agenda spotlight on local services...delivered coaching and facilitation to belper five medical...

Derbyshire�Community�Health�Services

Board

Board�Public�Session�-�27�October�2016

27�October�2016�-�13:00

St�Oswald's�Hospital,�Clifton�Road,�Ashbourne,�DE6�1DR

AGENDA

1.00�pmSpotlight�on�local�services

249 1.30�pmPART�2�–�Public�Session

250 INTRODUCTORY�ITEMS

251 Introductions�and�WelcomeOwner:�Prem�Singh

Verbal

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

Verbal

253 Declarations�of�InterestOwner:�Prem�Singh

Verbal

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

Verbal�

http://www.eshareuk.com

255 Patient�StoryOwner:�Carolyn�White

Paper�for�Information�and�Assurance

255�Patient�Story 6

256 Draft�Minutes�of�the�meeting�held�on�29�September�2016Owner:�Prem�Singh

Paper�for�Decision

256�Minutes�September�2016 9

257 Matters�ArisingOwner:�Prem�Singh

Verbal

258 Actions�MatrixOwner:�Prem�Singh

Paper�for�Information

258�Actions�Matrix 21

259 Chairman’s�ReportOwner:�Prem�Singh

Verbal

260 STRATEGY,�VALUES�AND�VISION

261 Chief�Executive’s�Report�inc�Public�Consultation�Response�to�Better�CareCloser�to�HomeOwner:�Tracy�Allen

Paper�for�Information�and�Assuarance

261�Chief�Executive�Report 23

262 QUALITY,�PERFORMANCE�AND�GOVERNANCE

263 Performance�ReportOwner:�Chris�Sands


263�Performance�Report 34


264 Financial�Performance�ReportOwner:�Chris�Sands

Paper�for�Assurance

264�Financial�Performance�Report 56

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


265�AAC�Summary�Report 69

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


266�QSC�Summary�Report 81

267 Quality�ReportOwner:�Carolyn�White


267�Quality�Report 88

268 Board�Assurance�Framework�Q2Owner:�Kirsteen�Farrar

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

268�BAF�Q2 116

269 CONSENT

270 NHS�England�Core�Standards�for�Emergency�Preparedness,�Resilience�&Response�(EPRR)�-�Annual�Self-AssessmentOwner:�William�Jones

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

270�EPRR�Core�Standards 162

271 CONCLUDING�ITEMS

272 Any�Other�BusinessOwner:�Prem�Singh

Verbal


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

Verbal

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

Verbal

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

Verbal


Index255�Patient�story.docx.............................................................................................................. 6

256�Minutes�September�2016.docx.......................................................................................... 9

258�Actions�Matrix.docx..........................................................................................................21

261�Chief�Executive�Report.pdf.............................................................................................. 23

263�Performance�Report.pdf.................................................................................................. 34

264�Financial�Performance�Report.pdf................................................................................... 56

265�AAC�Summary�Report.docx.............................................................................................69

266�QSC�Summary�Report.docx............................................................................................ 81

267�Quality�Report.docx......................................................................................................... 88

268�BAF�Q2.pdf.................................................................................................................... 116

270�EPRR�Core�Standards.pdf.............................................................................................162


TRUST BOARD Document Title: Patient’s Story

Presenter/Title: Carolyn White, Director of Quality and Chief Nurse

Contents of Paper were previously discussed by:

Outpatient Physiotherapy, Occupational Therapy & Musculoskeletal Services Governance Meeting.

Author/Title: Elizabeth Carter, Team Lead Physiotherapist.Contact Email and Telephone Number: [email protected] 01773 525038

Date of Meeting: 27 October 2016 AgendaItem No: 255/16

No of pagesinc. this one: 4

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

Purpose of Paper

This paper provides a local story of a patient who has had multiple unsuccessful interventions within the health system before accessing our services.

This patient story is focused around the Outpatient Physiotherapy Service at St Oswald’s Hospital, Ashbourne. It shows how the effective use of an individually targeted self-management approach can improve a patient’s quality of life

The story emphasises that the correct use of evidence based physiotherapy leads to efficient and cost effective management of patients, without the need of expensive interventions, whilst helping to reduce the costs to the wider health community.

Recommendations

For the Board to take assurance on the services provided.

Board Assurance Framework Risk Reference

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

1.4 There is a risk that DCHS does not provide patient centred care due to a lack of engagement and involvement of service users and stakeholders.

1.6 There is a risk to the provision of safe, effective care due to a lack of consistent employment of clinical governance standards.

2.1 There is a risk to providing high quality care due to national and local workforce supply shortages and the challenges of developing the workforce to have the appropriate skills and competencies to provide the future models of care.

255�Patient�story.docxOverall�Page�6�of�171Page�1�of�3

mailto:[email protected]


Financial Impact

There is a financial impact across the wider health community if patients do not get the right treatment by the right person at the right time

Further Information and Appendices

Sarah is a 37 year old woman who was an occupational therapist until starting a family 7.5 years ago. She had always been a very busy, fit and active young woman. She has two daughters aged 7.5 and 5.5 years. The two pregnancies close together and some complications during birth had left Sarah with some underlying weakness.

When her youngest was only 6 weeks old Sarah had a back injury whilst helping her eldest into a car seat. She had excruciating back and leg pain which was completely debilitating. Being a former health care professional she reassured herself that she would be ok and that she needed to keep moving, she told herself that ‘everything would be alright’.

She sought help from her GP who offered her some pain medication and a review in 4 weeks. This left Sarah feeling frustrated as she was ‘in pain now, and needed help now’. She was reluctant to take medication and so did not use the pain killers. The GP then referred her to the physiotherapist based within the GP practice. Sarah reported that this physiotherapy involved very little movement and was mainly talking. Sarah reports that the injury was attributed to having ‘weak core muscles’ from having two children and that she felt ‘fobbed off’. In her desperation to improve her pain and function she paid for private physiotherapy in Nottingham. This physio attributed the problem to the sacroiliac (SI) joint (The sacroiliac joint lies next to the bottom of the spine, below the lumbar spine and above the tailbone (coccyx)) and treated her for SI joint dysfunction. After several sessions there was no improvement.

A year had now passed and Sarah was feeling incredibly frustrated, worried and fearful. She went back to see her GP who ordered an MRI scan, this scan showed no neural compression and in fact changes on this scan were appropriate for the patient’s age. Following this Sarah was referred for another course of treatment with a physiotherapist within the GP practice. She also self-funded treatment with a chiropractor and an osteopath, but there remained no improvement.

By this time Sarah was working in a sedentary role doing finances for her husband’s company. Sarah decided to try and improve her pain by using a personal trainer. Initially this went well and she felt some symptom improvement with the exercises. Unfortunately, during one of the sessions Sarah injured her back and was left with the same agonising symptoms. At this point Sarah reports feeling very low. She went to see her GP again. Sarah had lost all confidence in her back and the treatment options that she had been given before. However, her friend had recommended going for physiotherapy at St Oswald’s. She ‘begged’ her GP to refer her there rather than to the in house physiotherapist and the GP agreed.

Sarah attended physiotherapy at St Oswald’s in October 2015. She was referred for an MRI to rule out serious pathology or nerve compression.

Sarah stated she had become ‘fearful of moving’. She was ‘terrified of the pain’.

The physiotherapy sessions at St Oswald’s consisted of reassurance, education and graded



exercises that focused on normal movement. There was a focus on achieving agreed goals, which the patient set. The exercises progressed from gentle, normal movements through to lunges and rotations with a medicine ball.

Sarah soon saw a significant reduction in her pain and her quality of life improved considerably. During her course of treatment Sarah gained a good understanding of back pain, normal degenerative processes and knows that exercise and movement is essential for back health. Sarah was pain free on discharge and had returned to all activities.

It is 9 months since Sarah was discharged from the physiotherapy service at St Oswald’s and she remains symptom free, confident and physically active. Sarah does Pilates classes twice a week to maintain her strength and flexibility and has even set up her own business in corporate flower rentals. This involves driving and delivering large, heavy vases and she manages this without pain. She is very appreciative of the care that she received from DCHS.

‘The physio at St Oswald’s was so brilliant; they gave me the confidence to move normally’

Sarah’s story highlights how using evidence based approaches and taking the time to support the patient to self-manage the condition can lead to a really good outcome. If Sarah had come to the service earlier on in her journey, she could have had a much improved quality of life and saved money for herself and the wider health community.

Physiotherapy delivered in this way is an efficient and cost effective service for patients, which can reduce both primary and secondary care costs.

Monitoring Information Brief Summary

What are the Governor Involvement implications?

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

What are the Equality and Diversity implications?

This story highlights the impact for one patient. It is vital that all patients can access safe effective healthcare regardless of any protected characteristics, and that this care is a positive experience. Maternity is one of the nine protected characteristics.

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

Patient Stories are one way in which patients’ views and experiences can be understood.

Risk Register

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

Does this update recommend a change in the current risk score? N/A



Minutes of the DCHS Board Meeting held on Thursday 29 September 2016The Peel Centre, Dronfield

Name Job titlePrem Singh PS ChairmanTracy Allen TA Chief Executive Chris Bentley CB Non-Executive DirectorKaye Burnett KB Non-Executive DirectorKirsteen Farrar KF Trust SecretaryWilliam Jones WJ Chief Operating OfficerIan Lichfield IL Non-Executive DirectorAmanda Rawlings AR Director of People & Organisational EffectivenessJames Reilly JR Non-Executive DirectorChris Sands CS Director of Finance, Information and StrategyNigel Smith NS Non-Executive DirectorBarbara-Anne Walker BAW Non-Executive Director Carolyn White CW Chief Nurse

Present

Tim Broadley TB Associate Director of StrategyJohn Coyne JC Non-Executive DirectorRick Meredith RM Medical Director

Apologies

Jim Austin JA Associate Director of TransformationDavid Boddy DB Corporate Governance ManagerNick Firth NF Clinical PsychologistLizzie Platt LP PatientJayne Needham JN Consultant in Public Health

In Attendance

Bola Owolabi BO Deputy Medical Director

Item Description Action

217/16 PART 2 – PUBLIC SESSION

218/16 INTRODUCTORY ITEMS

219/16 Introductions and Welcome

220/16 Apologies for Absence Apologies were noted as above.

256�Minutes�September�2016.docOverall�Page�9�of�171Page�1�of�12



221/16 Declarations of Interest

KB declared that she: Was a Director and Shareholder of Hornbeam Associates Delivered coaching and facilitation to Belper Five medical practices Provided coaching to GP’s in Leicester, Leicestershire and Rutland Was the Independent Chair for Better Care Together in Leicestershire,

Leicester and Rutland

JR declared his interests were: Trustee of Standing Together Against Domestic Violence Non-Executive Board Member – Methodist Homes Association Chair – Islington Council Safeguarding Board Independent Chair – Camden Council Safeguarding Board Director – James A Reilly Consultancy Ltd

222/16 Questions from the PublicThere had been no formal questions from the public received.

223/16 Patient StoryThe story described the positive impact of the Health Psychology Service, as described by LP.

LP described the collaborative and person centred approach to goal planning for long term pain management. LP talked about her “toolbox” of strategies to cope with her pain. LP went on to describe the improvement in her quality of life as well as the reduction in pain relief medication. The positive impact of the service has been life changing.

NF went on to describe the work of the service to address physical symptoms and mental health. NF said the service is very effective - LP’s story and her positive outcome area typical experience for patients referred in to the service.NF said that such patient stories are sent in a letter to new patients to overcome scepticism.

NF said that there is still a limited awareness of the service but that a steady stream of referrals comes from GP’s. The service is working very hard to provide a new understanding of the value of psychology. BO said that the potential cohort of patients for referral is huge.

BAW asked about how the techniques could be shared across the wider organisation and patients. TA confirmed that Dr Alan Blair has re-joined the Trust as Clinical Director of Psychology and will use his expertise to build up the capability of our colleagues.

PS said that the story described the collaborative work well. It had been a powerful story.

The Board thanked LP for telling her story and NF for coming to talk about the service.




224/16 Draft Minutes of the meeting held on 28 July 2016The minutes of the meeting held on the 28 July 2016 were agreed as accurate.

225/16 Matters ArisingThere were no matters arising.

226/16 Actions MatrixThe Board noted the actions with a deadline of July were complete.

178/16 funding for Quality Always – PS commented that the ongoing commitment to Quality Always was good to see

267/15 Derbyshire Youth Council – the timing of Board meetings had made it difficult for members of the Youth Council to attend. The objectives of the new Youth Council have changed and are not so aligned with DCHS. CW will meet with the Youth Council to discuss their objectives going forward and the Patient Engagement Team will work closely with them

202/16 Pressure Ulcer audits – NS asked about the delay in the audits because Project Mercury is not yet fully rolled out. CW will investigate further and communicate a response CW

227/16 Chairman’s ReportPS looked back over his activity, since the last Board meeting in July.

PS welcomed new Non-Executive Directors (NEDs) Kaye Burnett and James Reilly to their first Board meeting.

PS thanked the staff, Executive and Board colleagues for a fantastic Care Quality Commission (CQC) report that reinforces our good to great journey

The Quality Summit was well attended and supported by our partners who were very positive and complimentary.

We will be sending our Board’s formal response to the 21st Care consultation, incorporating comments we have received from staff (and Governors) that ended on 24th September.

The strategic theme is concerned with improving health, well-being and tackling inequalities. PS said that Better Care Closer to Home and the future direction of the health and care system Sustainable and Transformation Plan (STP) will need to ensure that we focus on the prevention agenda, build social capital, support carers and empower communities. The agenda included focus on housing and health and the significant correlation between the two. The strategic theme today is our collective focus, within the system, on the wider determinants of ill health and the inter relationship between, not only housing but deprivation, educational attainment, employment and community cohesion.

PS talked about the work to build strategic partnerships which included: Ongoing meetings with the Chair and Chief Executive of Derbyshire




Healthcare Foundation Trust (DHcFT) about closer working between the two Trusts and also a 1:1 with the Chair of Chesterfield Royal Hospital Foundation Trust

A really positive engagement event attended by Board members, Governors, staff partnership representatives from both DCHS and DHcFT who came together with colleagues from the Clinical Commissioning Groups (CCGs) and Councils to talk about what difference we could make across Derbyshire to our communities, patients and our staff by working more closely together. The event will inform the options appraisal the two Boards are doing over the next two months about how best we could capture and deliver these benefits. The event was followed by a Board to Board meeting.

PS and TA attended the Derbyshire Health and Wellbeing Board which received an STP update and discussed wider engagement particularly with Non-Executive Directors (NEDs) and Governors

Dame Gill Morgan, Chair NHS Providers will visit Clay Cross and Walton Hospitals

PS kept in touch with sites and services including: Attendance at the third Young Carers Celebration event, to receive a

“Partnership” award in recognition of the work of DCHS A morning with the Speech and Language Therapy team based at

Long Eaton Health Centre and observed their great work, patience and caring interaction with young children and their families

Joining with Board colleagues at the Trust’s third Long Service Awards tea party which celebrated the contribution of long serving staff members over 20,30 and 40 years.

Key Governance and Accountability activities included: Chairing the Charitable Funds Committee and attending the

Commercial Strategy Sub-Group meeting Work with governors involved another round of meetings with

Constituent governor groups which took place during August; August Governance Group meeting; Council of Governors meeting

The Annual Members Meeting gave us the opportunity to reflect on 2015/16's successes and challenges and talk about how we're working to ensure community services continue to play a growing and central role in Derbyshire's health and care system over the next 5 years

The NED’s meeting included an engagement meeting with the Governance Group

Finally PS has been involved in the preparation for the Extra Mile Awards (EMAs) - the big night is getting ever closer!

With respect to the National agenda, PS has: Attended various NHS Confederation meetings during August and

September Attended the NHS Employers Policy Board meeting where there was

focus on whether the challenging £22bn can be delivered and the challenges for our workforce in terms of transformation.

PS ended his report with some news highlights regarding:




Voting for the Governor elections is open until 30 September and we have been delighted by the interest shown by people wishing to volunteer as a governor, both from amongst staff and members of the public

The pleasing announcement that the Trust has been shortlisted in the HSJ Provider of the Year category. Judging will take place on 9th November and a small team will present our entry to the judging panel.

The Board received the Chair’s Report.

228/16 STRATEGY, VALUES AND VISION

229/16 Chief Executive’s Report TA reported on strategic policy, legislative and developmental issues affecting the organisation.

TA discussed two major guidelines: the 2017/18 Planning Guidance and the NHS Improvement Single Oversight Framework (SOF) and how they impact on DCHS. The Framework’s segments commence in October 2016.

The Trust is reviewing how its governance arrangements will need to be updated to ensure the requirements of the SOF are met, and that the Board gets sufficient assurance to agree the quarterly declarations. This work will be progressed through the Audit and Assurance Committee in October 2016.

TA went on to discuss System Transformation Updates including: The next iteration of the Derbyshire/Derby City Sustainability and

Transformation Plan which will be submitted to NHS England (NHSE) towards the end of October

The 21st Century Joined Up Care Programme – Better Care Closer to Home Consultation closes on October 5th. It has generated a significant level of community, political and media attention and been managed in a way that has supported a very high level of engagement across North Derbyshire

Work is continuing on the development of a Strategic Options Case around the proposed greater collaboration with Derbyshire Healthcare NHS Foundation Trust (DHcFT) that will be considered by both Trust Boards in October. A successful stakeholder engagement event was held at the end of August to share emerging thinking on the clinical case for change and get perspectives from governors, board members and partners

Erewash MCP and national MCP framework - the national New Care Models (NCM) Team at NHS England have published the long awaited comprehensive framework to develop MCPs. This has outlined a number of options for the contractual arrangements of an MCP which include a virtual or alliance option for providers to come together under an umbrella contract to deliver an MCP outcome based contract for a local population. The local option appraisal undertaken by the Erewash MCP partner providers has also been completed and suggests that this alliance approach would be the most pragmatic and acceptable approach for moving forward. Further work is underway across the provider partnership . This work is being undertaken in the




context of the STP which prioritises a place based across to develop integrated care across the county.

Trust highlights included: NHS Improvement 2016/17 Quarter 1 Trust Monitoring - DCHS

received formal notification from NHS Improvement that our organisational ratings for 2016/17 quarter 1 were Financial sustainability rating – 4 and Governance rating – Green

Care Quality Commission (CQC) Rating – DCHS has been given an overall rating of ‘Good with elements of Outstanding’ for the quality of the services we provide. This is an extremely strong rating. The ‘caring’ domain was rated outstanding overall across the Trust and all the other domains were good. Two individual services – Urgent care and Dental services – were also rated outstanding. Only one service, integrated sexual health services, was rated as requiring improvement. TA commented that this is about building in good practices. Improvements will be integrated within our Quality Framework. CB commented that the Quality Summit with the CQC was a very positive meeting. The Board went on to discuss how DCHS could improve its rating from Good to Outstanding. CW said this involves demonstrating that we continually look to improve ourselves.

Urgent Care Designation Process - NHS England have published guidance to designate the existing range of urgent care services using nationally agreed nomenclature. From the DCHS perspective this will include our four Minor Injury Units (MIUs). The guidance includes criteria that need to be met for a service to be designated as an Urgent Care Centre (UCC). The Trust’s Minor Injury Units will be the subject of an assessment by an expert panel from the CCGs. The criteria that appears to have potentially a significant impact on the MIUs is the requirement for UCCs to be open for 16 hours and also the increase in minor illness presentations. The Chief Operating Officer and his team are working closely with CCG colleagues and through the STP Urgent Care workstream to manage this process and ensure that the contribution that our MIUs make to urgent care across the county is developed and maximised as services are streamlined.

The Board received the Chief Executive’s Report.

230/16 Housing and Health Joint Needs Assessment – DerbyshireJN provided information on the findings of the recent Housing and Health Joint Health Needs Assessment1 (HNA) which has been commissioned by Derbyshire County Council Public Health and to indicate the relevance of the findings for DCHS.

The assessment was published in June 2016. The document, commissioned by Derbyshire County Council public health department, provides context to the current position regarding the interventions already in place and the potential to do more at a system level to address the impact of poor housing conditions on health.

Risks to health and wellbeing from the home and housing circumstances can be broadly categorised under three headings; 1. Unhealthy and unsafe homes




2. Unsuitable homes 3. Precarious housing and homelessness.

The statutory responsibilities for housing policy and planning, housing enforcement, adaptations and homelessness rest with the eight District Councils throughout Derbyshire. However the implications of poor housing on health mean that the impact is felt across the broader system.

The evidence of the impact of housing on health is strong and compelling. JN said that what needs to be better understood is the role of DCHS in improving this situation. There is potential for DCHS to contribute towards the overarching need to improve housing conditions for our population. JN described a number of ways in which DCHS could intervene and link in to other agencies to help clients recover.

JN asked the Board to consider what our role is and how we should engage with clients. This will require staff training to help them engage and be empowered to signpost vulnerable clients across the system. CW agreed that it is about letting people know what to do. Our existing Making Every Contact Count work might be an appropriate area in which to develop this engagement work. JN agreed that DCHS need to facilitate the opportunity to raise staff awareness. TA said that the Care Coordinators for Integrated Care Teams could become pivotal in this work

PS said that this work could add to the current very heavy workload. JR, however, considered that combined appointments with local housing providers might simplify and make work referrals more straight forward. BO said it would be important to build a systematic approach, with staff automatically capturing the determinants such as type of housing.

CB said this work will be about setting up systems to help people. Place based care will help us to engage.

The Board took note of the information provided and agreed the contribution which DCHS can make towards ensuring the recommendations of the HNA are implemented

231/16 Operational Plan UpdateCS updated the Board regarding the progress of the main projects in the plan.

The Board discussed the commissioner led review of the Wheelchair Services. Discussions have taken place at Executive level. The challenge is with respect to the high demand and the finance to meet it. The Board agreed that pace was required to resolve the matter. Options will be discussed if the quality standard cannot be provided.

The Board also discussed the implementation of a Trustwide Voice Over Internet Protocol (VOIP) telephony system. There have been a number of iterations of the design of the technical solution and a final proposal has been put forward by the preferred bidder; Vodaphone. The implementation and the benefits of VOIP will be realised during 2017.

The Board took Significant Assurance from the report.




232/16 QUALITY, PERFORMANCE AND GOVERNANCE

233/16 Performance ReportThe Board discussed the Performance Report in detail.

Quality Service IL asked about metrics to report on the positive work being done regarding Pressure Ulcers. CB described the Driver Diagram that Quality Service Committee (QSC) received in September and will discuss in detail in October. CB said that DCHS work had positively impacted on Pressure Ulcers within our control. However, the bulk of Pressure Ulcers are coming from elsewhere in the system. QSC have therefore asked to review the DCHS Pressure Ulcer performance via the Driver Diagram and have also asked that a further Driver Diagram is carried out for the whole system. IL said that it would be beneficial to have measures for Pressure Ulcers outside of our control as this would allow DCHS to focus on the good things that it is doing within its control. JR asked about the potential involvement of our psychologists within our strategies for self-harming patients or who suffer from dementia. CW said that DCHS have been working with them over the past year regarding motivational techniques to foster patient compliance.

Quality PeopleAR discussed the challenging agency spending trajectory for this year, despite the very good performance in 2015/16. The Board discussed the mixed challenges of effectively staffing services in order to deliver safe care and the negative impact on the organisation of failing to achieve the trajectory. AR updated the Board about the work underway to manage the agency spending. The Board will continue to be sighted on the issue. BAW talked about the work Quality People Committee is doing in monitoring performance. The Board acknowledged the impact of the additional work on Executives, Non-Executive Directors and managers to hit the target.

Quality BusinessThe Board noted the progress against the Information Management and Technology Plan is 64.2% against a target of 64.2%. This has been green rated.

The Referral to Treatment (RTT) admitted patient measure is no longer a national target. This will be removed from the Board dashboard.

The Board received the Performance Report and the Significant Assurance it provided.

234/16 Financial Performance Report

The Board reviewed the Financial Performance Report and the Significant Assurance it provided.

235/16 Quality Service Committee (QSC) Summary ReportCB presented the Summary Report and highlighted:




The Patient Story focused on the service provided by the Ward and Community Therapy team and also good joint working with Derbyshire County Council’s re-enablement service. The Committee discussed what lessons could be learnt from the story with respect to a less “bed based” future

Strategic Shift Deep Dive Update – the Committee reviewed progress from the acquisition of City Community services including progress on the implementation of the key actions identified in the first 100 days following the Strategic Shift in October 2015. The Committee discussed the persistent operational challenges post transfer and the actions being taken in relation to them. The Committee discussed the capability of the leadership of the services to drive the overcome the problems

Community Services Waiting Times Review - the Committee discussed the prioritisation of service waiting times not currently under the scrutiny of national or commissioner requirements

End of Life Care Audit Quarter 1 - The Committee reviewed Inpatient Mortality performance as well as Community team activity. The report reflected the big steps forward with End of Life care

Nutrition - work has commenced on an options appraisal for the long term model of specialist nutritional input into operational services across the Trust. Nutrition remains on the Trust risk register due to ongoing pressures within the system, particularly within community services where referrals to the specialist dietetic service can take up to 16 weeks in the south of the county

Quality Always - Hudson ward has now achieved green which was recognised as a significant achievement in recognition of the journey it has undertaken and the continued stability provided by the Ward Manager

Patient Experience and Engagement Group Summary Report - - the Committee took assurance that the comments received from BME service users were consistent with those from other patient groups

Endoscopy Service at Ilkeston Community Hospital – the Committee took Significant Assurance that the decision to cease the service has not negatively impacted on RTT times

The Board received the Summary Report and the Significant Assurance it provided.

236/16 Quality Service Committee (QSC) Risk Review Summary ReportCB presented the Summary Report and highlighted that there has been a 52% reduction in the number of incidents awaiting review.


237/16 Quality People Committee (QPC) Summary ReportBAW presented the Summary Report and highlighted:

Flu update - progress to date with the initiative to achieve the flu campaign target of 60% for 2016/17. The Board will receive regular communication on the progress through the campaign. CB commented




that he was impressed by the “marginal gains” approach to the campaign

Sickness absence - The Committee reviewed the reported reasons for sickness absence, particularly the fall in Anxiety. It is difficult to pinpoint a specific reason for the reduction because there is so much supportive activity taking place around sickness absence .The Committee recognised that Resolve have seen an increase in referrals but it was not able to say if there is any direct correlation with the reduction in absence owing to Anxiety.


238/16 Quality Business Committee (QBC) Summary ReportIL highlighted:

Information Management & Technology Quarterly Strategy Update – updated the Committee on the progress of the existing Informatics Plan. IL reported that progress is improving but will take time

Sexual Health Performance – the Committee took Significant Assurance from the financial performance of the service

Draft Financial Plan 2017/18 – 2019/20 – QBC reviewed the potential level of efficiency savings that will be required to be delivered over the next three years to ensure that the organisation is able to remain on a sustainable footing and to support the wider delivery of the Derbyshire STP

The Committee is monitoring the performance of the Health and Wellbeing contract that is currently causing concern. IL summarised from the meeting that it is important to have a grip on performance to make sure that the basics are right, particularly with respect to the new transformation work. Part of this is to ensure that the right metrics are in place

Lifestyle Contract Tender- there will be changes to the contract. The Tender Oversight Group will have sight of this in order to shape the bid. WJ will communicate with the STP to ensure this activity is included

The Board went on to discuss the importance of new policies when working in different ways as a result of integration.

CB informed the Board that, owing to challenge of producing adequate end of month data in time for QSC, the Committee had decided to review the full set of data from the previous month.


WJ

239/16 Council of Governors (CoG) Summary ReportPS presented highlights of the meeting.

The Board thanked Governors Barry Jex, Emma Brooks, Joan Johnson, Bridget Leech and Maggie Parry-Hughes for their service and their support to DCHS.




CB said that it was good to see governors attending the Quality Committees as observers.


240/16 Mental Health Act Committee (MHAC)BAW reported on the good progress of the Committee. The DCHS Mental Health Act Annual Report provided the Board with assurance that it is carrying out its duties under the Mental Health Act 1983 (MHA) with due care and diligence. PS thanked BAW for her leadership with this activity.


241/16 Charitable Funds Committee (CFC) Summary ReportPS highlighted from the report the work being undertaken by the Committee to deliver “value for money” for the charity.


242/16 Quality ReportCW discussed:

The independent report of the National Advisory Group on Health Information Technology, Making IT work, which was published in September and outlined the need for an NHS IT strategy which supports the NHS’s 2014 Five Year Forward View but also recognises the need for the development of expertise in the clinical workforce

Learning from mistakes - An investigation report by the Parliamentary and Health Service Ombudsman (PHSO) into how the NHS failed to properly investigate the death of a three-year old child. CW talked about the learning that DCHS will take from the report in order to improve our own processes

Safeguarding – DCHS will be involved in a Joint Targeted Area Inspection Mock Inspection

Child protection – Information sharing - A new national spine for child protection referrals which provides automatic flags across the whole health and social care system is currently in development with plans for roll out this year.

The Board received the Quality Report and the Significant Assurance it provided.

243/16 CONCLUDING ITEMS

244/16 Any Other BusinessWJ updated the Board regarding a challenging incident that occurred at Ash Green on 28th September. The Board thanked the Ash Green team for their professional work in the situation. The team managed the patient with dignity, safety and compassion. Equally, the Board thanked staff from other DCHS




sites that provided support for their Ash Green colleagues. TA said that the staff were brilliant regarding their patient management.

The Board went on to discuss the learning that will be taken from the incident, this will be reported to the Board.

245/16 Self-Certification / Risk / Board Assurance FrameworkThis is a standing item on the public Session of Board to provide an opportunity to reflect on the business discussed and consider any impact on Self-certification, risk, or the Board Assurance Framework.

246/16 Questions from the Public relating to Today’s Board BusinessThere were no questions from members of the public about the Board meeting.

247/16 Review of the Meeting and outcomesThe Board agreed that it had been an excellent meeting. Some matters could be speeded up. PS thanked the Board members for their cooperation.

248/16 Date of Next meetingThursday 27 October 2016 at St Oswald’s Hospital, Clifton Road, Ashbourne, DE6 1DR. Members of the public and staff are invited to join the Board for an informal discussion over lunch from 12.30pm; this will include a presentation on the services provided in that area. The Public Board meeting will commence at 1.30pm.



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

Date/Item No:

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

Progress: Responsible Person:

Deadline: Outcome:

Mar 201670/16

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

The evaluation was considered at the October meeting of the GP Strategy Group. The Group considered the practice developments to date, the information available from the patient survey, the alternate methods of collecting the data previously circulated by the Clinical Commissioning Groups, the emerging GP dashboard information, the progress in relation to the Care Quality Commission actions and the balanced scorecard information that is monitored at Directorate level. A report will be prepared for the next General Practice Board development session using these sources which captures the progress made and the areas for further action. This will be used to further inform the developing GP place based development strategy for DCHS.

Tim Broadley Oct 2016*Changed from Sept 2016

Complete

Sept 2016238/16

QBC Summary Report

WJ will communicate the changes to the Lifestyle Contract Tender with the STP.

Action undertaken. William Jones Oct 2016 Complete

258�Actions�Matrix.docxOverall�Page�21�of�171Page�1�of�2


Date/Item No:

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

Progress: Responsible Person:

Deadline: Outcome:

July 2016202/16

Audit and Assurance Committee Summary Report

Pressure Ulcer audits are behind timescale - to further investigate the delay with Project Mercury and provide a response

The delay is due to the roll out of TPP SystmOne.

Carolyn White

Oct 2016 Complete

Jan 201615/16

QPC Summary Report

New sentencing guidelines to be included in the Board Development Session on Health and Safety

This session has been arranged for 27 November 2016.

Amanda Rawlings

Nov 16*Changed from Sept 2016

July 2016200/16

Performance Report

AR to sign up to “a Time to Change” campaign.

The application process has been started – the organisation has to complete a questionnaire and go through an approval process.

Amanda Rawlings

Dec 2016

*Changed from Sept 2016

July 2016202/16

Audit and Assurance Committee Summary Report

To discuss the Pressure Ulcer audits which are behind timescale with the Chief Nurse and provide an update to Board

It has not been possible to commence the audit of pressure ulcer data directly from TPP records as Project Mercury is not fully rolled out. This is being addressed by the IT team. The audit data will be presented during Quarter 4.

Carolyn White

Feb 2017*Changed from Sept 2016

258�Actions�Matrix.docxOverall�Page�22�of�171Page�2�of�2


TRUST BOARD MEETING Document Title: Chief Executive’s Report

Presenter/Title: Tracy Allen, Chief Executive Contents of Paper were previously discussed by: n/a

Author/Title: Tracy Allen, Chief Executive Contact Email and Telephone Number:

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

Date of Meeting: 27 October 2016 Agenda Item No: 261/16

No of pages inc. this one: 11

Has an Equality Impact Assessment been undertaken Yes No X

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

Purpose of Paper

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

• NHS Improvement regulatory update including: o Trust Delivery and Improvement Director o Single Oversight Framework segmentation rating o 2017/18 control total o Agency spend reporting and oversight

• System transformation including:

o An update on the next iteration of the Sustainability and Transformation Plan o The Better Care Closer to Home consultation o Progress with our collaborative work with Derbyshire Healthcare NHS Foundation

Trust (DHcFT)

• Key achievements and open

• Rational issues

Recommendations

The Board is recommended to note the report.


Item 2.2 – BAF risk 3.7 Item 2.3 – BAF risk 2.1 Item 3 – BAF risks 3.1 and 3.3 Item 4.1 – BAF risk 1.6

261�Chief�Executive�Report.pdfOverall�Page�23�of�171Page�1�of�11



Financial Impact

None directly but items 2 and 3 will influence the trust’s financial position significantly and be picked up in 2017/18 operational plan and contracts that will be separately considered by the Board.


Chief Executive's Report October 2016

1. Purpose of the paper This paper is to provide the Trust Board with information about key national and local strategic issues affecting the Trust. 2. National planning and performance context – NHS Improvement (NHSI) regulatory

update 2.1 Single Oversight Framework (SOF) Segmentation Ratings The Board has discussed the introduction of the new NHSI regulatory framework previously. The Audit and Assurance Committee is considering the implications of the framework on the Trust’s internal governance processes at its October meeting – with particular reference as to whether the Trust should continue with an internal self- certification regime (no longer required by NHSI) and will share their recommendation at the Board meeting. The Trust has been verbally informed of its initial segmentation rating which was in line with our expectations and we expect the ratings to be published imminently. The key risk for the Trust within the new framework continues to be delivering a reduced agency spend in line with the NHSI trajectory we have been set for 2016/17 – see below. 2.2 2017/18 and 18/19 Trust Control Total Following the release of Trust level control totals for next year we have been in discussion with NHSI about the rationale behind the significant increase in the Trust’s required surplus. This appears to relate to NHSI assumptions about a significant income benefit to the Trust as a result of the introduction of HRG4+ which we have challenged. NHSI have asked the Trust to complete a detailed pro forma setting out our calculations of the impact of Healthcare Resource Group (HRG) 4+ and we are currently awaiting feedback. The Trust is required to confirm acceptance or otherwise of the control total with NHSI by the 24th November and it may therefore be necessary to consider and agree delegated authority to appropriate board members if a revised total is not received prior to the October meeting. This will be discussed in the confidential session of the Board meeting.



2.3 Agency Spend reporting and oversight As the Board is aware delivery of the agency expenditure trajectory the Trust has been set by NHSI remains a very significant risk in 2016/17. NHSI has recently written to all Trusts to re-emphasise the importance of achieving the trajectories, to introduce additional controls into the processes of authorising agency staff along with additional reporting requirements. They have also introduced a requirement from November for boards to work through a self certification checklist relating to agency expenditure in order to ensure that plans and actions targeted at reducing expenditure are receiving regular and robust board consideration and challenge, supported by high quality, timely information. The Director of People and Organisational Effectiveness will be taking a lead on presenting this to our November meeting. Our NHSI agency target for this year is set at £1.46m and we are currently forecasting a year end position of £1.6m. The monitoring of this target is overseen by our Quality People and Quality Business Committees supported by an Operational Workforce Planning Group. Since September, as a result of this performance, we have included from September the detail in our monthly performance report to Board. The current steps we are taking to further control our agency expenditure are: • Securing more resources to our Responsive Workforce team. The team now includes band 5

Staff Nurses, band 6 specialist nurses, a paramedic, and HCAs. We are currently recruiting to therapy posts. Staff are appointed onto flexible contracts and move across our county whether that be inpatient or community areas, supporting temporary staffing issues such as vacancies or long term sickness. Their assignments usually last between 6 and 12 weeks.

• Further strengthening the size of bank including adding sexual health nurses, and therapists. Our bank fill rate remains high in comparison to our peers at 84%. Further consideration is being given to how we can further increase our fill rates.

• Implementing ‘Responsive Bank’ shifts to our rosters, these are bank staff who at weekends can be moved at the last minute to respond to patient acuity or last minute sickness.

• Running a large scale recruitment campaign for inpatients and community nursing including Derby city, General Practitioners, Minor Injury Units, practice nurses for primary care, Advanced Clinical Practitioners /Advanced Nurse Practitioners, therapy and inpatient wards.

• Introduced a central ‘staffing monitoring’ service which provides daily monitoring of staffing, finding solutions to staffing gaps without using agency wherever possible.

• Ensuring that the Responsive Workforce Clinical Lead (nurse) challenges and confirms requests for agency spend and works with clinical teams to explore alternative options.

• Working with new national clinical staffing framework to avoid ‘over price-cap agency’. • Booking all agency through the electronic BankStaff system and no shifts can be booked

without going through the central electronic system. • We commissioned an external audit of bank and agency use in 2016 and have enacted all the

recommendations.

Progress with these initiatives will continue to be monitored closely by the executive team and reported through the governance channels outlined above.



2.4 Trust Delivery and Improvement Director Senior appointments into the new integrated NHSI structure are continuing to be made and we have recently received confirmation that Fran Steele, one of four Delivery and Improvement Directors appointed to work in the Midlands and East region, will have responsibility for the Trust, taking over from Frances Shattock. I have arranged to have an introductory meeting with Fran in order to introduce her to the Trust and our key issues. 3. System Transformation Updates 3.1 Developing the Derbyshire/ Derby City Sustainability and Transformation Plan (STP) The second iteration of the Derbyshire/Derby City STP will be submitted to NHS England (NHSE) on the 21st October. The key elements of the plan will be considered by the Board in its confidential session (in line with NHSE guidance) and build on the discussions the Board has had about the principles, direction, financial, commissioning framework proposed to support the very significant system transformation that we have to deliver together over the coming 4 years. System leaders are very keen to begin sharing the key elements of the plan with our local communities and wider staff groups in order that we can start to engage the public and NHS/Local Authority workforce in the meaningful discussions required to develop and refine detailed service proposals. We hope that this process will begin in November once feedback has been received from NHSE. 3.2 Better Care Closer to Home Consultation North Derbyshire and Hardwick Clinical Commissioning Groups (CCGs) Better Care Closer to Home Consultation concluded on the 5th October. After taking into account the feedback, ideas, issues and concerns from extensive discussions with governors and colleagues across DCHS, a written response to the CCGs was submitted by the Trust and this is attached for information as appendix A. The CCGs are working with an independent academic team who will be analysing the very high level of responses received before the health and social care partners involved in developing the proposals come back together to consider the key themes and issues that have been raised. 3.3 DCHS/DHcFT Collaboration The joint DCHS/DHcFT Project Board, supported by a joint project team and clinical and professional reference group, have completed the development of a Strategic Options Case (SoC) relating to our proposed collaboration. The SoC describes the case for change, the benefits for patients, staff and stakeholders of greater collaboration and considers which of the various ways in which the two organisations could work more closely together would best achieve these benefits. The SoC will be considered by both boards independently in the confidential sessions of our meetings on the 27 October. Any decision about a preferred option and commitment to continue



to work together to develop an outline business case to support it will be shared with our Council of Governors, colleagues across the Trust and key stakeholders following the meeting.

4. Trust Highlights and Key Operational Issues 4.1 Quality Always Gold accreditation awards Great progress is continuing to be made by teams across the Trust with their continuous improvement journeys and this month another three teams have been awarded gold Quality Always accreditation. I am sure Board members would like to join me in offering our congratulations to Alton Ward at Clay Cross Hospital, Orchard Cottage and Hillside Ward at Ashgreen. All three teams have demonstrated the achievement of the highest standards of care consistently and all three had some very special things to share too about their commitment to quality:

• Alton Ward Clay Cross shared some fantastic work on equality, diversity and inclusion and how they had had two patients who had disclosed issues regarding their sexuality where they could meet their individual needs from asking those difficult questions;

• Hillside Ward at Ashgreen who told three patient stories which really emphasised the care, compassion and specialist care they provide to clients and their families which makes such a difference to peoples’ lives, and;

• Orchard Cottage around the work on end of life care they are doing and how they are helping clients explore the impact of losing a loved one through the development of significant event life stories.

4.2 Minor Injury Unit (MIU) re-designation process In last month’s Board report I described a process being led by local CCGS to review the Trust’s MIUs against a national urgent care service specification for urgent care centres as part of a process to standardise services and nomenclature relating to urgent care access. We understand that the national specification for urgent care centres has now been withdrawn and this process will not proceed as planned. As part of the Derbyshire/ Derby City Sustainability and Transformation Planning process the development of the contribution that MIUs make to providing high quality access to care urgently will be considered alongside primary care (in and out of hours) within local communities to explore opportunities for providing a more comprehensive, joined up offer. 5. Organisational Performance September 2016 The Trust’s performance against our 2016/17 ‘Big 9’ for September is attached for information. Appendix A: Better Care Closer to Home Consultation – DCHS NHS FT response Appendix B: Headline organisational performance – ‘the Big 9’



Chief Executive: Tracy Allen Chair: Prem Singh

Headquarters Newholme Hospital

Baslow Road Bakewell

DE45 1AD

01773 824171 www.dchs.nhs.uk

30 September 2016 Steve Allinson, Chief Officer, NHS North Derbyshire CCG Andy Gregory, Chief Officer, NHS Hardwick CCG Scarsdale Nightingale Close Chesterfield S41 7PF

By email

Dear Steve and Andy

21C Joined Up – Better Care Closer to Home – feedback from Derbyshire Community Health Service NHS Foundation Trust Derbyshire Community Health Services NHS Foundation Trust (DCHS) has considered the 21c ‘Better Care Closer to Home’ public consultation at their Board Meeting on 29th September 2016. In terms of the clinical model and proposals for transforming inpatient assessment and treatment services for people with dementia and inpatient intensive rehabilitation and community services, the Board continues to support the plans as described. The new clinical models very much reflect our Trust strategy for the provision of these services and build on changes that we have implemented over the last 3 years. There were a number of important issues and concerns raised in the discussion that we feel need further consideration as part of the consultation process. These are in line with previous feedback regarding the proposals. The critical importance of carers supporting vulnerable people at home was a key point in

our previous discussions and the Board felt that there still needs to be a greater reference to their contribution and how they would be supported with the shifting focus to care at home. The final solution will need to consider dedicated resource to support this important issue.


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Appendix A

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Page 2

The Board have previously discussed resilience and how the new services will flex to manage seasonal, or other, surges in demand. Our system resilience response has, up to now, been largely predicated on the opening of additional inpatient capacity. Whilst the focus is shifting in 2015/2016 away from beds, implementation of these new models will require the development of a new approach to managing resilience which we felt requires further consideration.

There are significant workforce transformation challenges built into implementing the new models, including the recruitment of additional direct care capacity which we know is already challenging in many parts of the North Derbyshire system. While the financial aspect of the increase in provision is addressed in the business case, there is still a good deal of concern around the practical recruitment, training and retention of this hard-to-find group. The assurance from Commissioners that no service will be removed until the new service is up and running is helpful, but the practical challenge regarding finding the direct care staff still needs to be addressed. The Board appreciates that this is being looked at through the work currently underway in the Strategic Workforce Development Group.

Implementation of the new models will mark a step change in working across integrated

clinical and professional community based teams that we feel requires a greater focus and energy to support from the integrated governance enabling workstream. We do not feel fully assured that this workstream has published comprehensive and robust plans to take forward this work.

Members of the DCHS Executive and Senior Management Team conducted a series of staff briefing and drop-in sessions. We spoke to our Governors and with well over 1,000 colleagues face-to-face, taking on board their professional and personal opinions along the way. We were also pleased to be able to support the CCG-led public meetings, both as panellists and partners, to hear public opinion on the proposals. At every opportunity we have encouraged individuals and groups to feed back their comments directly to the consultation team. Additionally, we noted their collective comments, many of which were repeated. For completeness there is a summary attached at Appendix A, which should also be considered as an output from the consultation activity. Best wishes Tracy Allen Chief Executive [email protected] Cc Prem Singh, Chairman, Derbyshire Community Health Services NHS Foundation Trust Dr Ben Milton, Chair, NHS North Derbyshire CCG Dr Steve Lloyd, Chair, NHS Hardwick CCG




Appendix A Feedback noted by DCHS Executive and Senior Team Members from Trust Governors and staff feedback sessions: 1. In each locality there is vociferous support for their local hospital and wards. The public

recognise the very high standards of care that we deliver and in many cases associate this with the bricks and mortar of the buildings.

2. In the west of the County there was significant feedback about the perceived loss of 2 dementia Respite Care beds at Cavendish Hospital in Buxton. The CCG have confirmed that these beds are not part of this consultation.

3. The travel distances from the west of the County to Chesterfield for OPMH are seen as

onerous and impossible in the winter. Feedback from those in the Dales have made the same point.

4. Consideration needs to be given for family/carer transport solutions. At one meeting there was a commitment made by the Hardwick Chief Officer to fund this inevitable additional burden for those who need to visit in-patients where the travel distance is substantial.

5. There is a concern that clinicians may be less effective and efficient working in a community

team rather than in a centre. This fear relates to clinicians travelling between patient homes and also to equipment availability and the practical element of delivering therapy into people’s homes (e.g. parallel bars, rotundas).

6. A concern that the Dementia Rapid Response Teams (DRRTs) will only operate from 8am to

8pm, and that the out of hours requirements are not being addressed by the proposal. 7. Another particular concern linked to the 8pm-8am model was raised. When accompanied by

the cuts to social care budgets and access to care packages, there is a concern that the system may struggle to respond to a crisis after 8pm. It has been suggested that extending the scope of the current out-of-hours (OoH) nursing model should be considered to complement the existing Derbyshire Health United (DHU) service. Consideration should also be given to an OoH Integrated Community Team that includes the existing DHU nurses and care workers.

8. Significant concern was indicated about the lack of detail on the “beds with care” concept

and the local availability of this type of provision. Additionally some concerns were expressed about the private provision of these beds and that these should be commissioned through the public sector. It was suggested that the Care Homes Advisory Service could provide a useful resource (as has been demonstrated in the Amber Valley).

9. Consideration also needs to be given to the existing intermediate care beds at Eckington,

Dronfield and Stavely (each unit with 8 beds) as there will be implications if the proposed beds with care are commissioned i.e. beds will need to be de-commissioned.




Page 4 10. A number of comments have been received questioning whether the beds with care could

be attached to, or form part of, the retained inpatient bed base. 11. Any future model must give adequate consideration to accessing equipment and its safe use

in patients’ homes and the “beds with care”. A safe and clean care and working environment must be a priority to safeguard clinical quality. Consideration should be given to in-reach service provision of deep cleaning to those patients who will be cared for at home under the new model.

12. Significant clinical benefits are delivered in the current model to inpatients from receiving

quality food while in hospital. It has been suggested that high quality nutrition should be made available to patients being cared for at home by making food available on prescription from clinicians while they are in the care of the community and DRRTs.

13. Staff are aware of an imminent review of day services by Derbyshire County Council. We

believe it would be prudent therefore to review the day units across the County in partnership with Derbyshire County Council.

14. There were concerns raised that the current Integrated Community Teams already have

capacity challenges managing current demand and that this will need addressing before any expansion. Additionally, there were a number of comments on the training that would be required to help the staff transition into community roles, which acknowledged that this is already happening.

15. While the proposal is clear that the proposed rehabilitation beds at CRH will be managed by

DCHS, there were concerns that at times of significant pressure on beds at CRH that there would be significant pressure to breach the criteria for the ring-fenced rehabilitation beds. There was a request for more detail on how this will be addressed to ensure that only suitable patients were admitted to the rehabilitation beds.

16. The commitment by commissioners that no service would be removed without a new,

appropriate service being in place was welcomed. Commissioners will need to clarify how the demonstration of this will be measured and demonstrated in practice, and over what period.

17. Commissioners will need to clarify how this consultation links into and complements the

system-wide plans (STP), particularly with regard to joint funding across other parts of the County which are not included in the Better Care Closer to Home consultation.



Appendix B

Objective Priorities 2016/17 TargetPlan to end of

September

Clinical Effectiveness -Over 75 clients using our ICS services assessed for frailty (%) 95% 0% 0% (GREEN) 95% (GREEN)

Patient Experience - Improvement in time to respond to complaints 80% Within 40 Days 70% 50% (RED) 80% (GREEN)


September

Ensuring all staff are complaint with essential learning 96% 96% 95.5% (AMBER) 96% (GREEN)

Improving staff wellbeing by reducing work related stress and anxiety

20% reduction in number of days lost (300 days) to stress and anxiety based

on 15/16 averages to below (1,200 days)

20% 9% (RED) 20% (GREEN)


September

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

Quality Improvement Plan (SQIP)

£5m Sustainable Quality Improvement Plan (£000)

2,015.9 2,104.3 (GREEN) 4,827 (AMBER)

Measuring the progress towards becoming a more agile organisation by reducing the spend on non-

Clinical estateLess than 7,270m2 7,270m2 6,520m2 (GREEN) <7,270m2 (GREEN)

Responding to the main issue raised through staff feedback by monitoring the perceived improvement

in IT connectivity for staff

Less than 35% of staff Often or Always Experiencing Connectivity Problems 35% 33% (GREEN) <35% (GREEN)

Big 9 - September 2016

Quality Service

Achieved to end of

SeptemberForecast

To deliver high quality and sustainable services that echo the values and

aspirations of the community we serve

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

20% Reduction in Baseline of 793 Pressure Ulcers

5% (178) 9.9% (164) (GREEN) 20% (293) (GREEN)

Quality Business

Achieved to end of

SeptemberForecast

To ensure an effective, efficient and economical organisation which

promotes productive working and which offers good value to its community and

commissioners

Increase (GREEN)

Quality People

Achieved to end of

SeptemberForecast

To build a high performance work environment that engages, involves and supports staff to reach their full potential

Improved position of staff reporting incidents of violence and aggression they encounter at work

Month on month increase in reporting compared to 15/16 data 29 41 (GREEN)





Governor involvement will be key in developing the STP and the next stage of collaborative working with DHcFT.


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


Better Care Closer to Home consultation has involved very significant input from staff, patients, and the public. Engagement of the whole workforce will be required as the STP and DHcFT collaboration proceed.

Risk Register

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

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



TRUST BOARD Document Title: Performance Report

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

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

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



Has an Equality Impact Assessment been undertaken Yes No x

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

Purpose of Paper

The purpose of this paper is to present the Board Performance Report. The Performance Report sets out a summary of Derbyshire Community Health Services (DCHS) performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. The Balanced Scorecard has been reviewed to incorporate the contractual and other performance regime changes in 2016/17. There are 19 green, 5 amber, 4 red, and 2 unrated indicators this month.

Recommendations

Note and comment.


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

Financial Impact

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


Report attached

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


Equality and Diversity measurements are recorded in the report


The report includes measurements of service experienced by patients

Risk Register


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



Board Performance Report – September 2016 Background The Board Performance Report sets out a summary of Derbyshire Community Health (DCHS) performance against the three DCHS Way focus areas of Quality People, Quality Service and Quality Business. Section Index Document Page Number 1.1 - Executive Summary 2-3 2.1 - Performance Dashboard 4-5 3.1 - Quality Service Narrative 6 4.1 - Quality People Narrative 7-8 5.1 - Quality Business Narrative 9 6.1 - Appendix 1 – Exception Reports 10-14 6.2 - Appendix 2 – Key Issues Quality Service Committee – Pressure Ulcers

15-20



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

Quality Service

• Length of stay for September was 19.4 days and 19.8 days for the 3 month year to date.

• The Delayed Transfer of Care score for September was 9.5% against a target of 7.5%. This has been red rated. An exception report is presented at page 10.

• The overall occupancy rate for September was 76.8% against a target of 85%

• There were 7 avoidable grade 2, 3 & 4 pressure ulcers for the month. An improvement target of 34 has been developed for the year. More detail is provided in Appendix 2 at page 15.

• There were no falls in September.

Quality People • Staff Attendance was 95.08% against a target of 97% and 95.04% for the

average of the past 12 months.

• There were 2 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) Zero Harm events in September against the zero harm target. For the year to date we have had 8 events against an improvement target of 10. This has been green rated.

• Agency costs as a percentage of the pay bill were at £0.90m for the year to

date. The target is £0.63m. An exception report is presented at page 11.

• The Appraisal rate for September was 90.24% against a target of 96%. This has been red rated. An exception report is presented at page 14.



Quality Business

• The Sustainable Quality Improvement Plan (SQIP) stood at 42.1% for September against at target of 40.3%. This has been green rated. Details have been discussed in the Finance Report.

• Progress against the Information Management & Technology (IM&T) Plan is 65.3% against a target of 65.3%. This has been green rated. Quality Governance

• Our Governance rating is green rated. We are currently meeting all our Risk Assurance Framework targets and are forecasting to maintain our green rating for the year.



DCHS Board Performance Report 2016/1715/16 Month

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

QUALITY SERVICE

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

Length of Stay 20.3 19.4 19.8 20.0 20.0 - Inpatients

Delayed Transfer of Care 8% 9.5% 7.9% <7.5% <7.5% - Mental Heath 0.9%. Inpatients 9.5%

Occupancy 79% 77% 77% 85% 85% - OPMH & Inpatients. For information

Information Sharing - 88.0% 88.0% 82% 88% -

Caseloads - - - - - - Under development

RTT Admitted - 96% 91% For Information For Information -

RTT Non Admitted 98% 97% 97% 92% 92% >92%

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

Harm Free Care 93% 92.8% 92.9% 94% 94% 93%

Pressure Ulcers 63 7 30 22 34 - Target is an Improvement trajectory

% of Qualified Shifts Covered - 84% 84% 80% 80% 80%

Falls Resulting in Severe Injury 20 0 14 5 9 -

Never Events 0 0 0 0 0 0

Outturn

CARING

EFFECTIVE

RESPONSIVE

SAFE

Year to Date



DCHS Board Performance Report 2016/1715/16 Month

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

OutturnYear to Date

QUALITY PEOPLE

Appraisal Rate 94% 90% 90% 96% 96% 96%

Attendance Rate 95.62% 95.08% 95.04% 97% 97% 96%

Engagement Index 0 78 78 75 75 77

RIDDOR Reported Injuries 17 2 8 10 17 20

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

Agency Costs as percentage of Paybill (£m) 1.46 0.16 0.90 0.63 1.46 1.63 3% calculation - £1.46m for 16/17

QUALITY BUSINESS

I&E Surplus -2,654 -4,117 -4,117 -3,589 -4,560 -4,560

Cash 16,974 20,757 20,757 17,754 17,242 14,336

Sustainable Quality Improvement Plan 100.9% 42.1% 42.1% 40.3% 100% 96.6%

Progress against IMT Plan 61.2% 65.3% 65.3% 65.3% - -

Estate Utilisation-

- - - - - Proportion of space unoccupied (%) under development

QUALITY GOVERNANCE

NHS England Quality Surveillance Rating - Green Green Green Green Green

Governance Rating - Green Green Green Green Green

CoS Rating 4 4 4 3 3 4

AMHAM Audits - 0 5 5 10 10 Associate Mental Health Act Manager

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



3.1 – QUALITY SERVICE NARRATIVE

• Overall performance in month is positive with many metrics rated as green, the notable exception continues to be the number of pressure ulcers being managed across our services.

• Particular focus is being given in the Derby City area were the trend for

avoidable pressure ulcers is higher, an additional tissue viability specialist nurse has been allocated to this area to support improvement work.

• The trusts harm free care score continues to fall below our improvement

target of 94% due to the high prevalence of pressure ulcers. A driver diagram detailing key actions for driving down incidence of pressure ulcers has been developed and discussed at QSC.

• The trust has been rated as ‘Good’ by the Care Quality Commission for safe

care.



4.1 – QUALITY PEOPLE NARRATIVE

• Reduction in Time Lost to Stress and Anxiety (Big 9) (days) – has seen a very positive reduction in recent months, decreasing from 1,517 days in June to 1,191 in July, and staying relatively static at 1,251 in August, and 1,362 in September. We have therefore not achieved the Big 9 target this month of less than 1,200 days, by 162 days. There is a lot of focussed work occurring in this area. We launched a campaign on International Mental Health Awareness day to share stories of DCHS staff who have suffered with severe stress and anxiety in their past but have found ways to recover from that position. We have also managed to increase counsellor time at Resolve for October in response to an increase in referrals, particularly in areas affected by change such as the 21c consultation.

• Staff Attendance (%) – In September attendance decreased very marginally to 95.08%. The average of the last 12 months is 95.04%. The September absence rate is 4.92%. The activity of our Staff Wellbeing Lead is focussed around exploring all routes available to improve this figure as we are very aware that this is the one people KPI which is of persistent concern.

• Agency Costs as percentage of Paybill (£m) – As the Board are aware, the Trust has an NHS Information (NHSI) Agency usage ceiling set for us at £1.46 million. Agency costs are £0.90million for the year to date against a forecast of £0.63 million. This has been red rated and has been raised as a financial risk on DATIX. An exception report is provided with more detail, including a revised year-end forecast.

• Zero Harm - RIDDOR Reportable Injuries (no) – There were 2 incidences of Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) in September. That takes the annual total to 8 incidences against a target of 10. This remains green rated for now, but Board need to be aware that if we experience more than 2 more RIDDOR incidents this year, this KPI will be red rated. All RIDDOR incidents are thoroughly investigated by the Health and Safety Team and are discussed at length at both Staff Wellbeing and Safety Group and QPC and no trends are apparent in the incidences that have occurred this year.

• Essential Learning (% Compliance) – 95.47% (96%) of staff have completed their Essential Learning within the past 2 years, as at the end of September. This is a great position for this point in the year, in comparison to previous years.



Training - Resuscitation & Safeguarding (% Compliance) - Resuscitation

and Safeguarding compliance are the areas of concern across our Essential Learning topics. An exception report is provided for both.

• Staff with appraisal completed (% compliance) – This measure is red rated for September with 90.24% of staff being compliant against a target of 96% An exception report is enclosed.



5.1 – QUALITY BUSINESS NARRATIVE

• The financial position at month 6 is reporting a surplus of £4.12m which is a favourable variance to plan of £0.53m. We are planning to achieve our year-end control total of £4.6m surplus.

• The Sustainable Quality Improvement Plan (SQIP) plan is £0.093m ahead of plan, although this is supported by non-recurrent schemes. The outturn position is forecasting an underachievement of £0.1m, and a recurrent underachievement of £0.48m.

• Cash is £3.4m ahead of plan, with a cash balance at the end of the month of £20.8m. Cash is forecast to reduce over the second half of the year as disputed invoices are paid (in relation to property costs) and the capital programme accelerates.

• The Trust has yet to receive a control total for capital, and at this late stage in the year is unlikely to receive one. We are therefore planning on the programme submitted as part of the Annual Plan. We are experiencing slippage on some schemes, and the programme is being reviewed through the Capital and Estates Group. An update will be provided through to the November 2016 Quality Business Committee.

• The IMT plan is progressing. The roll-out of TPP, our clinical information system, in the community is on track. Deployments have begun in both the High Peak and Derby City localities.

• The business intelligence project is progressing well, with good evidence of increased user engagement as more products come on line. The Quality People dashboard has now been completed, and two business intelligence projects are now close to completion in the Health and Wellbeing Division. The Integrated Sexual Health KPI dashboard, results reporting dashboard and operational reporting dashboard is progressing well, and picks up on issues raised by the Care Quality Commission at their recent visit. Similarly progress is being made with the Childrens service KPI dashboard.



Measure Type Frequency2016/17 Full Year

TargetYTD Target Q2 Jul-16 Aug-16 Sep-16 YTD

Delayed Transfer of Care (%) - Inpatients & OPMH External Monthly <7.5% <7.5% 7.9% 7.6% 8.4% 9.5% 7.9%

`

1-Summary of Issues:

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

3-TimescalesFollowing November 3rd event actions will be implemted across DCHS Community Hospitals

4-Effect of this Exception on the Forecast Plan (how we get to our final forecast position from here)The Peer Review may well help with the DTOC position. Interagency referrals do not initiate the same level of response as those in the Acute Hospitals which directly affects the Commuity Hospital DTOC. This can be addressed within the Review and should have an impact on the DTOC rates by month 8.

Exception Report Analysis

DCHS continues to work with Acute hospitals and Adult Social Care colleagues in reducing delayed transfers of care (DTOC) across the system. The rehabilitation wards had a DTOC of 11%.The main area of concern continues to be accessing packages of care, mostly in the more rural areas but not exclusively. The closure of a Care Home in Ashbourne several weeks ago continues to have an impact and another one has given its residents 4 weeks notice.Specific issues are as follows;Butterly Ward at Ripley had a DTOC rate of 15.1% which was mostly due to 46 days awaiting care packages or long term care placement.Okeover Ward at St Oswald’s was 9.11% with 30 days waiting for either care home placements or packages of care to go home.Alton Ward at Clay Cross had particular difficulty with a care package for a patient that was self -funding and in getting in touch with family.Manners Ward at Ilkeston had one patient that agreed to a care package but then refused it when he realised he would have to make a financial contribution. Two others waited for care packages.Hopewell Ward at Ilkeston had five patients delayed through complex issues ranging from waiting for a stairlift to be fitted and being unable to find a temporary respite bed to waiting for allocation of a temporary social worker when the regular worker was on annual leave. Issues over funding of a complex care package led to the delay in being able to arrange care from several organisations.Hudson Ward at Bolsover had a DTOC rate of 16.6% with three patients being delayed. Two waited for packages of care, the third was a complex issue primarily because they were homeless.Oker ward at Whitworth again had complex discharges with one patient being delayed when spouse became ill and struggled to identify suitable residential home. When a home was identified a there was further two week wait for a place to become available. A funding decision for one patient, care manager allocation for another and specialist equipment for the third accounted for the rest of the delays.Fenton ward at Buxton and Baron Ward at Babington recorded DTOC rates of 3.6% and 4.6% respectively.

Action Plans

Derbyshire County Council Adult Care are undergoing a peer review into DTOC on November 3rd which DCHS representatives are attending in order to conduct a review of policy & procedure into DTOC taking the following into consideration and agreeing report conclusions and action planning• How delays are identified and recorded • Criteria for categorising a delayed transfer• Consistency of understanding and application• Reporting arrangements and interagency sign off System Resilience Lead & Community Hospital Matrons to identify specific escalation plans for ward staff to follow to ensure early interventions where potential delays can be predicted. Action System Resilience Lead & Community Hospital Matrons

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% o

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Actual %

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Measure Type Frequency Director2016/17 Full Year Target

YTD Target Q1 Jul-16 Aug-16 Sep-16 YTD

Agency Costs as percentage of Paybill (£m) External Monthly DoSD 1.46 0.90 0.53 0.67 0.74 0.90 0.90


2. Action Plan

3-Timescales

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


As Board are aware, DCHS have been issued an agency staff target spend of £1.46m for 2016/17 by NHS Improvement; this is inclusive of all agency workforce, not just nursing as was the case last year. This target is lower than our overall spend in 2015/16, which was £1.6m, so was always going to be a challenge to achieve. However, adding to this challenge, we now have additional services within DCHS including 3 GP Practices, and Derby City Community teams, both of which have a history of needing to use agency staff to meet demand.We reported last month that we were not meeting our trajectory to hit this target, and that trend has continued into September. We have now revised our forecasted year end position to £1.63m, increasing from the £1.6m forecast last month.

We are now forecasting a £1.63m expenditure.

All actions agreed at QPC and Executive Team Meeting are in progress, most are in place.

Below, Board can review a summary of actions taken and ongoing:Agency Expenditure Target- We have successfully recruited additional team members to our Responsive Workforce team. This now includes band 5 S/Ns, band 6 specialist nurses, a paramedic, and HCAs. We are currently recruiting to therapy posts.- We have introduced an incentive for bank staff who do more than 10 shifts per month to increase our bank fill rate.- We have been recruiting additional posts to our bank, including sexual health nurses, and therapists.- We are implementing ‘Responsive Bank’ shifts to our rosters, which are staff booked additional to establishment at weekends who book their shift on the basis they may be moved at the last minute to respond to patient acuity or last minute sickness.- We are in the middle of a large-scale recruitment campaign which aims to not only fill current vacancies across our clinical areas, but also anticipates where we might need extra staff or where vacancies might arise. A Recruitment Fair held at Chesterfield Market on 15th October has resulted in over 30 applications for posts. A second fair is happening on 22nd October in Derby to recruit to the south of the county.- We have introduced a central ‘staffing monitoring’ service within POE, which provides daily monitoring of staffing, finding solutions to gaps without using agency wherever possible.- We are now scrutinising agency spend line by line to remove any unnecessary expenditure.

Over Price-Cap Prevention- We have been heavily involved in a regional project to reduce agency rates with our main agency staff suppliers, bringing their costs ‘under price-cap’. The most recent agreement means that there are now only a handful of agencies who are not ‘under price-cap’.- All off-framework and over ‘price-cap’ agency usage is now authorised by an Executive Director providing senior oversight.

In addition to actions which are in progress, we are now also considering:- Further incentivising our bank pay rates to increase fill rate. However, this is to be discussed at a systems-wide level as increasing rates in one Trust will only affect another.- Discussing opportunities to work on this with DHFT to increase our effectiveness by working on a larger-scale.

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Agency Costs as Percentage of Paybill (£m) Cumulative - September




YTD Target Q2 Jul-16 Aug-16 Aug-16 YTD

Resus Training (% compliance) External Monthly DoSD 96% 96% 87% 86% 87% 87% 87%


2-Actions

3-Timescales



The compliance position has remained static at 87% this month. This is due to ILS compliance dropping have due to the move to the new Streamlining CSTF competencies, and this being a new requirement for OPMH/LD and Dental Staff which they weren't required to do before. Thus we are still catching up with this new requirement for these staff, affecting compliance. More ILS courses are required, as courses that were advertised earlier in the year were not been fully subscribed to due to service pressure and sickness.If we do not add these additional dates or up numbers (if possible) then we will not be on target for year end. We are currently working on freeing up capacity to add these required extra sessions.

We are expecting a steady increase in compliance from December.

Extra capacity for ILS is currently being worked up to improve compliance.

Between December 2016 and January 2017 more CPR and ILS courses will be required and the WFPD team are currently scoping this. If this is not undertaken the targets will not be met. Planning for next year a further 15% buffer will be required to cover DNAs as the current 10% is proving to be not enough.

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Resus Training (% Compliance) - September



Measure Type Frequency2016/17 Full Year Target


Training Children L2 (%) External Monthly 96% 96% 90% 87% 87% 88% 88%Training Children L3 (%) External Monthly 96% 96% 84% 79% 81% 80% 80%Training Adults L2 (%) External Monthly 96% 96% 92% 87% 87% 88% 88%


2. Action Plan

3-Timescales



Safeguarding training compliance has consistently been below target since the start of the financial year, although it has remained relatively constant. It should however, be noted that the requirements for safeguarding training changed in 2014 and it was agreed within the organisation that it would take approximately 2 years to see an improving picture with regards overall compliance rates. The Safeguarding Team will continue to provide extra sessions to meet demand. A process is being developed to ensure that the team are aware that sessions are full promptly so that they can add more capacity in times of higher demand.

It is expected that the plan of action will simplify/reduce the amount of training that Level 2 staff require, improving attendance and compliance. For current DCHS by end of the financial year and for new starters from April 2017. Therefore we expect to see small improvements in compliance immediately, with more radical improvement from January 2017.

Merging of Adult and Children's training will take place from January 2017. Changes to the Induction programme are planned for April 2017.

The training provided by the Safeguarding Service is currently under review. The Safeguarding Team plans to reduce/streamline the training requirements for DCHS staff by merging Children and Adult Level 2 Training (Think Family). The Safeguarding Service and WPDT are currently carrying out a review of the Induction Programme. These changes will ensure staff meet the requirement of the Intercollegiate Document which sets out the requirements for Safeguarding Training, whilst spending less time away from their workplace on training.

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Safeguarding (% Compliance) - September





Staff with appraisal completed (% compliance) External Monthly DoSD 96% 96% 90% 92% 92% 90% 90%


2. Action Plan

3-Timescales



There has been a reduction in compliance from 92% to 90%. This is the first time this financial year that we have seen any real decrease in this KPI.

By continuing with the current approach of email contact, but with the support of the business managers, an increase in completion should be seen to reach the YTD target of 96% by year end.

We expect the position to improve within the next quarter.

The Workforce Development Team continues to make contact with managers who have outstanding Appraisals. This is done by email with support offered from either the QBS or the WFD Team if there are process issues to blame for why Appraisals are not recorded as completed. This chasing system is going to be reviewed this month to ensure it is as responsive and efficient as possible. The Workforce and Development team are also going to work closely with Business managers to ensure the accuracy of compliance data across each of the Divisions.

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Appraisals Training (% Compliance) - September



APPENDIX 2 – KEY ISSUES QUALITY SEVICE COMMITTEE Pressure Ulcers (Analysis from Tissue Viability Matron) The prevalence in this area for September is 6.87% (August was 7.41%). ‘New PU’ prevalence for September is 1.15% (August was 1.03%). Current Position:

• Data Analysis - DCHS

Graph 1 provides a breakdown of the total number of pressure ulcers (304) reported and verified in September, of which 57% developed or deteriorated under DCHS care. The graphs control limits have been adjusted in line with strategic shift from October 2015.

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

TOTAL ACTIVITY TOTAL PUs Mean No. of PUs UCL LCL



Graph 2 relates to pressure damage developing or deteriorating within DCHS services. The data for September represents a downward trend with 173 incidents reported as acquired or deteriorated. There was 1 reported grade 1 ulcer (0.5%), this low number is due to a change in reporting where grade 1 ulcers are reported on SystmOne as it is not mandatory to report this level of damage as they usually resolve after 3-5 days. 122 incidents (70.5%) were reported as grade 2/multiple grade 2 ulcers. There were 14 (8%) confirmed grade 3 and multiple grade 3 ulcers. There was 2 grade 4 ulcer reported (1%) and a further 14 incidents (8%) were reported as potential grade 3, which are awaiting confirmation and the remaining ulcers 20 incidents (11.5%) were reported as deep tissue injuries of which the severity have not yet been confirmed as still in the early stages of evolution, so that it is not possible to see extent of damage. These incidences are being monitored on Datix. Drilling down into the locality level data, the 3 highest reporters of incidents of developed or deteriorated include the following; Derby City teams reported. 58 incidents (33.5%). Reporting is suggesting a downward trend. North Eastern Derby’s (previously known as North East & Bolsover) reported 36 incidents (20.8%) which is a slight decrease from last month. Chesterfield reported 24 Incidents in September with the majority of these being reported as grade 2 which suggests a proactive approach to reporting.

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Graph 2 - Developed and Deteriorated Pressure Ulcers for DCHS

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Graph 3 Avoidable Pressure Ulcers (Ambition One – grade 2,3,4 & multiples)

There were a total of 7 avoidable pressure ulcer incidents verified during September 2016. Investigations are still on-going to determine the avoidability of remaining incidents reported within September 2016.

Graph 4 demonstrates Grade 3 and 4 Avoidable Pressure Ulcers by locality and teams following RCAs. It should be noted that this data relates to the month the avoidable status

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Graph 3 - Total number of Verified Avoidable Pressure Ulcers by incident date for DCHS

TOTAL ACTIVITY TOTAL PUs Mean No. of PUs UCL LCL

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Graph 4 - Grade 3 and above verified avoidable pressure ulcer incidents 2016-17

Grade 3

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was verified and not the month the incident was reported. There are 19 avoidable grade 3 and 3 avoidable grade 4 pressure ulcers confirmed since the beginning of April 2016. 6 of which were verified during September

Graph 5 demonstrates the most common reoccurring themes in all incidents investigated which significantly relates to patient long term and complex conditions, and non-engagement of patients. In addition poor communications between teams, incomplete documentation, and recognising changing conditions, provision of equipment and escalating and updating documentation to reflect this. It is believed with the roll out of the SSKIN Templates on Systmone that the prompts within the template will help clinical staff achieve these standards more easily.

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Graph 6 demonstrates all grades of avoidable pressure ulcer incidents identified during September by teams. Themes for this are outlined under graph 4. Focused Actions Being Taken There is indication of increased uploading of photographs onto SystmOne, and discussions have been had with IT on exploring options as to how we can monitor this against Tissue Viability Response times. Systems and processes are being reviewed to see how this can be measured. It is also noted that it takes a significant amount of time for the photograph to open (up to 5 minutes) and IT have been asked how photographs could be opened in a more timely manner. Crib sheets including SSKIN, Wound Management and how to upload photographs have been uploaded to SharePoint so that clinical teams can access a quick’ how to guide’ to help support effective implementation as the project is rolled out further. Additional support to clinical teams can be arranged via locality Tissue Viability Nurse, Diana Mellor or Professional Standards. In line with new Serious Incident (SI) Reporting, Grade 3 and 4 ulcer incidents are being reviewed on an individual basis using the revised SI framework. Six questions have been agreed that will be piloted by locality teams investigating incidents to identify Pressure Ulcers grade 2,3 and 4 that do not meet the serious incident criteria. Initially these will be piloted using a form that can be uploaded to Datix and following review of pilot these will be added to the Datix so that trends can be monitored. It is believed the time released from RCA report writing could be invested in supporting the clinical team in a back to the floor day- where senior leaders will shadow and support teams in clinical practice. It is felt that having Senior Role Models shadowing and supporting clinical teams will help embed standards in care. A pre pilot survey has been developed to establish views from Intermediate Care Team Leaders and Tissue Viability team prior to the pilot

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Graph 6 - Derbyshire County Verified Avoidable pressure ulcers by ICBS or Ward 2016-17

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Work continues with piloting pressure mapping devices. Initial feedback is that this initiative has been received very positively by care staff as it prompts them to move patients more frequently as they can see early indication of increased pressure over bony prominences because of changes in colour to body map. There has been however difficulties in getting clinicians to complete the evaluation sheets and this has been escalated. An action plan has been developed to increase staff awareness of the benefits of this resource and discussions with patients and carers to invite to give their opinions in a patients story

• The Pressure ulcer project is on DCHS priority audit plan and is a multi-faceted project which involves Clinical Effectiveness and Audit Team working with Tissue Viability, Commissioning for Quality and Innovation (CQIN) and Quality Team as well as sharing learning from Quality Always and the Clinical records Audit.

o 1-Capture of patient outcomes as a result of audits completed 15/16 o 2- Audit of safe care assessments to ensure they are completed and inform

safe, effective care for patients. o 3- Evaluation of the changes to the Root Cause Analysis process, introduction

of the new processes o 4- Evaluation of new smart phones introduced. Demonstrate effectiveness. o 5- Evaluation of the introduction of pressure mapping devices

• Further adaptions have been made to the Pressure Ulcer Standards Tool and these

are being reviewed by Tracey Brailsford (Clinical Audit). It is anticipated that that this tool will be undertaken quarterly by the Safe Care Champions so as to help evaluate locality performance and evaluate progress in relation to meeting standards in the future. With the roll out of the new SSKIN Bundle, this will be more easily to complete as all relevant data will be available within the SSKIN Bundle templates on system one. Completed audits will be analysed by Tracey Brailsford, so that an overview of the Trust performance to standards can be monitored.

Recruitment has been successful for the clinical trainer and Band 6 Tissue Viability Specialist roles and it is expected that these colleagues will be in post by November.



TRUST BOARD Document Title: Financial Performance Report

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

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




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

Purpose of Paper

The paper sets out the financial performance of the Trust as at 30th September 2016. The report details performance against statutory and internal targets. The Trust is reporting a surplus position of £4.12m at month 6, which represents a £0.53m favourable surplus variance against the planned surplus of £3.59m. The cash position is £3.4m ahead of plan. A year end surplus of £4.56m is forecast. The cash position is forecast to be £14.3 million at the end of March 2017. The Trust is forecasting that it will meet all its statutory financial duties for the year.

Recommendations

Board Members are asked to receive the Report.


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

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

Financial Impact

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

264�Financial�Performance�RepoOverall�Page�56�of�171Page�1�of�13




Report attached



Governors will hold the Board to account around its financial position

What are the Equality and Diversity implications? None


None

Risk Register


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



WORKING CAPITAL20.76 G 14.34 R14.20 G 7.46 G

£m % £m % % £m % £m % £m % (13.50) G (9.71) GEBITDA (6.80) (7.07) (7.17) (7.42) 5.31 (10.99) (5.72) (10.60) (5.50) 0.40 (3.60)

Net (surplus)/deficit (3.59) (3.73) (4.12) (4.26) 14.71 (4.56) (2.37) (4.55) (2.36) 0.01 (0.22) RISK RATINGSFinancial Sustainability Rating - Capital Servicing (x times) 6.10 G 4.51 G

I&E SURPLUS (excl. IMPAIRMENT) I&E SUMMARY AS AT 30 SEPTEMBER 2016 Financial Sustainability Rating - Capital Servicing 4 G 4 GFinancial Sustainability Rating - Liquidity (days) 25.88 G 20.21 GFinancial Sustainability Rating - Liquidity 4 G 4 GFinancial Sustainability Rating - I&E margin (%) 4.26 G 2.37 GFinancial Sustainability Rating - I&E margin 4 G 4 G

(£m) (£m) (£m) (£m) (£m) (£m) Financial Sustainability Rating - I&E margin variance (%) 0.53 G 0.00 G(96.19) (96.54) (0.34) (192.08) (192.67) (0.59) Financial Sustainability Rating - I&E margin variance 4 G 4 G

PAY 64.81 64.73 (0.08) 130.55 130.82 0.28 Overall Financial Sustainability rating 4 G 4 GNON-PAY 24.58 24.64 0.06 50.54 51.25 0.70 Agency spend (£m) 0.90 R 1.63 ROTHER 3.22 3.05 (0.17) 6.43 6.04 (0.40)

(3.59) (4.12) (0.53) (4.56) (4.56) 0.00 PERFORMANCE AND SQUIP YTD FOTContract over/(under) performance (£m) 0.23 G 0.43 G

CAPITAL PROGRAMME MONTH END CASH BALANCE Over/(under)achievement of SQUIP target (£m) 0.09 G (0.17) A(Over)/underspend against investments (£m) 0.00 G 0.00 GNet impact of SQUIP/investments/NR savings (£m) 0.09 G (0.17) A

ADDITIONAL TRIGGERS YTD FOTReceivables aged over 90 days (%) 5.0 7.2 R 5.0 GPayables aged over 90 days (%) 5.0 45.9 R 5.0 GChange in Finance Director in last year 2 0 G 0 GInterim Finance Director in place over QE 2 0 G 0 GDays expenditure covered by QE cash 10 42.4 G 28.7 GCapital Expenditure % of plan (%) 85.0 47.7 R 100.0 G

DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST FINANCIAL PERFORMANCE REPORT

PLAN ACTUAL VARIANCE PLAN FOT VARIANCE

SEPTEMBER 2016 KEY FINANCIAL INDICATORS

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

SEPTEMBER 2016

FOTYTD

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

Current Liabilities Variance (£m)£m

VAR

FOT

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(0.53)

(0.36)

INCOME

TOTAL

SEPTEMBER 2016

YTD

FOTYTD

VAR

ACTU

AL

PLAN

0.0

1.0

2.0

3.0

4.0

5.0

Cum

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surp

lus

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)

Plan Actual Forecast

0.0

5.0

10.0

15.0

20.0

25.0

Cas

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m)


0.01.02.03.04.05.06.07.0

Cum

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(£

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DERBYSHIRE COMMUNITY HEALTH SERVICES NHS FOUNDATION TRUST

MONTHLY FINANCIAL PERFORMANCE REPORT FOR TRUST BOARD AS AT 30TH SEPTEMBER 2016

1. Introduction The purpose of this report is to update and inform the Trust Board on performance against key financial criteria for month 6 of the current financial year, 2016/17. The Trust is reporting a surplus position of £4.12m at month 6, which represents a £0.53m surplus variance against the planned surplus of £3.59m. We are forecasting a year end surplus of £4.56m, which is consistent with our control total set by NHS Improvement. The general mitigation reserve of £1.3m remains uncommitted and unallocated at Month 6. 2. Summary Financial Position The financial risk of the Trust is measured by the Financial Sustainability Rating as part of the provider license. A rating of 4 is low risk, whilst a rating of 1 is high risk. The Trust is forecasting a rating of 4 at the year-end. This reflects the strong balance sheet of the Trust and the forecast surplus position. The recent issue of the Single Oversight Framework will result in a change in the way the financial position is monitored by the Regulator. The new reporting will be introduced from month 7, and will be considered by the Audit and Assurance Committee at its October meeting. The Trust is forecasting a surplus of £4.56m. This is supported by £2.14 million non-recurrent income, and £0.3m non recurrent efficiencies. Therefore the underlying forecast outturn surplus position of the Trust is £2.12m surplus. Table One – Financial Sustainability Rating The Trust’s Performance against the new Financial Sustainability ratings is detailed in the table below. The Trust achieved a rating of 4 at year-end. This reflects the strong balance sheet of the Trust.

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

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

25% 25.88 4 20.21 4

Capital Servicing

Revenue cover available to service debt repayments

25% 6.10

4 4.51 4



I&E Margin (%)

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

25% 4.26 4 2.37 4

I&E Margin Variance (%)

Year to date variance from plan

25% 0.53 4 0.00 4

Overall Rating 4 4

To move to a forecast outturn rating of 3, there would need to be deterioration in the income and expenditure position of £2.6m. A further reduction to the position of £1.2m or a total of £3.8m would move the overall rating to a 2. Table Two – “Agency Spend” metrics The Trust’s performance against the Agency Spend metric is detailed below which shows our spend is behind the submitted planned run rate due to a combination of the following the impact of Flexing the number of beds DCHS have open, complexity of patients currently in the beds and out in the Community, the level of vacancies within the services and sickness levels across the Trust.

Measure Indicator Year to date Year End Outturn Actual

£m Target

£m Actual

£m Target

£m Agency Spend Spend against

Planned Trajectory

0.90 0.63 1.63 1.46

Due to the Actual Spend being significantly ahead of the Planned Trajectory an Exception Report on Bank and Agency spend will be included in the Performance Report. 3. Income & Expenditure Appendix 1 details the Income & Expenditure Statement as at month 6. More detail on the income and expenditure position is provided below.

3.1 Clinical Income At month 6 the clinical income position is showing an over performance of £0.23m against plan, an improvement of £0.42m from month 5. The year-end forecast has significantly improved and we are now anticipating £0.43m over performance. This improvement is partly due to previous issues with coding (linked to the new TPP system) now being resolved, and MIU activity seeing a significant increase. The main areas of over-performance being seen year to date are in Accident and Emergency (£0.18m, 9.5%) and Community Podiatry (£0.06m, 2.2%). This is being off-set by



underperformance in Sexual Health (£0.10m, 4.4%) and Speech and Language Therapy (£0.66m, 4.0%). Activity against plans will be closely monitored throughout the year to ensure early identification of under / over –performance and any associated risks to income.

3.2 Non-Clinical and Other Income

Across the majority of Services and Divisions Non-Clinical Other Income is ahead of plan by £0.11m due mainly to the receipt of additional non-recurrent income, however within the IFM Division there is an under-recovery of £0.06m against plan mostly due to other organisations leaving our premises and the loss of Contracts for Domestic Services within NHS Property Services premises.

3.3 Expenditure Overall, the Trust is reporting an underspend against the expenditure plan of £0.19m at month 6. Pay costs are underspent compared to plan by £0.08m which is predominantly due to the significant number of vacancies within Health and Wellbeing, Estates and Corporate Divisions which are helping to offset the underlying overspends on Bank and Agency within Integrated Care Services and Planned Care which are covering Bed Increases across a number of Wards, Patient Acuity, Vacancies and Absence. Other Pay issues relate to Medical Locum cover within General Practice. Total Agency and Flexible Workforce (DCHS Bank Staff) costs in September are slightly higher than the monthly average spend and combined together overall represent 2.9% of the Total Pay Spend to date. Agency Spend increased during September 2016 and although there is now increased security on shift requests, due to patient acuity, the volume of vacancies and sickness within General Practice the costs were slightly higher than the year to date average. Agency cost represents 1.4% of the Total Pay Spend to date. During September actual pay costs have increased by £0.19m compared to August due to the increase in Agency Spend and a number of new Health Visitors starting within Health & Wellbeing. Non-pay Costs are overall showing an underspend against plan of £0.11m. With the exception of Health and Wellbeing most Divisions have cost pressures within their Non-Pay Budgets. The main pressures on the Non-Pay Budgets are centred around increased Medical and Surgical Costs, Travel Costs and recharges from neighbouring Foundation Trusts associated to increased activity levels within Planned Care. Within the Corporate Division the centralised spend on VOIP and Mobile Phones are the key areas of concern. The non pay underspends within the Tendered Services of the Health and Wellbeing Division (£0.54m) is caused by a reduction in activity which as reflected in reduced expenditure to Accredited Providers, Voluntary Sector and Chlamydia Screening, which offsets the under-performance in activity highlighted under Clinical Income.



3.4 Cost Improvements Plan The Trust has a SQIP target of £5.0m for 2016/17. As at month 6 there is an under achievement against the planned schemes of £0.069m but mitigations have been found to offset this, resulting in an over achievement year to date of £0.093m. The year end forecast is currently a 2.8% under achievement of £0.141m by year end. The full year effect of recurrent schemes is forecast to be £4.52m, an under achievement of £0.48m against the £5.0m target. Further detail of the SQIP position can be found in Appendix 2. 4. Statement of Financial Position Appendix 3 sets out the Statement of Financial Position.

4.1 Cash At the end of August the cash balance was £3.4m ahead of plan (actual: £20.8m, plan £17.4m). The year-end forecast is now showing red on the dashboard. Following further discussion with the Estates team, we are now assuming that the Walton land disposal will not now be transacted until 2017/18. Our previous assumption was that this transaction would take place in quarter 4 of 2016/17. Cash balances will fall in the second half of the year due to the build-up of creditors (payables) being discharged as agreements are reached, particularly on property expenses, and due to the catch up in expenditure on the capital programme. The Trust continues to actively manage working capital in line with the Working Capital Framework. In particular, the Treasury team continues to chase outstanding debt and promote prompt invoicing of income. Further detail can be found in Appendix 4 attached. The detailed Treasury Management report is due to be presented to the Quality Business Committee in November 2016. 5. Capital Plans and Expenditure

The Trust’s capital plan for 2016-17 totals £5,893k. Year-to-date spend is £937k against a plan of £1,966k, an underspend of £1,029k. This is principally caused by slippage on capital schemes relating to work developing the site at Walton Hospital and the provision of equipment to facilitate mobile working. We are currently reviewing the capital programme and forecasting that we will meet the planned outturn of £5,893k. The outturn position will be considered at the next meeting of the Capital and Estates Group, and a full report provided to the November Quality Business Committee.



Further detail can be found in Appendix 5 attached. 6. Risks The main risk carried forward from the previous financial year is the delivery of activity targets in the sexual health service. The activity targets have been recast in consultation with the service to reflect 2015/16 outturn. We will continue to closely monitor performance with the service.

7. Summary

Board Members are asked to note the month 6 position against the financial targets. Chris Sands Director of Finance, Information and Strategy



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

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

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

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

OPERATINGIncome

Clinical Income -91,396 -91,167 -229 -14,814 -15,052 -15,942 -15,068 -15,036 -15,484 -15,302 -15,306 -14,923 -15,325 -15,227 -15,267 -182,746 -182,316

Other NHS Income -3,496 -3,357 -139 -500 -455 -486 -555 -811 -689 -546 -540 -541 -537 -535 -555 -6,750 -6,484

Education and Training -364 -408 44 -53 -55 -73 -64 -57 -62 -54 -54 -54 -54 -54 -54 -688 -782

Other Income -1,279 -1,261 -18 -209 -190 -202 -216 -197 -265 -201 -201 -201 -201 -201 -201 -2,485 -2,500

INCOME TOTAL -96,535 -96,193 -342 -15,576 -15,752 -16,703 -15,903 -16,101 -16,500 -16,103 -16,101 -15,719 -16,117 -16,017 -16,077 -192,669 -192,082

Operating ExpensesEmployee Benefit Expenses 64,733 64,808 -75 10,775 10,839 10,744 10,933 10,624 10,818 10,994 11,007 10,972 10,996 11,044 11,078 130,824 130,546

Drugs 777 809 -32 97 114 114 133 134 185 114 114 114 114 114 114 1,461 1,486

Clinical Supplies and Services 5,296 5,185 111 782 846 806 919 1,110 833 846 873 881 841 881 931 10,549 10,137

Other Costs 18,564 18,587 -23 3,066 2,828 3,205 2,659 3,253 3,553 3,244 3,520 3,529 3,552 3,408 3,420 39,237 38,919

OPERATING EXPENSES TOTAL 89,370 89,389 -19 14,720 14,627 14,869 14,644 15,121 15,389 15,198 15,514 15,496 15,503 15,447 15,543 182,071 181,088

OPERATING (PROFIT) / LOSS EBITDA -7,165 -6,804 -361 -856 -1,125 -1,834 -1,259 -980 -1,111 -905 -587 -223 -614 -570 -534 -10,598 -10,994

NON OPERATINGLoss / (Profit) on Asset Disposal -1 0 -1 0 0 0 0 -1 0 0 0 0 0 0 0 -1 0

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

Depreciation / Amortisation 1,904 2,000 -96 317 320 317 317 306 327 300 308 308 308 308 309 3,745 4,004

Interest (Receivable) / Payable -30 -35 5 -3 -7 -5 -6 -6 -3 -5 -4 -4 -5 -4 -5 -57 -70

Public Dividend Capital 1,175 1,250 -75 208 208 208 208 208 135 196 196 196 196 196 196 2,351 2,500

NON OPERATING TOTAL 3,048 3,215 -167 522 521 520 519 507 459 491 500 500 499 500 500 6,038 6,434

RETAINED (SURPLUS) / DEFICIT -4,117 -3,589 -528 -334 -604 -1,314 -740 -473 -652 -414 -87 277 -115 -70 -34 -4,560 -4,560

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

Donated Asset Depreciation 66 0 66 11 11 11 11 11 11 11 11 11 10 10 10 129 120

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

TOTAL ADJUSTMENTS 66 0 66 11 11 11 11 11 11 11 11 11 10 10 10 129 120

ADJUSTED RETAINED (SURPLUS) / DEFICIT -4,051 -3,589 -462 -323 -593 -1,303 -729 -462 -641 -403 -76 288 -105 -60 -24 -4,431 -4,440

STATEMENT OF INCOME & EXPENDITURESEPTEMBER 2016

Category

Year to Date Monthly Actual / Forecast

As at 30 September 2016



Appendix 2

R/NR Plan Actual Variance Risk Rating

Plan Out-turn Actual Variance Risk Rating

FYE Forecast

£'s % £'s %

Total SQIP 16/17 £2,015,906 40.3% £2,104,327 42.1% £88,421 4% £5,000,000 £4,827,355 -£172,645 -3.5% £4,522,583Recurrent SQIP R £1,842,800 £1,768,854 -£73,946 -4% £4,735,500 £4,420,500 -£315,000 -6.7% £4,522,583Non Recurrent SQIP NR £173,106 £335,473 £162,367 94% £264,500 £406,855 £142,355 54% £0

R/NR Plan Actual Variance Risk Rating

Plan Out-turn Actual Variance Risk Rating

FYE Forecast

£'s % £'s %

Integrated Community Based Services15/16 Schemes – (Bolsover Ward and Management Post) R £16,500 50.0% £16,500 50.0% £0 0% £33,000 £33,000 £0 0% £33,000OPMH/LD Medical Contract R £25,000 50.0% £25,000 50.0% £0 0% £50,000 £50,000 £0 0% £50,000Management cost savings R £85,000 50.0% £85,000 50.0% £0 0% £170,000 £170,000 £0 0% £170,000Inpatient Budget Consolidation R £45,000 50.0% £45,000 50.0% £0 0% £90,000 £90,000 £0 0% £90,000Babington seasonal bed flex NR £78,333 83.3% £0 0.0% -£78,333 -100% £94,000 £0 -£94,000 -100% £0Babington bed flex - Mitigations - DCC SLA ceased NR £0 0.0% £49,000 0.0% £49,000 0% £0 £49,000 £49,000 0% £0Buxton (Fenton Ward) seasonal bed flex NR £30,000 83.3% £21,300 59.2% -£8,700 -29% £36,000 £36,000 £0 0% £0Medical Staffing Review R £65,833 83.3% £0 0.0% -£65,833 -100% £79,000 £0 -£79,000 -100% £32,083Medical Staffing Review Mitigations R £0 - £4,583 - £4,583 0% £0 £32,083 £32,083 0% £32,083MARS - ICBS R £56,050 50.0% £56,050 50.0% £0 0% £112,100 £112,100 £0 0% £112,100Health, Wellbeing and InclusionChildren’s Reconfiguration School Nursing - County R £150,000 50.0% £150,000 50.0% £0 0% £300,000 £300,000 £0 0% £300,000Children’s Reconfiguration Health Visiting - County R £25,000 50.0% £25,000 50.0% £0 0% £50,000 £50,000 £0 0% £50,000Sexual Health NHS reconfiguration R £50,000 50.0% £50,000 50.0% £0 0% £100,000 £100,000 £0 0% £100,000Staff vacant posts - apprentice R £10,000 50.0% £10,000 50.0% £0 0% £20,000 £20,000 £0 0% £20,000Planned Care and Outpatient ServicesSavings through procurement – Dentistry & Podiatry R £20,000 50.0% £20,000 50.0% £0 0% £40,000 £40,000 £0 0% £40,000MARS – Planned Care R £10,850 50.0% £10,850 50.0% £0 0% £21,700 £21,700 £0 0% £21,700Integrated Facilities ManagementReduction in accommodation expenses - St Marys Ct R £56,500 50.0% £56,500 50.0% £0 0% £113,000 £113,000 £0 0% £113,000Reduction in cost of utilities; increased income from solar R £25,000 50.0% £25,000 50.0% £0 0% £50,000 £50,000 £0 0% £50,000Increased Income from Room rental R £25,000 50.0% £18,212 36.4% -£6,788 -27% £50,000 £29,000 -£21,000 -42% £29,000Catering income R £25,000 50.0% £0 0.0% -£25,000 -100% £50,000 £0 -£50,000 -100% £0IFM Catering Income Mitigations R £0 0.0% £25,000 0.0% £25,000 0% £0 £50,000 £50,000 0% £50,000IFM Procurement - e auction R £25,000 50.0% £11,850 23.7% -£13,150 -53% £50,000 £23,000 -£27,000 -54% £38,000IFM Mitigations R £0 0.0% £21,000 0.0% £21,000 0% £0 £42,000 £42,000 0% £42,000MARS – IFM R £160,550 50.0% £160,550 50.0% £0 0% £321,100 £321,100 £0 0% £321,100EstatesEstates posts and contracts R £67,500 50.0% £67,500 50.0% £0 0% £135,000 £135,000 £0 0% £135,000Estates posts and contracts - NR Mitigations NR £0 - £29,000 - £29,000 0% £0 £40,000 £40,000 0% £0MARS - Estates R £25,250 50.0% £25,250 50.0% £0 0% £50,500 £50,500 £0 0% £50,500Corporate15/16 Non recurrent schemes - recurrent effect R £200,000 50.0% £200,000 50.0% £0 0% £400,000 £400,000 £0 0% £400,000Corporate SQIP Target R £168,500 50.0% £168,500 50.0% £0 0% £337,000 £337,000 £0 0% £337,000ALPS (annual leave purchase scheme) NR £24,773 45.5% £24,773 45.5% £0 0% £54,500 £55,455 £955 2% £5,000Non Pay Inflation Reserve release R £250,000 50.0% £250,000 50.0% £0 0% £500,000 £500,000 £0 0% £500,000MARS - Strategy R £15,200 50.0% £15,200 50.0% £0 0% £30,400 £30,400 £0 0% £30,400MARS - POE R £24,900 50.0% £24,900 50.0% £0 0% £49,800 £49,800 £0 0% £49,800Capital Charges Review - Asset Lives R £0 0.0% £0 0.0% £0 0% £140,000 £140,000 £0 0% £140,000Agile Working R £50,000 50.0% £30,500 30.5% -£19,500 -39% £100,000 £61,000 -£39,000 -39% £61,000Digitilisation Opportunities R £16,667 33.3% £0 0.0% -£16,667 -100% £50,000 £0 -£50,000 -100% £0Telecoms Review NR £40,000 50.0% £15,000 18.8% -£25,000 -63% £80,000 £30,000 -£50,000 -63% £0OtherPharmacy Services Review R £0 0.0% £0 0.0% £0 0% £50,000 £50,000 £0 0% £100,000Babington Office Moves R £0 0.0% £8,992 30.0% £8,992 0% £30,000 £39,000 £9,000 30% £39,000Primary Care Contribution R £48,500 50.0% £48,500 50.0% £0 0% £97,000 £97,000 £0 0% £97,000Capital Charges Valuation R £0 0.0% £18,000 7.2% £18,000 0% £250,000 £250,000 £0 0% £250,000VOIP Implementation R £0 0.0% £0 0.0% £0 0% £100,000 £100,000 £0 0% £100,000Mitigation Reserve Reduction R £100,000 50.0% £100,000 50.0% £0 0% £200,000 £200,000 £0 0% £200,000

Total £2,015,906 £1,912,510 -£103,396 £4,484,100 £4,297,138 -£186,962 £4,188,766

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

Total £0 £0 £0 £515,900 £365,900 -£150,000 £365,900

R/NR

Corporate Vacancy Management NR £0 - £196,400 - £196,400 0% £0 £196,400 £196,400 £0Total £0 £196,400 £196,400 £0 £196,400 £196,400

£2,015,906 £2,108,910 £93,004 £5,000,000 £4,859,438 -£140,562 £4,554,666

MITIGATIONS

SQIP Monitoring 2016/17 September 2016

Summary of Overall SQIP Monitoring 2016/17

TO BE CONFIRMED SCHEMES

Year to Date Annual

Plan % of Annual

Actual % of Annual

Year to Date Annual

Plan % of Annual

Actual % of Annual

SQIP Schemes 2016/17

Scheme R/NR

Scheme

Scheme



Appendix 3

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

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

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

ASSETSNon Current

Tangible Assets 82,396 81,410 82,101 (691) 82,701 82,411 82,237 82,038 81,821 81,410 81,659 81,956 82,657 83,344 84,033 85,274 82,788

Intangible Assets 1,604 1,550 1,164 386 1,564 1,524 1,483 1,443 1,403 1,550 1,517 1,490 1,533 1,497 1,507 1,477 1,002

Total Non Current Assets 84,000 82,960 83,265 (305) 84,265 83,935 83,720 83,481 83,224 82,960 83,175 83,445 84,189 84,841 85,540 86,751 83,790

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

NHS Trade Receivabes 2,017 12,965 2,037 10,928 2,427 2,433 2,576 1,639 6,119 12,965 13,138 13,138 13,120 13,138 13,333 13,136 2,036

Non NHS Trade Receivabes 1,963 659 2,380 (1,721) 991 2,284 766 653 714 659 870 870 870 860 860 860 2,360

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

Bad Debt Provision (176) (177) (170) (7) (311) (203) (236) (205) (205) (177) (155) (150) (150) (150) (150) (150) (150)

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

Accrued Income 2,258 3,817 2,423 1,394 4,856 2,767 3,046 3,397 2,813 3,817 3,332 2,564 2,714 3,389 2,578 2,371 1,798

Prepayments 945 1,218 545 673 1,326 1,195 2,330 1,633 1,603 1,218 1,429 1,343 1,251 1,159 1,164 1,176 1,225

Other Receivables 858 812 1,286 (474) 790 809 826 684 773 812 818 915 969 828 628 803 1,003

Land Held For Sale 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Cash and Cash Equivalents 16,974 20,757 17,354 3,403 13,654 14,768 16,631 19,492 20,462 20,757 19,043 19,867 19,639 15,846 16,799 14,336 16,802

Total Current Assets 24,980 40,051 25,855 14,196 23,874 24,194 26,080 27,434 32,420 40,051 38,475 38,547 38,413 35,070 35,212 32,532 25,074

TOTAL ASSETS 108,980 123,011 109,120 13,891 108,139 108,129 109,800 110,915 115,644 123,011 121,650 121,992 122,602 119,911 120,752 119,283 108,864

LIABILITIESCurrent

Trade Payables (8,193) (5,227) (3,874) (1,353) (5,750) (4,930) (3,985) (5,518) (4,856) (5,227) (4,271) (4,272) (4,273) (4,273) (4,269) (3,669) (3,869)

Other Payables (3,754) (4,142) (4,157) 15 (4,147) (4,175) (4,050) (4,168) (4,088) (4,142) (4,094) (4,089) (4,136) (4,121) (4,224) (4,182) (5,482)

Public Dividend Capital Payable 0 0 0 0 (208) (417) (625) (833) (1,042) 0 (196) (392) (588) (784) (980) 0 0

Capital Payables (853) (479) (569) 90 (558) (703) (449) (526) (496) (479) (153) (361) (569) (153) (653) (153) (153)

Accrued Expenditure (3,036) (4,433) (4,066) (367) (3,739) (3,742) (5,515) (3,559) (3,960) (4,433) (3,590) (3,690) (3,740) (1,240) (1,280) (1,845) (2,345)

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

Deferred Income, Current (570) (12,337) (282) (12,055) (844) (794) (487) (874) (5,292) (12,337) (12,368) (12,314) (12,260) (12,211) (12,157) (12,089) 0

Provisions, Current (465) (221) (389) 168 (454) (336) (353) (373) (383) (221) (373) (183) (180) (158) (158) (17) (399)

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

Total Current Liabilities (17,406) (27,376) (13,872) (13,504) (16,235) (15,632) (16,001) (16,388) (20,654) (27,376) (25,582) (25,838) (26,283) (23,477) (24,258) (22,450) (12,743)

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

Provisions, Non Current (20) (30) (105) 75 (30) (30) (30) (30) (30) (30) (60) (70) (100) (110) (110) (110) (105)

Total Non Current Liabilities (20) (30) (105) 75 (30) (30) (30) (30) (30) (30) (60) (70) (100) (110) (110) (110) (105)

TOTAL LIABILITIES (17,426) (27,406) (13,977) (13,429) (16,265) (15,662) (16,031) (16,418) (20,684) (27,406) (25,642) (25,908) (26,383) (23,587) (24,368) (22,560) (12,848)

TOTAL ASSET EMPLOYED 91,554 95,605 95,143 462 91,874 92,467 93,769 94,497 94,960 95,605 96,008 96,084 96,219 96,324 96,384 96,723 96,016

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

Retained Earnings 69,759 73,810 73,348 462 70,079 70,672 71,974 72,702 73,165 73,810 74,213 74,289 74,001 74,106 74,166 74,190 73,483

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

TOTAL TAXPAYERS EQUITY 91,554 95,605 95,143 462 91,874 92,467 93,769 94,497 94,960 95,605 96,008 96,084 96,219 96,324 96,384 96,723 96,016

Year to DateAs at 30 September 2016

Monthly Actual / Forecast

STATEMENT OF FINANCIAL POSITION 2016-1730 SEPTEMBER 2016



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

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

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

SURPLUS / (DEFICIT) 4,052 3,589 463 323 593 1,303 729 463 641 405 76 (288) 105 60 24 4,434 3,251

Less Non Operating Income / ExpenditureFinance Income / Charges (30) (24) (6) (3) (7) (5) (6) (6) (3) (5) (4) (4) (5) (4) (5) (57) (50)

Depreciation and Amortisation 1,970 2,034 (64) 328 331 328 328 317 338 311 319 319 318 318 319 3,874 3,824

PDC Dividend Expense 1,175 1,248 (73) 208 208 208 208 208 135 196 196 196 196 196 196 2,351 2,350

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

OPERATING CASHFLOWS BEFORE MOVEMENTS IN WORKING CAPITAL 7,167 6,847 320 856 1,125 1,834 1,259 982 1,111 907 587 223 614 570 534 10,602 9,375

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

NHS Trade Receivabes (10,942) (20) (10,922) (412) (6) (143) 937 (4,475) (6,843) (176) 0 18 (18) (195) 196 (11,117) (19)

Non NHS Trade Receivabes 1,305 (423) 1,728 1,107 (1,401) 1,551 82 (61) 27 (233) (5) 0 10 0 0 1,077 (423)

Accrued Income (1,559) (190) (1,369) (2,598) 2,089 (279) (351) 584 (1,004) 485 768 (150) (675) 811 207 (113) 460

Prepayments (273) 400 (673) (381) 131 (1,135) 697 30 385 (211) 86 92 92 (5) (12) (231) (280)

Other Receivables 46 (428) 474 68 (19) (17) 142 (89) (39) (6) (97) (54) 141 200 (175) 55 (145)

Trade Payables (2,966) (4,499) 1,533 (2,443) (820) (945) 1,533 (662) 371 (956) 1 1 0 (4) (600) (4,524) (2,922)

Other Payables 388 403 (15) 393 28 (125) 118 (80) 54 (48) (5) 47 (15) 103 (42) 428 (1,038)

Accrued Expenditure 1,397 1,030 367 703 3 1,773 (1,956) 401 473 (843) 100 50 (2,500) 40 565 (1,191) (691)

Annual Leave Accrual 2 0 2 0 0 2 0 0 0 0 0 0 0 0 (42) (40) (40)

Deferred Income, Current & Non Current 11,767 (288) 12,055 274 (50) (307) 387 4,418 7,045 31 (54) (54) (49) (54) (68) 11,519 (570)

Provisions, Current & Non Current (234) 9 (243) (1) (118) 17 20 10 (162) 182 (180) 27 (12) 0 (141) (358) 19

Increase / (Decrease) in working capital (1,069) (4,006) 2,937 (3,290) (163) 392 1,609 76 307 (1,775) 614 (23) (3,026) 896 (112) (4,495) (5,649)

NET CASHFLOW FROM OPERATIONS 6,098 2,841 3,257 (2,434) 962 2,226 2,868 1,058 1,418 (868) 1,201 200 (2,412) 1,466 422 6,107 3,726

Property, Plant & Equipment Expenditure (937) (1,966) 1,029 (594) 0 (114) (90) (64) (75) (525) (589) (640) (970) (1,017) (1,215) (5,893) (5,893)

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

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

Increase / (Decrease) in Capital Payables (374) 516 (890) (295) 145 (254) 77 (30) (17) (326) 208 208 (416) 500 (500) (700) 100

NET CASHFLOW FROM INVESTING ACTIVITIES (1,311) (1,450) 139 (889) 145 (368) (13) (94) (92) (851) (381) (432) (1,386) (517) (1,715) (6,593) (1,693)

PDC Dividends Paid (1,175) (1,176) 1 0 0 0 0 0 (1,175) 0 0 0 0 0 (1,175) (2,350) (2,352)

PDC Received 141 141 0 0 0 0 0 0 141 0 0 0 0 0 0 141 141

Interest Received on Cash and Cash Equivalents 30 24 6 3 7 5 6 6 3 5 4 4 5 4 5 57 50

NET CASHFLOW FROM FINANCING ACTIVITIES (1,004) (1,011) 7 3 7 5 6 6 (1,031) 5 4 4 5 4 (1,170) (2,152) (2,161)

NET CASH INFLOW / (OUTFLOW) 3,783 380 3,403 (3,320) 1,114 1,863 2,861 970 295 (1,714) 824 (228) (3,793) 953 (2,463) (2,638) (128)

Opening Cash Balance 16,974 16,974 0 16,974 13,654 14,768 16,631 19,492 20,462 20,757 19,043 19,867 19,639 15,846 16,799 16,974 16,974

Net Cash Inflow / (Outflow) 3,783 380 3,403 (3,320) 1,114 1,863 2,861 970 295 (1,714) 824 (228) (3,793) 953 (2,463) (2,638) (128)

CLOSING CASH BALANCE 20,757 17,354 3,403 13,654 14,768 16,631 19,492 20,462 20,757 19,043 19,867 19,639 15,846 16,799 14,336 14,336 16,846

OPERATING ACTIVITIES

INVESTING ACTIVITES

FINANCING ACTIVITES

CASHFLOW STATEMENT 2015/1630 SEPTEMBER 2016

As at 30 September 2016Monthly Actual / ForecastYear to Date



Appendix 5

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

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

A5047 Walton Hospital Site Development Estates 12.2 4.3 4.9 -0.1 4.1 25.4 -25.4 A5050 Heanor Site Development Estates 1,958.0 -15.3 1.7 26.7 -3.0 2.1 14.0 100.0 150.0 150.0 350.0 500.0 700.0 1,976.2 -18.2 A5105 Buxton Site Development Feasibility Fees Estates 10.0 10.0 10.0A5107 Ilkeston Hospital Upgrade Main Reception & Entrance Estates 65.0 3.2 61.5 64.7 0.3A5104 Ripley Hospital Upgrade Reception (DDA) Estates 16.2 5.7 4.4 26.3 -26.3 A5057 Belper Provision of Health Facilities Estates 208.0 69.3 69.3 69.4 208.0A5093 Walton Hospital Car Parking and New Entrance Estates 765.0 1.5 3.8 1.0 12.3 -4.0 6.0 190.0 190.0 170.0 170.0 740.6 24.4A5103 London Road Community Hospital Microscopy Lab & Accommodation Estates 90.0 36.5 -0.4 67.2 16.7 120.0 -30.0 A5108 Ripley Hospital Upgrade Security - Lighting/CCTV Estates 9.0 9.0 -9.0 9.0 9.0A5109 Ilkeston Hospital Nitrous Oxide Storage Facility Estates 6.3 6.3 -6.3

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

A5473 IM&T - Mobile working IM&T 750.0 51.8 -51.8 125.0 125.0 125.0 125.0 125.0 125.0 750.0A5432 IM&T - Desktop renewal and local infrastructure IM&T 450.0 -12.5 38.5 13.0 57.5 24.0 24.0 37.5 37.5 37.5 37.5 75.0 75.0 444.5 5.5A5433 IM&T - System procurement IM&T 75.0 10.0 25.0 25.0 25.0 85.0 -10.0 A5434 IM&T - LAN/WAN Infrastructure IM&T 85.0 3.7 70.0 28.3 28.3 28.4 158.7 -73.7 A5435 IM&T - PAS Replacement IM&T 225.0 2.9 7.2 13.0 2.7 0.2 3.2 17.0 17.0 17.0 25.0 25.0 22.0 152.2 72.8

A5110 Cavendish Hospital visual field testing machine Equipment 29.9 29.9 29.9Equipment Equipment 313.1 70.0 70.0 70.0 70.0 70.0 350.0 -36.9

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

CONT Contingency Contingency 300.0 19.8 100.0 100.0 219.8 80.2

MISC Expenditure relating to all other Axxxx schemes Other 6.5 -2.7 -0.9 -4.1 -34.4 2.0 -33.6 33.6

Capital Programme Expenditure 5,893.0 593.6 0.6 113.7 89.7 64.0 75.4 524.7 589.5 639.5 969.9 1,017.6 1,214.8 5,893.0 -0.0

CAPITAL PROGRAMME 2016-1730 SEPTEMBER 2016

Scheme Number Scheme Description Category 2016-17

PlanPlan v

ForecastFull Year Forecast



Summary Report from Audit and Assurance CommitteeReport To: Board

Date: 27 October 2016

Name of Reporting Committee / Group: Audit and Assurance Committee

Date of Meeting: 21 October 2016

Presenter: Nigel Smith, Non-Executive Director

Author: David Boddy, Corporate Governance Manager

This paper is for Assurance

Key Issues discussed at meeting:Include:

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

Board Assurance Framework Reference and Level of Assurance Agreed

123/16 Assurance Framework Presentation: Governance - the Committee discussed the presentation and recommended:

Withdrawal of risk 4.4 (non-compliance of administration of the Mental Health Act) – as a result of reduced risk to the organisation

4.4 – the Committee to receive an update why there were overdue actions on Code of Practice action plan for three consecutive months

4.2 (meeting regulatory, contractual or legal obligations) – inclusion of forward looking measures

4.3 (strong risk management controls) – inclusion of mitigations instead of “top X” risks

4.5 (comprehensive data quality systems) – although performance metrics have recently changed there has been no reduction in performance Key Performance Indicators (KPIs) covered by the kitemark)

A new risk to be added regarding system wide governance

Significant Assurance4.3

124/16 Board Assurance Framework (BAF) Quarterly Review - the Committee considered the level of risk assigned to each strategic risk taking into account provision of assurance, KPI performance and operational risk profile. The Committee also considered any further ‘Gaps in Assurance or Control’.

The Committee requested that: A review is undertaken of measures across all the BAF risks. 1.2 (discontinuity between systems) – the gap in control is to

be better articulated as ensuring new teams joining DCHS are part of the DCHS Way and join in the culture of the organisation)

The timeframes in the Score Summary are to be reviewed by


265�AAC�Summary�Report.docxOverall�Page�69�of�171Page�1�of�12


each Quality Committee, particularly with respect to those dated April 2018. The work should identify progress against trajectory to understand those risks which will not be achieved on time

The Committee went on to review risks where the score had increased during the last quarter. The Committee was updated during discussion of risk 3.6 (financial stability of the organisation) that the November Quality Business Committee (QBC) meeting will discuss the revised forecast for the capital programme.

125/16 Counter Fraud Progress Report – the Committee discussed the work completed to date in respect of the 2016/17 Counter Fraud, Bribery and Corruption Operational Plan.

The counter fraud workbook continues to be issued to all new employees of the Trust as part of the induction programme. The Committee requested that work is undertaken to identify existing staff and teams across the organisation where it is important to deliver Counter Fraud training or awareness raising.


126/16 Counter Fraud – Benchmarking - 360 Assurance provides counter fraud services to 19 providers of healthcare services. The Committee discussed analysis of the number of days delivered, by the 360 Assurance Anti-Crime Services Team, to each Provider during 2015/16.

There were no concerns regarding the level of DCHS investment and targeted resource.

The Committee remained unsure how DCHS performed with respect to other organisations in identifying fraudulent activity. The Committee requested amendments to the report to provide further information.

Limited Assurance4.3

127/16 Counter Fraud 2015/2016 Staff Survey - the Committee discussed the survey which was designed to assess general staff awareness of the counter fraud, bribery and corruption initiative and arrangements for reporting suspicions, in addition to testing knowledge of their responsibilities under key organisational policies.

The report will be reviewed with the Head of People Services to address the wider issues including staff personal responsibilities.


128/16 Clinical Audit Update – the Committee was updated regarding the Clinical Effectiveness and Audit Programme 2016/2017 with respect to progress, findings and implementation of improvement actions.

The Committee discussed the participation in national audits which have seen the overall standard subscription fee increase to £10,000 for DCHS. Although the steep rise in cost has been challenged, the




fee has remained. The Executives will be asked to discuss how to respond further.

The Committee asked that the Information Technology section of the report includes targeted delivery dates so that progress can be measured against the trajectory.

The Committee agreed that the report demonstrated engagement with operational services. The report showed that audit was being actively translated into clinical practice.

130/16 Compliance with Governance Arrangements(including NHSLA claims scorecard) - the Committee discussed the previously reported Raising Concerns cases and in particular a case that involved derisory comments on Social Media sites. The Committee made a referral to the Quality People Committee (QPC) to investigate inclusion of comments on Social Media in DCHS policies (such as the Code of Conduct policy) as well as in professional codes.

The Committee went on to discuss: The reduction in the number of Whistleblowing cases The number of clinical and non-clinical claims. Trends, such

as slips trips and falls are investigated and fed back into the Lessons Learnt Panel. QPC had discussed issues such as slips trips and falls, staff anxiety and core strength training and that follow up actions had been taken.

KF reported that work will now be undertaken to review and refresh the content of the report.


131/16 Lessons Learnt – 2015/16 Year End Closedown Process - A year-end review meeting was held between PricewaterhouseCoopers (PwC) and Trust officers. The report detailed the learning and the resultant action points that are to be taken forward to further improve the process in 2016/17.


132/16 Review of Fixed Asset Accounting Process - the Trust has reviewed its process around accounting for Fixed Assets. This work built on the recommendations made by PwC as part of their audit work. The report updated the Committee with the details of the changes to the Trust’s processes that have now been adopted.A more analytical approach is now taken to the depreciation of each of the Trust’s fixed assets. The Committee asked that evidence is provided to show that the proposed lives are appropriate.The Committee approved the proposed revisions to the useful lives of equipment assets, subject to additional evidence being provided.




133/16 Financial Governance Review Action Plan – the Committee discussed the action plan with respect to financial governance arrangements.

A progress report will be presented to the Committee in April 2017.


134/16 Data Quality Update – the Committee was updated regarding the current status of the electronic clinical system coverage, an update on the current data quality improvement plan, and the plans for the next period with regard to continuous data quality improvement across the Trust.

NS noted that progress was being made, but at a slow rate. The Committee asked that progress against trajectory is reported. This should include the key milestones. A report on progress against trajectory will be presented to the November Quality Business Committee (QBC) meeting.


136/16 Internal Audit Progress Report (including recommendation tracking) - the progress of work from the 2016/17 Internal Audit Plan was reported including three Main Reviews:

Advanced Clinical Practitioner – Limited Assurance. This matter will be referred to QPC to discuss further

Information Management & Technology Asset Management – Limited Assurance. This has provided a baseline position and work is underway with Arden GEM who are responsible for registration, to track down missing assets. An update will be provided to the January AAC meeting

Nursing Revalidation – Significant Assurance.


137/16 Internal Audit Key Performance Indicators - a review of best practice Key Performance Indicators for Internal Audit, identified through benchmarking was discussed.

The Committee agreed to adopt the Key Performance Indicators.

Paper for Decision

138/16 Auditing your Financial Integrity and Reporting Arrangements Briefing Paper – the paper updated the Committee regarding a workstream to look at and provide assurance around our financial systems. Internal Audit will look at the integrity of the ledger and the reporting from it. The work will support the Internal Audit Opinion.


140/16 Audit Progress Report – the report discussed the key risks for the coming year’s audit, including the Sustainability and Transformation Plan with respect to Value For Money and Control Totals.

The Committee asked that reference to insights on whole governance systems are shared with the Committee.




142/16 Single Oversight Framework - NHS Improvement has recently issued its approach to overseeing providers using a Single Oversight Framework (SOF). The Trust responded to the consultation in July 2016, and the new Framework has now been issued.

The Committee agreed to continue with an internal self-certification regime. A report will be created that meets the requirements of the regulations as well as the Quality Governance Report.

The Committee went on to discuss the challenges of achieving the stretched target for agency spending. DCHS is one of the top three performing Trusts in the East Midlands with respect to agency spending and also has one of the lowest caps nationally for Foundation Trusts. The Committee acknowledged that Quality should not be compromised in the drive to achieve the target. QPC has oversight of the matter.

Paper for Decision

144/16 Audit Committee Annual Review - the Committee discussed the annual review and recommended it to the Board, subject to some minor amendments. The report is attached to this Summary Report.


148/16 Board Assurance Framework, Risk and Self Certification IssuesLimited Assurance was taken with respect to Counter Fraud – Benchmarking Resource Investment

Withdrawal of risk 4.4 (non-compliance of administration of the Mental Health Act) was agreed as a result of reduced risk to the organisation

A new risk to be added regarding system wide governance.

Policies ApprovedNone.Issues to be escalated to Board or a CommitteeReferral to November Board meeting

The Board should consider what training is required for the Non-Executive Directors with respect to the Quality Committees that they Chair or have membership.

Referrals to QPC: The Committee made a referral to the Quality People Committee (QPC) to investigate

inclusion of comments on Social Media in DCHS policies (such as the Code of Conduct policy) as well as in professional codes

Internal Audit report regarding Advanced Clinical Practitioner – Limited Assurance. QPC to investigate this matter further



Appendix 1

AUDIT AND ASSURANCE COMMITTEE ANNUAL REPORT FOR THE AUDIT YEAR 2015/16

1. SCOPEThis is the Annual Report of the Audit and Assurance Committee. This report covers the work of the Committee for the period July 2015 to June 2016. The report was not completed until June 2016 to allow the financial year to be completed.

2. INTRODUCTIONThe Board remains committed to the continued development of good governance principles that reflect the changing needs of the NHS, recognise the developments in broader corporate governance and ensure that the organisation remains relevant and responsive in this changing environment.

3. ROLE OF THE AUDIT AND ASSURANCE COMMITTEEAs the senior Board committee, the role of the Committee is central to the governance of the Trust. The role has continued to develop to incorporate a wider responsibility for scrutinising the risks and controls which affect all aspects of the organisation’s business whilst continuing to retain a critical financial focus.

The Committee met on a quarterly basis and reported directly to the Board. The membership of the Committee is confined to Non-Executive Directors, not including the Chairman of the Foundation Trust, and consists of three Non-Executive Directors appointed by the Board, including the Chair of the Committee. A quorum is not less than two Non-Executive Directors.

Membership (Period July 2015 to June 2016):

Name Title Membership Period

Nigel Smith Non-Executive Director - Chair July 2015 to June 2016

Barbara-Anne Walker Non-Executive Director July 2015 to June 2016

Ian Lichfield Non-Executive Director July 2015 to June 2016

Attendance at Audit Committee meetingsAll meetings were quorate. The attendees, including members and regular attendees at the meetings are listed below.

Audit and Assurance Committee Attendance Record: Members

Key: = Attended X = Did Not AttendNR = Not required for this meeting

Jul-15 Oct-15

Jan-16

Apr-16

May-16

Nigel Smith Chair, Non-Executive Director

Barbara-Anne Non-Executive Director X X



Walker

Ian Lichfield Non-Executive Director

Audit and Assurance Committee Attendance Record: Attendees

Key: = Attended X = Did Not AttendNR = Not required for this meeting

Jul-15 Oct-15

Jan-16

Apr-16

May-16

Chris Sands Director of Finance, Performance and Strategy

Kirsteen Farrar Trust Secretary X

Melanie Curd Acting Trust Secretary/Deputy Trust Secretary NR NR

Cath Benfield Head of Finance X

Rick Meredith or Carolyn White

Medical Director or Chief Nurse/Director of Quality X

Simon Gascgoine Associate Director, 360 Assurance X NR

Tim Thomas Head of Internal Audit, 360 Assurance X X X NR

Penny Gee or Robert Purseglove

Local Counter Fraud Specialist, 360 Assurance X NR

Ali Breadon Partner, PWC Not an attendee

Matt Elmer Senior Manager, PWC Not an attendee X

John Cornett Director, KPMG No longer an attendee

In general, Executive Directors were invited to attend when the Committee discussed areas or risk relating to the Director’s responsibilities and at the Committee’s discretion.

4. REVIEW OF BUSINESS 2015/164.1 Internal Control and Risk Management4.1.1 Review of Audit Committee Handbook Action PlanIn January 2016 the Committee reviewed the Trust’s position against the NHS Audit Committee Handbook Self-Assessment Checklist.

The Committee took significant assurance from the report.

4.1.2 Strategic Priorities



The Committee discussed and approved strategic priorities for the Audit and Assurance Committee and some of the challenges to their achievement:

To ensure control systems to manage strategic risks are operating effectively To ensure the Board Assurance Framework remains a live document which fully reflects the

risks and opportunities facing the Trust to deliver our vision To understand the implications of new models of care and to advise the Board as to the

emerging governance issues arising and the Trust’s response

4.1.3 Board Assurance Framework The Committee reviewed the Board Assurance Framework (BAF) quarterly and was satisfied that it was fit for purpose, that risks are appropriately identified and that it allowed the Board to understand the appropriate management of those risks. Areas of limited or negative assurance were presented in the report and were reviewed in detail by the Committee.

The Committee made progress in developing and improving its assurance framework during 2015/16. The Committee reviewed the updated version of the Board Assurance Framework at its January meeting. This was then used to support the Trust operational planning to ensure that strategic risks were being considered and addressed in the plan.

The Assurance Framework was the key assurance document for the Committee. This document underpins self-certifications made by the Trust to external bodies.

During the year the Committee also received presentations from lead directors regarding the strategic risks for Quality Service, Quality People, Quality Business and Quality Governance

4.1.3 Statutory SubmissionsThe Committee received a number of reports regarding governance arrangements and statutory submissions. The reports included:

Statutory Submissions Learning the Lessons

4.1.4 Self-certificate DeclarationsThe Committee has a role to review the assurances supporting the self-certification to Monitor, and to provide assurance to the Board as to the accuracy of any declarations made. The Committee reviewed and recommended to the Board reports on quarterly self-certificate declarations.

4.1.5 Governance ArrangementsThe Committee took assurance from quarterly reports that the Trust is complying with its governance requirements/arrangements and any instances where this is not the case. The quarterly review included: Coroners Inquests, Claims, Central Alert System, Losses and Compensations, Declarations of Receipt of Gifts, Hospitality and Donations, Declarations of Interest, Use of Powers, Legal Documents, Raising Concerns and Sponsorship.

The Committee was updated regarding Raising A Concern (Whistleblowing) and DCHS’s approach to implementing the actions, including our progress to embedding the policy and ensuring a culture exists which enables individuals to report concerns and managers feel confident in dealing with any issues identified.

4.1.6 Data Quality



The Committee reviewed and challenged progress against the data quality improvement action plan during the year.

4.1.7 NHS Counter Fraud Service The Trust is required to monitor and ensure compliance with the Provider Standards and the Standard Commissioning Contract regarding its arrangements for counter fraud and corruption work. A key role for the Committee is to provide assurance to the Board that these arrangements are robust. During the year, the Committee:

Monitored progress against the plan Took significant assurance from the Annual Report on Counter Fraud 2014/15 Procurement Report (Data Mining) – a proactive exercise that reported that no fraudulent

activity had been identified Approved the Counter Fraud, Corruption and Bribery Policy

4.1.8 Risk Management ReportsThe Committee reviewed the risk management work performed during the year including the key areas of success and further areas for improvement for 2016.

4.1.9 Consent, Capacity and the Mental Health ActThroughout the year the Committee monitored progress against the outstanding high risk actions from the Internal Audit Report, particularly with respect to practical application of Deprivation of Liberty Safeguards training. This had been included on the Annual Governance Statement as a control issue in 2014/15, and the Committee monitored the progress of actions to enable this to be addressed and therefore removed from the 2015/16 statement.

4.2 Clinical AuditThe Committee monitored the work of the revised team managing the Clinical Audit Programme. The Committee reviewed the progress of the Clinical Audit Programme 2015/16, monitoring the shift of focus from putting in place an effective process to the commencement of delivery of outcomes.

The detail of the Clinical Audit Programme was reported through to the Quality Service Committee.

4.3 Internal AuditThe Committee approved the Internal Audit Plan for 2016/17 to cover mandatory areas as required by Public Sector Internal Audit Standards, and to meet the statutory responsibility to provide a Head of Internal Audit Statement.

The Committee reviewed the Internal Audit Annual Report which provided a summary of the delivery of the internal audit service for the 2015/16 financial year.

4.3.1 Internal Audit Plan 2015/16:The Committee monitored progress of work from the 2015/16 Internal Audit Plan. The following audits were completed during the period.

Significant Assurance was taken from Quality Account Indicator Testing – data quality underpinning ‘Delayed Transfers of Care’

and ‘A/E 4 hour waits’ Monitor Self-Certification



Information Sharing Healthcare Income – Contract Management Key Financial Systems including Pay Expenditure Data Quality – Dental 18 -Week Referral to Treatment Standard Mental Health Act Compliance Implementation of NICE Guidance Information Governance Toolkit Appraisal Management and Incremental Pay Review

Limited Assurance was taken from: Quality Account Indicator Testing – data quality relating to the 18 week wait data for dental

services for 2014/15 Medicines Management Falls in the Community

Where weaknesses in control were identified the Trust agreed action plans to address the identified shortfalls and these were followed up by Internal Audit with progress reported to the Committee.

In the areas where limited assurance was provided, the Committee received further assurance from management that actions had been implemented...

4.3.2 Head of Internal Audit OpinionThe following opinion was provided by the Head of Internal Audit for the period 1st April 2015 to 31st March 2016:

“Significant assurance can be provided that there is a generally sound system of internal control, designed to meet the Trust’s objectives, and that controls are generally being applied consistently”.

The Opinion reported positively that the DCHS BAF continues to be aligned to the strategic direction of the organisation and that it has been closely monitored by the Audit Committee.

4.4 External AuditDuring the year, the Trust undertook a procurement exercise to market test its external audit function. Price Waterhouse Coopers (PwC) were appointed as the Trust’s new auditors for the financial year 2015/16 for a three year period with the option of a two year extension.

4.4.1 External Audit PlanThe Audit Plan set out the work to be undertaken in relation to the 2015/16 accounts and was developed on the basis of a risk-based approach to audit planning. The Committee reviewed the progress of work against the plan through the course of the year.

The external auditors provided quarterly progress reports and presented their Auditors Report on Annual Accounts to the Committee prior to the Committee’s review of the Annual Accounts in May 2016.

The auditors provided clean opinions for the period April 2015 to March 2016 that included: An unqualified opinion on the accounts – that they are materially true and fair; An unqualified opinion on the arrangements for securing economy, efficiency and

effectiveness in its use of resources



4.5 Reporting4.5.1 Annual Quality ReportThe external auditors reviewed the Annual Quality Report and provided a clean opinion.

4.5.2 Financial AccountsThe Committee reviewed the progress of preparation of the Trust’s fully audited Accounts. The Committee then reviewed the 2015/16 Financial Accounts and recommended to the Board that they were adopted.

The Committee was updated regarding the IFRS15 Revenue from Contracts with Customers.

4.5.3 Annual ReportThe Committee reviewed the Annual Report prior to submission to the Board, and made a recommendation to Board to adopt the annual report.

4.5.4 Going ConcernThe Committee, following review of the financial projections for 2016/17, satisfied itself that the Trust’s Annual Accounts for 2015/16 should be prepared on a “Going Concern” basis.

4.5.5 Annual Governance Statement (AGS)In April 2016 the Committee reviewed and approved the draft Annual Governance Statements for 2015/16.

The Committee discussed the control issues identified in the 2014/15 statement and agreed there were currently no control issues that are considered significant. The two significant control issues reported last year that were withdrawn were:

Consent, Capacity and the Mental Health Act Data Quality/ Referral to Treatment indicator

4.6 Other Matters4.6.1 Individual ReportsThe Committee reviewed a number of issues that were presented during the year. These included:

Attendance at Board and Subcommittee meetings Audit Committee Survey Health Sector Profile 2015 Standards of Business Conduct Policy (approved) Care Quality Commission Registration and Compliance Report on the level of bad debt in comparison to the previous year

4.6.2 Terms of ReferenceThe revised Terms of Reference were approved at the May 2016 Board meeting.

4.6.3 Recommendation TrackingThe Committee has a system of recommendation tracking to monitor the implementation of actions identified in audit reports. This is included in the internal audit progress report.

4.6.4 Annual Report of the CommitteeThis Annual Report summarises the work of the Committee for financial year 2015/16. This report will be presented to the Board.



4.6.5 Training for Committee MembersThe Committee reviewed training for committee members as set out as best practice in the Audit Committee Handbook. The members agreed that the training they had received was sufficient.

4.6.6 Referrals to other CommitteesThere were a number of referrals made to other Quality Committees regarding:

Board Assurance Framework risks – Board and QPC Employment Agency Pre-Employment Screening – QPC Medicines Management – QSC Participation in the National Diabetic Foot Care Audit - TME Consent, Capacity and MCA Audit – metric for number of staff to be trained – QPC Compliance with Governance Arrangements – whether Board should be sighted on

Coroner’s Cases – QSC Succession planning - RATS

5. COSTS OF THE COMMITTEEThere are costs incurred for running the Committee. These are the costs of attendance, costs of producing and circulating the papers, costs of audit attending, and cost of ensuring Committee members are up to date with the latest developments in governance. The Committee has its functions set out in its Terms of Reference.

The membership of the Committee is confined to Non-Executive Directors, but attendance of management to support the Committee is reviewed regularly to ensure best use of management time. The Committee also reviews how regularly it meets to ensure meetings are effective. The Committee currently meets on a quarterly basis with extraordinary meetings when required.

Through the Annual Report, it can be demonstrated the added value that the Committee brings to the governance of the organisation. It is the Committee’s view that this added value is delivered in an efficient manner

6. CONCLUSIONIn summary, the Trust has continued to strengthen internal control within the organisation.

The Committee has an important wide ranging set of responsibilities. To fulfil these responsibilities, the Committee is constantly reviewing how it undertakes its work, and its forward agenda. It has worked closely with the Quality Service, Quality Business and Quality People Committees to ensure a smooth transition of responsibilities, and to ensure that all Committees fulfil their roles effectively and efficiently.

This report demonstrates that the Committee has fulfilled its Terms of Reference and significantly contributed to improving internal control and assurance processes within the Trust.



Summary Report from Quality Service CommitteeReport To: Board

Date: 27 October 2016

Name of Reporting Committee / Group: Quality Service Committee

Date of Meeting: 18 October 2016

Presenter: Chris Bentley, Non-Executive Director

Author: David Boddy, Corporate Governance Manager

This paper is for Assurance

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

298/16 Patient Story – the Committee discussed the Sexual Health Service that has been extended to “difficult to reach” clients. The service is provided at Bayheath House, a location providing alcohol and drug reduction and probation services to newly released prisoners. Bayheath House is run by Derbyshire Healthcare Foundation Trust (DHcFT).

The Committee discussed the way the single point of access provided at this site has been successfully shaped to fit the needs of this cohort of patients. HB described the service provided by the team for these clients with complex histories like drug misuse. Focus is given to understand their issues – the team are aware that some patients need more time for trust to build so that care can be given.

This is a good example of work that DCHS could achieve in collaboration with DHcFT.

The staff working with this cohort of clients require a particular set of skills which are not necessarily transferable. The Committee discussed the importance of providing continuity planning for this team.

The Committee agreed that the story demonstrated how important it is for contracts to focus on outcomes for patients rather than on processes. The Committee considered how this particular model might be used across Derbyshire and Derby City. These complex patients provide a disproportionate health risk - although providing services to them is not efficient, it is cost beneficial. The story will be used during discussions about contract flexibility with the Clinical Commissioning Groups (CCGs).

Significant Assurance

303/16 Non-Medical Prescribing – the Committee received a deep dive review of Non-Medical Prescribing within DCHS. The review

Limited Assurance

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described the challenges to clearly understanding the level of Non-Medical Prescribing taking place by each qualified member of staff, particularly with respect to electronic coding records.

Approximately 150 full prescribers of controlled drugs mostly work in hospitals which are well governed. However, many of the staff work across two or three CCGs.

Although the large majority of Non-Medical Prescribing relates to dressings and other low risk treatments there is no systematic control and check in place.

The Committee went on to discuss the risks regarding: Potential prescribing without qualification The competence of qualified prescribers, especially if they

have not attended Continuing Professional Development (CPD) courses or if they have not prescribed on a regular basis

The Committee agreed the work being undertaken: Inclusion of Non-Medical Prescribing within clinical supervision Linking Non-Medical Prescribing into annual appraisals Appropriate staff training (including a “Return to Prescribing”

course) Improving IT systems to record prescribing activity

Although there is no evidence of prescribing by nurses and therapists outside of their remit there is a requirement for them to understand their roles and responsibilities. Attendance at CPD training and annual appraisal are therefore very important.

The Committee discussed the introduction in July of the Non-Medical Prescribing policy and the question of maintenance by qualified staff of their competency. It was agreed that the policy should be amended with respect to personal responsibility for maintaining professional competence.

The Committee acknowledged the extensive piece of work that has been undertaken to help the organisation better understand Non-Medical Prescribing activity. The paper had uncovered issues and risks and demonstrated that a clearer set of checks and balances needs to be in place. An assessment of the size of the risk to the organisation should be undertaken. It was agreed that the annual training requirement for each staff member should be appropriate and blended so not to unnecessarily put a burden on operations.

The Committee took Limited Assurance requested that an action plan is presented to the November QSC meeting. The paper will also bring clarity to the Non-Medical Prescribing risk on the risk register.



305/16 Integrated Sexual Health Services Update – the paper presented an update regarding the internal governance framework and the quality of service delivery for the Integrated Sexual Health Service.

Actions arising from the Care Quality Commission (CQC) have been amalgamated with the ISHS action plan.

Progress is being made regarding a model of employment, guidance and procedures and directives. It was acknowledged that barriers to change remained at “ground” level and this presented a challenge to DCHS as the lead provider. Progress now depends upon effectively embedding the amended structure. To help, a monthly incident report is to be adopted regarding claims, complaints and trends.

The Committee will continue to receive monthly updates regarding the progress of the action plan via the Quality Assurance and Compliance Report and also further reference will be made in the Divisional Governance Report.

Limited Assurance

306/16 Tissue Viability Driver Diagram – the Committee discussed the goal in the Diagram to reduce the incidence of pressure ulcers by 20% within one year. The Committee discussed whether this would mean influencing services across the system where Pressure Ulcer incidents are subsequently inherited by DCHS. It was agreed that, with limited resources to train staff across the healthcare system, the goal of 20% may need to be revisited if it is found that a number of the Pressure Ulcers are outside of our control.

The Driver Diagram is very helpful and explicit in setting out the outcomes as measures.

The Committee asked if the focus is on prevalence (what we do about Pressure Ulcers) or incidence (what happens elsewhere) and what we should take responsibility for. We should set an improvement trajectory for avoidable Pressure Ulcers and then consider what else we can do. The Committee agreed that the target should be redefined by what DCHS can control.

Further actions will include: Revisiting the work in order to look at other Primary Drivers.

There is an opportunity to work with the East Midlands Lead for Patient Safety on this matter

Reviewing the Driver Diagram with respect to focus on certain geographical areas such as North East Derbyshire and Derby.


307/16 Quality Performance Report - the Committee discussed the prevalence of Pressure Ulcers in Derby, illustrating where focused work may have an impact on reducing the overall number of DCHS Pressure Ulcers.




The Committee also discussed in detail the Coroner’s Cases Report presented to the Board in July 2016 which involved included a case which related to Negative Pressure Wound Therapy used to treat wound dehiscence (rupture of wound along a surgical incision line) relating to the treatment of a spinal stenosis. The Board had asked QSC to look at the case in more detail.

The Committee reviewed the Root Cause Analysis and discussed the lessons learnt from the case. These included a focus on more structured communications at discharge and also discussions with the CCGs regarding potentially unfamiliar equipment.

Work is underway with the Chief Operating Officer at Derby Hospitals on a more effective discharge procedure -the case study will feed into their work. Further learning may come from the Coroner’s findings.

308/16 Board Assurance Framework Quarterly Report - the Committee reviewed the quarterly report and discussed in detail the proposal for a further risk is required to support our commitment to becoming a public health led provider. More work will be undertaken to provide appropriate wording for the additional risk.


309/16 Risk Management Report - JH updated the Committee regarding the corporate risks which have a risk rating of 10 and above. Highlights included:

There were no Never Events There were no overdue risks Work was going on to reduce the backlog of incidents Work was also underway with respect to risks raised by the

visit from the CQC The number of red RAG rated risks had reduced to only two


310/16 Quality Assurance and Compliance Report – the report detailed:

The next steps taken following the Care Quality Commission (CQC) Quality Summit

The initial findings of the organisational triangulation exercise which took place in September

The Q2 National Institute for Health and Care Excellence (NICE) summary position


311/16 Divisional Governance Report - developments and issues from each division included:

The Back to the Floor initiative is using the theme of Falls in October

Good progress has been made with the work on (Commissioning for Quality and Innovation) CQUINs which is ahead of the trajectory compared to last year

The roll out of TPP is proceeding well The wheel chair contract discussions are proceeding with the




CCGs The compliance rates across the Planned Care Division stand

at 86.8% over the last four month period Health Wellbeing and Inclusion (HWBI) have commenced an

internal assurance process that mirrors the corporate triangulation process. It will utilise the Key Lines of Enquiry to assess levels of assurance across all elements of service delivery within the division.

312/16 Research and Innovation Progress Report – the report informed the Committee of progress made in implementing the DCHS Research and Innovation Strategy. Since February 2016, the Research and Innovation Strategy Task and Finish Group has overseen development of infrastructure and partnerships.

The Group has been actively engaged in developing the Key Performance Indicators. The Committee agreed that the task and finish group would be replaced by a subgroup that reported in to QSC.


313/16 Legal Issues Report - the Committee discussed the quarterly activity for managing Claims and Coroner’s inquests/investigations.


314/16 Safeguarding Governance Group Summary Report – highlights included:

Information Sharing - DCHS are acting upon the recommendations in the recent briefing paper “Information Sharing to Protect Vulnerable Children and Families” from the Centre of Excellence for Information Sharing. It has been recognised in Serious Case reviews that information sharing is often poor and organisations need to act upon the recommendations outlined in the paper.

Unaccompanied Asylum Seeking Children Derbyshire will shortly be taking around 130 unaccompanied asylum seeking children. These children will be cared for as “Looked After Children” but due to their vulnerabilities, complex health and cultural needs, this is expected to impact on Children’s Services, MIU, Safeguarding, translation/linguistics and Resolve services. The Committee talked about the importance of providing a single point of contact within our organisation


315/16 Clinical Safety Group Summary Report – a highlight from the report was:

PLACE results - a very positive report was received with the majority of areas scoring above the national average


316/16 Equality Diversity and Inclusion Leadership Forum Summary Report - highlights included:

The results of the most recent equalities audit were shared with the Forum and showed improvements in some areas. The performance varies between different divisions




The Committee asked that the leadership of the HWBI division are provided with some targeted training

Clarification was sought on how the recommendations of the Board Equality Forum meeting are taken forward between meetings

317/16 Clinical Effectiveness Group Summary Report - highlights included:

Clinical Documentation Report - electronic documentation SystmOne has 16 associated outstanding actions. These are being reviewed and supported corporately with the support of the Senior Matron for Professional standards, but little progress has been made.

Clinical Records Audit (CRA) Report – progress to align the CRA questions with the CQC domains and ensure that they are fit for purpose in meeting documentation requirements in DCHS’s diverse services. The Consent element of the CRA had shown a decrease in compliance. After investigation this was found to relate to the ability of participants to ‘move on’ without completing this fundamental element. This is now being addressed.

Clinical Records Audit Q1 Report - the results were presented and the necessity to do further work with HWBI and Sexual Health was noted


318/16 Patient Engagement and Experience Group Summary Report – highlights included:

Patient Experience Monthly Report – there were delays in responses to complaints. Steps are being taken to resolve this problem

There was a significant concern from members of the group that the feedback from patients using Sexual Health Services and General Practices was less positive. Some specific comments were highlighted in relation to Sexual Health Services relating to attitude of staff and privacy and dignity. The representative from the HWBI division was asked to bring detailed response to those comments to the October meeting.

The Chair of the Frontline Care Council has stepped down, prompting discussion regarding the future role of the Council. The Committee discussed the potential overlap with other groups and forums. It was agreed that the matter would be referred to the People and Organisational Effectiveness team and the Staff Partnership Forum within the broader context of staff engagement.


319/16 Lessons Learnt Panel Update - the Committee took Significant Assurance from the work of the group.


320/16 Information Governance (IG) Group Summary Report - highlights included:

Continued progress against IG Toolkit and Training compliance DCHS has received notification from the Information




Commissioners Office (ICO) regarding the incident relating to a box of diabetes records that could not be located. The ICO have confirmed that they are taking no enforcement action

Cyber Security - Arden & Greater East Midlands (GEM) Commissioning Support Unit (CSU) provided an update on the work undertaken to progress the ‘Ten Steps to Cyber Security’ work programme. The group were assured of the work undertaken and requested that security standards are also confirmed for the three GP Practices managed by DCHS

Terms of Reference - the Committee approved the Terms of Reference.

321/16 Records Management Group including Summary Report The Committee discussed the background, issues and reasons for the creation of the Records Management Group.

The Committee agreed that the group would report into QSC.

Terms of Reference - the Committee approved the Terms of Reference.

Paper for Information

Policies ApprovedNone.

Issues to be escalated to Board or a CommitteeNone.



TRUST BOARDDocument Title: Quality Report

Presenter/Title: Carolyn White Chief Nurse / Director of QualityContents of Paper were previously discussed by:

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

Author Carolyn White Chief Nurse Director of Quality, Jo Hunter, Deputy Chief Nurse

Contact Email and Telephone Number:

Carolyn White [email protected] Hunter [email protected]

Date of Meeting: 27 October 2016 AgendaItem No: 267/16

No of pagesinc. this one: 28

Has an Equality Impact Assessment been undertaken Yes No x

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

Purpose of Paper

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

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

Recommendations

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


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

2.4 There is a risk to organisational performance due to the high volume of organisational and health system change, which is likely to continue to be a feature of our health economy for several years

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

4.2 There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions

Financial Impact

There are financial consequences related to the use of agency staff both from the additional costs incurred and from the potential impact of breaching the centrally identified cap.

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1.0 The National Agenda / Department of Health

1.1 Preventing Antimicrobial Resistance 2016 Review of the 2013-18 Strategy The overall goal of this new cross-government UK strategy is to slow the development and spread of antimicrobial resistance by focusing activities around 3 strategic aims:

improve the knowledge and understanding of antimicrobial resistance conserve and steward the effectiveness of existing treatments stimulate the development of new antibiotics, diagnostics and novel therapies

The use of antimicrobials has a wider cost to society that is not faced by the individual who receives them or practitioner who prescribes them. This cost is due to resistance to antimicrobials, which is predicted to rise over time without intervention. This may lead to a situation where multi-drug-resistant microbes increase, so that regular surgery & other medical procedures (e.g. chemotherapy) carry a substantial risk of death. Few new drugs are coming onto the market that would be able to treat these bacteria. As a result, antibiotics are likely to be overused and intervention is necessary to ensure that these external costs (of increased resistance) are taken into account by practitioners and individuals. The analyses assume that there will not be a substantial change in the number of antimicrobials prescribed. This is a reasonable assumption, as the main intention is to ensure that the most appropriate antimicrobials are used, rather than reducing the number. https://www.gov.uk/government/publications/progress-report-on-the-uk-5-year-amr-strategy-2015

The Impact on DCHS Through the auspices of the Antimicrobial Pharmacist DCHS currently audits the use of antimicrobial prescribing within inpatient areas, however, this is not undertaken in the community setting. Further development of the information technology will allow this in future and this has been identified as a priority with the trusts new Head of medicines management.

All antimicrobial audits undertaken by the Antimicrobial Pharmacist are reported to the Infection Prevention and Control Committee. In addition prescribing data is considered and appropriate challenges made to individual prescribers if they are considered to be outliers in their antimicrobial choices.

1.2 Report on abortion statistics in England and Wales for 2015 This report presents statistics on abortions carried out in England and Wales in 2015. It is the fourteenth in an annual series published by the Department of Health (DH), the first of which was for abortions in 2002. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/529344/Abortion_Statistics_2015_v3.pdf

The Impact on DCHS DCHS doesn’t provide any abortion services however Primary Care Services and the Integrated Sexual Health Services will make a number of referrals over a 12 month period and receive into their care women who have undergone a pregnancy termination.

2.0 Care Quality Commission (CQC) / NHS Improvement2.1 Building bridges, breaking barriers: Integrated care for older people The CQC gathered evidence from a range of sources, undertook site visits and spoke with older people and their carers to understand how integration across services affected their experiences of care. The teams looked for examples of where care was coordinated effectively and identified barriers that


https://www.gov.uk/government/publications/progress-report-on-the-uk-5-year-amr-strategy-2015

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/529344/Abortion_Statistics_2015_v3.pdf

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/529344/Abortion_Statistics_2015_v3.pdf


prevent it from working well. http://www.cqc.org.uk/sites/default/files/20160712b_buildingbridges_report.pdf

The Impact on DCHS DCHS is a key participant in the Health and Social Care economy and is strongly engaged in the development of the Sustainability and Transformation plan (STP) for Derby and Derbyshire. In addition locally integrated ‘place based care’ is under development with partners and Stakeholders across the Health and Social Care community.

2.2 Analysis of the patient safety incidents reported in England and Wales to the National Reporting and Learning System (NRLS) up to June 2016. The quarterly data summary reports set out the number of patient safety incidents reported to the National Reporting and Learning System (NRLS) and describe their patterns and trends. The data include all patient safety incidents reported by NHS organisations in England and Wales. https://improvement.nhs.uk/resources/national-quarterly-data-patient-safety-incident-reports-september-2016/

Two sets of data and analysis are presented in each quarterly data summary:

the number of reports made to the NRLS by quarter, using data based on the date that the report was received

an overview of patterns and trends in incident reports using data based on the date that the incidents occurred

Implications for DCHS The Head of Patient Safety and Risk Management manages the system of reporting into the NRLS and on publication receives this data directly from the NRLS. The data is reviewed and reported through the Clinical Safety Group to QSC and is a formal reporting requirement in the Annual Quality Report (Account).

3.0 Local Agenda

3.1 Better Care Closer to Home DCHS has now formally submitted a robust trust-wide response to the Better Care Closer to Home consultation in North Derbyshire. Staff continue to be informed of progress with the consultation and facilitated discussions with staff regarding the implications for them and their patients continue to be held.https://my.dchs.nhs.uk/Portals/0/Consultation%20DCHS%20response.pdf

4.0Staffing for Quality (see Appendix 1)

From April 2016 NHS Improvements issued further guidance around bank and agency spend. We now have to report all types of agency spend across DCHS not just nursing as was previously the case. Alongside this, rather than reporting as a % of our budget we have been given a financial ceiling rate for DCHS for 2016/17 this is £1.46 million noting that in 2015/16 our actual spend was £1.6million making this target challenging to achieve. A plan of action identifying a forecast spend based on the outturn for 2016/17 is in place with monthly reporting against this. Focused actions looking at how we can address learning from the work we have undertaken in nursing and spread this across other areas is currently taking place. Expenditure against our trajectory is monitored monthly as part of the financial performance report. For September there has been an increase in spending – see table below. Further detail is provided in the Board performance report.


http://www.cqc.org.uk/sites/default/files/20160712b_buildingbridges_report.pdf

https://improvement.nhs.uk/resources/national-quarterly-data-patient-safety-incident-reports-september-2016/

https://improvement.nhs.uk/resources/national-quarterly-data-patient-safety-incident-reports-september-2016/

https://my.dchs.nhs.uk/Portals/0/Consultation%20DCHS%20response.pdf


Apr May Jun Jul Aug Sep

2016/17 Actual Expenditure Actual Actual Actual Actual Actual Actual

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

Registered Nursing 89 49 66 85 34 68

Scientific, Therapeutic and Technical 61 34 47 24 -7 34

Medical and Dental 9 3 15 3 14 20

Support to Clinical 53 16 18 28 16 31

Managers and Infrastructure Support 27 13 23 3 14 11

239 115 169 143 71 164

Variance against Plan 132 175 200 222 199 272

5.0Care Quality Commission(CQC)DCHS is currently in the process of assessing the findings of the recent CQC formal reports. Action plans regarding Creswell and Langwith practice and Melbourne and Linacre MHA inspections have both been submitted with Sexual Health action plan being submitted week commencing 17th October 2017.

All of the recommendations regarding actions that ‘Must’ and ‘Should’ be considered have been collated into a central development plan which will be monitored through divisional governance meetings and reported to QSC via the compliance and assurance report. In addition individual services will be supported to analyse how they continue to make progress towards the ‘Outstanding’ criteria.

Castle Street Medical practice have been notified of their CQC inspection which is now due to take place on 31st October 2016, the local team are being supported to ensure learning from Creswell and Langwith and Ripley medical centres have been adopted.

CQC rating boardsPublication of the final CQC ratings, as per the statutory requirements, has been actioned within the required timescales. Portable table top displays are available to be utilised by DCHS clinical staff who are providing care within a range of settings.

6.0 Triangulation VisitsOn the 30th September 2016 a further eight services were visited by an internal independent



triangulation team comprising of non-clinical and clinical leads from across quality and operational divisions. The overall rating for the triangulation was ‘good’, which mirrors that reported by the CQC, and the Caring domain was also found to be outstanding. Some immediate actions were taken with services following identification of a number of environmental issues highlighted during the Babington Day Unit visit. All other areas identified on the feedback call requiring immediate attention have been addressed.

Positive feedback was received on the process by both the assessors and the staff who hosted the visits. The high level feedback is summarised in the table below:

Location: Triangulation Team Lead

Triangulation Support SAFE EFFECTIVE CARING RESPONSIVE WELL-LED OVERALL

SCORE

Day Unit Babington Hospital

Sue Ryan Lisa Hall Requires improvement

Requires improvement





Leg Ulcer Clinic Derby City

Tracey Brailsford Carl Ramsdale Requires

improvementRequires

improvement Outstanding Requires improvement



Ripley Medical Practice

Carolyn White Andy Cole Good Good Good Good Good Good

Rowsley Ward Trish Bailey Marcia Young Requires improvement

Requires improvement Outstanding Good Good Requires

improvement

Podiatric Surgery Buxton

Lisa Barrett Kavi Berry Requires improvement Good Outstanding Good Requires

improvementRequires

improvement

DTC Ilkeston Sally-ann Jo Sills Good Outstanding Good Good Good Good



Hospital Coope

Consultant Out-patients Mark Roberts Kate O’Brien Good Good Good Good Good Good

Starting Point Mel Parkin Catherine Wright Outstanding Good Good Good Outstanding Outstanding

7.0 Falls Awareness DayA falls awareness day was held at Babington Hospital Day unit on 7th October. This informative market style event showcased a range of support services for older people to improve falls management including dietary advice, footwear, support for the visually impaired, mobility aids and included voluntary and partner organisation including out local community police team. A range of taster exercise classes were held during the day. The event was open to members of the public and staff.

8.0 Schwartz RoundThe trusts first Schwartz round was held in Buxton on 13th October. Schwartz rounds provide a structured forum where staff can come together to discuss difficult emotional and social issues arising from patient care in a confidential and supportive setting.

The session was introduced by Mary Heritage and facilitated by Ian Lawrence and Lisa Barrett who along with three other colleagues have received training to manage Schwartz rounds. A five person panel each shared their experience under the title ‘A patient I will never forget’. The session was attended by a range of staff from the Buxton area including clinical staff, managers and administration staff. The session was observed by a colleague from Derbyshire Healthcare trust who is acting as a mentor to our Schwartz round team.

Further Schwartz rounds will be held across the county over the coming months.

9.0 Quality Always Gold AccreditationHillside ward Ashgreen, Alton ward Clay Cross and Orchard Cottage Respite Core Unit Whitworth all presented their areas for accreditation on 6th October as part of the final stage of the Quality Always accreditation process. Each presentation was unique in its own way and show cased the work of the respective areas. Clients from both learning disability units attended and added to the richness of the presentations and demonstrated how well these services are valued by their users. All three areas received their Gold accreditation which were presented by the Chairman.



10.0 Care Homes Stakeholder Event.The Care Home Advisory Service held their annual stakeholder event on 5th October. The theme of the event was Dementia care and presentations included the subjects of frailty and falls management. The event was well attended by staff from local care homes and very well evaluated at the end of the day.


What are the Governor involvement implications?

The Chief Nurse presents a paper covering the Quality Agenda reflected in this report to the Council of Governors. Governors may be involved in some of the pieces of work reported in this paper.


Individual items within this report will have implications for Equality and Diversity. It is always possible to present the information in more accessible formats should this be required.

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

The report covers Clinical Quality which impacts on Patients, Public, staff and in many cases will have stakeholder implications.

Risk Register

Is the issue on the current Risk Register? Yes Risk ID 3062


N/A



Appendix 1 Staffing for QualityAshgreen – Hillside

Reported as a site



Ash Green – Valley View

Reported as a site



Ash Green Site

Ash green has 2 wards on site, Hillside offering assessment and treatment and Valley View offering social short breaks

There is currently one ward manager at Ashgreen who covers across both wards

Due to the acuity of patients fluctuating staff are working across the site to meet patient need and bed occupancy giving consideration to skill mix required at any given time

Due to the high levels of patient acuity on Hillside this area has qualified nurses at all times and they cover valley view when required ensuring best use of staffing across the service



Babington Hospital - Baron Ward

There has been some staff unavailability and vacancy, requiring the use of bank and a small amount of agency. This in order to ensure safe staffing against bed numbers and patient dependency, afternoons having the greatest demand hence extra support available



Bolsover Hospital - Hudson Ward

Bed occupancy has fluctuated dependant on demand .There has been some staff unavailability and some increase in acuity but staffing has been adjusted to manage this. There has been some registered nurse bank and agency use



Cavendish Hospital - Fenton Ward

Staffing has been adjusted across the month in response to flex in beds and adjusted in response to patient dependency at each shift .During the day support is available from the ward manager in addition to nursing numbers reported.



Cavendish – Spencer Ward

Staffing levels are dependent on patient acuity and bed occupancy which can fluctuate Bank has been used to enable flex of staffing levels as required.

Bed numbers have been lower this month and staffing adjusted accordingly. This is an Older persons mental health ward and increased support is required at night from HCA



Cavendish Hospital Site



Clay Cross Hospital - Alton Ward

There is some Registered nurse vacancy within the area at present requiring some support from bank and agency, mainly for registered nurses, bed numbers are reduced at present.

Support is available from responsive workforce in this area to ensure quality and consistency



Ilkeston Hospital - Heanor Ward

There has been some bank HCA use due to vacancies which are open to recruitment. Bed occupancy has flexed to meet demand .Responsive workforce are providing additional cover on this ward to ensure consistency

Staff work across the wards at Ilkeston to ensure Registered nurse support is always available so staffing levels will fluctuate across the two wards to ensure this cover is available



Ilkeston Hospital - Hopewell Ward

Staff are utilised across site to make efficient use of skill mix.

Responsive workforce are providing additional cover on this ward due to increasing beds and vacancy There has been some bank used to give additional HCA support

These staffing levels are balanced across the two wards at Ilkeston Hospital



Ilkeston Hospital Site

All grades of staff work across site to provide appropriate cover especially at night the wards alternate cover to ensure one RN on each ward and an extra person across the wards where required dependant on dependency of patients

Extra staffing has been provided to meet the higher acuity of patients mainly HCA at night

Flex of staff across the site makes best use of skill mix



Newholme Hospital - Riverside Ward

The skill mix on this ward fluctuates dependant on patient acuity and service demand .There is some use of bank HCA required as opposed to RN

The bed numbers are lower this month which reflects in staffing levels and skill mix .This is one of the older people’s mental health wards so acuity fluctuates and staff flex to meet this demand



Newholme Hospital - Rowsley Ward

There is some registered nurse vacancy on the ward at the moment so the skill mix has been adjusted to allow safe staffing dependant on acuity and lower bed occupancy. There is always a registered nurse on the ward on all shifts and cover available in the day from the ward manager



Newholme Hospital site



Ripley Hospital – Butterley Ward

Due to acuity extra HCA support has been required which has been met through bank and agency



St Oswald’s Hospital – Okeover Ward

There has been an increase in HCA shifts sent to bank and agency this is due to fluctuations in bed numbers and high patient acuity



Walton Hospital - Linacre Ward

There are currently RMN vacancies which are open to recruitment. Bank HCA were used to cover some of these shifts following review of acuity and occupancy.

Staff continues to flex staff across both wards to meet service and patient need

There is always a nurse on the ward and when required an additional nurse works across the two wards but sometimes this additional staff is an HCA dependant on need



Walton Hospital – Melbourne Ward

Due to vacancies which are open to recruitment and unavailability bank staff was used to cover some of these shifts following review of acuity and occupancy. Melbourne has a number of high acuity patients.

Staff continues to flex staff across both wards. The skill mix is adjusted to reflect demand

There is always a registered nurse on the ward and when required a nurse is available to work across the wards in addition sometimes this additional nurse is a HCA dependant on need



Walton Hospital Site

All Grades of Staff flex across both wards to maintain Staffing levels. Bank is used due to patient acuity/ vacancies, however, this is mainly HCA bank/agency. Nights when required flex 3 RN to cover both wards; there is always one RN on each ward. Staff flexed across site to ensure numbers at required level with HCA



Whitworth Hospital – Oker Ward

There have also been fluctuations in acuity .Some bank and agency use following flex in beds. Staffing remains consistent on this ward



TRUST BOARD

Document Title: Board Assurance Framework (BAF) Quarter 2

Presenter/Title: Kirsteen Farrar, Associate Director of Corporate Governance/ Trust Secretary

Contents of Paper were previously discussed by:

Quality People and Business Committee in September 2016 Quality Service Committee – 18 October 2016 Audit and Assurance Committee – 21 October 2016

Author/Title: Melanie Curd, Deputy Trust Secretary

Contact Email and Telephone Number:

[email protected]



Has an Equality Impact Assessment been undertaken

Yes No x

Document is for: (more than one box can be ticked)

Information x Decision x Assurance x

Purpose of Paper

The purpose of the paper is to present the Board Assurance Framework (BAF) to the Board for approval.

Recommendations

The Board is asked to agree to the removal of risk 4.4 regarding compliance with the Mental Health Act and approve the BAF for Quarter 2.


4.3 - There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly

Financial Impact

There is no direct financial impact linked to this report.


There are 31 strategic risks on the BAF; five high risks, four within the Quality Business section and one in the Quality People section. The remaining risks on the BAF are all medium risks with the exception of 4.4 regarding Mental Health Act Compliance which is a low risk. Since Quarter 1, further work has been undertaken on the BAF:

the Quality Business and Quality People sections have maintained the same number of risks but have clarified the detail of the wording of the risks and the scores

the Quality Service section has two new risks (1.7 and 1.8) and it is proposed a further risk is added regarding public health. This was agreed at the Quality Service Committee on 18 October 2016 and DCHS’ Consultant in Public Health has been asked to provide the

268�BAF�Q2.pdfOverall�Page�116�of�171Page�1�of�46


wording. This will be added to the BAF from Quarter 3.

the Quality Governance section has had a risk regarding data quality added at 4.5 which was previously on the Quality Business section

The appropriate section of the BAF has been presented to the Quality Committees in September and October and it has been presented in its entirety to the Audit and Assurance Committee (AAC) on the 21 October 2016. Following discussion at AAC, it was agreed:

a full review of the Key Performance Indicators will be undertaken during Quarter 3

a new system wide governance risk is to be added to the Quality Governance section for Quarter 3

to establish trajectories to achieve the target risk scores so we can identify which risks will meet the timescales and which are not on track and require further action

to propose to Board remove risk 4.4 regarding compliance with the Mental Health Act as this is no longer a strategic risk

Attached is the Summary View which details all areas of limited assurance. Assurance is formally recorded on the BAF using the colour scheme below:

Green – Significant Assurance

Amber – Limited Assurance with clear action to resolve,

Red – Negative Assurance The Board is asked to agree to the removal of risk 4.4 regarding compliance with the Mental Health Act and approve the BAF for Quarter 2.


What are the Governor involvement implications?

The Governors receive the BAF on a quarterly basis as part of the Board papers.


There are specific risks on the BAF in relation to Equality and Diversity.

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

The BAF is a public document and in the public domain.

Risk Register

Is the issue on the current Risk Register?

N/A If yes, what is the Risk Number?


All operational risks are aligned to the BAF risks. This allows an operational profile to be established. These have been updated on the BAF as of 11 October 2016



BOARD ASSURANCE FRAMEWORK RISK SCORE SUMMARY 2016/17

BAF No

Risk Description Baseline

Risk Score

Target Risk

Score

Timeframe to achieve

Target Risk Score

Movement

Q2 Risk

Score

Q3 Risk

Score

Q4 Risk

Score

1.1 There is a risk to management capacity and overall service continuity from the process of bidding for and acquiring new services and/or the requirement to retender for existing services

12 L3xC4

8 L2xC4

April 2018

1.2 There is a risk to comprehensive patient information due to discontinuity between systems employed

12 L3xC4

8 L2xC4

April 2018

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

10 L2xC5

5 L1xC5

April 2018

1.4 There is a risk that DCHS does not provide patient centred care due to a lack of engagement and involvement of service users and stakeholders

8 L2xC4

8 L2xC4

N/A

1.5 There is a risk that our Clinical Governance initiatives do not deliver the outcomes necessary to support our strategy for high quality care

8 L2xC4

4 L1xC4

April 2018

1.6 There is a risk to the provision of safe, effective care due to a lack of consistent employment of the trust’s quality improvement and assurance framework

10 L2xC5

10 L2xC5

N/A

1.7 There is a risk to the provision of effective care due to a failure to learn and share lessons and implement change resulting from audit and feedback

8 L2xC4

4 L1xC4

April 2018

1.8 There is an overarching risk to patient quality and safety during periods of major system change and employment of new governance systems and processes related to PLACE based care.

12 L3xC4

8 L2xC4

April 2018

2.1

There is a risk of our staff not being able to provide high quality care due to national and local workforce supply shortages and the challenges of developing the workforce to have the appropriate skills and competencies to provide the future model of care resulting in poor patient outcomes

15 L3xC5

8 L2xC4

April 2018



BAF No


Risk Score

Target Risk

Score


Target Risk Score

Movement

Q2 Risk

Score

Q3 Risk

Score

Q4 Risk

Score

2.2

There is a risk to patients, service-users and employees due to staff performance and behaviours not being monitored and improved resulting in an adverse impact on the provision of high quality care and organisational reputation

6 L2xC3

6 L2xC3

N/A

2.3 There is a risk that the Trust fails to develop a proactive Health and Safety culture across the organisation, resulting in the trust not achieving zero harm to staff, visitors, contractors and members of the public.

9 L3xL3

6 L2xC3

April 2017

2.4 There is a risk to organisational performance due to the high volume of organisational and health system change, which is likely to continue to be a feature of our health economy for several years

12 L4xC3

12 L4xC3

April 2018

2.5

There is a risk to service users, staff and DCHS’ reputation due to staff not adhering to the principles of an equal, diverse and inclusive culture, resulting in discriminatory and non-inclusive behaviours, non-compliance with Equality Act and potential legal costs

9 L3xC3

6 L2xC3

April 2017

2.6 There is a risk to the personal engagement, morale, and health and wellbeing of our staff due to the uncertain operating environment DCHS is working in

12 L4xC3

9 L3xL3

April 2018

3.1

There is a risk to the organisation achieving strategic objectives due to inconsistent implementation / organisational support of the Sustainability and Transformation Plan resulting in poor outcomes for patients and poor use of resources

15 L3xC5

10 L2xC5

April 2018

3.2 There is a risk to the organisation of delivering public health contracts due to local authority price cuts resulting in poor outcomes for patients and poor use of resources

12 L3xC4

8 L2xC4

April 2017

3.3 There is a risk to future sustainability due to change in national policy for out of hospital care and commissioner priorities

15 L3xC5

10 L2xC5

April 2017



BAF No


Risk Score

Target Risk

Score


Target Risk Score

Movement

Q2 Risk

Score

Q3 Risk

Score

Q4 Risk

Score

3.4

There is a risk to the effective and efficient provision of DCHS services due to the impact of funding cuts within Local Authorities resulting in greater activity being directed towards health services, and flow of patients being disrupted

12 L3xC4

8 L2xC4

April 2018

3.5 There is a risk to the organisation due to capital controls leading to poor estate impacting upon patient care resulting in poor outcomes

12 L3xC4

8 L2xC4

April 2017

3.6 There is a risk to the organisation regarding the efficient use of resources constrained by Health Economy Plans

12 L3xC4

9 L3xC3

April 2018

3.7 There is a risk to the financial stability of the organisation of not meeting future Sustainable Quality Improvement Programme over the next two years (2016/17 and 2017/18)

15 L3xC5

10 L2xC5

April 2017

3.8 There is a risk to the organisation that activity levels will exceed contractual activity and capacity plans, resulting in financial risk and / or increased waiting times

12 L3xC4

8 L2xC4

April 2017

3.9 There is a risk to the organisation due to non-delivery of elements of the IM&T strategy, resulting in financial risk benefits not being realised and impact on patient care

16 L4xC4

8 L2xC4

April 2018

3.10 There is a risk to the organisation due to lack of comprehensive financial data quality systems resulting in poor decisions that could affect outcomes and financial loss

8 L2x4

8 L2x4

N/A

3.11 There is a risk to the Trust’s resilience, due to an emergency or severe disruption, resulting in an impact on patient care, inability to meet targets, loss of revenue

10 L2xC5

10 L2xC5

N/A

3.12 There is a risk to the organisation, due to failure to align and influence stakeholders resulting in poor relationships that impact on patient care

12 L3xC4

8 L2x4

April 2018

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

10 L2xC5

8 L2xC4

April 2018



BAF No


Risk Score

Target Risk

Score


Target Risk Score

Movement

Q2 Risk

Score

Q3 Risk

Score

Q4 Risk

Score

4.2 There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions

10 L2xC5

8 L2xC4

April 2018

4.3 There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly

8 L2xC4

8 L2xC4

N/A

4.4 There is a risk to the organisation due to non-compliance of administration of the MHA 1983 resulting in poor patient outcomes and breaches in legislation

4 L1xC4

4 L1xC4

N/A

4.5 There is a risk to the organisation due to lack of comprehensive data quality systems resulting in poor decisions that could affect outcomes and financial loss

12 L3xC4

8 L2xC4

April 2018



QUALITY SERVICE - Quarter 2 2016-17

Objective: To deliver high quality and sustainable services that echo the values and aspirations of the communities that we serve

Lead Committee: Quality Service Committee, chaired by Chris Bentley, Non-Executive Director Lead Executive Director: Carolyn White, Director of Quality/ Chief Nurse Strategic Priorities 2016/17

1. Ensure delivery of safe and clinically effective services 2. Ensuring a positive patient experience and meaningful engagement 3. Develop comprehensive and effective systems of quality improvement and assurance

Summary of Quality Service BAF Risks by Lead Executive Director: During quarter 2 the trust has received feedback from the Care Quality Commission which provides independent assurance on the good quality of many of the services we manage. The exceptions to this include primary care and integrated sexual health services which are both areas the trust had identified prior to inspection that required further work to provide robust assurance on consistent provision of quality care. Action plans to support both areas are currently in development and both areas are subject regular review through established governance processes. In addition concerns regarding clinical care continue to be managed within the derby city community team. Opportunities to learn from the transfer of these new services which are all currently falling below the expected standards for care at DCHS are being undertaken. The Trust continues to perform well with regard to patient feedback through the established patient experience feedback processes and was overwhelmingly positive within the CQC report. DCHS continues to develop its quality assurance framework central to this is Quality Always and it is pleasing to see that 6 clinical areas have achieved Gold accreditation within this reporting period. Quarterly triangulation visits during Q2 were suspended due to the recent CQC inspection and will be reinstated in September. We have strengthened our internal assurance processes by the introduction of weekly “Back to the floor” visits during August to facilitate clinical managers working more closely with their teams and to better understand the issues which inhibit good patient care. Senior managers and executives undertake these visits monthly.



Board Assurance Framework Risk 1.1 Risk Register ID 2990 Risk Description Previous Quarters Risk Score Operational Risk

Profile There is a risk to management capacity and overall service continuity from the process of bidding for and acquiring new services and/or the requirement to retender for existing services. Lead Committee/Group:

Q1 - L3 x C4=12

L3 x C4=12 Medium

High Medium Low

1 2 0

Controls Identified Lead KPIs Quarter 2 1. Comprehensive due diligence checks including quality

assessment and staffing profile Measure July Aug Sept

2. Risk Strategy and Register Number of risks within top X related to service delivery in lead service area - 5 4

3. Central corporate team to coordinate processes 4. Commercial Strategy

All papers presented for Assurance in Quarter 2 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Quality Performance Report – falls and pressure ulcers Sept – Falls performance (a)

Sept – Pressure ulcers performance (a)

Sept - Planned Driver Diagram, Falls Strategy, Falls Implementation Programme which will be audited. Deep dives on falls to go to QSC Sept – Planned work re Driver Diagram




Profile There is a risk to comprehensive patient information due to discontinuity between systems employed Lead Committee/Group:

Q1 - L3 x C4=12 L3 x C4 = 12 Medium

High Medium Low

0 10 2

Controls Identified Lead KPIs Quarter 2 1. IMT strategy and provision of TPP SystmOne across all services Measure July Aug Sept 2. Records audits

Information governance training 94% 94% 93%

3. Information Governance group 4. Caldicott Guardian

All papers presented for Assurance in Quarter 2were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Quality Performance Report – falls and pressure ulcers Falls performance (a)

Pressure ulcers performance (a)

Planned Driver Diagram, Falls Strategy, Falls Implementation Programme which will be audited. Deep dives on falls to go to QSC Planned work re Driver Diagram

Strategic Shift – outcomes yet to be achieved There is a gap and some challenges in some areas of performance, when compared to other DCHS services, process have stretched staff and their leaders (c) Sept – ensuring teams joining DCHS are part of the DCHS Way and the culture of the organisation (a)

An interim leader has been put in place to help mirror our systems and processes to support the alignment with DCHS City service leaders to attend Quality Always Development Centres

Gaining Assurance – Clinical Records Audit results Over-reliance on CRA tool cause for concern © Developments to be made to support managers utilise with local ownership and accountability




Profile There is a risk to the provision of safe, effective care due to a lack of consistent clinical leadership and expertise Lead Committee/Group:

Q1 - L2 x C5 = 10 L2 x C5 = 10 Medium

High Medium Low

0 2 0

Controls Identified Lead KPIs Quarter 2 1. NICE standards and review group Measure July Aug Sept 2. Rotating clinicians from acute services STEIS reportable incidents (total opened within month) 5 6 6 3. Policies and procedure Never Events 0 0 0 4. Quality Always Process

All papers presented for Assurance in Quarter 2 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Quality Performance Report – falls and pressure ulcers Falls performance (a)






Profile There is a risk that DCHS does not provide patient centred care due to a lack of engagement and involvement of service users and stakeholders Lead Committee/Group:

Q1 - L2 x C4 = 8 L2 x C4 = 8 Medium

High Medium Low

0 0 0

Controls Identified Lead KPIs Quarter 2 1. Patient and engagement and experience group Measure July Aug Sept 2. EDILF Friends and family test (target 95%) 98% 97.8% 98% 3. Stakeholder focus and engagement groups Number of complaints upheld by ombudsman 0 0 0 4. Council of Governors Number of complaints responded to within 40 working days 90% 56% 5. Policies related to Duty of candour Number of engagement groups 40 6. Insight visits Number of serious incidents were Duty of candour applies 5 6 6 7. Consultation and engagement Processes Dignity in care achievements ---

Number of Insight visits completed with feedback 3 2 4




Equalities Update (QPC) Reporting on equalities needs to demonstrate impacts and outcomes against trajectories which should then be triangulated with feedback from the Staff Survey (c)

AR / SE to work up a Driver Diagram which will be brought back to the November QPC meeting

Equalities Update – Equality Impact Statements (QPC) Completion of EIS statements patchy (a) Further work to be undertaken




Profile There is a risk that our Clinical Governance initiatives do not deliver the outcomes necessary to support our strategy for high quality care Lead Committee/Group:

Q1 - L2 x C4 = 8 L2 x C4 = 8 Medium

High Medium Low

0 0 0

Controls Identified Lead KPIs Quarter 2 1. Quality Improvement and Assurance Framework Measure July Aug Sept 2. Quality Always Process Number of avoidable pressure ulcers 2 4 6 3. Clinical policies and procedures Number of patient falls 3 2 0 4. Datix Risk Management System Never Events 0 0 0 5. Learning Lessons Panel STEIS reportable incidents (total opened within month) 5 6 6




General Practice Quarterly Update Policies and Procedures (c) Work is underway towards reviewing, refreshing and making consistent policies and procedures

Strategic Shift – outcomes yet to be achieved There is a gap and some challenges in some areas of performance, when compared to other DCHS services, process have stretched staff and their leaders (c) Sept – ensuring teams joining DCHS are part of the DCHS Way and the culture of the organisation (a)





Profile There is a risk to the provision of safe, effective care due to a lack of consistent employment of the trust’s quality improvement and assurance framework Lead Committee/Group:

Q1 - L2 x C5 = 10 L2 x C5 = 10 Medium

High Medium Low

0 14 0

Controls Identified Lead KPIs Quarter 2 1. Quality Improvement and Assurance Framework Measure July Aug Sept 2. Quality Always Process Friends and family test (target 95%) 98% 97.8% 98% 3. Clinical policies and procedures Number of complaints upheld by ombudsman 0 0 0 4. Datix Risk Management System Number of gold accredited clinical teams 6 5. Insight and Back to the floor visits 6. Triangulation Visits

All papers presented for Assurance in Quarter 2 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Strategic Shift – outcomes yet to be achieved There is a gap and some challenges in some areas of

performance, when compared to other DCHS services, process have stretched staff and their leaders (c) Sept – ensuring teams joining DCHS are part of the DCHS Way and the culture of the organisation (a)





Profile There is a risk to the provision of effective care due to a failure to learn and share lessons and implement change resulting from audit and feedback Lead Committee/Group:

New risk in Q2 L2 x C4 = 8 Medium

High Medium Low

0 1 0

Controls Identified Lead KPIs Quarter 2 1. Lessons Learned Panel Measure July Aug Sept 2. Datix Risk Management System TBC 3. Clinical Audit Programme

All papers presented for Assurance in Quarter 2 were received positively Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales):




Profile There is an overarching risk to patient quality and safety during periods of major system change and employment of new governance systems and processes related to PLACE based care Lead Committee/Group:

New risk in Q2 L3 x C4 = 12 Medium

High Medium Low

0 0 0

Controls Identified Lead KPIs Quarter 2 1. Sustainability and Transformation Plan Measure July Aug Sept

TBC




QUALITY PEOPLE - Quarter 2 2016-17

Objective: To build a high performance work environment that engages, involves and supports staff to reach their full potential

Lead Committee: Quality People Committee, chaired by Barbara-Anne Walker, Non-Executive Director Lead Executive Director: Amanda Rawlings, Director of People and Organisational Effectiveness Strategic Priorities 2016/17 1. Effectiveness workforce planning and development to meet our current and future patient needs. 2. Ensuring DCHS maintains its excellent staff engagement and grows this further. 3. To build cultural competence and awareness across DCHS to ensure we deliver equity of access and outcomes for staff and service users. 4. To ensure DCHS is compliant with health and safety legislation and builds a zero harm environment.

Summary of Quality People BAF Risks by Lead Executive Director: The Quality People BAF was significantly amended during the start of 2016 and the new version came into effect from the start of Quarter 1. This, coupled with the strategic changes we are expecting in coming months, has meant that a number of Committees have critically reviewed it during Quarter 1 and Quarter 2, leading to a number of actions to further clarify it. There are now 6 Quality People risks. The scores have been reviewed and target scores and timescales have been included for each risk. After a period of ‘bedding in’ during Quarter 1 and 2, we now feel confident that the BAF accurately reflects the key People risks that DCHS faces at this time. When presented to QPC in September, there were two red risks on the Quality People section of the BAF; one regarding the impact of the large amount of organisational change which is a feature of our health economy, and a second very much related one regarding our staff not being able to provide high quality care due to national and local workforce supply shortages and the challenges of developing the workforce to have the appropriate skills and competencies to provide the future model of care. These two risks are very closely linked and relate to the changing operating environment DCHS is currently a part of in line with STP plans, 21C consultation and our work with Derbyshire Healthcare Foundation Trust. Mitigation against both of these risks is fast becoming the priority work of the POE Directorate as we seek to support the organisation during this time of unprecedented change.



Examples of this work include:

• DCHS Lead for Workforce Planning seconded to the STP to work up the Derbyshire-wide workforce plan to ensure we are well-informed and equipped for future workforce needs

• Derbyshire-wide ACP Academy, developing future workforce • Work to develop the Nurse Associate role at DCHS • Actions to reassure staff in affected areas regarding 21c through recruitment activity • Planned recruitment campaign to fill all current known and upcoming vacancies, being proactive about anticipating upcoming gaps.

Post meeting note: Risk 2.4 Following Quality People Committee in September 2016 the consequence to reduce to 3 due to DCHS working with current competitors as part of an integrated system) reducing the risk from a high to a medium.



All papers presented for Assurance in Quarter 2 were received positively with the exception of

Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): People Performance Report – Sickness and Absence Figures

Jul - Overall 12 month cumulative trend is that sickness is increasing

Jul - Case management regarding long term sickness continues between the Head of People Services and the Chief Operating Officer on a monthly basis Staff Wellbeing Lead now in post and is working on the wellbeing strategy to better understand reasons for absence Introduction of the Social Movement with a focus on mental health. Further analysis needed to enable setting of meaningful targets to reverse current trends

People Performance Report – Agency Spending Performance

Sept – level of vacancies in Allied Health Professionals and nurse staffing (a)

Sept – recruitment activities are underway


Profile There is a risk of our staff not being able to provide high quality care due to national and local workforce supply shortages and the challenges of developing the workforce to have the appropriate skills and competencies to provide the future model of care resulting in poor patient outcomes Lead Committee/Group: Workforce Planning and Development

Q1 - L3 x C5 = 15 L3 x C5 = 15

High

High Medium Low

0 4 1

Controls Identified Lead KPIs Quarter 2 1. Regular reporting of training compliance to Ops Management, WFPDG and QPC Measure Jul Aug Sept 2. Revised Training needs analysis aligned to Service and strategic workforce plans Essential learning compliance 95% 96% 95% 3. Clinical Audits (e.g. Quality Always Assessment) Appraisal compliance 92% 92% 90% 4. Friends and Family Test No. of failed revalidations 0 0 5. Re-registration policy Care certificate attainment compliance 100% 6. Staff Survey Preceptorship compliance -

Total no of preceptees joining DCHS – Q2 35

7. DATIX Incidents • Newly qualified RN and AHP 19 8. Internal Intelligence Group • New to community 9 • New to this trust and joining within the first year of qualifying 6 • Return to Practice 1



Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Responding to Changing Operating Environment: Our Responsive Workforce Model

Jul – Agency staff target spend of £1.46m by NHS Improvements, overall spend last financial year was £1.6m

Jul – Targeted recruitment events taking place to recruit staff to the bank and the Responsive Workforce team

Staffing for Quality Report Level of vacancies in Allied Health Professionals and nurse staffing (a)

Recruitment activities are underway




Profile There is a risk to patients, service-users and employees due to staff performance and behaviours not being monitored and improved resulting in an adverse impact on the provision of high quality care and organisational reputation Lead Committee/Group: Staff Partnership Committee

Q1 - L2 x C3 = 6 L2 x C3 = 6 Medium

High Medium Low

0 2 0

Controls Identified Lead KPIs Quarter 2 1. Robust People Policies (e.g. Disciplinary, Performance Attendance) Measure July Aug Sept 2. Outcomes and actions from result of Staff Survey and Pulse checks

Av number of days an Employee Relations case takes to complete 57 44 56

3. Resolve Staff Support service

Attendance % 95.73% 95.68% 95.08% 4. Feedback and action from “Raising Concerns” app

Pulse Checks Staff Engagement score 77 78 78

5. Friends and Family test No. of complaints from Patients that lead to employee investigations or performance management 0 0 0

6. Revalidation / Registration and monitoring process Number of Employment Tribunals ongoing 1 1 1 7. Quality Always development centre Essential Learning compliance 95% 96% 95% 8. DATIX incidents Appraisal compliance 92% 92% 90%






Sept – level of vacancies in Allied Health Professionals and nurse staffing (a)

Sept – recruitment activities are underway



Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Strategic Shift – outcomes yet to be achieved (QSC) There is a gap and some challenges in some areas

of performance, when compared to other DCHS services, process have stretched staff and their leaders (c) Sept – ensuring teams joining DCHS are part of the DCHS Way and the culture of the organisation (a)





Profile There is a risk that the Trust fails to develop a proactive Health and Safety culture across the organisation, resulting in the trust not achieving zero harm to staff, visitors, contractors and members of the public. Lead Committee/Group: Staff Health Safety and Wellbeing Group

Q1 - L3 x C3 = 9 L3 x C3 = 9 Medium

High Medium Low

0 7 0

Controls Identified Lead KPIs Quarter 2 1. Health and Safety Strategy (September 2016) Measure Jul Aug Sept 2. Manager Training for Health and Safety (April 2016) Safety frequency rate (no) 0.34 0.34 0.35 3. Health and Safety Training for all staff Safety severity rate (no) 3.12 3.39 3.61 4. Dedicated Health and Safety Manager in post Lost time injury cost £110,116 £115,214 £137,616 5. Annual Health and Safety Self Audits Zero Harm- Riddor Reportable Injuries. 2 2 0 6. Regular reports from Occupational Health and Resolve on activity % of managers who have received Health and Safety training 98% 98% 98% 7. Policies and Operating Standards for health and safety activities. 8. Banksmen Training



Jul - Overall 12 month cumulative trend is that sickness is increasing (c) Sept – Extended discussion on a number of areas of sickness and absence policy, including anxiety, disabilities and high number of sickness in certain areas effecting figures (c)

Jul - Case management regarding long term sickness continues between the Head of People Services and the Chief Operating Officer on a monthly basis Staff Wellbeing Lead now in post and is working on the wellbeing strategy to better understand reasons for absence Introduction of the Social Movement with a focus on mental health. Further analysis needed to enable setting of meaningful targets to reverse current trends Sept –An action plan to be regarding all areas discussed will be presented to the January QPC meeting


Level of vacancies in Allied Health Professionals and nurse staffing (a)

Recruitment activities are underway



Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales):


Sept – Demand for agency staff usually increases during the winter months so a control of spending needs to be maintained (c)

Sept – Agency spend now monitored by the NHSI Oversight Framework; the Board will be briefed regarding the challenge of controlling the Budget and the risk involved with respect to the NHSI Oversight Framework

Health and Safety Update – further outcomes Further core strength training required to help with the risk of musculoskeletal injury (a)

Core strength training will feed into the Health and Safety Strategy and will feature in the forthcoming Board Development Session

Strategic Shift – outcomes yet to be achieved (QSC) There is a gap and some challenges in some areas of performance, when compared to other DCHS services, process have stretched staff and their leaders (c) Sept – ensuring teams joining DCHS are part of the DCHS Way and the culture of the organisation (a)




Board Assurance Framework Risk 2.4 Risk Register ID 2998 Risk Description Previous Quarters Risk Score Operational Risk Profile There is a risk to organisational performance due to the high volume of organisational and health system change, which is likely to continue to be a feature of our health economy for several years. Lead Committee/Group: Staff Partnership Committee

Q1 - L4 x C4 = 16 L4 x C3 = 12 Medium

High Medium Low

0 4 0

Controls Identified Lead KPIs Quarter 2 1. Organisational Change Policy Measure Jul Aug Sept 2. Dedicated POEM support to each organisational change Staff turnover 11.43% 10.01% 9.9% 3. Check and challenge of each organisational change proposal

through the Management of Change section of SPC % of staff successfully redeployed after being placed at risk of redundancy N/A N/A N/A

4. Tracking of Management of Change processes through SPC Numbers of Grievances re: org. change 0 0 0 5. Derbyshire-wide HR Policy Sub-Group agreement on cross –

organisational support during organisational change Attendance % 95.73% 95.68% 95.08%

6. Resolve staff support service Appraisal % 92% 92% 90% 7. Clinical Vision Events Essential Learning % 95% 96% 95.5% 8. DCHS Leadership Development Friends and Family Test 98% 97.80% 98%


Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Strategic Workforce Report - Flu campaign 2016/17 CQUIN target given of 75% of staff to be vaccinated

(c) A number of different actions taking place to increase uptake. Also, Chief Nurse is liaising with commissioners to clarify if room for negotiation on the target

People Performance Report – Sickness and Absence Figures

Overall 12 month cumulative trend is that sickness is increasing (a)

Case management regarding long term sickness continues between the Head of People Services and the Chief Operating Officer on a monthly basis Staff Wellbeing Lead now in post and is working on the wellbeing strategy to better understand reasons for absence Introduction of the Social Movement with a focus on mental health. Further analysis needed to enable setting of meaningful targets to reverse current trends



Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): People Performance Report – Agency Spending Performance

Demand for agency staff usually increases during the winter months so a control of spending needs to be maintained (c)

Agency spend now monitored by the NHSI Oversight Framework; the Board will be briefed regarding the challenge of controlling the Budget and the risk involved with respect to the NHSI Oversight Framework

Strategic Shift – outcomes yet to be achieved (QSC) Sept – There is a gap and some challenges in some areas of performance, when compared to other DCHS services, process have stretched staff and their leaders (c) Sept – ensuring teams joining DCHS are part of the DCHS Way and the culture of the organisation (a)

Sept – An interim leader has been put in place to help mirror our systems and processes to support the alignment with DCHS Sept – City service leaders to attend Quality Always Development Centres



Board Assurance Framework Risk 2.5 Risk Register ID 2999 Risk Description Previous Quarters Risk Score Operational Risk Profile There is a risk to service users, staff and DCHS’ reputation due to staff not adhering to the principles of an equal, diverse and inclusive culture, resulting in discriminatory and non-inclusive behaviours, non-compliance with Equality Act and potential legal costs Lead Committee/Group: Equality, Diversity & Inclusion Leadership Forum

Q1 - L3 x C3 = 9 L3 x C3 = 9 Medium

High Medium Low

0 2 0

Controls Identified Lead KPIs Quarter 2 1. Equality and Diversity Training for staff Measure Jul Aug Sept 2. Board Equalities Action Plan

% of actions in (1) Corporate, (2) Board and (3) Service-level Equalities Action Plans achieved

Under Development

3. Corporate Equalities Action Plan % of services using TPP that are using the Equality Monitoring Questionnaire (Big 9) for service users 42.85% 50% 42.85%

4. Directorate / Service-level Equalities Action Plans Level of EDS2 achieved (at ‘Developing’ moving to ‘Achieving’) Achieving Achieving Achieving 5. Workforce Equality Data Analysis

DCHS Workforce profile Vs Derbyshire population profile

DCHS Derbyshire 6. Service User Equality Data Analysis White 94% 96% 7. People Policies BME 4% 4% 8. People Strategy Disability 3% 14%

Male 11% 49% Female 89% 51% LGB 0.33%-0.42% 4%-7% Christian 50% 63%







Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): People Performance Report – Agency Spending Performance

Demand for agency staff usually increases during the winter months so a control of spending needs to be maintained (c)

Agency spend now monitored by the NHSI Oversight Framework; the Board will be briefed regarding the challenge of controlling the Budget and the risk involved with respect to the NHSI Oversight Framework

Equalities Update – Equality Impact Statements Jul – Completion of EIS statements patchy (c) July – Further work to be undertaken Equalities Update Sept - reporting on equalities needs to demonstrate

impacts and outcomes against trajectories which should then be triangulated with feedback from the Staff Survey (c)

Sept - AR / SE to work up a Driver Diagram which will be brought back to the November QPC meeting

Board Assurance Framework Risk 2.6 Risk Register ID 3045 Risk Description Previous Quarters Risk Score Operational Risk Profile There is a risk to the personal engagement, morale, and health and wellbeing of our staff due to the uncertain operating environment DCHS is working in Lead Committee/Group:

New Risk during 2016/17 Q1 L4 x C3 = 12

High Medium Low

0 0 0

Controls Identified Lead KPIs Quarter 2 1. Health Needs Assessment and associated Action Plan Measure Jul Aug Sept 2. Supporting and Maintaining Attendance Policy

Staff engagement score (Pulse Checks) 77 78 78 3. Occupational Health Service Pulse Check response rate 41% 50% 50% 4. Resolve Staff Support Service Attendance rate 95.73% 95.68% 95.08% 5. Supporting and Maintaining Attendance Manager

Training

6. Organisational Change Policy and Guidance 7. Positive Staff Partnership relationship

No papers presented for Assurance in Quarter 2 Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales):



QUALITY BUSINESS - Quarter 2 2016-17

Objective: To ensure an effective, efficient and economical organisation which promotes productive working and which offers good value to its community and commissioners

Lead Committee: Quality Business Committee, chaired by Ian Lichfield, Non-Executive Director Lead Executive Director: Chris Sands, Director of Finance, Information and Strategy Strategic Priorities 2016/17 1. To deliver a resilient current and future financial position, and be able to demonstrate value for money in the use of resources 2. To develop the Trust’s estate and infrastructure to support patient care ensuring benefits are identified, tracked and delivered 3. To explore, implement and monitor technical innovative approaches to providing care in a better way whilst demonstrating value for money 4. To develop the Trust in line with the commercial strategy to support the health economy in delivering the 5 year forward view Summary of Quality Business BAF Risks by Lead Executive Director: The Trust has 4 red risks on the Quality Business Section of the BAF. There is a risk to the organisation achieving strategic objectives due to inconsistent implementation / organisational support of the Sustainability and Transformation Plan resulting in poor outcomes for patients and poor use of resources. The Sustainability and Transformation Plan was submitted in draft to NHS England on 30th June. This was well received, and the feedback from NHS England encouraged the STP to now focus upon the implementation plans. A refresh was submitted on 16th September, which provided further detail around future capital requirements, and reclassified planned efficiencies against national definitions. Work continues for the next submission date which is the 21st October. The focus of the work over the next few weeks will be about further developing the business cases to support the key work programmes planned for 2017/18. This will then inform the next version of the financial plan. Alongside this, proposals are being developed as to how the system operates differently to develop contracts which promote system wide working in line with the principles of the STP. Contracts are due to be signed at the end of December 2016. At this stage we will review the current risk. There is a risk to future sustainability due to change in national policy for out of hospital care and commissioner priorities. The STP has developed a plan for out of hospital care which is based upon the delivery of services at a PLACE level. At this stage, there is further work required by the system to define what this will look like in practice. The Trust continues to be involved in these discussions.



There is a risk to the financial stability of the organisation of not meeting future Sustainable Quality Improvement Programme over the next two years (2016/17 and 2017/18). The Trust is making progress in delivering the 2016/17 SQIP plan, although there is some risk around delivery of the full plan on a recurrent basis. Mitigations are being pursued. Work has commenced across the Trust to develop the 2017/18 programme. This work is being developed alongside a number of workstreams aligned to the STP. The 2017/18 plan requires further work to ensure a robust efficiency plan is in place. A first draft of the 2017/18 financial plan will be reviewed by the Quality Business Committee at its September 2016 meeting, and the SQIP programme will be reviewed at the November meeting. There is a risk to the organisation due to non-delivery of elements of the IM&T strategy, resulting in financial risk benefits not being realised and impact on patient care. The IMT strategy is a key enabler to delivering high quality effective and efficient care. The Trust is developing its processes to better evidence the benefits being realised from the investments being made in IMT. Therefore the implementation of, and the evidencing of the benefits created, is a key area of focus for the IMT team. Progress with the development of the plan will be reviewed at the September Quality Business Committee.



All papers presented for Assurance in Quarter 2 were received positively Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Procurement Strategy Update Illustrated achievements to date against year-end

concerning (a) Future reports to include details of forecast shortfalls or recovery. To be reported to every QBC going forward

General Practice Strategy Group Summary Report inc Action Plan

Action plan and appraisal paper needs further work (a)

To be discussed at Board Dev Session planned for 6/10/16


Profile There is a risk to the organisation achieving strategic objectives due to inconsistent implementation / organisational support of the Sustainability and Transformation Plan resulting in poor outcomes for patients and poor use of resources Lead Committee/Group: Quality Business Committee

Q1 - L2 x C4 = 8 L3 x C5 = 15 High

High Medium Low

0 3 0

Controls Identified Lead KPIs Quarter 2 1. IBP 5. Performance Reports Measure Jul Aug Sept 2. LTFM 6. Chief Executives Report NHS Improvement Sign Off of Plan Green Green Green 3. Annual Plan 7. Policies and Procedures Governance Risk Rating Green Green Green 4. Operational Plan Updates 8. Transformation Update Finance Risk Rating 1 1 1




Profile There is a risk to the organisation of delivering public health contracts due to local authority price cuts resulting in poor outcomes for patients and poor use of resources Lead Committee/Group: Board

Q1 – L2 x C5 = 10 L3 x C4 = 12

Medium

High Medium Low

0 1 0

Controls Identified Lead KPIs Quarter 2 1. Business Development Reporting Measure Jul Aug Sept 2. Commercial Strategy

Tenders Won (Number) 2 1 0

3. Business development framework (eg investment policy / decision making tool) Tenders Lost (Number) 0 0 0

4. Competitor and market analysis Value of Tenders Won (£,000) 92 710 0

5. Tender oversight and analysis Tenders Lost (Value) 0 0 0

All papers presented for Assurance in Quarter 2 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Performance Report Missing data and targets on report (c)

Management control of contracts (c)

Comprehensively updated report to be presented to the next meeting Crucial part of Sustainability and Transformation Plan work. Also to be raised at next Execs meeting

Procurement Strategy Update Illustrated achievements to date against year-end concerning (a)

Future reports to include details of forecast shortfalls or recovery. To be reported to every QBC going forward




Profile There is a risk to future sustainability due to change in national policy for out of hospital care and commissioner priorities Lead Committee/Group: Quality Business Committee

Q1 - L3 x C5 = 15 L3 x C5 = 15

High High Medium Low

0 3 0

Controls Identified Lead KPIs Quarter 2 1. Contract management and negotiation process Measure Jul Aug Sept 2. Board and Executive colleagues meetings with Commissioner Chief Officers /team/ other contacts

3. Analysis of commissioning intentions as part of planning process 4. SQIP indicate level of commissioner support 5. Tender oversight and analysis 6. Board and Executive colleagues attendance at National Meetings / National Groups





Profile There is a risk to the effective and efficient provision of DCHS services due to the impact of funding cuts within Local Authorities resulting in greater activity being directed towards health services, and flow of patients being disrupted Lead Committee/Group: Quality Business Committee

Q1 – L4 x C4 = 16 L3 x C4 = 12

Medium

High Medium Low

0 0 0

Controls Identified Lead KPIs Quarter 2 1. Health and Wellbeing Board Measure Jul Aug Sept 2. Contract Management Board Delayed Transfer of Care (Rehabilitation) 10.1% 11% 12.9% 3. Transformation groups Delayed Transfers of Care (MH) 0.0% 1.2% 0.0% 4. Better Care Fund Number of Patients waiting for a DoLS assessment Direct impact on contracts portfolio in HWBI

Assurances 2015/16 (old BAF Risk Number in brackets)

External Assurance Provided

Oct

Nov

Dec

Jan

Feb

Mar Gaps in Control (c)/Assurance (a) Action Planned

Internal Assurance Provided

Oct

Nov

Dec

Jan

Feb

Mar Gaps in Control (c)/Assurance (a) Action Planned

Transformation Update (3.1.4) x x Strategic Priorities Paper (3.1.4) x QBC Annual Report (3.1.4) x Erewash Multi-Specialty Provider Update (3.1.4) x Transformation Group Summary Report (3.1.4) x

Assurances 2016/17 External Assurance Provided A

pr M

ay Jun Jul

Aug

Sept Gaps in Control (c)/Assurance (a) Action Planned

Internal Assurance Provided

Apr

May

Jun Jul

Aug

Sept Gaps in Control (c)/Assurance (a) Action Planned

Performance Report (Board) x x x x x Quality Improvement and Assurance Framework (QIAF)(QSC) x Transformation Progress Report x Business Development Report x x x Capital & Estate Programme Group Summary Report x x x

All papers presented for Assurance in Quarter 2 were received positively Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): 268�BAF�Q2.pdf

Overall�Page�148�of�171Page�33�of�46



Profile There is a risk to the organisation due to capital controls leading to poor estate impacting upon patient care resulting in poor outcomes Lead Committee/Group: Capital and Estate Programme Group

Q1 – L2 x C4 = 8 L3 x C3 = 12

Medium High Medium Low

0 6 2

Controls Identified Lead KPIs Quarter 2 1. Estates Planning System Measure Jul Aug Sept 2. Capital Planning System

Proportion of estate at B or above Under

development Under

development Under

development 3. Progress Reports against Estates Strategy Percentage of unutilised estate Under

development Under

development Under

development 4. Planned Preventative Maintenance System Percentage of non-patient facing estate Under

development Under

development Under

development 5. Policies and procedures

6. Facet Survey





Profile There is a risk to the financial stability of the organisation due to resources not being used efficiently, and planned benefits not being realised Lead Committee/Group: Capital and Estate Programme Group

Q1 – L3 x C3 = 9 L3 x C4 = 12


0 1 0

Controls Identified Lead KPIs Quarter 2 1. Capital Planning System Measure Jul Aug Sept 2. Progress Reports against Estates Strategy 100% Delivery of Capital Programme 67% 57% 48%



Profile There is a risk to the financial stability of the organisation of not meeting future Sustainable Quality Improvement Programme over the next two years (2016/17 and 2017/18) Lead Committee/Group: Quality Business Committee

Q1 - L3 x C5 = 15 L3 x C5 = 15

High

High Medium Low

0 3 0

Controls Identified Lead KPIs Quarter 2 1. Finance Reports Measure Jul Aug Sept 2. SQIP Reports Recurrent SQIP Planned (£,000) 1,219 1,531 1,843 3. Performance Management System Recurrent SQIP Actual (£,000) 1,133.5 1,489.7 1,768.0 4. PMO Office Forecast SQIP (£,000) 4,894 4,916 4,827 5. Policies and procedures 2017/2018 SQIP Planned (£,000) Under Development

All papers presented for Assurance in Quarter 2 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Transformation Update including DCHS Mileage Claims Comparison and Smartphone roll out

Jul - Further work requested regarding agile working in regard to mileage claims (a)

July – Two teams, one agile vs one not agile, to be compared. Also two team, one rural vs one city. Also to look at how many staff are returning to base inbetween meetings rather than working agilely.

Cost Improvement Report Jul - Variances that should have fallen into this year have reduced significantly in a month

Jul - Paper to be revisited to explain why some reds from the previous report were suddenly achieved and to give an explanation of why this has happened




Profile There is a risk to the organisation that activity levels will exceed contractual activity and capacity plans, resulting in financial risk and / or increased waiting times Lead Committee/Group: Quality Business Committee

Q1 - L3 x C4 = 12 L3 x C4 = 12


0 4 0

Controls Identified Lead KPIs Quarter 2 1. Finance Reports Measure Jul Aug Sept 2. Performance Reports Income - Planned (£,000) 63,771 80,022 96,193 3. Performance Management System Income - Actual (£,000) 63,934 80,035 96,535 4. Policies and Procedures Income Forecast - (£,000) 190,640 192,173 192,669 5. Planning Process Activity -Planned (no) 141,845 173,900 209,389 6. Contract Management meetings with Commissioners Activity Actual (no) 160,377 203,528 241,493

All papers presented for Assurance in Quarter 2 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Performance Report Missing data and targets on report (c)

Management control of contracts (c)


Procurement Strategy Update Illustrated achievements to date against year-end concerning (a)

Future reports to include details of forecast shortfalls or recovery. To be reported to every QBC going forward




Profile There is a risk to the organisation due to non-delivery of elements of the IM&T strategy, resulting in financial risk benefits not being realised and impact on patient care Lead Committee/Group: Information Management & Technology Group

Q1 – L3 x C4 = 12 L4 x C4 = 16

High High Medium Low

1 7 0

Controls Identified Lead KPIs Quarter 2 1. IM&T Reporting Measure Jul Aug Sept 2. IM&T Strategy Proportion of Services on an Electronic System (%) -

Progress Against IM&T Plan (%) 62.9% 62.4% 65.3% 3. IMT Group 4. Policies and Procedures Information Sharing within the Trust Percentage 82.4% 82.4% 88%

All papers presented for Assurance in Quarter 2 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Benefits Realisation July – No evidence of tangible benefits in paper July – Trust needs to be assured that money being

spent correctly – CS to consider allocating approval of projects to a member of the finance team

IM&T Strategy Quarterly Update Report lacked actual vs plan data, cost vs target data and any information around returns on investment (a)

JA to pick up with CS and get some accounting support to improve figures in report going forward

IM&T Group Summary Report Delay in aspects of Business Intelligence in the Data Quality Kitemark work.

Delays are attributable to lack of resource which is in the process of being addressed




Profile There is a risk to the organisation due to lack of comprehensive financial data quality systems resulting in poor decisions that could affect outcomes and financial loss Lead Committee/Group: Information Management & Technology Group

New in Quarter 2 L2 x C4 = 8


0 0 0

Controls Identified Lead KPIs Quarter 2 To be confirmed Measure Jul Aug Sept To be confirmed





Profile There is a risk to the Trust’s resilience, due to an emergency or severe disruption, resulting in an impact on patient care, inability to meet targets, loss of revenue Lead Committee/Group: Quality Business Committee

Q1 - L2 x C5 = 10 L2 x C5 = 10


2 1 0

Controls Identified Lead KPIs Quarter 2 1. Accountable Emergency Officer appointed Measure Jul Aug Sept 2. Member of the multi-agency Local Health Resilience Partnership Gold Training -Number Compliant (no) 7 7 7 3. Member of the multi-agency Local Resilience Forum Gold Training -Number Available (no) 7 7 7 4. Framework for Responding to Industrial Action in-place Gold Training (%) 100% 100% 100% 5. Quarterly reporting to the board via QBC Silver Training -Number Compliant (no) 8 8 8 6. Major Incident Plan/Business Continuity Plan Silver Training -Number Available (no) 8 8 8 7. Site Contingency Plan in-place Silver Training (%) 100% 100% 100% 8. Pandemic Influenza Contingency Plan in-place Core Standards Training (%) >90% >90% >90% 9. Internal assessment against NHS England's Core Standards for EPRR undertaken





Profile There is a risk to the organisation, due to failure to align and influence stakeholders resulting in poor relationships that impact upon patient care Lead Committee/Group: Board

Q1 – L2 x C4 = 8 L3 x C4 = 12


0 1 0

Controls Identified Lead KPIs Quarter 2 1. Communications and marketing strategy Measure Jul Aug Sept 2. Board level lead for communications and marketing Staff and service user friends and family test 98.0% 97.8% 98.0% 4. Staff survey 5. Partnership strategy and governance 6. Tender oversight includes review of necessary partnership arrangements

All papers presented for Assurance in Quarter 2 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales):



QUALITY GOVERNANCE - Quarter 2 2016-17

Objective: To manage and develop a successful organisation Lead Committee: Audit and Assurance Committee, chaired by Nigel Smith, Non-Executive Director Lead Executive Director: Kirsteen Farrar, Trust Secretary Strategic Priorities 2016/17 1. To ensure control systems to manage strategic risks are operating effectively 2. To ensure the Board Assurance Framework remains a live document which fully reflects the risks and opportunities facing the Trust to deliver

our vision 3. To understand the implications of new models of care and to advise the Board as to the emerging governance issues arising and the Trust’s

response Summary of Quality Governance BAF Risks by Lead Executive Director: There are no red risks on the Quality Governance section of the BAF. During Quarter 2, external assurance was provided by 360 Assurance on Mental Health Act Compliance – the follow up report confirmed good progress had been made on all the actions and an opinion of Significant Assurance was provided. Compliance in this area continues to be monitored by the Mental Health Act Committee who has identified the need for further work regarding our compliance with restrictive interventions best practice; this is an area of limited assurance at present however there are plans in place to address this. It has been proposed risk 3.10 regarding data quality be moved from Quality Business to Quality Governance – this has now been included at 4.5.




Board Assurance Framework Risk 4.1 Risk Register ID 3000 Risk Description Previous

Quarters Risk Score Operational Risk Profile

There is a risk to the organisation due to not having strong corporate governance systems in place resulting in Trust vision not being delivered Lead Committee/Group: Audit & Assurance Committee

Q1 - L2 x C5 = 10 L2 x C5 = 10


0 1 1

Controls Identified Lead KPIs Quarter 2 1. Constitution and Procedures 5. Counter Fraud Reports 9. Board Assurance Framework Measure Jul Aug Sept 2. Board Committee Reporting 6. External Audit Reports 10. Clinical Audit Programme Governance Rating 3. Quality Governance reporting 7. Scheme of Delegation 11. Annual Governance Statement 4. Internal Audit Reports 8. Self-Certification Reporting




Profile There is a risk to the organisation due to not meeting regulatory, contractual or legal obligations resulting in sanctions Lead Committee/Group: Audit & Assurance Committee

Q1 - L2 x C5 = 10 L2 x C5 = 10

Medium

High Medium Low

0 5 1

Controls Identified Lead KPIs Quarter 2 1. CQC Compliance Reporting Measure Jul Aug Sept 2. Monitor Self-Certification CQC Non-Compliance with Fundamental Standards resulting in Enforcement Action (no) 0 0 0 3. Performance Reporting CQC Compliance Action Outstanding (no) 0 0 11 Governance Risk Rating Continuity of Service Rating 4 4 4

All papers presented for Assurance in Quarter 2 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Equalities Update (QPC) Sept - reporting on equalities needs to demonstrate

impacts and outcomes against trajectories which should then be triangulated with feedback from the Staff Survey (c)

Sept - AR / SE to work up a Driver Diagram which will be brought back to the November QPC meeting

Equalities Update – Equality Impact Statements Jul – Completion of EIS statements patchy July – Further work to be undertaken Update on Reporting of Restrictive Interventions (MHAC)

Sept – Work needed to be carried out regarding external review of the use of restrictive interventions in line with NG10 guidance (c)

Sept – A small working group is to be formed to pick up the issue of how best to carry out these reviews

Pre-Campaign Flu Update – outcomes of the campaign

Sept –Pending commencing the campaign once the vaccines arrive late Sept/early October (c)

Sept – new logistical actions planned following a review of lessons learnt from previous campaigns. Regular updates through QPC to the Board




Profile There is a risk to the organisation due to not having strong risk management controls in place resulting in failure to put effective mitigation plans in place promptly Lead Committee/Group: Quality Service Committee Risk Register Review Meeting

Q1 - L2 x C4 = 8 L3 x C4 = 8


0 0 0

Controls Identified Lead KPIs Quarter 2 1. Risk Management Strategy Measure Jul Aug Sept 2. Board Assurance Framework Number of top X risks 30 33 27 3. Risk Register 4. Risk Management Policy Number of overdue risks 0 0 1 5. DATIX Risk Management System 6. Annual Governance Statement

All papers presented for Assurance in Quarter 2 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Maintenance of Surgical Power Equipment (QSC) Jul – Actions being undertaken to ensure equipment

is maintained, in efficient working order and good repair (a)

Jul – An update to be provided to QSC in October



All papers presented for Assurance in Quarter 2 were received positively with the exception of: Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Update on Reporting of Restrictive Interventions Sept – Work needed to be carried out regarding

external review of the use of restrictive interventions in line with NG10 guidance (c)

Sept – A small working group is to be formed to pick up the issue of how best to carry out these reviews

Board Assurance Framework Risk 4.4 Risk Register ID 3003 Risk Description Previous

Quarters Risk Score Operational Risk Profile

There is a risk to the organisation due to non-compliance of administration of the MHA 1983 resulting in poor patient outcomes and breaches in legislation Lead Committee/Group: Mental Health Act Committee

Q1 - L1 x C4 = 4 L1 x C4 = 4

Low High Medium Low

0 0 1

Controls Identified Lead KPIs Quarter 2 1. AMHAM Audits Measure Jul Aug Sept 2. MHA Scheme of Delegation Completion of 2 AMHAM Audits per year OPMH and LD inpatient services Currently being arranged for Nov 16

and March 2017 3. MHA Code of Conduct Unrectifiable errors on section paperwork 0 1 0 4. Regular training updates for staff Overdue actions on Code of Practice action plan 5 5 5 5. Policies and procedures



Board Assurance Framework Risk 4.5 (previously 3.10) Risk Register ID 3059 Risk Description Previous Quarters Risk Score Operational Risk

Profile There is a risk to the organisation due to lack of comprehensive data quality systems resulting in poor decisions that could affect outcomes and financial loss Lead Committee/Group: Information Management & Technology Group

Q1 – L3 x C4 = 12 L3 x C4 = 12


0 0 0

Controls Identified Lead KPIs Quarter 2 1. Performance Reporting - Data Quality issues Measure Jul Aug Sept 2. Data Quality Kitemark

CIDS-Services Under Kitemark (%) Under development 3. Policies and procedures Kitemarked KPIs 12 or above (%) Under development 4. IM&T Strategy Performance KPIs covered by kitemark (%) 61% 61% 61% 5. IMT Group SUS-Patient Records With NHS Number (%) 99.8% 99.8% 99.8%

All papers presented for Assurance in Quarter 2 were received positively with the exception of Name of Paper Identified Gaps in Control (c) /Assurance (a): Action planned to address (and timescales): Benefits Realisation July – No evidence of tangible benefits in paper July – Trust needs to be assured that money being

spent correctly – CS to consider allocating approval of projects to a member of the finance team

IM&T Strategy Quarterly Update Report lacked actual vs plan data, cost vs target data and any information around returns on investment (a)

JA to pick up with CS and get some accounting support to improve figures in report going forward

Performance Report Missing data and targets on report (c) Management control of contracts (c)




TRUST BOARD Document Title: NHS England Core Standards for Emergency Preparedness,

Resilience and Response (EPRR) - Annual Self-Assessment Presenter/Title: William Jones, Chief Operation Officer Contents of Paper were previously discussed by: Security and EPRR Group

Author/Title: Chris Wildsmith, General Manager (Head of EPRR) Contact Email and Telephone Number: 07964 123952




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

Purpose of Paper

To present the Core Standards for Emergency Preparedness, Resilience and Response for review and approval by the Board, as requested by NHS England.

Recommendations

The Board is asked to review and approve the Trust’s self-assessment against NHS England’s Core Standards for Emergency Preparedness, Resilience & Response.


3.11There is a risk to the Trust’s resilience, due to an emergency or severe disruption, resulting in an impact on patient care, inability to meet targets, loss of revenue.

Financial Impact

None. Work will be undertaken within existing staff and management costs.


NHS England requires all NHS Trusts to review their compliance against the Core Standards for EPRR on an annual basis. As part of this process, NHS England request that Trust Boards are sighted on the self-assessment and agree it is a true representation of the Trust’s level of compliance against the standards. Since their introduction in 2013 the Core Standards have been used to inform the work programme within DCHS, and subsequently the Trust has held a strong position in this area. In 2015-16 the Trust recorded substantial compliance overall, with full compliance against the main set and substantial compliance against those relating to HazMat and CBRN (planning for incidents involving hazardous materials, chemical, bacterial, radiological, and nuclear). HazMat & CBRN standards were new for 2015-16, and became the focus for planning during Q4 of 2015-16 and into early 2016-17. This led to the creation of a set of procedures for the Minor Injury

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Units to deal with contaminated self-presenters. In July 2016, a self-assessment of the Trust’s compliance with the Core Standards was undertaken by Chris Wildsmith (General Manager / Head of Emergency Planning) and William Jones (Chief Operating Officer / Accountable Emergency Officer). This involved RAG (Red Amber Green) rating each of the applicable core standards. At this point all areas were determined to be ‘green’, with the exception of one ‘amber’ against lockdown planning. Whereas the Trust has a current Lockdown Policy, this area was self-assessed as ‘amber’ as it was felt that further work was required to create site specific lockdown procedures for all community hospitals (currently four of these are in place). This self-assessment was presented to the Security and EPRR Group on 17 August where it was agreed to be a true representation of the Trust’s level of compliance. A list of the applicable Core Standards with comments against each standard can be found in appendix i. A subsequent Confirm and Challenge meeting was held with Suzanne Pickering (Head of Governance at North Derbyshire CCG) and Chris Leach (EPRR Coordinator for NHS England North Midlands) on 8 September 2016. During this session Suzanne and Chris reviewed each of the individual assessments. They advised that they felt that the Trust had met the requirement to achieve a ‘green’ rating against lockdown planning, giving the Trust ‘Full Compliance’ overall. The CCG and NHS England met again on the 6 October 2016 to review and agree levels of compliance for Trusts and they agreed to formally award DCHS ‘Full Compliance’. This has been confirmed in writing from Mark Smith (Chief Finance Officer at North Derbyshire CCG) and Marcel Comer (Head of EPRR at NHS England North Midlands). A copy of the letter can be found in appendix ii.


What are the Governor Involvement implications? There are no specific Governor involvement implications.


Certain types of incidents may have the potential to impact on the Trust’s ability to provide accessible services. It is also noted that incidents may affect certain groups differently, for example, high risk groups for influenza. The potential impact on different groups is to be considered when responding to any incident.


There are no specific Patient, Public and Stakeholder implications. However, the process helps to ensure public confidence in the Trust.

Risk Register


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



Appendix i – Core Standards for Emergency Preparedness, Resilience & Response Core Standards for Emergency Preparedness, Resilience & Response Ref Standard Comments 1 Organisations have a director level

accountable emergency officer who is responsible for EPRR (including business continuity management)

William Jones (Chief Operating Officer) is the Trust’s Accountable Emergency Officer.

2 Organisations have an annual work programme to mitigate against identified risks and incorporate the lessons identified relating to EPRR (including details of training and exercises and past incidents) and improve response.

Work programme is based upon the Core Standards.

3 Organisations have an overarching framework or policy which sets out expectations of emergency preparedness, resilience and response.

The Trust has a Strategy for EPRR.

4 The accountable emergency officer ensures that the Board and/or Governing Body receive as appropriate reports, no less frequently than annually, regarding EPRR, including reports on exercises undertaken by the organisation, significant incidents, and that adequate resources are made available to enable the organisation to meet the requirements of these core standards.

EPRR activities are delivered through the Security & EPRR Group, this is a sub-group of the Quality Business Committee (QBC), a sub-committee of the Board. The Group meets roughly quarterly and summary reports are presented to QBC.

5 Assess the risk, no less frequently than annually, of emergencies or business continuity incidents occurring which affect or may affect the ability of the organisation to deliver its functions.

EPRR risks form part of the wider risk management system. The Trust also reviews the Community Risk Register.

6 There is a process to ensure that the risk assessment(s) is in line with the organisational, Local Health Resilience Partnership, other relevant parties, community (Local Resilience Forum/ Borough Resilience Forum), and national risk registers.

The Trust is also involved in the development of the Local Resilience Form (LRF) and Local Health Resilience Partnership (LHRP) risk assessment processes.



Appendix i – Core Standards for Emergency Preparedness, Resilience & Response 7 There is a process to ensure that the

risk assessment(s) is informed by, and consulted and shared with your organisation and relevant partners.

The Trust is also involved in the development of the Local Resilience Form (LRF) and Local Health Resilience Partnership (LHRP) risk assessment processes.

8 Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resources and capacity. Have arrangements for (but not necessarily have a separate plan for) some or all of the following (organisation dependent) (NB, this list is not exhaustive): • Incidents and emergencies

(Incident Response Plan (IRP) (Major Incident Plan))

• corporate and service level Business Continuity (aligned to current nationally recognised BC standards)

• HAZMAT/ CBRN - see separate checklist on tab overleaf

• Severe Weather (heatwave, flooding, snow and cold weather)

• Pandemic Influenza (see pandemic influenza tab for deep dive 2015-16 questions)

• Mass Countermeasures (eg mass prophylaxis, or mass vaccination)

• Mass Casualties • Fuel Disruption • Surge and Escalation Management

(inc. links to appropriate clinical networks e.g. Burns, Trauma and Critical Care)

• Infectious Disease Outbreak • Evacuation • Lockdown

The following plans are in place: • Major Incident & Business

Continuity Plan (this also covers severe weather and telecommunications failure).

• Framework for Responding to Industrial Action.

• Pandemic Influenza Contingency Plan.

• Fuel Disruption Contingency Plan.

• MIU Procedures for Dealing with Contaminated Self-Presenters and Mass Casualties.

• Lockdown Policy. • System Resilience Plan. • Generic Inpatient Off-Site

Evacuation Plan (in draft) In addition to these the Trust also operates under a number of multi-agency plans. Including for example: Public Health England’s Outbreak Management Plan.



Appendix i – Core Standards for Emergency Preparedness, Resilience & Response

• Utilities, IT and telecommunications failure

9 Ensure that plans are prepared in line with current guidance.

The Trust has a robust process for developing plans and ensuring good housekeeping.

10 Arrangements include a procedure for determining whether an emergency or business continuity incident has occurred. And if an emergency or business continuity incident has occurred, whether this requires changing the deployment of resources or acquiring additional resources.

The Trust has a joint Major Incident & Business Continuity Plan that describes these.

11 Arrangements include how to continue your organisation’s prioritised activities (critical activities) in the event of an emergency or business continuity incident insofar as is practical.

The Trust has undertaken a Business Impact Analysis process.

12 Arrangements explain how VIP and/or high profile patients will be managed.

This is outlined within the Security Policy.

13 Preparedness is undertaken with the full engagement and co-operation of interested parties and key stakeholders (internal and external) who have a role in the plan and securing agreement to its content

The Trust is an active member of the Local Health Resilience Partnership (LHRP).

14 Arrangements include a debrief process so as to identify learning and inform future arrangements

This is outlined within the Major Incident & Business Continuity Plan.

15 Arrangements demonstrate that there is a resilient single point of contact within the organisation, capable of receiving notification at all times of an emergency or business continuity incident; and with an ability to respond or escalate this notification to strategic and/or executive level, as necessary.

The Trust has a two tier On-Call Team for resilience and to also support the Trust’s command and control structure.

16 Those on-call must meet identified competencies and key knowledge and skills for staff.

National competencies are followed; this is outlined within the Strategy. The On-Call Team members are required to undertake either the Tactical Emergency Management or Strategic Leadership in a Crisis course.



Appendix i – Core Standards for Emergency Preparedness, Resilience & Response 17 Documents identify where and how

the emergency or business continuity incident will be managed from, ie the Incident Co-ordination Centre (ICC), how the ICC will operate (including information management) and the key roles required within it, including the role of the loggist.

This is outlined within the Major Incident & Business Continuity Plan and the supporting On-Call Pack.

18 Arrangements ensure that decisions are recorded and meetings are minuted during an emergency or business continuity incident.

On-Call Team members receive training around log keeping as part of the agreed courses. The Trust also has a number of trained Loggists.

19 Arrangements detail the process for completing, authorising and submitting situation reports (SITREPs) and/or commonly recognised information pictures (CRIP) / common operating picture (COP) during the emergency or business continuity incident response.


22 Arrangements demonstrate warning and informing processes for emergencies and business continuity incidents.

The Major Incident & Business Continuity Plan has a section on Media Management, including warning and informing. The Local Resilience Forum has a multi-agency Warning & Informing Plan.

23 Arrangements ensure the ability to communicate internally and externally during communication equipment failures


24 Arrangements contain information sharing protocols to ensure appropriate communication with partners.

The Trust is signed up to a multi-agency information sharing agreement via the Local Health Resilience Forum and Local Resilience Forum.

25 Organisations actively participate in or are represented at the Local Resilience Forum (or Borough Resilience Forum in London if appropriate)

The Trust is an active member of the Local Health Resilience Partnership and also sits on a Local Resilience Forum sub-group.

26 Demonstrate active engagement and co-operation with other category 1 and 2 responders in accordance with the CCA

The Trust is an active member of the Local Health Resilience Partnership and also sits on a Local Resilience Forum sub-group.

27 Arrangements include how mutual aid The Trust has signed up to a 270�EPRR�Core�Standards.pdf

Overall�Page�167�of�171Page�6�of�10


Appendix i – Core Standards for Emergency Preparedness, Resilience & Response

agreements will be requested, co-ordinated and maintained.

memorandum of understanding covering this.

30 Arrangements demonstrate how organisations support NHS England locally in discharging its EPRR functions and duties


33 Arrangements are in place to ensure attendance at all Local Health Resilience Partnership meetings at a director level

It has been agreed that the first Local Health Resilience Partnership of each year will be at the director level, with responsibility delegated to a General Manager level for the remaining meetings.

34 Arrangements include a training plan with a training needs analysis and ongoing training of staff required to deliver the response to emergencies and business continuity incidents

This is outlined within the Strategy.

35 Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs future work.

This is outlined within the Strategy. A training and exercising record is held by the Head of EPRR.

36 Demonstrate organisation wide (including on-call personnel) appropriate participation in multi-agency exercises

Members of the On-Call Team and key staff are encouraged to participate in and observe exercises. A training and exercising record is held by the Head of EPRR.

37 Preparedness ensures all incident commanders (on-call directors and managers) maintain a continuous personal development portfolio demonstrating training and/or incident /exercise participation.

As above.

HazMat & CBRN Standards Ref Standard Comments 38 There is an organisation specific

HAZMAT/ CBRN plan (or dedicated annex)

This is outlined within the Major Incident & Business Continuity Plan. A specific set of procedures have been developed for the Minor Injury Units (deemed as the most likely service to receive contaminated self-presenters).



Appendix i – Core Standards for Emergency Preparedness, Resilience & Response 39 Staff are able to access the

organisation HAZMAT/ CBRN management plans.

The Minor Injury Unit procedures are available locally at each unit.

40 HAZMAT/ CBRN decontamination risk assessments are in place which are appropriate to the organisation.

This risk has been considered and it has been determined that a formal risk assessment is not required to go on the risk register. This process found that the Minor Injury Units were the most likely service to receive contaminated self-presenters, and subsequently a set of procedures have been drawn up especially for them.

42 Staff on-duty know who to contact to obtain specialist advice in relation to a HAZMAT/ CBRN incident and this specialist advice is available 24/7.

This is outlined within the On-Call Pack. The Minor Injury Units also hold this information.

43 There is an accurate inventory of equipment required for decontaminating patients in place and the organisation holds appropriate equipment to ensure safe decontamination of patients and protection of staff.

Each Minor Injury Unit holds a pack of equipment and consumables. These are maintained locally by the units.

49 Internal training is based upon current good practice and uses material that has been supplied as appropriate.

Training materials from NHS England and Public Health England have been shared with the Minor Injury Units. Staff from the units have discussed and ran through scenarios in order to familiarise themselves with the Trust’s procedures.

51 Staff that are most likely to come into first contact with a patient requiring decontamination understand the requirement to isolate the patient to stop the spread of the contaminant.

This forms part of the Minor Injury Unit procedures. Each unit has identified an isolation room.



Clinical Leader/Chair: Dr Ben Milton Chief Officer: Steve Allinson

CCG Headquarters

Nightingale Close Off Newbold Road

CHESTERFIELD Derbyshire

S41 7PF

Tel: 01246 514964 Fax: 01246 514164

Anglesey House Wheelhouse Road

Towers Plaza Rugeley

Staffordshire WS15 1UL

10th October 2016

Letter sent by email:

To: William Jones, DCHS Accountable Emergency Officer

Chris Wildsmith, DCHS Emergency Planning Officer

Cc: Mark Smith, North Derbyshire CCG Accountable Emergency Officer

Marcel Comer, NHS England North Midlands Head of EPRR

Dear William,

Re: 2016/17 EPRR Assurance Process for Derbyshire Community Healthcare Services NHS

Foundation Trust (DCHS)

Subsequent to the submission of your 2016/17 EPRR Self-Assessment and the Assurance Process,

undertaken on the 8th September 2016, I can confirm that the North Derbyshire CCG Confirm and Challenge

panel evaluated your organisations Level of Compliance to be Full.

The panel considered that your organisation has a number of effective mechanisms in place for EPRR. It

was pleasing that we were able to consider the progress and work undertaken during the year, specifically

regarding the site specific lockdown procedures for all hospital sites.


http://www.mindfulemployer.net/


Clinical Leader/Chair: Dr Ben Milton Chief Officer: Steve Allinson

We are confident that you have plans in place for business continuity as referenced in the business

continuity deep dive and detailed fuel demand summary you have completed.

In order to assess progress against the EPRR Work Plan, we will arrange for a meeting to be convened in

February 2017.

Kind regards

Yours sincerely

Marcel Comer

Mark Smith Accountable Emergency Officer North Derbyshire Clinical Commissioning Group

Marcel Comer Head of EPRR NHS England North Midlands

