Directors are appointed to investigate and produce the report. The learning from this is clearly detailed in the report and feedback to the appropriate teams.

• Example Individual SIRI Report • QAC Agenda • QAC Minutes • SIRI Quarterly report

F16

• When a series of incidents and investigations occur with a theme a deep dive is instigated to identify any key issues.

• Example Deep Dive Report Paper i.e. Sidmouth Hospital

• QAC Agenda W3k



• QAC Minutes • In response to the new Legislation Duty of Candour the

Trust sourced external training from Bevan Brittan and provided a series of training workshops for all levels of staff

• Dates of Workshops • Bevan Brittan Presentation

• To maximise the learning from incident investigations an external organisation was sought to implement specific Root Cause Analysis training for all Senior Managers who would be undertaking investigations

• Root Cause Analysis Training Dates • Example Attendance sheets • Root Cause Analysis Guidance

W3k

• Where key themes are identified from Incidents, the learning that is made is translated into a Patient Safety Alert which is cascaded to all staff to prevent any further incidents that may cause harm to patients

• Patient Safety Alert example • Screenshot of Patient Safety Alerts from Bob • Email cascading Patient Safety Alert

Staff are encouraged to use information and regularly take time out to review performance and make improvement

• Performance meetings are held at Directorate level and cascaded through all the staff roles. Each Division has its own governance structure and is responsible for gaining assurance on the performance, including quality indicators, of their services.

• Directorate Performance Report • Directorate Meeting Agendas • Directorate Meeting Minutes • Example of Directorate staff meetings i.e.

Medicine and Maternity


Ref Action Comments Lead Due date Status 5.1

DOMAIN 3 – Process and structure

Q6: Are there clear roles and accountabilities in relation to board governance (including quality governance)? Monitor Prompts Actions Evidence

The Board and other levels of governance within the organisation function

• Board sub-committees have clear terms of reference that are reviewed on an annual basis. An annual committee compliance report is published that sets out the key

• A&A Terms of Reference • A&A Compliance Report • QAC Terms of Reference

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effectively and interact with each other appropriately.

areas of work completed by each committee, as well as details such as membership attendance. These reports are presented to the Trust Board.

• QAC Compliance Report • RMC Terms of Reference • RMC Compliance Report • Board minutes where compliance reports

presented • Information on the significant issues, key risks and key

decisions discussed at each Board sub-committees is routinely presented to the Board.

• Example Trust Board Agenda • Example Board Minutes

• A Scheme of Delegation and Standing Financial Instructions are in place and they are reviewed on an annual basis.

• Scheme of Delegation • Standing Financial Instructions • Board Paper for review of the Scheme of

Delegation and Standing Financial Instructions

• The Trust Board papers are required to have an Executive Summary which is a template promoting the author to provide the relevant information. This template also clearly defines why a paper is being presented to board. i.e. Approval, Note etc.

• Example Papers • Trust Board Minutes showing Board decision

• The Trust Board is appropriately balanced and focuses on Strategy, performance and quality and each paper has a corresponding Agenda item number for ease of identification

• Trust Board Agenda Template • Example Trust Board Agenda

Structures processes and systems are accountability, governance and management of partnerships, joint working arrangements and shared services are clearly set out, understood and effective.

• All formal meetings are required to have Terms of Reference, ensuring the governance arrangements for all departments are clear and show the reporting lines through to the Trust Board

• Example sub group i.e. COSHH group • Health and Safety Committee minutes • Trust Board showing presentation of Health

and Safety report

• All roles within the organisation have a structured job description identifying responsibilities and reporting lines

• Example Job Description • Department Structure diagram W2b

• The Complex Care teams working in the Community are dual roles for providing care for both Health and Social Service Care patients and provide a holistic service, often incorporating other care providers

• Hospital@Home service description • Complex Care Team roles and Responsibilities • Virtual Ward meeting minutes

W2b

• There is a structured Internal Audit programme, agreed by the Director of Finance and provided by the South West Audit team. The reports of these audits often have an action plan attached which is managed through the

• Internal Audit programme • Example Internal Audit report • Internal Audit action plan • Copy of Risk Report showing Internal Audit

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Risk Management Process to ensure completion of actions are monitored.

action plan • Risk Management meeting minutes

• Any incidents of Fraud are dealt with through the Counter Fraud Manager Specialist and his reports are presented to the Audit & Assurance Committee, a sub-committee of the Trust Board.

• Example Fraud Reports • Example Audit and Assurance Committee

Agenda • Example Audit and Assurance Committee

Minutes

Quality receives sufficient coverage in board meetings and in other relevant meetings below board level

• Quality has a section of its own on the Trust Board agenda and papers are presented monthly

• Example Board Agenda • Example Board Minutes

• There is a Quality Assurance Committee that meets monthly where all items of quality are presented and discussed. The meetings of this committee are presented to Trust Board

• QAC Committee Agenda • QAC Committee Minutes • Trust Board Papers

• The Quality Assurance Committee is chaired by a non-executive Director with two other Executive Directors as members of the committee. There is an open section and a confidential section.

• QAC Terms of Reference • QAC Compliance Report

• Any new interventional procedures to be undertaken within the Trust are presented to the Quality Assurance Committee for approval and require best practice to be demonstrated

• New Interventional Procedure presentation • QAC Minutes of presentation • Interventional Procedures policy


Ref Action Comments Lead Due date Status 6.1 Details of who our Stakeholders

are and how they are included in our services should be made available to all staff.



Q7: Are there clearly defined, well-understood processes for escalating and resolving issues and managing performance? Monitor Prompts Actions Evidence

The organisation has the processes and information to manage current and future performance

• The Integrated Performance Report includes exception reports of indicators that have been escalated due to ongoing poor performance is presented to Trust Board

• Integrated Performance Report • Trust Board Agenda • Trust Board Minutes

W2g

• Each Directorate has a performance report for their Directorate meetings to identify poor performance and enable actions to be implemented

• Example Directorate Performance Report • Example Directorate Agenda • Example Directorate Minutes • Any action plans in place

W2e

• Poor performance is managed by the process of escalation by the appropriate Director. Any service reporting a shortfall in performance will be required to develop an action plan on how it will return to compliance

• Cancer waits performance report • Cancer waits presentation • Cancer wait action plan • Cancer pathway maps • Patient flow action plan

Performance issues are escalated to the relevant committees and the Board through clear structures and processes

• All departments/services provide reports to the appropriate Committees, any performance issues will be escalated to that committee for action.

• QAC Minutes of meeting where Audit department escalated lack of progress with Audit programme, showing subsequent action.

• QAC minutes of meeting where Research and Development raised the issue of non-attendance at meetings.

• Individual performance issues are managed by line managers supported by HR Advisors.

• Disciplinary Policy • Managing Performance concerns for Clinical

and Dental Staff Policy • Pay Performance Framework Policy

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• There is a Workforce and Organisational Development Committee which meets monthly any workforce issues would be escalated to this committee

• Workforce and Organisational Committee Agenda

• Workforce and Organisational Committee Minutes

Clinical and Internal Audit Processes function well and have a positive impact in relation to quality Governance, with clear evidence of action to resolve concerns.

• The Audit department have a continuous rolling audit programme which includes the national audits and the local audits scheduled for the forthcoming year. This programme is monitored through the Quality assurance Committee

• Audit programme • Audit performance reports • QAC Minutes • Screenshots of Audit pages on the Intranet

• Any action plans that are implemented as a result of any audit would be presented to the relevant service. The

• Example Audit Report • Example Audit Action Plan



action plan would be placed on the Risk Register and monitored through the Risk Management process.

• Risk Report for RMC Committee • RMC Committee minutes

• Internal Audit has an agreed schedule of audits for the Trust agreed by the Finance Director. All audits are undertaken and reports supplied. Action plans are monitored by the Risk Management Process

• Internal Audit Programme • Medicines Management Audit Report • Medicines Management Audit Action Plan • Risk Report • RMS Committee minutes where this risk is

presented


Ref Action Comments Lead Due date Status 7.1 Benchmarking data should be

provided for all services so they can identify if they are performing well or require improvement.

Q8: Does the Board actively engage patients, staff, governors and other key stakeholders on quality, operational and financial performance?


A full and diverse range of people’s views and concerns are encouraged, heard and acted on. Information on people’s experience is reported and reviewed alongside other performance data.

• The Trust actively engages in a range of patient feedback projects which are analysed and reported through the Patient Experience Group

• Patient Experience Group Agenda • Patient Experience Group Minutes • Patient Experience Annual report

F255 K3

• The Friends and Family Test has been introduced where patients who have received care are provided with the opportunity to feedback immediately.

• Friends and Family Test Results • Screenshots of Friends and Family Internet

pages • Friends and Family report • Integrated Performance Report (Includes F&F)

F254 F286

• There is opportunity for patients to feedback on the Trust Intranet as well as a Facebook page and also the national

• The responses of patients are reviewed by the Patient Experience Team and any shortfalls are

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Patient Opinion and NHS Choice. All feedback is responded to.

addressed • Evidence from Katherine re: Patient Opinion

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• Consultations are held with the public when a change of service is about to happen, or the Trust is required to implement a change of use of a location

• Torrington Consultation reports • Axminster Consultation reports • Moretonhampstead Consultation reports • Chemotherapy Unit consultation

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• Patients can access the PALS desk situated in the Foyer of the hospital or by telephone for any issues they may wish to raise, where support and assistance will be offered. There have been recent capacity issues within the PALS team, but these are now rectified.

• Reports of PALS responses are presented to the Patient Experience Group W4b

• Patients and their families can make a complaint to the Trust if any aspect of their care causes concern. The complaints department has a timeline process for responding to complaints. The Executive Directors review and sign-off all responses

• Patient Experience Report • Patient Experience Strategy • Example Anonamised Response letter • Screenshots of Complaints Web Page • Complaints and raising concerns Policy

W4d

• The Patient Experience report is presented to Board • Patient Experience Report • Board Papers

• Patients stories are actively sought and routinely presented to both the Trust Board and the Quality Assurance Committee in a variety of ways, e.g. patient attending, DVD or report, providing an identified source of patient experience.

• Patient Story • Board Minutes • Quality Assurance Committee Minutes • Patient Stories DVD

W2j W4a F112

The service proactively engages and involves all staff and assures that the voices of staff are heard and acted on.

• Staff are encouraged to participate in the national staff survey. Once feedback is received, an action plan is developed to further improve any identified gaps

• Staff Survey Results • Staff Survey Action Plan • Trust Board paper where Staff Survey is

presented to Board

W4d F111

• The Trust is a Listening into Action Trust and has run the first wave of initiatives that will be fed back to the staff through the ‘Pass it on events’. This has provided staff with opportunities to generate improvement ideas and contribute to the business of the organisation

• List of Key Projects • Action plans of projects • Email to all staff from CEO 14.04.15

W2j

• The Trust has Staffside representation who attends meetings and committees to represent the staff’s views and value the input they provide.

• Workforce and Development committee Terms of Reference

• Health and Safety Committee Terms of



Reference • The formal interface between the Trust and Staffside is

through the Partnership Forum. This works well with a highly constructive relationship in place

• Partnership Forum ToRs and Minutes

Staff actively raise concerns and those who do (Including external whistle blowers) are supported. Concerns are investigated in a sensitive and confidential manner, and lessons are shared and acted on.

• Staff are encouraged to raise issues with their line managers, but can also approach the HR Advice line for independent advice.

• HR Advice line details from Bob • Raise a Concern or Complaint Policy • Whistleblowing (Speak Up and Speak Out)

Policy

• The Trust has a union office within the hospital and supports

• Unison leaflet • Unison Intranet Pages

• ‘Raising concerns’ is a standing item on the Part 2 Board Agenda • Board minutes

• Allegations of Bullying and Violence are treated seriously and in a sensitive manner. The Occupational Health team are available for independent support and staff are able to make a self-referral.

• Occupational Health Helpline leaflet • Occupational Health Intranet Pages • Bullying and Harassment Policy • Violence and Aggression Policy • Supporting people involved in an incident,

complaint or claim

The service is Transparent, collaborative and open with all relevant stakeholders about performance

• The Trust Board has an open section where any staff member or member of the public can attend. The Integrated Performance Report is presented in the open section. Questions can be asked at the Board meetings. The minutes are published on the Trust Web Pages.

• Standing Financial Instructions • Scheme of Delegation • Screenshot of Webpages for Board Meeting

Dates • Screenshot of Webpages for Board Minutes • Example of questions to the Board by members

of the Public

• Consultations are held with the public when a change of service is about to happen, or the Trust is required to implement a change of use of a location

• Torrington Consultation reports • Moretonhampstead Consultation reports • Chemotherapy Unit consultation

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• Care pathways are developed jointly with the GP’s and there is a specific area on the Trust Intranet where information for the GPs and policies they need to be aware of are placed.

• Stroke Pathway • End of Life Pathway

F11

• Meetings are held with the Commissioners on a regular basis where performance is discussed and any issues

• IPAM Agenda • IPAM Minutes

F125 F132



raised are investigated. • The Trust takes a pro-active approach to highlighting

performance concerns with stakeholders • IDM minutes with TDA F132

• The Trust is revisiting the templates for SIRI reports, in order that they can be published on the Trust website. They are already shared with the patients/family concerned.

• SIRI Guidance • SIRI Templates


Ref Action Comments Lead Due date Status 8.1 Review external stakeholder

engagement plans From BGAF – Link to current strategies and formalise.

8.2 Develop a governors’ Strategy From BGAF - 2015-16 strategy developed. To be reviewed with refreshed Membership Strategy

March 2014

Closed

8.3 Develop a governors’ induction plan

8.4 Develop a governors’ election timetable

8.5 Refresh SIRI template to enable publication

DOMAIN 4 - Measurement

Q9: Is appropriate information on organisational and operational performance being analysed and challenged? Monitor Prompts Actions Evidence

Integrated reporting supports effective decision-making

• The Integrated performance report is presented to the Trust Board and includes all services

• Example Integrated Performance Report • Trust Board Minutes W2e

• Dashboards have been developed for services to enable • Example Dashboards



them to develop their own metrics and KPI’s and monitor performance

• Operations Directorate Performance Review Report

• There is a distinct structure of meetings, groups, sub-committees up to Board level. All have Terms of Reference which detail Roles and Responsibilities. Exception reports are presented to the Board for action or decision making purposes.

• Committee/ Board Structure • Group/Committee Meeting Minutes • Board Minutes showing escalation

• Serious Incidents Requiring Investigation are done on a personal level and each individual report is approved at the Quality Assurance Committee. When several incidents have occurred in any area a deep dive is commissioned.

• Example of SIRI Report • QAC Minutes showing challenge • Example of Amended report • QAC Minutes showing approval or actions

• Where a service identifies that it is performing outside the ‘normal’ range, the Board will ask for benchmarking information against other Trusts of the same size.

• Board Minutes requesting Benchmarking • Benchmarking report W5c

Performance information is used to hold management and staff to account.

• Performance reports and dashboards are presented to divisional and operational teams. These are used to provide assurance of performance to the Executive Team

• IPCC Meeting Minutes after CQC Inspection • Action Plan implemented as a result of the

Meeting • Monitoring of the Infection Control Action

Plan

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• The CRAB data system, which is a tool for the appraisal and revalidation of medical staff, is used to assist the Trust to drive clinical improvements.

• CRAB Report F193

• Software Applications have been procured and implemented to enable performance to be measured in an established process to identify sudden increases or decreases in activity.

• Covalent Performance Indicator Report • Health Assure Safer Staffing Tool • Health Assure E-Rostering tool • ESR Reports

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Q10: Is the Board assured of the robustness of information? Monitor Prompts Actions Evidence

The Information used in reporting, performance management ad delivering quality care is accurate, valid, reliable, timely and relevant.

• Information used in the dashboards and performance reporting is triangulated wherever possible. National Standards are used wherever possible to ensure the Trust performance is within mean.

• Safer Staffing paper to Board aligned with Legislation

• E-Rostering reports • Integrated Performance Reports

K6

• The Incident Reporting System (DATIX) is reported on and individual dashboards have been developed for services. DATIX is uploaded fortnightly to the NRLS system and can be validated at any point.

• Incident Reports • NRLS Reporting Schedule

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• The Integrated Performance Report uses information from Doctor Foster and other national measuring processes, therefore performance is measured against what should be ‘normal’.

• Integrated Performance Report • Doctor Foster Information

• The Board has received a briefing session on the management of performance data and the accuracy, validation and quality checks.

• Board Briefing Presentation

• The performance data is subjected to routine accuracy, validation and quality checks as set out in the Data Quality Policy.

• Data Quality Policy • Annual external audit of Quality Accounts

• A three year strategic internal audit plan is developed by the executive team and approved by the Audit & Assurance Committee. Changes to the plan throughout the year are reported to the Audit & Assurance Committee. Where relevant, a follow-up audit may be requested

• Internal Audit Programme • Internal Audit Paper to QAC • QAC Minutes

• The Audit & Assurance Committee receives the summary reports of all completed internal audit reports and seeks assurance that actions arising from these reports are effectively monitored via the Trust’s risk management processes

• Internal Audit Programme • A&A Committee Papers of programme

presentation • Example Report



