board papers january 2016

Surrey and Sussex Healthcare NHS Trust

Board papers

January 2016

Trust Board Meeting – IN PUBLIC

Thursday 28th January 2016 - 11:00 to 13:30

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

AGENDA

1

11:00

GENERAL BUSINESS 1.1 Welcome and apologies for absence 1.2 Declarations of Interests 1.3 Minutes of the last meeting held on 17th December 2015 - For approval 1.4 Action tracker 1.5 Chairman’s Report

For assurance

1.6 Chief Executive’s Report For assurance

1.7 Board Assurance Framework & Significant Risk

Register – For approval & assurance

A McCarthy A McCarthy A McCarthy A McCarthy A McCarthy M Wilson G Francis- Musanu

Verbal

Verbal

Paper

Paper

Verbal

Paper

Paper

2

11:30

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1 Clinical Presentation – Gastroenterology/IBD

For assurance 2.2 Chief Nurse & Medical Director’s Report

For assurance

D Holden/ Dr Ansari D Holden/ F Allsop

Paper

Paper

3

12:15

OPERATIONAL PERFORMANCE 3.1 Integrated Performance Report (M09)

For assurance

3.1.1 Operational & Quality Key Performance Indicators

3.1.2 Workforce Key Performance Indicators 3.1.3 Finance Key Performance Indicators

3.2 Finance & Workforce Committee Update For assurance

3.3 Audit & Assurance Committee Update For assurance

A Stevenson D Holden/ F Allsop F Allsop P Simpson R Durban P Biddle

Paper

Paper

Paper

4

13:05

RISK, REGULATORY AND STRATEGY ITEMS 4.1 Review of Quality Impact Assessments for 2015/16 For assurance 4.2 Emergency Preparedness Resilience Plan For approval & assurance 4.3 NHS Planning Guidance 2016/17 – 2020/21 For assurance 4.4 Annual Plan Update – Q3 For assurance

D Holden A Stevenson M Wilson S Jenkins

Paper

Paper

Paper

Paper

5

13:25

OTHER ITEMS 5.1 Minutes from Board Committees

to receive & note 5.1.1 Finance and Workforce Committee

5.1.2 Audit & Assurance Committee

5.2 ANY OTHER BUSINESS 5.3 QUESTIONS FROM THE PUBLIC

Questions from members of the public may be submitted to the Chairman in advance of the meeting by emailing them to: [email protected]

5.4 DATE OF NEXT MEETING

25th February 2016 at 11.00am

All A McCarthy A McCarthy

mailto:[email protected]

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Minutes of Trust Board meeting held in Public Thursday 17th December 2015 from 11:00 to 13:30

Room AD77, Trust Headquarters, East Surrey Hospital

Present

(AM) Alan McCarthy (MW) Michael Wilson

Chairman Chief Executive

(PS) Paul Simpson Chief Finance Officer / Deputy Chief Executive (DH) Des Holden (FA) Fiona Allsop

Medical Director Chief Nurse

(AS) Angela Stevenson Chief Operating Officer (PB) Paul Biddle Non-Executive Director (RD) Richard Durban Non-Executive Director (PL) Pauline Lambert Non-Executive Director (RS) Richard Shaw Non-Executive Director In Attendance

(GFM) Gillian Francis-Musanu (SJ) Sue Jenkins (LB) Liz Butterfield (CP) Colin Pink

Director of Corporate Affairs Director of Strategy Patient Story Head of Corporate Governance (Notes)

1. General Business

1.1 Welcome and Apologies for absence The Chairman opened the meeting by welcoming Trust Board members, members of the public, shadow governors and staff. Apologies for absence were noted from Alan Hall.

1.2 Declarations of Interest The Chairman asked whether any of the Board members had any new or additional declarations of interest. Pauline Lambert stated that she had started her new role as safeguarding named nurse at Queen Victoria Hospital NHS Foundation Trust. There were no other declarations.

1.3 Minutes of the last meeting – 26th November 2015 The minutes of the meeting held on 26th November were discussed. RD asked that for item 3.2 the minutes be amended to reflect the ‘extra benefits and opportunities made possible by the extra capital spend’ to explain the increased cost. PS highlighted the miss spelling of Filipino in section 2.2. With these amendments the minutes were approved as a true and accurate record.

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1.4 1.4.1

Action Tracker GFM updated the Board on the following actions: TBU-01 – is not due until 31.03.16 TBU-02 is not due until 31.01.16 TBU-03 is not due until 31.01.16 TBU-04 Board to received and review the Right Place, Right Time, Better Transfers of Care report is complete and the action closed. There were no other matters arising.

1.5

Chairman’s Report for Assurance The Chairman stated that there was nothing of interest to report since the last Board meeting which was not already covered within the body of the Chief Executives report.

1.6

Chief Executives report for Assurance The Board received and noted the Chief Executive’s report in advance of the meeting. MW introduced the report highlighting the plans to develop a national whistleblowing policy as part of the “Freedom to Speak Up, open consultation from Monitor MW was also pleased to announce that the shared funding of the new Integrated Re-enablement Unit (IRU) was approved at Surrey County Council’s cabinet. The new unit will be an excellent addition to the growing health campus at SASH and will significantly improve pathways for patients who need assistance with the transfer from acute to primary care. The planned junior doctor strike had been cancelled at short notice which had impacted on circa 750 patients through canceled elective procedures and appointments. The Chairman reiterated the good news of development of the IRU, highlighting the benefits for patients and innovative development of joint working with the County Council. The Board duly noted and took assurance from the report.

1.7 Board Assurance Framework (BAF) and Significant Risk Register (SRR) for Approval and Assurance GFM introduced the board assurance framework and significant risk register. The BAF detailed 13 risks to the trusts strategic objectives which had been updated by the Executive team through December. The SRR has 11 operational significant risks following the downgrading of the cancer performance risk and merging of two financial risks. The Board discussed how the BAF financial risks did not reflect all of the detail of the finance papers. PS highlighted that due to the early December meeting that

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the BAF had been updated before the finance papers had been prepared. This would be better reflected in the January 2016 updates. Action 1: PS RS asked for assurance as to why the cancer performance risk had been downgraded. AS stated that the associated pathways had been reviewed and improved to allow better management of individual patient pathways, which also increased accuracy of prediction of performance. There is also greater engagement with tertiary centres and the Trust was focusing on specific pathways. PB indicated that the BAF risk relating to delivery of income plan (5.1) could be amended to indicate the likelihood of delivery based on the Trust’s forecast. PS agreed stating that the risk was reviewed each month but that at present there was still opportunity to achieve the planned income. The Board duly approved and took assurance from the report.

2. Safety, Quality and Patient Experience 2.1 Patient Story for Assurance

DH introduced Liz Butterfield, a pharmacist by profession, who had been a recent emergency admission. DH reflected that Liz’s story was valuable as it describes how she perceived her care and re-assuring, as this was largely positive. LB thanked the Board for the opportunity to share her experience praising the efficiency of staff and the care she received. Liz explained that she had presented at the emergency department on a Saturday with breathing pain, triage and testing was quick and a working diagnosis of pneumonia was made. At this point she was told that she was being moved to ‘majors’ and despite knowing what this meant the terminology was still a cause of anxiety. In majors the multi-disciplinary team (MDT) worked well together and staff both cared and explained what was happening well. The decision was made to admit and the staff stated that she was being moved to the ‘Acute Medical Unit’ (AMU), and again the terminology caused anxiety. She had been reviewed quickly by a consultant on AMU and received good care and an explanation of the use of antibiotics. However, she noted that she received an anti-thrombosis drug in the middle of the night with no prior warning or explanation that it would be given or what it was for. On Monday she was transferred to Tillgate Ward where once again she received good care and stated that the nursing team was impressive. On the Wednesday her blood test indicated that the antibiotic treatment had been successful, which was followed by a sudden decision that she was fit for discharge. This had come as a surprise and LB went on to reflect that although this was not a problem for her, she imagined that it might be difficult for people with different circumstances. MW asked whether she had been given an estimated discharge date. LB confirmed that although she had been told that it would be a short admission she did not know an expected discharge date. RD asked if personal and case information had been passed between the various effectively. LB stated that she was asked background questions regularly but this was not annoying and was actually more reassuring.

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FA asked what kind of discharge information had been given. LB stated that she could not recall but noted that she was given the discharge summary but was not concerned about details of the medication she was given on discharge. DH asked LB whether anything about the admission had left her feeling angry or upset. LB stated that nothing had caused her to feel angry or upset, reflecting that the staff had been caring pleasant and that she had been generally well informed. LB went on to state that during her admission she observed that all the patient’s around her appeared to be treated well and with compassion. The Chairman thanked Liz for sharing her story and welcomed her feedback and insight. PL agreed reflecting that LB’s reflection on our use of language, such as ‘Majors’ was an important reminder to all our staff. The Board noted and took assurance from the report.

2.2

Chief Nurse and Medical Director’s Report for Assurance The Board received and noted the report in advance of the meeting. FA presented the Chief Nurse’s report stating that the drive to increase the number of midwifes had been successful and that all had now commenced bringing the ratio up to 1 to 32. FA went on to assure the Board that mitigation is in place to ensure safe provision in service for safer staffing metrics in the birthing centre. The Chairman asked for an update on recent international nursing recruitment drives in Europe. FA stated that the majority of the appointed nurses had arrived and work was underway to make them familiar with the hospital and differences in expected essentials of care. DH presented the Medical Directors report commenting on the recent engagement with the Trust’s Foundation Trust members to seek people willing to be involved in a survey of carers who support someone with dementia. The Board discussed diagnostic SIs, and associated capacity and staffing issues. PL commented on the SQC conversation and the Trust aim to achieve a zero error rate. DH reflected that issues in labs tend to relate to the misinterpretation of the sample where as in radiology incidents issues tend towards review of actions. DH went on to confirm that there was a capacity issue within radiology and that people were working extra hours to support the system. Extra Consultants are being recruited and there is an expectation that staffing will improve in Q4. The Board duly noted and took assurance from the report.

2.3

Safety & Quality Committee (SQC) Update for assurance The Board received and noted the report in advance of the meeting. RS introduced the report highlighting the Trust’s work to review ratios of female consultants and gender imbalance in surgical consultants. A focus group is meeting to consider ways of making the role more attractive for female consultants.

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The SQC had received an overview of the implementation of the dementia strategy which was well received. There was agreement that there was work to do to ensure that the strategy reached all staff as it is not just a care of elderly responsibility and acknowledgment that some 1300 staff had received awareness training since the start of the strategy. RS went on to highlight ongoing issues with response rates to ‘Friends and Family’ tests and that the Executive Team would be considering the approach and use of ‘Your Care Matters’ systems. The Chairman asked for an update on CCG chaired ‘Single Performance Conversation’ which has been cancelled recently due to the lack of issues to discuss. MW confirmed that conversation’s had taken place and that it is expected that this important meeting would recommence. The Board noted the full report and gained assurance.

2.4 15 Steps Challenge – Update for Assurance & Approval The Board received and noted the report in advance of the meeting. FA introduced the report, giving a brief background of the scheme and some of the improvements that had been following direct observations such as the admission lounge refurbishment. FA went on to highlight plans to consider amending the scheme to include elements of transformational programme linked to the SASH + VMI work such as waste walks. The Board discussed this plan considering potential quality improvements, the cultural change and need to maximise impact. PL stated that she would like to see the 15 step programme remain in place. RD suggested that it would be more appropriate if teams requested a “15 Step” visit, perhaps after some VMI enabled change, rather than external teams independently looking at areas such as waste which risks the perception of inspection. Action: 2 FA The Board agreed that the guiding team would discuss and report back on the specifics of the proposal. The Board duly took assurance and approved the report.

3.

Operational Performance

3.1

2016/17 Cost Improvement Programme for Approval The Board received and noted the report in advance of the meeting which had been reviewed previously by the FWC. PS introduced the Trust’s indicative cost improvement plans for 2016/17 which will form the basis of the final plan to be agreed in March 2016. The plan explicitly does not include any SASH+ activity. PS stated that actions generated from the Carter report are not identified within this CIP noting that the methodology needs refinement. The Board discussed the potential make up of the CIP and the balance between pure cost reduction and greater contribution from increased income resulting from better productivity. The Board noted that the current financial years CIP was not going to plan and forecast was well below target. However plans such as the clinical supply reductions had been successful and there is expectation of further success in

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2016/17. The Board noted how pressures from emergency activity and workforce issues had adversely affected delivery, notably against agency targets. The Board welcomed the early site of plans and noted the progress made to date. RD confirmed that the FWC would continue to review the CIP as it developed and start to review key projects. PS stated these included reduction in nurse agency costs. The Board asked FA for a report on nurse recruitment and agency use including the recruitment vs saving calculation went to the FWC. Action:3 FA The Chairman noted that delivery of CIPs had been a particular challenge for the Trust in 2015/16 and stated that we should be mindful of the implications of the Lord Carter report on efficiencies delivery of CIPs would require close monitoring in the future. The Board duly approved the indicative plan which would be signed off as final as part of the budget in March 2016.

3.2 Finance & Workforce Committee Chair Update – for Assurance

The Board received and noted the report in advance of the meeting. RD reported that the FWC had met on the 15th December. The Committee had received the business case for refurbishment of ED’s resuscitation area and purchase of a CT scanner for ED which had been approved. It had also received updates on the radiology equipment replacement programme. It had agreed that the Managed Print Service full business case would now be approved by the Executive Committee as the contract value was below £1 million. The Committee had discussed the Trust’s 15/16 CIP and noted that £2.8 million pounds had been achieved to date with a forecast of £4.6 million, 56% of the target. The committee noticed that there had been some slippage since the month 7 position. The FWC had received the month 8 finance report. PS stated that the year to date deficit was £4.2m which is £2.2m adverse to the revised Trust plan submitted to the TDA. This position is also £0.6m adverse to the Q2 forecast. This continues to be driven by non-elective and emergency activity and the impact on ability to deliver elective activity. The Trust had kept the TDA appraised over its financial position and forecast end of year position. MW highlighted that a recent local decision to suspend elements of external end of life care until January would impact on these issues. PS went on to state that cash advances from CCG’s had been secured and cash flow in the short term was manageable. The backlog of creditors had been extended. Capital spend continues to remain on track and that capital to revenue transfer conversations have commenced. The Board discussed this position and noted that formal dispute processes had commenced with East Surrey CCG in relation to payment of income. The Private Board had reviewed the Trust full year forecast, noting continued adverse performance against the forecast at quarter 2. It had agreed that the Trust should revise its forecast to a deficit and inform the TDA. The deficit would

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be approved through a delegated process, to the Chair and Chief Executive, next week. The Board duly noted and took assurance from the report.

3.3 Breaking the Cycle Update – for Assurance and Approval The Board received and noted the report in advance of the meeting. AS introduced the report which provided a review of the November and December breaking the cycle weeks. The aim of each cycle is to improve patient care, patient flow and reduce the number of patients who are ready for discharge. The paper listed the key actions taken. One of the key elements was to manage the balance between admissions and discharges which impacts on getting patients into the right bed. The December cycle week had a challenged start with breaches and surges in ED activity. AS reminded the Board of issues relating to the ED targets, ambulance attendances and batching of GP patient attendances. However, the Trust had learned from the November cycle and achieved a good bed balance going into the weekend with high numbers of medically ready for discharge patients identified and prepared and significant drop in medical outliers. AS went to reflect that the focus must remain on clinical buy-- in, partnership working with the community, reducing escalation, reducing outliers and improving weekend care. The Board discussed how effective the cycle had been and asked when this would become the norm rather than an initiative. AS stated that there was a great deal to learn and adopt as business as usual but there remained a need to have the ability to do something different. PB asked whether there was any level of effect on line management in particular disempowerment caused by the level of management engagement. AS stated that the general commentary indicated that it was a constructive process and was not aware of any feelings of disempowerment. MW commented on the assurances and management of risk highlighting issues relating to ambulance attendance, awareness of pathways and poor predictive information relating to private ambulance arrivals. The Board noted this and agreed that there was strength in the real-time understanding of the situation that is developed during each cycle. The Chairman thanked AS for the report and all staff for their efforts during the period. The Board duly took assurance and approved the report.

4. Risk, Regulatory and Strategy Items

4.1 Serious Incidents Report - for Assurance The Board received and noted the report in advance of the meeting. FA introduced the paper highlighting the key information relating to the two new declared incidents a fall with harm and an MRSA blood stream infection. FA went

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on to state that there are no overdue reports and similarly no related backlog. The Board duly took assurance from the report.

4.2 SaSH + (VMI Update) – for Assurance The Board received and noted the report in advance of the meeting. SJ introduced the paper which gave an overview of the 5 year programme and progress so far such as development of governance identification of the Trust’s 3 initial value streams and development of compacts between Trust’s and the TDA. SJ stated that the supporting team (Kaizen Promotion Office) had been established with taster sessions and management training sessions planned. The Board discussed both the benefits of the programme for the Trust and the NHS. Key to this conversation was the recognition that the Virginia Mason Hospital was 13 years into its journey and the NHS needed to learn quickly from the vast experience of the teams involved to identify issues and innovate rapidly to continue to meet the needs of patients and also the broader challenges facing the NHS. The Board went on to reflect that as a whole the Board needed to become more familiar with the programme, start to use the language and challenge key issues such as ‘passing on defects’ within a system. SJ confirmed that this would be included in future Board development seminars. DH reminded the Board that in this early stage of the journey the emphasis must remain on going and seeing the care provided at the front line in order to get a richer understanding of the reality of day to day practice. The Board agreed that they would like to have early sight of the Trust’s Clinical Compact with its staff. Action:4 SJ The Board duly took assurance from the report.

Other Items 5.1 Minutes of Board Committees to receive and note

5.1.1 Finance and Workforce to receive and note

The minutes of the Committee were noted with no questions raised.

5.1.2 Safety and Quality The minutes of the Committee were noted with no questions raised.

5.2 Any Other Business AS stated that the Trust had received a request to provide assurance of preparedness for involvement in the management of an emergency incident. Following the recent Paris terrorist attack the national threat level had been assessed as high. The NHS England return asks for assurance over issues relating to emergency preparedness such as management of telecoms and ability to receive casualties. AS confirmed that the response would be prepared and included in the January 2016 agenda item relating to the annual Emergency

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Planning, Resilience and Response return.

5.3

Questions from the Public There were no questions raised.

5.4 Date of the next meeting Thursday 28th January 2016 at 11.00am in Room AD77, Trust Headquarters, East Surrey Hospital

Note: This is a public document and therefore will be placed into the public domain via the Trust’s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation. These minutes were approved as a true and accurate record. Alan McCarthy Chairman: Date:

TRUST BOARD ACTION TRACKER - PUBLIC BOARD MEETING

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

TBPU-01 TB Public Patient story

The Board requested that Dr J Webb update the Board on findings and actions of the sample group. Dr Zara Nadim will now be undertaking this work. ZN/DH 28/08/2015 31/03/2016 Not Due

TBPU-02 TB Public Patient story

The Board asked for feedback on the outcome of the retrospective audit to ensure that patients have received the correct follow up. SI action to be considered by the Effectiveness Committee. FA 26/10/2015 31/03/2016 Not Due

TBPU-03 TB Public Q2 Annual Plan Update

The Executive team is asked to consider the scoring of elements to ensure consistency across reports for the next quarterly update with particular focus on elements already RAG rated as red.

SJ / Executive Team 26/10/2015 31/01/2016 On agenda

TBPU-04 TB Public BAF & SRRTo update BAF to take into account FWC and Board conversations throughout December. PS 17/12/2015 31/01/2016 On agenda

TBPU-05 TB Public 15 Step Challenege

The Board agreed that the guiding team would discuss and report back on the specifics of the proposal to amend the 15 step programme to include elments of SASH+ work. FA 17/12/2015 31/01/2016 Verbal update

TBPU-06 TB PublicCost Improvement Programme

Provide a report on nurse recruitment and agency use including the recruitment vs saving calculation went to the FWC. FA 17/12/2015 31/03/2016 Not Due

TBPU-07 TB Public SaSH + (VMI Update) The Board agreed that they would like to have early sight of the Trust’s Clinical Compact with its staff. SJ 17/12/2015 28/02/2016 Not Due

ACTIONS FROM PUBLIC BOARD MEETINGs - December 2015

TRUST BOARD IN PUBLIC

Date: 26th January 2016 Agenda Item: 1.6

REPORT TITLE: CHIEF EXECUTIVE’S REPORT

EXECUTIVE SPONSOR: Michael Wilson Chief Executive

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

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

Action Required:

Approval ( ) Discussion (√) Assurance (√)

Purpose of Report: To ensure the Board are aware of current and new requirements from a national and local perspective and to discuss any impact on the Trusts strategic direction. Summary of key issues National: • Joint Working by NHS Improvement/TDA and the Care Quality Commission Local: • Lord Prior Visit • Black Escalation Summit • Opening of Integrated Reablement Unit • Junior Doctors Industrial Action • Opening of Macmillan Cancer Information Centre

Recommendation:

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

Relationship to Trust Strategic Objectives & Assurance Framework:

SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment:

Legal and regulatory impact Ensures the Board are aware of current and new requirements.

Financial impact N/A

Patient Experience/Engagement Highlights national requirements in place to improve patient experience.

Risk & Performance Management Identifies possible future strategic risks which the Board should consider

NHS Constitution/Equality & Diversity/Communication

Includes where relevant an update on the NHS Constitution and compliance with Equality Legislation

Attachment: N/A

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TRUST BOARD REPORT – 26th January 2016 CHIEF EXECUTIVE’S REPORT 1. National Issues 1.1 Joint Working by NHS Improvement/TDA and the Care Quality Commission

The Trust received a joint national letter to Chief Executives, Finance and Medical Directors along with the Chief Nurse from Jim Mackey Chief Executive of NHS Improvement and Professor Sir Mike Richards, Chief Inspector of Hospitals at the Care Quality Commission (CQC) made clear that success is the delivery of the right quality outcomes within available resources. The letter also confirmed that quality and financial objectives cannot trump one another and that our responsibility as a Provider is to deliver the right quality outcomes; confirmation was also given that improving quality is more important than staying in financial surplus. There will be some changes in the regulatory framework from both NHS Improvement and CQC inspection regime going forward. A consultation will shortly be launched on the CQC’s future strategy and a single new NHS Improvement regulatory framework for providers. Both organisations have recognised the importance of a joint single clear and consistent message. The changes will include a jointly designed approach which the CQC will use to assess trusts’ use of resources. Consideration will be given as to how the CQC can use the financial data NHS Improvement holds and use the expertise of NHS Improvement staff in reaching its judgements on use of resources. Similarly, as NHS Improvement develops its view of the role of quality in the new, single, provider regulatory framework, this will be undertaken jointly by the CQC and NHS England. They will also be sharing revised National Quality Board staffing guidance and a new metric looking at care hours per patient day that will be used in looking at how trusts manage staffing resources. In practical terms, there is a desire for regulators and commissioners to rely on each other’s work, rather than duplicating effort, and create a single unified framework with a single way of measuring success that is used by all. This should bring greater clarity and consistency and reduce the regulatory burden. One of NHS Improvement’s early priorities will be to work with organisations with large deficits to help them return to surplus and ensure that even in trusts which face some of the biggest financial challenges support is provided to balance finance and quality.

2. Local Issues

2.1 Lord Prior Visit The Trust was pleased to welcome Lord Prior, Minister for NHS Productivity on 20th January 2016. This was a welcomed and very positive opportunity for a range of clinical and senior leaders with the Trust to meet and discuss a diverse number of key issues affecting the NHS from a local and national perspective with Lord Prior who was very keen to hear from front line staff as well as tour the hospital.

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2.2 Black Escalation Summit As the system wide Black status has continued for longer than a period of 3 or 4 days a black summit should be held with all the executive directors from each organisation to understand the overarching clinical risk and patient safety issues across the health system. The TDA or Monitor representatives should also be invited to attend. The Black Escalation Summit has been convened and is due to take place on 28th January 2016 at 3.00pm and will be chaired by the NHS England (South – Local Team) to provide leadership and support to issues identified as well as to agree actions to de-escalate the system. 2.3 Opening of Integrated Reablement Unit We are pleased to confirm that the Integrated Reablement Unit opened on 21st January 2016. This is a unique collaborative partnership between SaSH, Surrey County Council and East Surrey CCG and will provide a dedicated unit for patients who no longer need to be in hospital and are medically ready for discharge. 2.4 Junior Doctors Industrial Action On 12 January 2016 around 38,000 junior doctors went on strike for 24 hours – the first industrial action of its kind for 40 years. This industrial action led to the cancellation at a national level of approximately 1,425 inpatient operations and procedures, while 2,535 outpatient appointments were also cancelled. Emergency only cover was provided on this day and significant. At SaSH we believe around 90% of junior doctors took industrial and there was significant impact on our services locally. The planned additional industrial action for 26th January has been recently suspended as negotiations continue at a national level. 2.5 Opening of Macmillan Cancer Information Centre I am also pleased to confirm the official opening of the Macmillan Cancer Information Support Centre on 27th January 2016. This brand new facility brings specialist care and support closer to home for local people and builds on our strong partnership with Macmillan.

3. Recommendation

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

Michael Wilson Chief Executive 26th January 2016

1 An Associated University Hospital of

Brighton and Sussex Medical School



REPORT TITLE: Board Assurance Framework & Significant Risk Register

EXECUTIVE SPONSOR: Gillian Francis-Musanu Director of Corporate Affairs

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

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

AAC 15th January 2016 Executive Team 20th January 2016

Action Required:

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

Purpose of Report:

The 2015/16 BAF highlights potential risks to the Trust’s strategic objectives and mitigating actions and the implementation of its programme of objectives for year two of the five year plan. The Significant Risk Register (SRR) details all risks on the Trust risk register system that are recorded as significant and the links to the Board Assurance Framework.

Summary of key issues

The BAF details 13 risks to the trusts strategic objectives, 6 of which are recorded as key strategic risks and red rated. It is proposed that BAF risk 5.2 be rescored from a 15 to a 12 to reflect ability to achieve forecast end of year budget. There are 10 significant risks recorded on the Trust risk register. One risk has been downgraded since the December Board relating to divisional overspend linked to the BAF risk above.

Recommendation:

The Board is asked to discuss and approve the report and consider the following:

• Consider the proposed reduction in risk 5.2

• Does the Board agree with the recorded controls and assurances

• Note the updated risks included in the Significant Risk Register


SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model



Corporate Impact Assessment:

Legal and regulatory impact The report is a requirement for all NHS organisations.

Financial impact As discussed in sections 5 (Income generation linked to activity referred to throughout the document)

Patient Experience/Engagement Patient experience and engagement is one of the Trusts strategic objectives. .

Risk & Performance Management These are highlighted throughout the report.


Discussed throughout the report but with the greatest detail in objective 3.

Attachment:

January 2016 BAF and the current SRR



TRUST BOARD REPORT – 28th January 2016 BOARD ASSURANCE FRAMEWORK and SIGNIFICANT RISK REGISTER 1. Board Assurance Framework The Board Assurance Framework (BAF) describes the principal risks that relate to the organisation’s strategic objectives and priorities. It is intended to provide assurances to the Board in relation to the management of risks that threaten the ability of the organisation to achieve these objectives. The Trust has identified five main strategic objectives for 2015/16:

1) Safe: Deliver safe services and be in the top 20% against our peers 2) Effective: Deliver effective and sustainable clinical services within the local health economy

3) Caring: Ensure patients are cared for and feel cared about 4) Responsive to people’s needs: Become the secondary care provider and employer of choice for the catchment population 5) Well led: become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model

These objectives are broken down into specific areas and the BAF details the key risks that the Trust faces to the delivery of these priorities. Each risk details the controls that are in place, the sources and effects of assurance and mitigating actions to reduce the likelihood of the impact of the risk materialising. (Some priorities have more than one associated risk) The Significant Risk Register (SRR) supports the BAF and details the highest rated operational risks that have been raised by the Executive Team and Divisional Management. The SRR is regularly reviewed and moderated by the Executive Team to ensure alignment with the BAF and other key risks to the Trust. 2. Current status Following discussions at AAC and the Executive team it is proposed that the strategic risk relating to ‘Failure to stop divisional overspending against budget’ (5.2 BAF) is reduced to 12. This is based on the Trust’s current financial position and end of year focus. One of the purposes of the BAF is to ensure that all risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to green (low impact, low likelihood). There have been minor amendments throughout regarding controls, actions and assurances. The 15/16 BAF (attached) details a total of 13 risks to the 6 Trust strategic objectives which are scored as follows (not including proposed reduction):



Objective Red

(15-25) Amber (8-12)

Green (1-6)

1.Deliver safe services and be in the top 20% against our peers

0 2 0

2.Deliver effective and sustainable clinical services within the local health economy

1 0 1

3.Ensure patients are cared for and feel cared about

1 0 0

4.Responsive - Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex

1 0 0

5. Well Led - become an employer of choice and

deliver financial and clinical sustainability around

a clinical leadership model 3 4 0

Total 6 6 1

One of the purposes of the BAF is to ensure that all risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to green (low impact, low likelihood). There have been minor amendments throughout regarding controls, actions and assurances. 2.2 Headline information by objective (BAF)

Objective 1 - Safe Deliver safe services and be in the top 20% against our peers

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties.

S4 x L3 = 12 S4 x L2 = 8 S4 x L1 = 4

1.2 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care

S3 x L4 = 12 S3 x L4 = 12 S3 x L3 = 9

Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy



Target Risk Score

2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties

S3 x L3 = 9 S3 x L2 = 6 S3 x L1 = 3

2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.

S5 x L3 = 15 S5 x L3 = 15 S5 x L2 = 10



Objective 3 - Caring – Ensure patients are cared for and feel cared about



Target Risk Score

3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits.

S3 x L4 = 12 S3 x L5 = 15 S3 x L2 = 6

Objective 4 – Responsiveness – Become the secondary care provider for the catchment population



Target Risk Score

4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage pressures has a significant impact on the Trust's ability to deliver high quality care

S4 x L4 = 16 S4 x L4 = 16 S4 x L2 = 8

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model



Target Risk Score

5.1 Failure to deliver income plan S5 x L3 = 15 S5 x L3 = 15 S4 x L2 = 8 5. 2 Failure to stop divisional overspending against budget S5 x L3 = 15

Proposed S4 x L3 = 12

S3 x L2 = 6

5. 3 Unable to deliver realistic medium term financial plan S5 x L3 = 15

S5 x L3 = 15

S4 x L2 = 8

5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position

S5 x L3 = 15 S5 x L3 = 15 S4 x L3 = 12

5.5 There is a risk we will fail to realize the strategic benefits of having an Achievement Review Process that effectively monitors and influences behaviour and performance.

S3 x L3 = 9 S3 x L3 = 9 S3 x L2 = 6

5.6 The Trust remains within the current FT pipeline and awaits national guidance on potential new organisational forms which could result in changes to the current timescale and associated requirements to the process. Due to the merger of the NHS TDA & Monitor and creation of NHS Improvement there is uncertainty over the longevity of the current FT model.

S4 x L2 = 8 S4 x L2 = 8 S4 x L1 = 4

5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems

S5 x L3 = 15 S4 x L3 = 12 S3 x L3 = 9



2.3. Key risks Strategic risks Identified The BAF highlights the following 6 key red risks to the Trust objectives that have been identified at time of updating the framework (not including the proposed reduction). These are: Risk description Current

rating Target risk score

2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity to deliver the activity income that underpins the LTFM.

S5 x L3 = 15 S5 x L2 =10


S3 x L5 = 15 S3 x L2 = 6


S4 x L4 = 16 S4 x L2 = 8

5.1 Failure to deliver income plan S5 x L3 = 15 S4 x L2 = 8 5. 3 Unable to deliver medium term financial plan S5 x L3 = 15 S4 x L2 = 8 5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position

S5 x L3 = 15 S4 x L3 =12

3. Significant Risk Register The Executive Committee has reviewed and agreed the content of the significant risk register. There are 10 risks on the Trust significant risk register. Risk 1688, Risk of potential overspending from operational pressures, has been downgraded to reflect the reduction in risk. Each risk is in date and has mitigating actions to reduce the level of risk to an acceptable level. 3.1 SRR Breakdown

ID Title Initial Rating

Current Rating

Residual Rating

Next Review

1401 Risk of outbreak of viral gastroenteritis 16 15 9 31/03/2016

1491 Failure to maintain Emergency Department performance

20 16 6 31/01/2016

1501 Patient admitted to the right bed first time 9 15 6 31/03/2016

1603 Unable to provide realistic medium term financial plan 15 15 8 31/01/2016

1604

Liquidity: Inability to pay creditors/staff resulting from insufficient cash due to poor liquid position

15 15 12 31/01/2016



ID Title Initial Rating

Current Rating

Residual Rating

Next Review

1663 Risk of not achieving Cost Improvement Plan 9 15 6 31/01/2016

1672

Increasing Sickness Absence Levels with impact on day to day management and expenditure

15 15 9 31/01/2016

1678 RTT Access Standards

15 15 6 11/02/2016

1689 Risk of Contract income below plan 15 15 12 31/01/2016

1697

Financial risks linked to National Quality Board Paper, 7 day working and Carter productivity report

15 15 9 31/01/2016

4. Discussion/Action This report brings together the BAF for the Trusts strategic objectives and the Significant Risk Register into one report. The Board is asked to discuss and approve the report and consider the following:

• Consider the proposed reduction in risk 5.2

• Does the Board agree with the recorded controls and assurances

• Note the updated risks included in the Significant Risk Register

Gillian Francis-Musanu Colin Pink Director of Corporate Affairs Head of Corporate Governance January 2016



Appendix 1: Risk Appetite – 2015/16 The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives. The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. The key following principles further define this stance with an opinion from the Board:

Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk only if, upon consideration, the benefits of the risk improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green

Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice both internally and across the wider health economy. Target: Amber

Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. The Board will seek to innovate and take risks where there is potential to develop inspirational leadership as it recognises that this is key to both becoming the local employer of choice and developing strategic partnerships with new bodies. Target: Green

Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. There will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber

Reputation: The Board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green

Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. The Board recognises the complications attached to recruitment and retention that are caused by geographical and national position and takes this into account when reviewing workforce related risks. Target: Amber



Appendix 2: SASH risk quantification matrix



Risk Type Insignificant Minor Moderate Major Extreme

Patient Safety • No obvious injury / harm • Non-permanent avoidable injury / harm requiring only first aid / minor treatment

• Short-term avoidable injury / harm with recovery / treatment up to 1 month

• Long-term (>1 month) / permanent avoidable injury / harm / illness or any of the following: � Infant abduction � Infant discharged to wrong family � Rape or serious assault

• Avoidable death

• Injury / illness requiring more complex treatment, e.g. stitching, plaster, medication course, minor theatre operation etc.

• Minor harm event involving >5 patients • Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

Patient 'Experience' & Care Pathways and Involvement of Service Users

• No significant impact on patient experience

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

• Major unsatisfactory patient experience related to poor treatment / care

• Upheld complaints regarding death in the Trust

• No complaints / concerns raised • Informal complaints raised / PALS contacted

• Formal complaints raised and/or MP / independent advice / advocacy contacted

• Legal action against the Trust initiated / local media involvement

• National media coverage / political action against the Trust

• Care pathway problems resulting in short-term treatment / care delay <3 hours

• Care pathway problems resulting in short-term treatment / care delays (3 hours – 1 day)

• Care pathway problems resulting in medium term delays (up to 1 month) or 5-10 patients affected

• Care pathway problems resulting in medium term delays (1-6 months) or 10-20 patients affected

• Care pathway problems resulting in long term delays (>6 months) or >20 patients affected

Health & Safety • No harm injury • Short term / non-permanent injury / ill health.

• Medical treatment required • Permanent or extensive injury / ill health / permanent disability or loss of limb (RIDDOR reportable)

• Death (RIDDOR reportable)

• Injury / ill health resulting in 0-7 days absence from work.

• Injury / ill health resulting in >7 days absence from work or restricted duties for >7 days (RIDDOR reportable)

Financial Management • Small loss <£1K • Minor loss £2K to £100k • Moderate loss, £100k - £1M • Major loss, £1M-£10M • Loss > £10M

Governance Arrangements

• Concern raised by internal or external systems that can be resolved through normal governance processes in < 3 months (e.g. one financial quarter)

• Concern raised by internal or external systems that will take > 3 months to resolve but does not fulfil the criteria of moderate consequence

• Concern raised in external inspection report or raised in single performance conversation with commissioners / TDA (or equivalent) due to a failure to provide “well led” services as described by the CQC

• Suspension of services provided due to a failure to provide “well led” services as described by the CQC

• Permanent removal of services and / or prosecution due to a failure to provide “well led” services as described by the CQC

• Any issue that would have to be recorded in annual governance statement or annual report (e.g. significant issue “red risk” audit produced by Internal Audit)

• Act or omission that could led to removal of the Board

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

Quality of Service

• Insignificant interruption of service(s) which does not impact on the delivery of patient care or the ability to continue to provide service

• Short term disruption to service(s) with minor impact on patient care

• Some disruption to service(s) provision with unacceptable short-term impact on patient care. Temporary loss of ability to provide service(s)

• Sustained loss of service which has serious impact on patient care resulting in major contingency plans being involved

• Permanent loss of core service or facility

Abridged consequence chart

Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers Priority ID and reference 1.A Consistently meet national

patient safety standards in all specialties and across divisions

Director responsible Chief Nurse

Initial Risk S4 x L3 = 12 Key Action for 2015/16 objectives and description of any potential significant risk to this priority

1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties.

Current rating S4 x L2 = 8

Target risk score

S4 x L1 = 4

Linked to Risk 1009,1055

Controls in place (to manage the risk) Gaps in Control 1. Clinical teams in place to implement patient safety plans in the Trust (falls,

pressure ulcers and infection control) 2. Regular review of patient safety data including the Safety Thermometer at

divisional, executive and board level 3. Groups/Committee established including SQC, ECQR and its subcommittees,

N & M and Divisional Governance 4. Policies, procedures and guidelines provide the framework by which risks and

incidents are managed. 5. Work undertaken to deliver ‘5 sign up to safety pledges’ (Monitoring patients for

early signs of deterioration, Pain management for Dementia, Duty of Candor, COPD EQ pilot and improve shared learning from incidents)

6. Matron on site 7 days a week to monitor nursing patient care and staffing 7. Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) 8. Nursing staffing levels monitored daily and issues managed 9. Incident reporting policy in place and monitored 10. Ward safety boards updated regularly and ward performance discussed at

divisional level 11. Serious incident review group established to monitor and evaluate investigation

progress and progress against actions 12. Training undertaken for clinical staff in the assessment and management of

patients at risk of falls 13. Patient falls strategic group meet monthly and report KPIs to the patient safety

committee.

14. System developed to split Trust and Community acquired VTE events which are reviewed at Clinical Effectiveness, Patient Safety and ECQR.

1) Developing ward safety dashboards 2) Ward accreditation system under development as part of 15/16 CQUIN 3) Updating and planning RCA analysis training for new managers/leaders 4) Embedding DATIX incident review process within 14 day timeframe

Potential Sources of Assurance (documented evidence of controls effectiveness)

Actual Assurances: Positive (+) or Negative (-)

1) External reports and visits to clinical areas both scheduled and unscheduled (e.g. 15 step challenge)

2) Ward Dashboards 3) Divisional and Trust Level Dashboards 4) VMI/SASH Plus Program

Positive (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST audit (+) QGAF assessment and action plan (+) New EWS trialed and audited (+) Meeting minutes and action plans, evidence of presentations and board discussion (+) Patient safety related KPI agreed and monitored at Board and Divisional Level (+) Datix incident reporting and analysis including increase in reporting (+) Monthly trust wide reporting using national benchmarking (+) Falls Training data (+) Annual Falls Report 14/15

(+) Clinical Nurse Consultant for Falls and Patient Safety commenced 4 December 2014 (+) 15 Steps quality program (+) Annual Falls report 2013/14 reduction in falls with harm in year (+) Resource focus on patient safety and falls (+) Strong evidence of improved SI investigation management and closures

(+) Improved reporting of patient falls has enabled the Trust to understand fall profile and identify gaps in the falls management strategies available (+) Established links with falls team within community Negative (-) Never events incidence (-) NRLS reporting

Gaps in assurance Assurance Level gained: RAG Ability to benchmark in real time

Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1) VMI/SASH plus development program 2) 5 work streams identified in Trusts sign up to Safety Pledges (Monitoring patients for early signs of deterioration, Pain management for Dementia, Duty of Candor, COPD EQ pilot and improve shared learning from incidents)

1) Ongoing 2) Ongoing action plan

Update by FA 08/01/16

Date discussed at board To be discussed at January Board

Objective 1 - Safe –Deliver safe services and be in the top 20% against our peers Priority ID and reference 1.A.1 Consistently meet national

patient safety standards in all specialties and across divisions

Director responsible Medical Director

Initial Risk S3 x L4 = 12

Key Action for 2015/16 objectives and description of any potential significant risk to this priority

1.2 Failure to maintain systems to control rates of HCAI will affect patient safety and quality of care


Target risk score S3 x L3 = 9

Linked to Risk 1049, 1050, 1401, 1514

Controls in place (to manage the risk) Gaps in Control

1)IPCAS Team and Group in place, Weekly taskforce in place 2)Infection control manual in place and information resources available 3)Antibiotic policy and guidelines in place 4)Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues. 5)MicroApp implemented for antimicrobial stewardship guidelines 6)Consultant led RCA and presentation of HCAI (MRSA, MSSA, C. diff). All cases C. diff joint review by CCGs and Trust. 7) Discussion group being setup to discuss any lapses of care in C. diff

cases. 8) Prevalence studies and Enhanced surveillance of catheter-associated UTI part of annual programme. 9) 3 ICE-POD units in place – ED, HDU and Hazelwood. 10) Developed a system where site team and matrons during the weekend are responsible in checking wards that have received positive results (See 4 above) 11)Focus on risk and mitigation of VHF involving ED/Micro/ITU/PHE 12)Antibiotic Stewardship group revitalized 13)Decontamination group informing development of strategy for IPCAS 14)Policy on screening appropriate patients from abroad for CP Enterococci.

1)Risk assessment of patients with diarrhoea is not consistent, in particular on admission and at first onset 2)Variation in line care demonstrated by audit 3)High bed occupancy can cause infection control risk to increase (e.g. side room availability)



1)KPI indicators 2)Reducing numbers of cases of C. diff year on year 3)Divisional and departmental governance meeting minutes 4)Output of CCG and Trust meetings regarding lapses of care in C. diff

cases

Positive (+)Antimicrobial prescribing audit compliance (+)Actions taken as part of annual program (updated July 2015) (+)1

st TDA visit inspecting controls and procedures

(+)2nd

TDA visit comparison with other Trusts and brokered meeting with CCGs (+)PHE and NHSE walkthrough ED for VHF risk provides good assurance (+)Management of diarrhoea agreed as one of first ‘VMI Value Streams’ (+)Initiation of ‘Stop, Access, Send’ initiative for the management of Negative (-)Incidence of CDI 2015/16

Gaps in assurance Assurance Level gained: RAG

Extensive auditing and monitoring in place. Trust position known


1) Roll out of Urinary catheter Passport 2) Full list of actions in IPCAS Annual Programme of work (2015/16) 3) Ongoing discussion with commissioners about penalties applying only to cases with poor/inadequate care. This conversation is nationally mandated 4) Considering implementation of two low risk C. diff Antibiotics (Fidaxomicin and Chloramphenicol IV)

1) Embedding 2) 2015/16 3) Ongoing 4) Under review

Update by DH 22/01/16

Date discussed at Board To be discussed at January Board

Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy Priority ID and reference 2.A Achieve the best possible

clinical outcomes for our patients Director responsible Medical Director


2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties


Target risk score

S3 x L1 = 3

Linked to Risk 1460


1) Safety thermometer data is reviewed by wards and specialties at regular meetings 2) HSMR/SHMI/Datix incidents are reviewed at divisional and trust level 3) Groups/committees established including SQC, ECQR, Effectiveness committee and its subcommittees 4) Specialty deep dive process identified areas of best practice and also areas for improvement, which have been actioned and monitored by relevant clinical leads

1) Evidence of learning from incidents/audit 2) Time lag with which some data sets are released



1. PROMS 2. Minutes of divisional meetings including M & M 3. Minutes of Clinical Effectiveness and Patient Safety and Risk

subcommittees 4. Patient tracking and analysis (whiteboard project) 5. Datix reporting and analysis 6. Clinical Nurse Consultant for Patient Safety and Falls commenced

02/12/14 7. Results from National Clinical Audit Programme 8. Benchmarked reports from Academic Health Science Network

Enhancing Quality and Recovery Programme 9. Reviewing all deaths proactively where coding wish to apply diagnostic

code 10. Working with the 4 other successful Trusts in the TDA/Virginia Mason

development program

Positive (+) Sharing data through VM program with identified peers (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) The latest HSMR data shows overall Trust mortality is lower than expected for our patient group (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) New EWS implemented (+) Increase in reporting trends (+) National falls data benchmarks favorably (Trust desire to improve position) Negative (-) Never events incidence (-) NRLS reporting (-) HSMR for low risk procedures is 116


Ability to benchmark in real time National Safety Dashboard to be implemented when available


1) Development of ward based performance dashboards 1) Start date 01/04/2015

Update by DH 22/01/16


Objective 2 - Effective –Deliver effective and sustainable clinical services within the local health economy Priority ID and reference 2.B Deliver services differently to

meet need of patients, the local health economy and the Trust

Director responsible Chief Operating Officer



2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.


Target risk score

S5 x L2 = 10

Linked to Risk 1221, 1480, 1601, 1405, 1547


1) Transformation Team in place 2) System Resilience Group 3) 3x3 meetings 4) CEO strategic meetings 5) Partnership boards 6) Trust part of national Virginia Mason transformation Programme 7) Integrated Reablment Unit build complete

1) Pathway redesign needs to ensure its appropriate and fit for purpose 2) Repatriation of tertiary services effected and influenced by external factors 3) Clear action plans linked to root causes of efficiency issues and using service improvement methodologies not yet fully embedded



1) Contracts 2) Plans 3) Referral activity 4) GP Support 5) Breaking the cycle 6) Divisional Performance Reviews 7) Productivity reporting

Positive (+) Contract 14/15 signed with BICS (+) Internal audit of readmission figures provides positive assurance (+) Feedback following initial work on discharge process 2013/14 (+) Joint working with Royal Surrey County ( Chemo and Radiotherapy) (+) Pathology joint venture BSUH (+) Bowel screening (+) BOC respiratory unit (+) Extended theatre working days Crawley (20% increase capacity) (+) Second Cath Laboratory in place (+) VMI Guiding Team established, initial Value Streams agreed Negative (-) Medically ready for discharge (100 pts vs target 90) (-) Nationally an outlier on emergency length of stay by 1 day (-) Unplanned increase in >1 LOS emergency admission patients (10% vs 2% plan)


Agreed activity modelling across SEC National policy decisions and effective of general election


1) Full action plan development for transformation programme (theatres, outpatients, VMI Value streams) 2) Breaking the cycle and reducing LOS action plan

1) End of quarter 4 2) Ongoing

Update by AS 21/01/2016 Date discussed at Board To be discussed at January Board

Objective 3 - Caring – Ensure patients are cared for and feel cared about Priority ID and reference 3.B Deliver high quality care around

the individual needs of each patient Director responsible Chief Nurse and Medical Director





Linked to Risk 770, 1295, 1580, 1652


1. Workforce KPIs including vacancy rates, turnover and temporary staffing monitored by Nursing agency PMO, Workforce subcommittee, Exec Committee and the Board

2. Monitoring of Safety Thermometer, patient experience and staff turnover, sickness at ward level and at associated subcommittee, Exec and the Board

3. Planned versus actual staffing levels monitored on a shift by shift basis, reported daily by Matrons and issues escalated to DCNs with evidence actions taken

4. PMO in place to monitor agency use and progress of the five related work streams

a. E-roster- migration to v10 approved and project commenced b. Nursing recruitment plans developed by DCN and DCM in

response to Right Staffing review and monitored by Agency PMO, Workforce subcommittee and divisional team meetings

c. Recruitment process reviewed, KPIs in place to provide assurance

d. Bank recruitment in progress to reduce use of agency nursing staff

e. International recruitment undertaken but start date has been delayed. Further local and EU recruitment in progress. Monitored via temp staffing PMO

f. Weekly reporting in place to TDA/Monitor in place on all agency use above cap or outside framework

g. Monthly reporting of total agency spend against TDA/monitor agreed trajectory

5. SNCT/Birthrate Plus tool/NICE guidelines utilized to monitor patient

acuity and dependency presented to relevant committees including Board to determine future staffing demand

6. Work underway to develop SASH recruitment brand and retention strategy including the development of new nursing roles

7. SASH funded by HEKSS to develop and lead on physician associate training and recruitment for SEC

8. Foundation doctors workloads re-modelled such that 95% of time is spent with no more than 14 patients.

9. Strong relationship with HEKSS who place junior doctors in the organisation

10. Practice development nurses recruited to support ward nursing teams improve retention.

1. E-Roster system is not updated out of hours 2. Unfilled shifts both nursing/midwifery and medical 3. The Trust still carries a volume of vacancies specifically in clinical areas and

turnover in some areas is above Trust target 4. Imperfect induction for short notice, short term medical locums 5. Aiming for full nursing/midwifery and medical recruitment (influenced by HEKSS) 6. Medical trainees select a preference that affects the decision



1. Ward staffing templates monitored daily by Matrons and escalated to the Divisional Chief Nurses to ensure safe levels to meet patient needs.

2. Staff absence reports and monitored in divisions 3. % of vacant shifts filled by Trust and agency staff 4. Revalidation (GMC) for locums 5. Monitoring agency utilisation and spend at PMO 6. Weekly & monthly reporting of agency use to TDA/Monitor

Positive (+)SNCT data (+) Recruitment plans developed by ward and reported monthly (+) Matron for workforce recruited (+) International recruitment for nurses undertaken (+) CQC Chief Inspector of Hospitals Report - Good rating

(+) Daily ward staffing review (+) Reports regarding reducing vacancy rates, sickness, absence (+) Incident reporting via Datix (+) Patient experience data by ward or unit (+) Junior Doctors feedback regarding quality of experience and breadth of exposure (+) European recruitment undertaken Negative (-)Benchmarked high proportion of agency staff usage against other Trust’s (-) Vacancy rates and turnover rates (-) Temporary staffing Internal Audit (-) Junior Doctors feedback relating to high workload


Trust position known - no identified gaps in assurance


1. Continue to monitor effectiveness of recruitment plans 2. 7 day working plans for medical staff under development across the Trust 3. Implement e-roster upgrade and utilize core functionality (bank and messaging)

4. Implement plans to manage staffing issues in Theatres 5. Increasing direct entry nursing students by 100% (40 to 80) from February 2016

1. Ongoing 2. Being implemented 3. Embedding and under review 4. Being implemented 5. February 2016

Update by FA 08/01/2016 and DH 22/01/2016


4 - Responsive to people’s needs – Become the secondary care provider of choice for the catchment population Priority ID and reference 4.A.1 Deliver access standards Director responsible Chief Operating Officer






Linked to Risk 1220, 1491


1) EDD Patient Pathway 2) Site management team and Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches weekly to implement lessons learnt 5) Site Management Team and Discharge Team 6) Circa 50 additional community beds made available 7) 7 day medical consultant ward rounds established 8) Additional community beds 9) Tilgate annex opened providing extra surgical capacity 10) 10

th Theatre opened (May 15)

11) Increasing hospital at home capacity 12) Integrated Reablement Unit built

1)Identified on a rolling basis as part of weekly review 2)It is difficult for the Trust to influence the output of decision making across the local health economy 3)Ambulatory pathways yet to imbed (New Consultant undertaking review) 4)Support of partners required to effectively reduce and sustain numbers of patients medically ready for discharge



1) NHS England aware 2) Combined weekly Quality and Performance Dashboard for ED reporting on a combination of quality and safety standards and the ED national indicators reported to exec meeting weekly 3) Performance Management Framework and reporting to Trust Board 4) External stakeholder inspections 5) Daily sit rep reporting to the TDA 6) Daily winter Sit Reps (Commenced November) Urgent Careboard Area Team. 7) Whole system operational resilience plans signed off for 14/15 8) 2020 whole system review of discharge process, reviewing recommendations

9) Clinical audit of clinical pathways which impact on reducing emergency re-admissions.

Positive (+) MRD Summit June agreed map capacity available across Surrey and Sussex (+) ED Standard delivered April, May, Aug, Sept, Oct and Dec 2015 (+) Process improvement (+) Working with partners commissioners / partners to expedite flow through hospital (Medihome and community beds) (+) Top 20 patient delay weekly meetings (+) Monitoring and managing compliance #NOF, Stroke and medical outliers (+) Bed modelling refreshed including emergency demand increases Negative (-) ED standard not delivered June, July and Nov 2015 (-) Quality indicators for time to assessment / treatment. Surrey and Sussex local lead. (-) EDD Section 2 and section Patient tracking system (-) Number of patients safe to discharge at any one time (-) Adult Bed occupancy remains higher than plan due to increased activity Circa 100 medically fit for discharge patients (-) Local availability of Nursing home beds / ability to start complex packages of care (-)Unplanned increase in >1 LOS emergency admission patients (10% vs 2% plan)


Winter plans and local health economy position going into winter months


1) Comparison between 2014/15 Q1 vs on 2015/16 Q1 assumptions and activity to identify variance 2) Refresh winter capacity plans based on assessment of Q1 activity 3) Planned local health economy summit regarding emergency growth

4) Agreed breaking the cycle 2 encompassing internal and external bodies

5) Planned breaking the cycle throughout weeks throughout winter

1) Complete 2) Oct 2015 3) Complete 4) Complete 5) March 2016

Update by AS 21/01/16 Date discussed at Board To be discussed at January Board

Objective 5 – Well Led Priority ID and reference 5.A Live within our means to remain

financially sustainable

Director responsible Chief Finance Officer



5.1 Failure to deliver income plan Current rating S5 x L3 = 15


Linked to Risk 1689


1) Business Plans and budgets (activity and financial) savings / transformation plans. 2) Agreed contracts in place with main sets of commissioners (NHSE and CCGs) – all Contracts were finally signed in August. 3) Contract management process in place (this operated effectively in 2014/15). 4) Financial reporting, including periodic forecast scenarios, is in place and effective – a detail forecast was provided to Board in July and internal PMOs are based on that forecast. 5) Chief Officer meeting (which includes coordination of has been in place since Nov 2014. Its structures are still embedding.

1) There are issues with Sussex over the under commissioning of activity and contractual action has started to correct activity plans. 2) The Trust is also concerned over the robustness of plans for winter, noting delayed decision on investment in community schemes. A risk summit is being held to discuss winter pressures (focus isn’t income, but planning) 3) The strategic management of activity is not currently effective, but the Trust is doing all it can to support making it so. Note: other gaps in previous reports mitigated by actions currently in train with CCGs.



1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board (including CQUIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output and reporting from health system management (e.g.: System Resilience Groups and Chief Officer Meetings) 5) Output of Contract Management Process .

Positive (+) 2014/15 activity and income met the Plan (noting that individual elements (e.g.: elective activity) did not) (+) Reconciliation process working with CCGs in 2014/15 and year end settlement achieved with all commissioners in 2014/15 with no outstanding disputes. (+) Contracts include clauses to allow inclusion of growth in indicative activity plans, and (vice versa) for any emergency activity reductions (+) resolution achieved on Endocrinology business case activity – part year shortfall, but underlying issues have now been corrected (+) Agreement now reached with Sussex over MRET and handover fines – surrey not expected to be far behind [but not yet agreed] Negative (-) Risk over income growth assumptions, now materialized – risk in last 3 months is from balance of emergency activity and capacity. . (-) Adverse income variance at M09 (-) Monitor response to MRET complaint provided no useful application in 2015/16 (-) Too much non elective activity, not enough elective – risk over emergency demand in 2015/16. (-) disputes now received from Surrey – only one from Sussex – escalation status not confirmed by CCGs


Red because of level of risk, activity planning differences, issues with strategic health system management of urgent care activity and transactional processes with CCGs.

Mitigating actions underway

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing.

1) COO meetings have been held, COG updated - there is clear progress in Surrey, not in Sussex. 2) Complete all contractual commitments by revised long-stop dates (end date – now Q2 reconciliation,

which is now in process); 3) Revised forecast for elective activity completed, now being monitored 4) Specific action around dermatology, diabetes and cardiology where there is under delivery (and there

is improvement in all these areas) 5) The integrated reablement unit opens on 21 January. 6) Robust contractual processes being operated.

Actions proceeding to timetable.

Update by PS 20/01/16 Date discussed at Board To be discussed at January Board





5. 2 Failure to stop divisional overspending against budget



Linked to Risk 1663,1688


1) Business Plans and budgets (activity and financial) savings / transformation plans 2) Divisional activity plans 3) Internal Performance Review (PMO) process and CEO review 4) Forecast scenarios presented to Board – a detail forecast was provided to Board in July and internal PMOs are based on that forecast. 5) TDA agency reduction plan now submitted

1) Management of increased levels of emergency activity subject to review; 2) At M09 cost improvement plans are not fully delivering with adverse performance

on agency and escalation in particular. Red rated savings have been partially mitigated. The forecast provides a £3.3m risk to savings delivery.

3) There is overspending in 2 areas against agreed forecast control totals at M09 The overspending risk has been reduced because overall we have been within the forecast for some months and the overspend is recorded in the forecast.



1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board UIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output in financial reporting describes improvement and risk mitigation. 5) Agency PMO.

Positive (+) Budget changes made to match activity to Q1, and recovery plan actions largely complete in Medicine (although overspending against forecast in recent months); (+) All bar 2 areas meeting YTD forecast spend (+) Internal audit advises CIP process is sound Negative (-) Internal audit advises effectiveness of savings delivery rated red/amber. (-) Emergency activity pressures have continued to be greater than expected (-) Overall agency costs remain very high, with escalation still in use and significant costs (albeit within forecast) across Divisions. (-) Agency costs are high in Nursing still, with adverse increase in past months, but which is plateauing. (-) The forecast provides an adverse variance to plan.


Overspending is the main area of risk and the ability of the Trust to reduce the rate of spend while maintaining services adequately.


1) PMO/Performance structure continues - Divisions have been required to produce recovery plans and PMO meetings have become weekly, now, for all Divisions. Nursing agency PMO and fortnightly agency steering group.

2) Controls are being exercised in divisions and centrally – vacancy restriction and non-clinical procurement.

3) Decisions on business cases are now taken in light of affordability against forecast.

Actions proceeding to timetable






5. 3 Unable to deliver medium term financial plan



Linked to Risk 1603


1) Items referred to in 5.A.1 and 5.A.2 above 2) V7.0 long term financial model and integrated business plan

completed (submitted to Monitor in April 2015) 3) TDA Plan submitted in April 2015

4) Board to Board held with the TDA in November 2014, Monitor assessment now in train culminating in Monitor Board to Board in June 2015.

5) Cost improvement plan process in place (including PMO structure) 6) Elective/outpatient activity growth and income plan in place –

capacity created

7) Contracts with CCGs allow for payment for “over performance”

1) Items listed above (5.A.1, and 5.A.2) are applicable here 2) Lack of alignment between CCG activity plans and actual performance. 3) Reliance on centrally determined rules for PbR, Better Care Fund and the wider

NHS finance regime. 4) Risk over capacity from other operational pressures 5) Overall health system financial view (Chief Officer’s Finance Sub-Group)

describes significant loss of resource to BCF funding – this reduces resource available for health and social care overall.

6) Lack of clarity over tariff assumptions for 2016/17 – this is crucial to medium term planning [some information now available]

7) Central actions over NHS overspend may have an adverse impact on Trust because of manner of application (e.g.: withholding capital).



1) Delivery of 2014/15 financial position and delivery of 2015/16 financial plan 2) Production of 2016/7 budget, revised long term financial model and integrated business plan documentation, and delivery against them

Positive (+) Delivery of performance in 2014/15 (noting a deficit was recorded, but position was as forecast) Negative (-) alignment with CCG plans is not complete with significant variances between actual performance on activity and CCG plans [CCGs are paying over performance] (-) overall health system loss of resource Overall, on basis of current assumptions, RAG has turned red with the impact of urgent care activity and the level of risk to the forecast. Assurance RAG red.


Central actions to manage costs across the NHS are not yet clearly described and the tariff is not yet defined, plus cumulative impact of other finance risks here.


Please see items above. Additional CIP contingency is identified, more is being sought. Monitor has agreed postponement of FT process. Board will review in November the suggested timetable. Tariff information is now emerging, but is nowhere near coherent or complete. The 2016/17 budget process will begin in September.

Progress is on timetable






5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position



Linked to Risk 1604


1) Bi weekly review of forward cash flow by finance team and CFO 2) Cash and working capital management processes 3) Annual cash plan linked to business plan and capital plan ( see link with Risk 1134)

NOTE: This risk was reviewed at FWC 22 September and agreed to be maintained noting working capital facility. Additionally capital loan is now secure. An application for a £9.6m working capital loan has now been submitted

1) No agreement on medium term solution to liquidity – being pursued during 2015/16 – a loan application has been drafted and submitted – awaiting confirmation of agreement

2) Delay in receiving cash payments to match accrued income from CCGs, although main CCGs are providing cash advances

3) Threat of central cash controls in line with control totals (nb: which the Trust has not agreed) – need to hear more detail on operation. This point is important and the rigidity of application provides an increased level of risk

Rating maintained after last discussion at Board (November) – position monitored



1) Twice monthly reporting to CFO by finance team, SBS reporting on bank balance

2) Monthly finance reporting to Executive Committee, Finance and Workforce Committee and Trust Board

3) Confirmation of working capital injection (either through a loan, working capital facility or, if available, PDC)

Positive (+) Cash targets met in 2014/15 (+) Liquid ratio has followed expectations (+) Cash has been managed well in 2015/16 to date, (+) Green internal audit report on cash management Negative (-) no additional cash to resolve underlying liquidity problem – can only be resolved in FT application process (through a working capital loan) and which is now paused (-) cash flow dependent on financial outturn described in 5.A.1 and 5.A.2 above. Overall rating “red” noting risk to forecast I&E. Assurance RAG "amber" - no current cash problem but underlying problem unresolved.


In terms of cash flow management to end year, no material gaps in assurance. In terms of resolving the actual risk (liquidity), there is no confirmation of additional cash to resolve SoFP weakness. Assurance level “red” noting unresolved underlying cash issue.


1) Day to day cash control is main action currently, coupled with actions to maintain service income and manage spend 2) Long term financial model, and TDA plan now provides additional validation of the level of cash injection required and the interaction from an improving financial position within the model 3) Discussion will continue with the TDA as the FT timeline progresses.

Actions proceeding to timetable


Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference 5.E We are an organisation that is

clinically led and managerially enabled.

Director responsible Director of Human Resources



5.5 There is a risk we will fail to realize the strategic benefits of having an Achievement Review Process that effectively monitors and influences behavior and performance.


Target risk score

S3 x L2 = 6

Linked to Risk 1740

Controls in place (to manage the risk) Gaps in Control 1) New Achievement Review Policy with implementation /communication and

training plan. 2) Personal objectives are being linked to Trust/Divisional and team

objectives and the SMART methodology is being used to assess performance

3) New AR process includes assessment of Behaviours against Trust values 4) Personal Development Plans as part of AR identify development needs 5) Training Need’s Analysis at Divisional level extrapolated to Trust level

inform strategic planning of development priorities. 6) AR Task and Finish group continues to embed new process and

implement for medical staff during 2015/16

1) New system yet to reap full benefits 2) Activity levels in the Trust affecting capacity for compliance 3) Change to annual timetable with delivery in first part of financial year yet to embed 4) An agreed model for medical and dental Achievement Review yet to be agreed.



1) AR review audits focusing on objective setting and linked to quality of services 2) staff survey results 3) Feedback from junior doctors 4) Monthly reporting against AR completion timetable at Divisional and Trust level at ECQR&CC – Workforce Committee and Finance Investment and Workforce Committee through 5) Development of behavior based recruitment systems will support the long term strategic implementation of achievement reviews.

Positive (+) Task and Finish group successful launch of new policy and process slides and comms plan for launch at ESH and Crawley (+) development of toolkit and intranet resources (+)TNA update to August 2015 Finance Investment and Workforce Committee (+) recent audit personal quality objectives in appraisals (+) 2014 staff survey results for quality of appraisals puts us in the top 20% of Trusts (+) Culture champion led initiative on standards of behavior (+) 64% compliance achieved following significant focused effort Negative (-) 2014 staff survey Q on appraisal in last 12 months is in bottom 20% (-) compliance rates for Achievement Review remains adverse to plan

Gaps in assurance Assurance Level gained: RAG New AR process is yet to provide any evidence that demonstrates mitigation of this risk or completion of AR’s


1) Recovery plan for compliance in place 2) Series of training courses to support implementation commenced and will run throughout 2015/16 3) T&F to support development of AR for Doctors and dentists – acceptance that AR process needs to be the

same across all staff groups 4) Trust wide culture champion launch to include significant focus on the trust values and behavioural anchors 5) Establish process for annual performance review to identify and talent map for Medical Dental, 8a’s and

above

1) 31 March 2016

2) 31 March 2016 3) Underway initial meetings positive 4) Complete and ongoing 5) February 2016

Update by 19/01/2016 JM Date discussed at Board To be discussed at January Board

Objective 5 - Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference 5.G.2 We are a well governed

organisation Director responsible Director of Corporate Affairs



5.6 The Trust remains within the current FT pipeline and awaits national guidance on potential new organisational forms which could result in changes to the current timescale and associated requirements to the process. Due to the merger of the NHS TDA & Monitor and creation of NHS Improvement there is uncertainty over the longevity of the current FT model.



Linked to Risk 1531


1) Successful outcome from the formal Monitor assessment process 2) Achievement of FT project plan milestones 3) Formal approval by TDA Board to move to Monitor assessment phase target 4) Successful elections to the Council of Governors 5) FT Project Board 6) Implementation of Board development programmer

No significant gaps in control identified



1) LTFM agreed by the Board 2) Submission of Integrated Business Plan to TDA & Monitor 3) Public Consultation completed with positive outcome 4) QGAF External assessment completed with implementation of action plan 5) TDA Formal approval to move to the Monitor stage 6) Chief Inspector of Hospitals Inspection – “Good” 7) Elections to Shadow Council of Governors 8) HDD to be completed as part of Monitor phase 9) Submission of all current Monitor information requests

Positive (+) Completion of Monitor pre-assessment phase (+) Election to the Council of Governors complete (+) FT membership over 10,000 (+) Monitor Exe to Exe Challenge took place on 1

st June 2015

(+) External assessment of QGAF score 3.5 (+) Quality Governance Memorandum submitted to Monitor with score of 2.0 (+) Monitor confirmed QGAF score as 3.5 – Further actions being implemented (+) Successful elections - Shadow Council of Governors in place (+) Discussion with Monitor on final timescales & remainder milestones to re-start the process (+/-) Awaiting national guidance on future FT model (NHS Improvement)


Completion of Historical Due Diligence


1) Shadow Council of Governors in place 2) Monitor formal assessment currently paused

1) Ongoing 2) Plans are on track

Update by GFM 13/01/16 Update by To be discussed at January Board

Objective 5 – Well Led- become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Priority ID and reference 5.F. Ensure IT support/optimise

patient experience by improving patient interface, sharing and capture of patient information and patient communication

Director responsible Director of Information and Facilities



5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems



Linked to Risk 1428, 999, 1483


1) Move to direct contract with Cerner now happened and Trust has exited NPfIT well ahead of schedule 2) IT Strategy aligned with Clinical Strategy and IBP and reviewed Oct 14 3) Clinical Informatics Group 4) Clinical IT leads 5) Various project groups (EPMA etc.) 6) Project management controls (Descried in Internal Audit of project management) 7) EPR costs identified in LTM 8) CCIO and CNIO roles being implemented – greater clinical buy-in 9) Cerner Optimisation Group now in place 10) IT Road Map presented to FWC and Executive 11) EPR Roadmap signed-off by Executive November 2015 and Trust working on implementation plan and business case with EPR Provider

1) Insufficient focus on change benefits realization due to financial constraints 2) Lack of operational involvement in identifying and delivering benefits



Efficiencies being delivered through IT enabled change

Positive (+) Improving infrastructure (e.g. Wi-Fi move to Windows 7) (+) Development of existing EPR platform (e.g. EPMA and move to Cerner) (+) EPR Contract signed and data center move finished (+) Trust moved to latest version of EPR software (+) Business Continuity System now in place (7/24)


Trust position known, no identified gaps in assurance


1. Procurement and implementation of replacement EPR - complete 2. Establishment of Chief clinical Information Officer role - complete 3. Clinical Cerner Optimisation Group now in place with strong leadership 4. Greater focus on IT in Capital Plan for 2015/16 and future years 5. EPR Roadmap now approved by Executive

1. Completed 2. 724 Go-live November 2014. 3. PC Upgrade plan in-place, funded and business

continuity almost complete 4. Network review first draft now complete and

action plan being prepared.

Update by IM 19/01/16 Date discussed at Board To be discussed at January Board

Appendix 1

Abridged consequence table taken from Trust guidance

Risk Type Insignificant Minor Moderate Major Extreme

Patient Safety • No obvious injury / harm • Non-permanent avoidable injury / harm requiring only first aid / minor treatment

• Short-term avoidable injury / harm with recovery / treatment up to 1 month

• Long-term (>1 month) / permanent avoidable injury / harm / illness or any of the following: � Infant abduction � Infant discharged to wrong family � Rape or serious assault

• Avoidable death

• Injury / illness requiring more complex treatment, e.g. stitching, plaster, medication course, minor theatre operation etc.

• Minor harm event involving >5 patients • Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

Patient 'Experience' & Care Pathways and Involvement of Service Users

• No significant impact on patient experience

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

• Major unsatisfactory patient experience related to poor treatment / care

• Upheld complaints regarding death in the Trust

• No complaints / concerns raised • Informal complaints raised / PALS contacted

• Formal complaints raised and/or MP / independent advice / advocacy contacted

• Legal action against the Trust initiated / local media involvement

• National media coverage / political action against the Trust

• Care pathway problems resulting in short-term treatment / care delay <3 hours

• Care pathway problems resulting in short-term treatment / care delays (3 hours – 1 day)

• Care pathway problems resulting in medium term delays (up to 1 month) or 5-10 patients affected

• Care pathway problems resulting in medium term delays (1-6 months) or 10-20 patients affected

• Care pathway problems resulting in long term delays (>6 months) or >20 patients affected

Health & Safety • No harm injury • Short term / non-permanent injury / ill health.

• Medical treatment required • Permanent or extensive injury / ill health / permanent disability or loss of limb (RIDDOR reportable)

• Death (RIDDOR reportable)

• Injury / ill health resulting in 0-7 days absence from work.

• Injury / ill health resulting in >7 days absence from work or restricted duties for >7 days (RIDDOR reportable)

Financial Management • Small loss <£1K • Minor loss £2K to £100k • Moderate loss, £100k - £1M • Major loss, £1M-£10M • Loss > £10M

Governance Arrangements

• Concern raised by internal or external systems that can be resolved through normal governance processes in < 3 months (e.g. one financial quarter)

• Concern raised by internal or external systems that will take > 3 months to resolve but does not fulfil the criteria of moderate consequence

• Concern raised in external inspection report or raised in single performance conversation with commissioners / TDA (or equivalent) due to a failure to provide “well led” services as described by the CQC

• Suspension of services provided due to a failure to provide “well led” services as described by the CQC

• Permanent removal of services and / or prosecution due to a failure to provide “well led” services as described by the CQC

• Any issue that would have to be recorded in annual governance statement or annual report (e.g. significant issue “red risk” audit produced by Internal Audit)

• Act or omission that could led to removal of the Board

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

Quality of Service

• Insignificant interruption of service(s) which does not impact on the delivery of patient care or the ability to continue to provide service

• Short term disruption to service(s) with minor impact on patient care

• Some disruption to service(s) provision with unacceptable short-term impact on patient care. Temporary loss of ability to provide service(s)

• Sustained loss of service which has serious impact on patient care resulting in major contingency plans being involved

• Permanent loss of core service or facility

ID Op

en

Da

te

Sp

eci

alt

y

Ris

k O

wn

er

Ris

k T

yp

e

Title (Policies) Description (Policies) Existing controls

Init

ial

Ra

tin

g

Cu

rre

nt

Co

nse

qu

en

ce

Cu

rre

nt

Lik

eli

ho

od

Cu

rre

nt

Ra

tin

g

Treatment Plan Due date Done date

Re

sid

ua

l R

ati

ng

Ne

xt R

ev

iew

14

01

23

/01

/20

13

CO

RP

Me

dic

al D

ire

cto

r's O

ffic

e

Pa

tie

nt

Sa

fety

Risk of outbreak of viral gastroenteritis Risk of outbreak of viral gastroenteritis (outbreak of

diarrhoea and vomiting). Impact on patient safety

and trust reputation. Has operational impact due to

bed closures.

D&V policy

Hydrogen peroxide system for terminal cleaning

Use of Actichlor Plus for environmental cleaning

Use of Tristel Jet for commode and bed pan cleaning

Use of SEC Norovirus Toolkit

Outbreak control Group

Surveillance of diarrhoea and vomiting

Red aprons system

Stat and mandatory training

Policy

Communications messages to staff, visitors and patients

Norovirus leaflets

Hand hygiene facilities

Restricted visiting

Use of signs at entrance to wards and bays, and red aprons to

facilitate communication that an outbreak is taking place.

16 3 5 15

Develop RAG rated system for terminal cleaning

Audit terminal cleaning

Implement ATP testing

Dedicated internal norovirus planning meeting.

Use of red aprons during outbreaks of D&V

Meeting with stakeholders regarding norovirus

preparedness

Audit of post-outbreak cleaning

Pilot Patient Hand Hygiene Champions in Elderly

Care

Stakeholders meeting to discuss health system

norovirus planning

Monitor use of ED risk assessment for patients

admitted with diarrhoea and/or vomiting

Monitor ward refurbishment programme

Stakeholder norovirus study day

Prepare options appraisal for emptying bays to

facilitate terminal cleaning following outbreak

31/03/2013

30/06/2013

01/04/2013

02/09/2013

31/03/2014

31/03/2013

20/03/2015

01/03/2015

22/09/2014

31/03/2014

30/03/2013

25/09/2013

31/01/2013

06/12/2013

26/07/2013

26/07/2013

02/09/2013

11/02/2014

06/12/2013

22/09/2014

21/05/2014

26/07/2013

25/09/2013

26/07/2013

9

31

/03

/20

16

1491 29/08/2013 CORP

Op

era

tio

ns

Invo

lve

me

nt

of

Se

rvic

e U

se

rsFailure to maintain Emergency

Department performance

Failure to maintain Emergency Department

performance because of lack of capacity in health

system to manage winter pressures has a

significant impact on the Trust's ability to deliver

high quality care.

1) EDD Patient Pathway

2) Discharge management

3) Plans for escalation areas agreed and management tools in place

4) Reviewing all breaches on weekly to implement lessons learnt

20 4 4 16

As described on the board assurance framework

Implementation of divisional escalation plan following

key triggers.

Escalation bed plan agreed implementation plans in

place for each area.

Ambulance handover escalation plan agreed and in

place with new process for managing handovers

agreed to maintain flow. Escalation to division with

clear triggers in place.

Weekly ED review meeting to review previous weeks

performance and implement lessons learnt

Plans in place to manage with reduced capacity

during January through March 2016 whilst building

works are underway.

31/03/2014

14/12/2015

30/09/2015

14/12/2015

31/01/2016

31/12/2015

30/09/2015

6

31

/01

/20

16

1501 19/09/2013 CORP

Op

era

tio

ns

Invo

lve

me

nt

of

Se

rvic

e U

se

rs Patient admitted to the right bed first

time

If the Trust does not maintain and improve ability to

allocate the right bed first time there is an increased

risk of receiving poor quality of our care

(effectiveness, experience and safety)

1) Operational meeting three times a day chaired by AD Site

Services with clinical involvement from Matrons, Nurse Specialists

and therapists

2) Daily Board rounds by clinical site team. Focusing on #NOF,

Stroke and Medical outliers

3) Live 'To come In' lists available to view in all specialty wards to

encourage active pull of patients from AMU to the correct specialty

bed

4) Matrons review ward areas on a daily basis

5) Matron on site 7 days a week

9 3 5 15

As described on BAF

Reviewing compliance to establish a key baseline

target

Build an integrated discharge unit to increase

community capacity

27/06/2014

31/08/2015

18/01/2016

31/03/2014

23/11/2015

6

31

/03

/20

16

1603 18/06/2014 CORP

Fin

an

ce

- F

in.

Ma

na

ge

me

nt

Fin

an

cia

l M

an

ag

em

en

t Unable to deliver realistic medium term

financial plan

As described on the BAF 1)Items referred to in 5.A.1 and 5.A.2 above

2)V3.0 long term financial model and integrated business plan

completed (submitted to TDA in February 2014) V4.0 now

approaching completion

3)TDA Plan submitted January 2014

4) Timetable for refreshed IBP and LTFM going forward is part of

national planning guidance (next iteration due 20 June)

15 5 3 15

As described on the BAF 31/03/2016

8

31

/01

/20

16

1604 18/06/2014 CORP

Fin

an

ce

-

Fin

.

Ma

na

ge

me

nt

Fin

an

cia

l

Ma

na

ge

me

nt Liquidity: Inability to pay creditors/staff

resulting from insufficient cash due to

poor liquid position

Risk of not being able to pay suppliers from in

sufficient cash due to poor liquidity problem

1) Bi weekly review of forward cash flow by finance team and CFO

2) Cash and working capital policy and strategy

3) Annual cash plan linked to business plan and capital plan 15 5 3 15


12

31

/01

/20

16

1663 09/12/2014 CORP

Fin

an

ce

-

Fin

.

Ma

na

ge

me

nt

Fin

an

cia

l

Ma

na

ge

me

nt

Risk of not achieving Cost

Improvement Plan

Risk of not achieving financial plan as a result of

non-delivery of Cost Improvement Plans

i) Delivery of savings managed through PMO (ongoing)

9 5 3 15


6

##

##

##

##

1672 01/02/2015 CORP

HR

- W

ork

forc

e

Sta

ffin

g -

ge

ne

ral Sickness Absence Levels with impact

on day to day management and

expenditure

Continuing risk to the delivery of effective services

and Trust Strategic Objectives caused by the

resources required to actively manage the Trusts

rising Sickness Absence rate and ensure safe

services. This is also having a significant effect on

the ability to control the Trusts temporary staffing

costs.

Firstcare real time sickness absence monitoring reports and daily

updates to managers inbox.

Daily sit reps at ward level used to ensure shift by shift safe levels of

service.

eRostering software to manage rota's prospectively.

Agency PMO.

15 3 5 15

Actions described in the Agency PMO

Focused interventions to support the Trust's Stress

Management Policy (Anxiety/Stress/Depression has

been highest reason for absence for past 8 months)

31/03/2015

31/08/2015

9

31

/01

/20

16

1678 23/03/2015 CORP

Op

era

tio

ns

Se

rvic

e A

cce

ss

RTT Access Standards Due to on-going operational pressures and

increasing demand for elective services, the Trust

cannot offer all services within the 18 weeks

standards set out in the NHS Constitution. Longer

waiting times result in poor patient experience and

increase the number of formal and informal

complaints

1. Access Policy revised 2014

2. Weekly PTL / performance meetings to monitor progress.

3. Service Level plans to increase capacity where required.

4. Operational plan for winter 2015/16 to support inpatient elective

care15 3 5 15

Manage the number of IPs booked on lists to avoid

cancellations

Improve Theatre Utilisation

Ring-fencing of Tandridge and Woodland Wards

27/02/2015

20/06/2015

15/05/2015

09/02/2015

05/08/2015

18/09/2015

6

11

/02

/20

16

1689 01/04/2015 CORP

Fin

an

ce

- F

in.

Ma

na

ge

me

nt

Fin

an

cia

l M

an

ag

em

en

t

Risk of Contract income below plan Risk the Trust does not achieve its financial plan as

a result of lower than planned contract income.

i) Quarterly reconciliation with CCGs will inform variations to the

monthly contract values (over performance at Q1 is likely to reduce

the risk).

ii) Manage emergency activity within capacity through structural

changes to ward configuration, improving length of stay (notably in

cardiology to release beds) and other actions to improve efficiency.

Iii) Ring fence elective beds after new capacity has opened and

monitor delivery.

15 5 3 15


12

31

/01

/20

16

1697 11/06/2015 CORP

Fin

an

ce

- F

in.

Ma

na

ge

me

nt

Fin

an

cia

l M

an

ag

em

en

t Financial risks linked to National

Quality Board Paper, 7 day working

and Carter productivity report

Risk of failure to meet the financial plan as a result

of a) increased costs to deliver staffing ratios, 7 day

costs and expectations detailed in national guidance

and plans, and b) failure to deliver adequate

adjusted treatment index (Carter).

The Trust has set aside reserve budget for the cost of proposals to

increase nurse/midwifery staffing, but this is funded partly by income

from CCGs, which is not secure. 7 day working is already in place

partially (part of the forecast). Additional nursing staff to deliver

agreed ratios have been agreed, with implementation spread over 2

years and recruitment starting when agency is at acceptable levels.15 3 5 15

Review and develop plans; to brief the Board on

progress against risks of establishment targets not

being met and any potential action to review the

Board's decision on implementation.

30/09/2015

9

31

/01

/20

16

Presentation Title

36pt Arial Bold

Sub heading 24pt Arial

Clinical presentation

28th January 2016

Dr Ansari

The Patient Will See You Now

Medicine's "Gutenberg moment."

Digitised and Democratized

Obstacles and objectives

Kings Fund co-ordinated care • patients engaged in decisions about

their care

• supported self-management • prevention, early diagnosis and

intervention • emotional, psychological and

practical support

Case 1

• 23 year old recurrent bouts of ulcerative colitis

• X6 courses of steroids/ 2 years + x3 Hospitalisations

• Weight gain/diabetes/bruised skin

• Social isolation

• Fear about loosing employment

• X 2 Hospital OPD DNA’s

• Moved to ESH area- picked up by IBD service

New Colitics: 90 year olds

• Mr JD 91ys x3 hospitalisations with a steroid dependent flares of UC

• Mr J: 89 severe diarrhoea- severe UC diagnosed

Patient Management System Patient Knows Best (PKB)

APatient knows best and iPhone apps

Patient knows best Automatic upload of data

Scales (£70),

thermometer (£11),

blood pressure (£47-110)

and glucose meter (£25-

£60)

• Personalised web site

• Secure and safe

• Instant symptomatic assessment

• Instant management advice is possible

• Direct alert system to the IBD Team

• Library of advice leaflets

• Direct portal of access to the hospital specialists

• Access - worldwide

• Integration with hospital results system

• iPhone and Android apps

• Patients are transferred to remote community care, with specialist overview - NOT discharged

Initiatives for success

Patient Benefits

Improve • Patient satisfaction

• Disease monitoring and instant notification

• Empower patients

• Confidence and knowledge to self manage

• Access to specialist advice

Reduce • Negative impact on

work and normal activity

• Flare ups • Opportunistic infection

rate • IBD complications rate • Demand on outpatients • Hospital attendance

and admission

Clinical and service benefits

Improve • Patient satisfaction

surveys • Quality standards • Overview of community

management • Access to specialist

advice • Auditing and research • Develop a competitive

IBD Service

Reduce • Demand on and waiting

times for outpatient appointments and endoscopy

• Reduce workload by automating testing

• Reduce workload of immunity and vaccination screening

• Overall morbidity and mortality

CCG and financial benefits

Improve

• GP vaccination

targets

• Specialist Led support

Reduce

• Outpatient clinic visits

• Unnecessary colonoscopies

• Unnecessary X-ray procedures

• GP clinic visits

• Hospital admissions

• Surgical interventions

Usual practice

GP Appropriate advice Or treatment

Steroids

PATIENT

Referral to GI Service

Hospitalisation and complications

IBD Service

Transformation

PATIENT

IBD service Email

Telephone Patient management Service

Early appropriate intervention

GP’s Practice Nurses

Health Care workers

Better outcomes ↓ hospitalisations ↓ Less Surgeries

Hospitalisation

Improvements

• Patient support structures: Email, telephone, patient management software

• Improved and increased use of immunosuppressive combating severe disease

• Multidisciplinary service with good communication between clinicians

• Shared care, rapid referral pathways

• Patient Pathways

IBD Service: Examples of improvements

Increased patient centred support: early detection

• 3500-4,000 non face to face contacts: Patients satisfied

• Reduced Costly Hospitalisations: UK wide Ulcerative colitis Audit: 2720 bed days saved

• Reduced need for high cost drugs: £ 3 million/yr

• Clinicians feel safer starting potentially toxic therapies

• Patients perceive this confidence

Aza use and admission

Admissions ulcerative Colitis

Telephone and Email

0

500

1000

1500

2000

2500

3000

3500

4000

4500

2010 2011 2012 2013 2014 2015

Telephone and Email workflow

0

500

1000

1500

2000

2500

Monitoring Advice Flare Prescriptions Appoitments Medications Other

Nu

mb

ero

f ap

tein

ts

Conclusion

• Benefits: patient and economic • Stresses all conventional NHS structures • Resourcing: Falls outside usual mechanisms • Service redesign achieved for IBD: transferable to

other specialities • SASH experience: Great interest to

commissioners and clinicians nationally • Academic opportunities • Resource gap needs to be bridged if service is to

continue


Date: 28 January 2016 Agenda Item: 2.2

REPORT TITLE: Chief Nurse & Medical Director Report

EXECUTIVE SPONSOR: Fiona Allsop, Chief Nurse Des Holden, Medical Director

REPORT AUTHOR (s): Fiona Allsop, Chief Nurse Des Holden, Medical Director


N/A

Action Required:

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

Purpose of Report:

To provide an update on continuing work in relation to safe and quality focussed patient care that sits outside the operational performance reports including monthly Safer Staffing information and exception reports.


The Safer Staffing report (December 2015 data) indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template.

The current progress on nursing recruitment is outlined.

An update is provided on nurse revalidation and on the ward accreditation CQUIN

We have successfully recruited a consultant to take on clinical lead for radiology and for health informatics

We will establish a novel way of working with patients and industry so that the benefits from drugs which matter most to patients are understood by the pharmaceutical industry having received the go ahead from NHS England

Recommendation:

To note the report.




Legal and regulatory impact Yes



Financial impact Yes

Patient Experience/Engagement Yes

Risk & Performance Management Yes


Yes

Attachment:



Chief Nurse/ Medical Director Report – 28 January 2016 Chief Nurse Report 1. Introduction To provide an update to the Board on nursing staffing in relation to planned versus actual staffing, an update regarding safer staffing monitoring, and a summary of the recent correspondence in relation to staffing and efficiency and on recruitment activity. 2. Staffing Planned versus Actual – December 2016

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

Abinger Ward 430 - GERIATRIC MEDICINE 31 91.59% 100% 95.74% 100% 93.77% 100% 95.99%

Acute Medical Unit 300 - GENERAL MEDICINE 31 95% 98.62% 87.87% 93.55% 92.91% 96.77% 94.63%

Birthing Centre 501 - OBSTETRICS 31 95.58% 79.03% N/A N/A 95.58% 79.03% 87.31%

Bletchingley Ward 300 - GENERAL MEDICINE 31 97.11% 96.77% 94.87% 93.75% 96.03% 95.54% 95.84%

Brockham Ward 502 - GYNAECOLOGY 31 93.89% 97.8% 97.83% 103.03% 95.19% 99.19% 96.79%

Brook Ward 100 - GENERAL SURGERY 31 100% 98.36% 96.87% N/A 98.94% 98.36% 98.71%

Buckland Ward 101 - UROLOGY 31 94.1% 98.39% 90.67% 95.16% 92.87% 96.77% 94.32%

Burstow Ward 501 - OBSTETRICS 31 98.11% 77.17% 86.89% 90.32% 94.37% 82.47% 88.98%

Capel Annex l Ward 100 - GENERAL MEDICINE 31 100% 100% 97.85% 100% 99.08% 100% 99.41%

Capel Ward 430 - GERIATRIC MEDICINE 31 93.53% 100% 90.91% 100% 92.53% 100% 95.76%

Chaldon Ward 300 - GENERAL MEDICINE 31 94.52% 100% 98.91% 100% 96.37% 100% 97.63%

Charlwood Ward 301 - GASTROENTEROLOGY 31 91.05% 100% 110.36% 100% 98.5% 100% 99.07%

Copthorne Ward 301 - GASTROENTEROLOGY 31 96.49% 96.77% 101.62% 101.61% 98.2% 99.19% 98.6%

Coronary Care Unit 320 - CARDIOLOGY 31 93.57% 98.41% N/A 100% 95.71% 98.95% 97.34%

Delivery Suite 501 - OBSTETRICS 31 93.34% 94.62% 89.76% 96.77% 92.44% 95.16% 93.8%

Discharge Lounge 300 - GENERAL MEDICINE 31 98.25% 100% 94.48% 100% 96.41% 100% 97.61%

Godstone Ward (Haem) 303 - CLINICAL HAEMATOLOGY 31 96.77% 100% N/A N/A 96.77% 100% 98.39%

Godstone Ward (Med) 300 - GENERAL MEDICINE 31 94.17% 100% 97.85% 97.85% 95.55% 98.92% 96.99%

Hazelwood 300 - GENERAL MEDICINE 31 95.93% 98.36% 97.34% 100% 96.62% 99.18% 97.65%

Holmwood Ward 320 - CARDIOLOGY 31 91.71% 100% 100% 100% 93.95% 100% 96.08%

ITU/HDU 192 - CRITICAL CARE MEDICINE 31 98.59% 97.3% 86.16% 113.33% 96.81% 98.5% 97.62%

Leigh Ward 110 - TRAUMA & ORTHOPAEDICS 31 94.75% 100% 98.75% 96.77% 96.47% 98.36% 97.1%

Meadvale Ward 430 - GERIATRIC MEDICINE 31 88.61% 100% 97.83% 100% 93.41% 100% 95.63%

Neonatal Unit 420 - PAEDIATRICS 31 97.45% 100% 96.77% 100% 97.26% 100% 98.53%

Newdigate Ward 110 - TRAUMA & ORTHOPAEDICS 31 92.63% 95.16% 112% 101.56% 100.65% 98.41% 99.89%

https://bi01/information/ddc-monthview-ward.php?period=2015-12&ward=O000000096



























Nutfield Ward 430 - GERIATRIC MEDICINE 31 96.09% 98.39% 101.6% 100% 98.03% 99.19% 98.43%

Outwood Ward 420 - PAEDIATRICS 31 91.28% 100.54% 88.96% 74.19% 91% 96.76% 93.41%

Rusper Ward 501 - OBSTETRICS 31 99.19% 100% 100% N/A 99.21% 100% 99.47%

Surgical Assessment Unit 100 - GENERAL SURGERY 31 95.16% 96.77% 96.77% 100% 95.48% 98.39% 96.77%

Tandridge Ward 300 - GENERAL SURGERY 31 92.17% 96.77% 94.2% 96.77% 93.08% 96.77% 94.26%

Tilgate Annex 100 - GENERAL MEDICINE 31 94.16% 96.92% 95.71% 100% 94.74% 98.43% 95.99%

Tilgate Ward 300 - GENERAL MEDICINE 31 108.46% 119.23% 113.04% 119.23% 110.19% 119.23% 113.2%

Woodland Ward 100 - GENERAL SURGERY 31 91.28% 100% 94.31% 91.67% 92.43% 95.9% 93.58%

Total

95.15% 97.89% 97.11% 98.27% 95.81% 98.03% 96.69%

Commentary The Trust has delivered planned versus actual staffing profile for December. The variance in the Birthing Centre and Burstow ward was due to staffing shortfalls related to short notice sickness and active management by the matrons ensured no adverse outcomes in re lat ion to c l in ica l care. The materni ty service is now fu l ly recru i ted. .

Nursing Recruitment National and international nursing recruitment continues. The Filipino recruitment is continuing and the first cohort of staff of 10 staff have commenced in the Trust. In addition 6 trained nurses have also commenced from the EU bringing the total number of international nurses to commence in the organisation to approximately 60 since July 2015. Agency cap Weekly reporting is now established and demonstrates a reduction in overall nursing agency usage against the cap parameters. An exception has now been received for two non-framework providers until 31 March 2016. Nurse Revalidation Revalidation for registered nurses commences in April 2016. The Trust has identified that there are approximately 90 staff members due to revalidate in the first quarter of 2016/17. All of these nurses have been contacted with key information and advice on the actions that need to be undertaken. A dedicated revalidation page has been set up on the intranet with links to the relevant documentation on the NMC website and drop in clinics have been arranged for the 27th January and the 24th February. In addition, ward based training has been made available and a stand outside of the Three Arches restaurant will be held on February. Ward Accreditation Over recent months, the Trust has been developing a multi-disciplinary ward accreditation tool. The purpose of the tool is to develop a single method of measuring how each ward is performing against the CQC standards, for wards to analyse and learn from the outcomes of these measures and then for support to be provided to those areas that need it. Equally, its aim is to celebrate success by developing a system for recognising high performing wards which have the standard of an accredited ward. A pilot and three workshops have been held to date, with a work stream now in place to develop the electronic data entry system. Going forward, a long term aim and use of the tool will be for wards to demonstrate how they have incorporated the SASH+ principles into clinical











practice by demonstrating that quality improvements have been made through the implementation of the SASH+ methodology. Ward Accreditation is a local CQUIN for 2015/16 and the Trust is currently on track with the requirements of the quality improvement measure. Medical Director Report 3. Clinical Lead for Radiology and Clinical Chief of Informatics. We have recruited Dr Tony Newman – Sanders to lead radiology (taking over from Dr Riaz Ahmed) and provide clinical leadership for the health informatics processes formerly led by Dr Ben Upton. Tony is an established consultant currently working at Croydon University hospitals. He has a lot of experience with Cerner and is also the medical director of the Health Innovation Network (The South London Academic Health Science Network) a role he will continue. 4. What medication outcomes mater to patients? Unlike in the USA where pharmaceutical companies can market direct to patients, it has become clear that industry has difficulty finding out what therapeutic outcomes matter to patients from the drugs they make available to clinicians. We have received permission (and encouragement) from Sir Bruce Keogh, medical director of NHS England, to explore how we as a hospital can work with the pharmaceutical industry to promote a dialogue between us, them and patients so that industry contribute in a more focussed and precise way on meeting the therapeutic needs of patients. Sir Bruce’s challenge to us is to make it happen in a way that benefits the wider NHS. 5. Recommendation To note the report Fiona Allsop Des Holden Chief Nurse Medical Director 25th January 2016

An Associated University Hospital ofBrighton and Sussex Medical School

1

Integrated Performance Report

M09 – December 2015

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



22

Patient Safety

• There were seven SIs declared in December 2015 and no Never Events.

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

• The Trust had no MRSA bloodstream infections and six Trust acquired C-Diff cases in December 2015.

Clinical Effectiveness

• The Clinical Effectiveness Committee continues to monitor the latest HSMR data for the Trust and mortality is lower than expected

for our patient group when benchmarked against national comparators.

• Maternity indicators continue to show expected performance.

Access and Responsiveness

• The 4hr ED standard was achieved with performance of 95.5% in December 2015.

• The Two Week and 62 Day Cancer standards were achieved in December 2015.

• The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end of each month.

Patient Experience

• In December 2015 the Inpatient FFT remained at 95.1%. The ED FFT decreased to 97.5%

Workforce

• The Trust is actively reviewing initiatives to improve recruitment and retention, such as reducing time to recruit and ongoing local

and overseas recruitment.

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

place and is reviewing recent Department of Health proposals for the management of temporary staffing spend, particularly fornursing.

Performance – December 2015


33

Action: The Board are asked to note and accept this report

Legal:All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance on safe high quality

care (Including mortality).

Regulation:The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore license

care services under the Health and Social Care Act 2009 and associated regulations.

Patient experience/ engagement:

This paper includes significant detail on both patient experience and access to services.

Risk & performance management

This is the main Board assurance report for performance against quality and financial measures and is linked to risk management

through the SRR.

NHS constitution; equality & diversity; communication.

This report covers performance against access standards with the NHS Constitution.

Finance

• At the end of Month 9 the Trust has a YTD I&E deficit (after donated asset technical adjustments) of £(5.3)m which is £(4.0)m adverse to the revised TDA plan.

Key Risks

• The Significant Risk Register for the Trust includes six quality risks in relation to “Right bed first time”, ED Access standards,

Outbreak of viral gastroenteritis, Increasing sickness absence levels and RTT Access Standards.

Performance – December 2015


4

Patient Safety

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

• There were no Never Events reported in December 2015.

• VTE risk assessment performance for December 2015 is undergoing validation following changes in system usage within the Surgical

Division. Performance of 95% is expected.

Patient Safety

Indicator Description Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Trend

No of Never Events in month 0 0 0 1 1 0 0 0 0 0 0 0 0

No of medication errors causing Severe Harm or Death 0 0 0 0 0 0 0 0 0 0 0 0 0

Safety Thermometer - % of patients with harm free care (all harm) 93.0% 93.0% 92.0% 92.0% 91.3% 93.5% 92.0% 95.0% 92.2% 93.2% 95.4% 90.3% 92.6%

Safety Thermometer - % of patients with harm free care (new harm) 97.0% 96.0% 95.0% 96.0% 95.9% 97.3% 95.2% 97.7% 94.8% 96.7% 97.6% 95.0% 96.2%

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

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

Number of Sis 2 5 6 5 3 3 6 1 1 4 6 2 7

Serious Incidents - No per 1000 Bed Days 0.11 0.26 0.35 0.26 0.16 0.16 0.33 0.05 0.05 0.23 0.32 0.11 0.38

Percentage of Patient Safety Incidents causing Severe harm or Death 0.2% 0.6% 0.7% 0.6% 0.2% 0.6% 0.5% 0.0% 0.2% 0.8% 0.6% 0.4% 0.8%

Number of overdue CAS and NPSA alerts 0 1 1 0 0 0 0 0 0 0 0 0 0


5

Seven SIs were declared in December 2015 (in all cases full investigations have been started):

• 2015/37455 Fall. The patient, a 78 year old male, was admitted to ED following a fall at home on 27th August 2015 which resulted in a subdural haematoma. The patient was transferred to Copthorne ward where he was to be treated conservatively and was given a

catheter due to urine retention. In the early hours of 28th August the patient fell over his catheter and a CT head scan showed that the subdural haematoma had increased. The patient died on 5th September 2015.

• 2015/37463 Sub-optimal care of deteriorating patient. The patient, a 78 year old male, was admitted to CDU from ED following a fall downstairs on 13th June 2015. Although his imaging was clear he was having difficulty mobilising due to leg and knee pain. He was

known to have bowel cancer with metastasis. He was referred to the physicians for further assessment and admitted to SAU on 14thJune. The clinical documentation states that although he was slightly hypotensive he was considered to be well, with no evidence of

shock or tachycardia. At approximately 01:00 on 15th June the patient suffered a sudden deterioration and died the following morning.

• 2015/37802 Fall. The patient stood up from her chair and fell forward, landing on the floor on her left side. Imaging confirmed fractured

neck of femur.

• 2015/38654 Fall. Patient had an unwitnessed fall. No immediate action was taken at the time except for neuro observations which

showed a GCS of 15/15. The patient reported to staff that she had not hit her head so the fall was not escalated to the doctors or the site team. The following day the patient's condition deteriorated and a CT scan showed a subdural haematoma and widespread

malignancy. GCS deteriorated to 5/15, advice was obtained from St Georges. The patient has since died.

• 2015/38769 Fall. Patient had an unwitnessed fall which resulted in a fractured neck of femur.

• 2015/38771 Fall. Patient stood up from the bed and fell resulting in a fractured neck of femur.

• 2015/37473 Sub-optimal care of deteriorating patient. The patient was admitted on 25th January 2014 with abdominal pain and

urine retention. His past medical history of renal colic was noted and bloods taken. The blood results were abnormal, high creatinine

and CRP were noted but no further action was taken until the patient arrested on the evening of 26th January 2014. The patient was transferred to ICU but died on 27th January, the post mortem result stated the cause of death as complications of sepsis.

Patient Safety


6

Infection Control

• There were no cases of MRSA in December 2015 and six cases of Trust acquired C.diff.

• In light of the risk of outbreaks of viral gastroenteritis, the following risk is on the Trust's significant risk register:

• Risk of outbreak of viral gastroenteritis - Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on

patient safety and experience – Risk score 15 (Likelihood of 5 and consequence of 3).

Patient Safety


MRSA BSI (incidences in month) 0 0 1 0 0 0 0 0 0 0 0 1 0

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

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

E-Coli 16 14 18 12 11 23 20 18 34 27 29 18 23


7

Mortality and Readmissions

• Latest HSMR data for the Trust shows mortality remains lower than expected for our patient group when benchmarked against national

comparators.

Maternity

• Maternity indicators continue to show expected performance.

Clinical Effectiveness


C Section Rate - Emergency 17% 18% 16% 17% 13% 17% 18% 14% 17% 17% 14% 15% 16%

C Section Rate - Elective 11% 7% 11% 8% 11% 9% 10% 11% 13% 8% 13% 10% 9%

Admissions of ful l term babies to neo-natal care 6.3% 6.0% 6.0% 6.0% 7.0% 6.2% 4.0% 5.0% 5.1% 5.8% 7.1% 6.6% 5.9%


HSMR (56 Monitored diagnoses - 12 Months) 93.3 92.8 92.6 93.4 93.0 95.0 95.0 93.5 94.0 95.2

Emergency readmissions within 30 days (PBR Rules) 7.1% 6.9% 6.7% 6.6% 6.4% 7.0% 7.2% 7.7% 7.4% 7.3% 6.3% 6.3%


8

Emergency Department

• Despite continuation of pressure on the emergency department with high levels of emergency admissions, the ED 4hr standard was

achieved in December 2015 with performance of 95.5%

• Over the third quarter of the year, overnight non-elective admissions are up 7% (3% for East Surrey CCG and 16% for Crawley CCG)

compared to last year.

• Ambulance turnaround performance showed improvement in December and had the lowest number of delays over one hour since the

previous December. The recent work on processes has been reviewed positively by CCGs and SECAmb have commended the Trust’sresilience over the recent period.

• In light of the on-going operational pressures in the Trust, the following risks are on the significant risk register:

• ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system –

Risk score 16 (Likelihood of 4 and consequence of 4)

• Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed first

time, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5and consequence of 3)



ED 95% in 4 hours 93.3% 92.0% 91.3% 95.0% 96.8% 96.0% 94.8% 94.3% 96.1% 97.1% 95.5% 92.9% 95.5%

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

Ambulance Turnaround - Number Over 30 mins 344 163 259 247 199 170 206 238 220 225 225 231 191

Ambulance Turnaround - Number Over 60 mins 10 26 51 31 19 34 38 32 30 29 31 30 10


9

Cancer

• In December 2015, all Cancer Access Standard except the 31 Day Diagnosis to Treatment standard were achieved.

• On the 31 Day Diagnosis to Treatment pathway, 8 patients breached the standard as a result of capacity issues for Dermatology minor

operations. Action has been taken to address this issue.



Cancer - TWR 93.1% 93.1% 93.1% 93.1% 93.3% 94.2% 93.1% 93.1% 93.0% 89.6% 89.9% 93.2% 94.3%

Cancer - TWR Breast Symptomatic 93.5% 93.4% 96.3% 93.8% 93.8% 93.8% 90.6% 93.2% 93.3% 94.2% 93.8% 93.4% 96.2%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer - 31 Day Second or Subsequent Treatment (DRUG) 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Cancer - 31 Day Diagnosis to Treatment 98.4% 97.1% 100.0% 100.0% 98.2% 97.0% 96.2% 98.3% 99.2% 99.3% 98.2% 96.6% 92.4%

Cancer - 62 Day Referral to Treatment Standard 86.1% 85.4% 88.0% 83.7% 86.4% 83.9% 86.5% 80.7% 84.2% 86.2% 85.6% 88.3% 85.8%

Cancer - 62 Day Referral to Treatment Screening 100.0% 92.3% 100.0% 92.3% 84.6% 92.3% 100.0% 87.5% 88.9% 100.0% 87.5% 90.9% 100.0%


10

Referral to Treatment (RTT) and Diagnostics

• At aggregate level, the trust continues to deliver against the incomplete pathways standard which measures % of patients waiting lessthan 18 weeks at the end of each month.

• Challenges remain in General Surgery, Trauma and Orthopaedics and Cardiology. A number of newly recruited consultants will

increase capacity and support reduction in patients over 18 weeks.

• The diagnostic standard continues to be achieved and capacity across all areas is subject to review in order to plan for expected growth

over the coming 18 months as a result of the National Cancer Strategy.

• 54 patients were cancelled at the “last minute” for non clinical reasons.

• The following risk is on the significant risk register:

• RTT Access Standards - Due to on-going operational pressures and increasing demand for elective services, the Trust cannotoffer all services within the 18 weeks standards set out in the NHS Constitution. Longer waiting times result in poor patient

experience and increase the number of formal and informal complaints. (effectiveness, experience and safety) – Risk score 15(Likelihood of 5 and consequence of 3)



RTT Incomplete Pathways - % waithing less than 18 weeks 92.2% 92.1% 94.0% 93.7% 93.6% 93.5% 92.6% 92.2% 92.0% 92.1% 92.2% 92.5% 92.1%

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

RTT Admitted - 90% treated within 18 weeks 91.1% 90.2% 82.1% 88.4% 91.6% 90.1% 92.0% 84.0% 81.5% 77.9% 78.5% 80.7% 81.1%

RTT Non Admitted - 95% treated within 18 weeks 95.0% 91.7% 91.0% 93.5% 93.6% 95.3% 93.4% 89.4% 89.1% 88.7% 87.9% 85.2% 85.4%

Percentage of patients waiting 6 weeks or more for diagnostic 0.1% 0.9% 0.7% 1.4% 1.0% 0.2% 0.8% 1.0% 0.1% 0.5% 0.2% 0.2% 0.1%

Last Minute Elective Cancellations for non clinical reasons 50 18 26 45 11 37 45 24 25 44 41 133 54

% of operations cancelled on the day not treated within 28 days 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 2.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%


11

Patient Voice

• Inpatients – The December Friends and Family Test (FFT) score for inpatient wards remains stable at 95.1%, based on a 30%

response rate. The response rate dropped from the 40% that has been achieved over the last four months.

• Emergency Department – The December FFT score has increased slightly to 97.5%, based on a response rate of 19%, a very slight

drop from 20% in November.

• Maternity – FFT scores for both the antenatal the postnatal delivery touchpoints have remained stable at 96.0% and 88.9%

respectively. There has been a drop in the FFT score for delivery (91.7% compared to 97.6% in November). The response rate for

touchpoints two and three remain at 22%, the response rate for touchpoint one has dropped to 13% (down from 17% in November). Following an improvement in the response rate for touchpoint four in November, it has dropped back to 1% in December.

National comparisons for November

• Inpatients/daycases – The Trust was ranked below average (94.9% against a national average of 95.4%). The combined response

rate was also just below average (23% compared to 24%).

• Emergency Department – the department was ranked 3rd best in the country, based on an above average response rate

Patient Experience


Inpatient FFT - % positive responses 95.0% 95.7% 96.9% 94.2% 94.4% 95.1% 94.7% 95.1% 95.3% 96.1% 95.0% 95.1% 95.1%

Emergency Department FFT - % positive responses 93.0% 95.8% 97.1% 94.7% 95.4% 95.3% 93.7% 91.4% 95.8% 96.9% 95.3% 97.3% 97.5%

Maternity FFT - Antenatal - % positive responses 90.0% 97.6% 97.1% 97.0% 96.3% 100.0% 83.3% 94.1% 98.8% 94.3% 96.5% 96.1% 96.0%

Maternity FFT - Delivery - % positive responses 100.0% 95.5% 97.2% 100.0% 94.7% 97.0% 94.9% 93.8% 87.9% 95.4% 95.1% 97.6% 91.7%

Maternity FFT - Postnatal Ward - % positive responses 96.0% 85.9% 91.0% 97.3% 86.7% 91.0% 86.5% 90.0% 87.7% 87.9% 88.9% 88.8% 88.9%

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

Complaints (rate per 10,000 occupied bed days) 20 18 26 22 25 22 27 29 33 27 24 19 17


12

Workforce

• Compliance rate with the new Achievement Review (Appraisal) process is starting to improve as the organisation moves along its three

year implementation plan.

• Sickness absence reduced to 3.8% in December 2015, 0.7% less than the prior year..

• The increasing trend on sickness absence levels which impacts on day to day management and expenditure remains on the Trust’s

significant risk register – Risk score 15 (Likelihood of 5 and consequence of 3)

• Streamlined nursing recruitment with a new recruitment tracker with ward dashboard to highlight blockages is now in place and is

discussed on a weekly basis. Activity around international recruitment continues. New staff are in post but do not all have their PINs

which means there are short term double running costs.

• Staff Turnover fell for the second month in a row to 13.8% in December 2015 as initiatives to improve retention and staff experience

take effect.

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

Workforce


Average fi ll rate – registered nurses/midwives (%) - Day 95.1% 94.8% 95.9% 96.5% 96.8% 95.7% 96.9% 93.3% 92.5% 95.0% 95.1% 95.4% 95.1%

Average fi ll rate – care staff (%) - Day 93.1% 92.6% 93.8% 94.5% 96.1% 93.8% 93.5% 94.3% 94.5% 95.1% 97.2% 98.7% 97.1%

Average fi ll rate – registered nurses/midwives (%) - Night 97.3% 97.2% 97.7% 96.7% 96.5% 97.1% 94.1% 95.2% 94.3% 96.4% 96.9% 97.2% 97.9%

Average fi ll rate – care staff (%) - Night 93.7% 93.3% 94.9% 94.9% 95.2% 95.9% 94.9% 94.4% 93.8% 96.4% 96.9% 97.8% 98.2%

Overall Sickness Rate 4.5% 4.3% 4.4% 4.2% 4.2% 4.3% 4.1% 3.9% 3.7% 4.4% 4.4% 4.0% 3.8%

%age of staff who have had appraisal in last 12 months 72% 67% 68% 73% 71% 68% 58% 56% 57% 64% 72% 74% 74%

Staff Turnover rate 15.6% 15.7% 15.7% 15.2% 15.5% 15.9% 15.6% 15.6% 15.2% 15.2% 15.0% 14.4% 13.8%


13

Finance

• The Trust is reporting against the revised plan submitted to the TDA in September 2015.

• At the end of Month 9 the Trust has a YTD I&E deficit (after donated asset technical adjustments) of £(5.3)m which is £(4.0)m adverseto the revised TDA plan.

• Month 9 includes a £0.4m income accrual in respect of anticipated reimbursement from the TDA in respect of lost income resultingfrom the Junior Doctors industrial action in December.

• The underlying position at the end of December is a £(5.9)m deficit, reflecting the non recurrent use of the Trust’s balance sheet

provisions. The Trust forecast is now a £(3.0)m deficit (after donated asset technical adjustments). This position includes £3.0m non-recurrent income from the TDA.

• The Trust has achieved £3.2m of savings to date (a £2.1m shortfall measured against the TDA plan). The forecast CIP position is£3.5m adverse to the full year plan and this has been factored into the overall Trust forecast.


Outturn £m Surplus / (Deficit) - Plan 2.3 2.3 2.3 2.3 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6

Outturn £m Surplus / (Deficit) - Forecast 2.3 2.3 (2.5) (2.4) 1.6 1.6 1.6 1.6 1.6 1.6 1.6 1.6 (3.0)

YTD £m Surplus / (Deficit) - Plan 1.0 1.9 1.4 2.3 (0.8) (1.2) (2.0) (1.1) (0.7) (0.6) (2.0) (2.0) (1.3)

YTD £m Surplus / (Deficit) - Actual 1.0 1.9 (2.9) (2.4) (0.8) (1.1) (2.0) (1.3) (2.6) (3.3) (3.6) (4.2) (5.3)

Outturn UNDERLYING £m Surplus / (Deficit) - Plan 3.4 3.4 3.4 3.4 3.8 3.8 3.8 3.8 3.8 3.8 3.8 3.8 3.8

Outturn UNDERLYING £m Surplus / (Deficit) - Actual (5.2) (5.2) (5.2) (5.2) 3.8 3.3 3.3 3.3 3.3 3.3 3.3 3.3 (6.3)

YTD Savings £m - Actual 7.4 8.6 9.8 11.0 0.3 0.5 0.8 1.3 1.9 2.1 2.5 2.8 3.2

OT Risk £m Surplus / (Deficit) - Assessment (6.3) (5.5) (0.7) 0.0 0.0 (1.0) 0.0 0.0 0.0 0.0 0.0 0.0 0.0

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

YTD Cash position £m Fav / (Adv) - Actual 4.8 3.8 3.8 2.6 3.2 2.9 2.6 2.5 3.0 3.9 4.8 5.0 5.7

YTD Liquid ratio - days (8.0) (8.0) (18.0) (21.0) (20.0) (21.0) (23.0) (22.0) (25.0) (19.0) (13.0) (16.0) (16.0)

YTD BPPC (overal l) volume £m 88% 87% 86% 82% 62% 75% 78% 78% 76% 69% 59% 60% 60%

YTD BPPC (overal l) value £m 84% 83% 83% 81% 65% 73% 75% 75% 74% 68% 61% 63% 63%

Outturn Capital spend Fav / (Adv) - forecast 19.3 19.3 19.3 19.3 17.1 17.1 17.1 17.1 17.1 17.1 17.1 17.1 14.1


14

Finance

• The Trust’s cash balance at the end of December was £5.7m, with a forecast year end cash balance of £2.5m. Backlog creditors

increased by a further £2.2m in month.

• The capital spend forecast this year has reduced by £3.0m, from £17.1m to £14.1m following an application to TDA for Capital to

Revenue transfer which has been provisionally approved.



REPORT TITLE: Finance & Workforce Committee Chair Update – Part 1

EXECUTIVE SPONSOR: Paul Simpson (Chief Financial Officer)

REPORT AUTHOR (s): Richard Durban (Non-Executive Director and FWC Chair)


No – Board Update

Action Required:

Approval ( ) Discussion ( ) Assurance (√)

Purpose of Report:

To update the Board on the discussions and actions from the Finance and Workforce Committee.


The Finance and Workforce Committee met on the 25th

January 2016 and was quorate.

• The UKPN Addendum was approved.

• M09 reports were received for Finance & the 15/16 CIP, Workforce and Organisational

Development, Capital and IT.

• The Trust has year to date I&E deficit of £(5.3m) which is £(4.0m) adverse to the revised

TDA plan.

• The Trust’s cash balance at the end of December was £5.7m, with a forecast year end

cash balance of £2.5m

• The Trust has delivered £3.2m of savings and is behind both the TDA plan and also the

internal plan

Recommendation:


SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model


Legal and regulatory impact

The FWC reviews assurance in respect of workforce, capital

and investment projects, business planning (which includes

financial planning) and cash aspects. Employment law: laws

governing the rights of individuals and terms and conditions

2An Associated University Hospital of


terms include: National Minimum Wage Act 1998; the

Working Time Regulations 1998; Employment Rights Act

1996; Equality Act 2010; Employment Rights Act 1996, and;

the Transfer of Undertakings (Protection of Employment)

Regulations 2006. Other key laws affecting employees

include the Pensions Act 2004 and the Trade Union and

Labour Relations (Consolidation) Act 1992.

Financial performance is subject to Schedule 5 of the NHS

Act 2006 which provides the “breakeven duty”. Legal aspects

related to capital works will depend on the nature of the

works.

The main regulators, are as follows:

- External audit (the Grant Thornton for this Trust)

gives an opinion on the Trust’s compliance with

International Financial Reporting Standards and with

NHS accounting conventions – this is not purely

financial and deals with procurement, fraud,

transparency and legal duties. It also gives a Value

for Money Conclusion on the Trust’s ability to put in

place arrangements to deliver economy, efficiency

and effectiveness in its use of resources.

The Care Quality Commission registers the Trust according to

its compliance with regulations concerning the safety and

quality of services

Financial impact The report provides assurance about savings, capital spend

and the structure of the business planning process.

Patient Experience/Engagement Indirect impact through Trust planning and workforce.

Risk & Performance Management The committee, and this report, provides assurance about

workforce and capital management.


Attachment:

Report Paper



TRUST BOARD REPORT – 28 January 2016

Finance & Workforce Committee Chair Update

The Finance and Workforce Committee met on 25th

January 2016 and it was quorate. The key

points from Part 1 were as follows:

- An update was received on the current legal and financial situation between the Trust and UK

Power Networks (UKPN) and following negotiations the extra claim has been reduced to £61K

plus VAT. Assurance was received that no further costs should now arise. The Committee

approved the addendum on a “full and final” basis.

- The Communication Plan was welcomed by the Committee. The plan provides a set of actions

for 16/17 across all platforms. The Committee noted the progress made to date. It asked for an

update on outcomes and a view on achievement against the strategic objectives at an

appropriate time.

Month 9 CIP report

- The savings target YTD in the submitted TDA plan for 2015/16 is £5.3m and at month 9 the Trust

has delivered £3.2m of savings and is behind both the TDA plan and also the internal plan.

Contingency savings of £0.6m have been used to achieve this position. The Committee noted

that achieving the year end forecast of £4.8m would require delivery of £1.6m in Q4 against a

quarterly average of £1.1m.

Draft 16/17 Revenue Budget

The draft budget shows a deficit of £(4.1m). This position is predicated on achieving the 15/16

forecast of £(6.0m) set off by the capital to revenue transfer of £3m ie a net position of a deficit

of £(3.0m) . There are four main actions required to firm up the budget:

- Complete a demand & capacity plan for emergency activity

- Surgical Division to provide a capacity plan for elective activity describing cost and income

- Complete a demand and capacity plan for outpatients

- Directors to complete actions on the CIP

The Committee noted that the CIP is set at £9.2m v a forecast outturn of £4.8m for 15/16

although it recognised the contingency in the budget of £3.5m of which £1.5m is specific to

nurse costs. The Committee asked that a percentage of the saving be applied depending on

which gateway had been achieved; that the CIP is phased to show the rate required by quarter

and that a total in excess of £9.2m be scoped to allow for underachievement; the Carter analysis

may be helpful.

- The Month 9 Workforce and Organisational Development paper was presented. The

Committee noted plans against each of the 6 strategic objectives would be refreshed, that a

new set of KPIs would be in place for the new financial year, that work to deliver the

Achievement review target would continue and that the definition and approach to delivering

mandatory training was being reviewed.



- The Month 9 Capital report was presented. The Committee noted the openings of the IRU and

the Macmillan Information Centre.

- The IT report was noted and the Committee extended their congratulations to the IT team in

the successful upgrade to the new Cerner version.

[END]



REPORT TITLE: Audit & Assurance Committee Chair Update

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

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

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) Audit & Assurance Committee – 15/01/16

Action Required:

Approval (√) Discussion () Assurance (√)

Purpose of Report: This report provides the Board with an executive summary of the January Audit and Assurance Committee. Summary of key issues • Review of BAF and linkages to SRR focussing on financial risk management and

assurance. • Tender results for Internal Audit and Counter Fraud provision. • Internal audit findings;

i. Significant improvement in NICE compliance monitoring ii. Cash flow forecasting (Green) iii. Backlog maintenance (Green Amber)

• Focussed review of Internal Audit findings into CIP systems and delivery

Recommendation:

To note the report.



Legal and regulatory impact

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

2 An Associated University Hospital of Brighton and Sussex Medical School

The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all regulation applied to an NHS Trust. The main regulators, however are as follows: - External audit (the Audit Commission for this Trust) give an opinion on the Trust’s compliance with International Financial Reporting Standards and with NHS accounting conventions – this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trust’s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources. The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services.

Financial impact Committee review of Trust financial position

Patient Experience/Engagement No relevant aspects

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

NHS Constitution/Equality & Diversity/Communication No relevant aspects

Attachment: N/A


TRUST BOARD REPORT – 28/01/2016 Audit & Assurance Committee Chair Update The Audit and Assurance committee met on the 15/01/2016; it was quorate. 1) Board Assurance Framework & SRR The Committee discussed the board assurance framework prior to the January public board. It focussed on the long-term strategic and operational risks relating to the management of patient flow through the ED and into the hospital. The committee noted the transition to business continuity and the effect this had had on local health economy. The Chief Finance officer indicated that the strategic risk relating to divisional overspend would reduce as the Divisions are on track to meet the forecast. The committee were assured that plans to apply for a £9.6 million working capital loan would stabilise the liquidity risk. 2) Standards of Business Conduct Policy review The Director of Corporate Affairs presented the review, highlighting that the policy had been amended to further strengthen controls relating to declarations of interest and referral to commercial representatives. Our Counter Fraud service agreed to review the revised policy and once this had been completed the policy was approved and would be presented to the Board for ratification in February

3) Internal Audit and Counter Fraud Management confirmed that RSM had successfully been appointed following tendering to provide internal audit and counter fraud services. This is welcomed as there are potential benefits for the Trust from a direct linkage between audit and counter fraud expertise. Internal Audit presented their update report, which detailed improvements in internal controls to support oversight of NICE compliance this represents, a significant improvement since the last audit. The Committee discussed the CIP audit which highlighted good processes but significant under achievement of delivery in year. The Committee noted that the main emphasis for improvement in processes is the ability to provide greater testing and assurance of delivery of plans before they are approved. Internal audit went on to highlight that the review of the Trusts systems to support cash flow forecasting had been particularly positive (Green no recommendations). Backlog maintenance review had been scored as amber green with no significant concerns. The Committee noted that there were no overdue actions developed from internal Audit recommendations. 4) AAC Annual Report The Committee reviewed the AAC annual report to Board which was accepted with some minor amendments. In particularly the committee noted the need to review the work of both the Charitable Funds and Remuneration Committee during 2016 as theses had not been considered recently.


The Committee agreed that the three lines of defence model of assurance is recognised as best practice and will seek to identify assurance at all level through 2016. The ‘First line’ of defence relates to risk and control systems at local level, the ‘Second line’ of defence relates to oversight and scrutiny by Executive Team and the Board and the third level refers to external assurances.

-End-

TRUST BOARD IN PUBLIC Date: 28TH January 2016

Agenda Item: 4.1

REPORT TITLE: 2015/16 CIP & QIA In year review

EXECUTIVE SPONSOR: Dr Des Holden Fiona Allsop

Medical Director Chief Nurse

REPORT AUTHOR (s): Maria Gubala – Finance Manager

REPORT DISCUSSED PREVIOUSLY:

(name of sub-committee/group & date)

Action Required:


Purpose of Report:

To update the Board on the assessment of the impact on quality and patient care of the

2015/16 Cost Improvement schemes on quality.


This paper evaluates whether the delivery of 15/16 CIP plan have had any adverse effect

on quality and patient care. It considers both schemes that did not deliver and those that

did deliver a financial return and whether in either case there was an impact on quality

(positive or negative). By analysing the 2015/16 CIP delivery in this way we hope to draw

conclusions which may help in subsequent CIP design and delivery.

Recommendation:

For discussion and assurance.


SO5: Well led: Become an employer of choice and deliver financial and clinical

sustainability around a clinical leadership model


Legal and regulatory impact No legal breach is reported or forecast.

Financial impact Savings delivery impacts on the overall

financial position of the Trust.

Patient Experience/Engagement

No adverse impact reported or expected.

All savings plans are subject to Quality Impact

Assessments (QIAs).

Risk & Performance Management No compliance issues.

Risks are stated in the report.

NHS Constitution/Equality &

Diversity/Communication No compliance issues.

Attachment:

None

TRUST BOARD REPORT – 28th January 2016

2015/16 Quality Impact Assessment of CIPs

1. Introduction

The Trusts financial plan for 2015/16 includes a CIP target of £8.168m.

The M09 (Dec 15) summary of the CIP have been delivered to date is tabled below: -

2015/16

£’000s

CIP plan for year 8,168

Position @M09:

YTD target 5,287

YTD actual 3,200

YTD variance (2,087)

1. Quality and patient experience review of delivered CIP plans

To date £3,200k of savings have been delivered with £1,902k (59%) of this related to Central schemes and £1,298k (41%) to Divisional schemes.

Before being signed off, all schemes have their quality indicators reviewed by both the Medical Director and the Chief Nurse for any adverse impact on quality, safety or patient experience. The schemes are then reviewed in year as they have progressed.

2. Findings from reviews and lessons learnt

Division of Surgery

As at M09 the Division has achieved £311k saving. Of this total, clinical supplies account for 71% and medical agency 22%.

The Chief of Surgery has stated that:-

“Clinical Supplies - this has been largely successful and is expected to deliver most of the projected savings. The items do not have a clinical impact but are about reducing waste with standard work and using cheaper alternatives. E.g. Hip prostheses, anaesthetic disposables

Medical Agency- we have reduced our use of agency locums in most specialties and have only a consultant agency locum in ophthalmology. We still require agency

locums in General Surgery to cover gaps in the Core Trainee rota but the new rota will come into force in February will reduce that

Non-clinical agency - this has been achieved without impact on quality.

Private Patients - we have been unable to use the beds on Brook for private patients or amenity beds due to bed capacity problems. This has impacted marginally on patient experience.”

Division of Medicine

As at M09 the Division has delivered £122k worth of savings, of which 50% relates to clinical supplies, 30% to junior medical agency and 15% to Pharmacy agency.

As per the ADO for Medicine, there has “been no reported unintended consequences” arising from the savings that have been delivered.

The schemes with the highest scores for the quality impact assessments prior to schemes starting related to changes in the supply of drugs, particularly related to cancer care, to Boots the chemist. The risk was assessed as an 8 as the impact of supply going wrong on our reputation and on patient care was considered significant. These schemes were impact assessed after three and six months and we found no adverse effect, and a well evaluated service change by patients.

WaCH

As at M09 the Division has delivered £57k worth of savings, with 79% of this arising from

Medical agency.

Some comments from the WaCH ADO:

There are no concerns arising from the savings on quality.

Due to the large level of Corporate schemes the process this year feels very

different.

Approximately half of planned schemes have been delivered.

An issue relating to the use of Masimo probes has come to light. The probes appear

to fall off children more easily than the previous product leading to a second probe

being attached. In order to confirm the validity of the claim, a review of the spend is

being undertaken to see whether an increased total number of probes has offset the

cheaper unit price. No clinical impact of this has been seen.

Cancer

As at M09 the Division has delivered £56k worth of savings, with 80% of this attributable to

agency.

No feedback received.

Estates and Facilities

As at M09 the Division has delivered £484k with 44% due to cark park income and 22% from

catering income.

No feedback received

Other schemes

As at M09 the Central schemes have achieved £1,902k saving with 51% relating to reserves, 11% on CNST improved rate due to CQC rating, 9% on contracts and 6% on improved income.

Lessons learnt include:

Where clinical staff were unhappy with taking forward a CIP scheme, the CIP was not actioned. Issues included insufficient capacity and the inability to recruit.

The reviews have been time consuming with difficulties in being able to find sufficient diary time.

Successful implementation and outcomes were greatly facilitated by medical agreement.

The review meetings have given the opportunity to have specific feedback on product changes. For example:

o QIA 1.21 Tissue Adhesion a detailed evaluation paper was presented on the use of Derma+flex. The results of which proved that this product could be used safely and effectively for the closure of appropriate wounds with 100% patient satisfaction and no reports of pain, burning or adverse effects.

The review meeting has also given the opportunity for project leads to ask for assistance when they have issues in implementation. For example DH 1.15 – Banning the use of couriers delivering discharge medicines

The under estimation of lead in times for projects is still an issue, with some schemes now commencing in 2016/17.

It is suggested that a financial review is undertaken at the end of 15/16 in order to identify those scheme types that have proved successful and those that have failed to deliver. This will help identify pitfalls and help in future planning.

Dr Des Holden Medical Director

Fiona Allsop Chief Nurse

Maria Gubala Finance Manager, Division of Medicine

28th January 2016

TRUST BOARD PUBLIC

Date: 26TH January 2016 Agenda Item: 4.2

REPORT TITLE: Emergency Planning Resilience and Response Core Standards Assurance

EXECUTIVE SPONSOR: Angela Stevenson Chief Operating Officer

REPORT AUTHOR (s): Jamie Hogg Emergency Planning Manager


Executive Committee

Action Required:

Approval (√) Discussion Assurance (√)

Purpose of Report:

NHS England has issued revised core standards for Emergency Planning, Resilience and Response (EPRR). As a Trust we are required to benchmark ourselves against these standards and put in place an action plan to meet them. The key desired outcomes in this area are: • Ability to respond to a business continuity incident (e.g. flooding) • Ability to respond to a major incident (e.g. mass casualty, pandemic flu, terrorist incident) • Ability to maintain services during peak stresses (e.g. winter, heatwave) The supporting requirements are: • Adequate plans (over-arching and local) – e.g. Incident Response Plan, Pandemic Influenza Plan, business continuity plans • Systems and infrastructure – e.g. resilient IT, telecoms and internal communications • Competent staff – based on training, exercising, live and simulated incidents


Executive Summary: The attached document gives our benchmarked position now and over the next six to twelve months, by which time we aim to be fully compliant. This document was submitted to NHS England on 24th September 2015, and presented at an assurance meeting on 9th October. A similar formal assurance process took place last year. In overall terms based on RAG ratings, current standing is as follows:

2015

Red 0%

Amber 17%

Green 83%

Some specific areas of improvement already addressed include:

• The trust undertook and completed the three yearly mandated a major incident exercise in September 2015. With some lessons to learn from the exercise. The feedback from Public Health England reflected that, overall it successfully achieved the aim and the objectives set for this exercise.

• Further mandated training took place for senior staff who attended a bespoke



training session on ‘surviving public enquiries’. The amber areas in the RAG rating relate to:

• Key areas developing their business continuity plans to support • Delivery of training and development of a BCM/Evacuation exercise which is in progress.

• Continue with the development of additional telecoms resilience

• Provision of improved storage for chemical protection suits

Recommendation:

Agree the core standards report and actions to achieve full compliance.




Legal and regulatory impact This is a legal requirement

Financial impact Non compliance could have potential implications

Patient Experience/Engagement Compliant

Risk & Performance Management Compliant


Compliant

Attachment:

Surrey & Sussex NHS Healthcare Trust, EPRR Core Standards, Self-Assessment 2015

NHS England Core Standards for Emergency preparedness, resilience and responsev3.0

The attached EPRR Core Standards spreadsheet has 6 tabs:

EPRR Core Standards tab - with core standards nos 1 - 37 (green tab)

Pandemic Influenza :- with deep dive questions to support the pandemic influenza 'deep dive' for EPRR Assurance 2015-16 (blue) tab)

HAZMAT/ CBRN core standards tab: with core standards nos 38- 51. Please note this is designed as a stand alone tab (purple tab)

HAZMAT/ CBRN equipment checklist: designed to support acute and ambulance service providers in core standard 43 (lilac tab)

MTFA Core Standard: designed to gain assurance against the MTFA service specification for ambulance service providers only (orange tab)

HART Core Standards: designed to gain assurance against the HART service specification for ambulance service providers only (yellow tab).

This document is V3.0. The following changes have been made :

• Inclusion of Pandemic Influenza questions to support the pandemic influenza 'deep dive' for EPRR Assurance 2015-16

• Inclusion of the HART service specification for ambulance service providers and the reference to this in the EPRR Core Standards

• Inclusion of the MTFA service specification for ambulance service providers and the reference to this in the EPRR Core Standards

• Updated the requirements for primary care to more accurately reflect where they sit in the health economy

• update the requirement for acute service providers to have Chemical Exposure Assessment Kits (ChEAKs) (via PHE) to reflect that not all acute service

providers have been issued these by PHE and to clarify the expectations for acute service providers in relation to supporting PHE in the collection of

Core standard Clarifying information

Acu

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Am

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Men

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CC

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Pri

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(GP

, co

mm

un

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harm

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Oth

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NH

S f

un

ded

org

an

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on

s Evidence of assurance

Self assessment RAG

Red = Not compliant with core standard and not in the

EPRR work plan within the next 12 months.

Amber = Not compliant but evidence of progress and in the

EPRR work plan for the next 12 months.

Green = fully compliant with core standard.

Action to be taken Lead Timescale

Governance

Organisations have a director level accountable emergency officer who is responsible for EPRR (including

business continuity management)Y Y Y Y Y Y Y Y Y

COO has the lead as the accountable emergency officer for the Trust. COO

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.

Lessons identified from your organisation and other partner organisations.

NHS organisations and providers of NHS funded care treat EPRR (including business continuity) as a systematic and continuous process and

have procedures and processes in place for updating and maintaining plans to ensure that they reflect:

- the undertaking of risk assessments and any changes in that risk assessment(s)

- lessons identified from exercises, emergencies and business continuity incidents

- restructuring and changes in the organisations

- changes in key personnel

- changes in guidance and policy

Y Y Y Y Y Y Y Y Y

There is a rolling programme of work, covering equipment, training exercising and planning. Audit and

assurance is provided through a review process and held on a database, this records all planned and

unplanned events that could impact on service delivery. Where appropriate these are debriefed and feed

into future planning through lessons learned.

Organisations have an overarching framework or policy which sets out expectations of emergency preparedness,

resilience and response.

Arrangements are put in place for emergency preparedness, resilience and response which:

• Have a change control process and version control

• Take account of changing business objectives and processes

• Take account of any changes in the organisations functions and/ or organisational and structural and staff changes

• Take account of change in key suppliers and contractual arrangements

• Take account of any updates to risk assessment(s)

• Have a review schedule

• Use consistent unambiguous terminology,

• Identify who is responsible for making sure the policies and arrangements are updated, distributed and regularly tested;

• Key staff must know where to find policies and plans on the intranet or shared drive.

• Have an expectation that a lessons identified report should be produced following exercises, emergencies and /or business continuity incidents

and share for each exercise or incident and a corrective action plan put in place.

• Include references to other sources of information and supporting documentation

Y Y Y Y Y Y Y Y Y

The Trust has a Resilience policy which is in date and provides the foundation for the emergency planning

and business continuity arrangements.

The accountable emergency officer will ensure that the Board and/or Governing Body will 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.

After every significant incident a report should go to the Board/ Governing Body (or appropriate delegated governing group) .

Must include information about the organisation's position in relation to the NHS England EPRR core standards self assessment.Y Y Y Y Y Y Y Y Y

There is an agreed reporting process.

Duty to assess risk

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 it's functions.

Y Y Y Y Y Y Y Y Y Y Y

The work to imbed the Trust and

service levelt BCM planning is

ongoing with a proprtion of

departments seen and others

still to be consulted and

supported in producing their

plans.

Resilience

Manager

Dec-15

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.


There is a process to ensure that the risk assessment(s) is informed by, and consulted and shared with your

organisation and relevant partners.

Other relevant parties could include COMAH site partners, PHE etc. Y Y Y Y Y Y Y Y Y Y Y

Duty to maintain plans – emergency plans and business continuity plans

Incidents and emergencies (Incident Response Plan (IRP) (Major Incident Plan))Y Y Y Y Y Y Y Y Y Y

Trust level business continuity plan is in draft and awaits presentation to board for sign off. Plan to be ratified by board Resilience

Manager

Oct-15

corporate and service level Business Continuity (aligned to current nationally recognised BC standards)


There is a chmical incident plan in place and in date. The required level of equipment is in place in line with

NHS England and PHE guidnace. There is a rolling programme of training for staff to fulfil the role during

the response to a chemical incident.

Detailed at 5 Resilience

Manager

Dec-15

HAZMAT/ CBRN - see separate checklist on tab overleaf

Y Y Y Y Y Y

There are plans in place for Heatwave, Cold Weather both of which are in date. The snow plan to be

published later this year. The Trust has invested in a add on snow plough to aid site clearance.

Severe Weather (heatwave, flooding, snow and cold weather)Y Y Y Y Y Y Y Y Y Y Y

Key plans support sevre weather response and strong connections with partners to ensure timely

notifications and response if needed.

Pandemic Influenza (see pandemic influenza tab for deep dive 2015-16 questions)Y Y Y Y Y Y Y Y Y Y Y

Influenza & pandemic Flu plan reviewed yearly and in response to any significant new guidnace or

unseasonal outbreak.

Mass Countermeasures (eg mass prophylaxis, or mass vaccination) Y Y Y Y Y Y Y Mass propalaxis plan in place

Mass CasualtiesY Y Y Y Y Y Y

LRF Mass Casualty plan is in place as gudiance and local major incident plan supports a no notice

escalation.

Fuel Disruption


LRF fuel plan puts the onus on organisations to have BCM planning developed and Trust has a series of

mitigations to ensure electircal supply is maintained and a regieme of generator testing. Distribution of fuel

through filling stations to support staff working off site would need LRF support. Details of supply chain for

fuel for on site generator need to be included in Estates BCM plan.

Estates & facilites BCM plan

under review

Estates

Manager

Nov-15

Surge and Escalation Management (inc. links to appropriate clinical networks e.g. Burns, Trauma and Critical Care)Y Y Y Y Y Y Y Y Y Y

There is currently an escalation policy, which is about to be reviewed and recorded therefore as work in

progress.

Escalation policy to be reviewed A/D Site

Services

Nov-15

Infectious Disease OutbreakY Y Y Y Y Y Y Y Y Y

There is an infectious disease woubreak plan the the Trust supported the development of the Ebola

planning

EvacuationY Y Y Y Y Y Y Y Y Y Y

The existing fire plan supports a progressive invacuation and shelter in situ process. Work has

commenced on developing a specific evacuation plan. This will require exercising.

Fire evacuation forms the inerim

position ahead of a review of a

specific non fire evacuation

Fire Safety

Advisor

Dec-15

LockdownY Y Y Y Y Y Y Y Y

There is a lockdown policy in place. It is planned to test / exercise an abduction from maternity in the curent

year.

Utilities, IT and Telecommunications Failure


Key site services have an established down time plan for loss of IT. A series of telecomms exercises has

taken place and the switchboard are developing a more robust fallback capability. DR for IT systems needs

to be incorporated into the IT BCM plan.

Switchboard

Manager and

IT Manager

Dec-15

Excess Deaths/ Mass Fatalities

Y Y Y Y Y Y

LRF plan for managing excess deaths plan is in place if needed. Local planning to manage mortuary

capacity is well established and was highlighted as good practice during peak demand in 2014 to 15

having a Hazardous Area Response Team (HART) (in line with the current national service specification, including a vehicles and equipment

replacement programme) - see HART core standard tabY

N/A

firearms incidents in line with National Joint Operating Procedures; - see MTFA core standard tab Y N/A

Ensure that plans are prepared in line with current guidance and good practice which includes: • Aim of the plan, including links with plans of other responders

• Information about the specific hazard or contingency or site for which the plan has been prepared and realistic assumptions

• Trigger for activation of the plan, including alert and standby procedures

• Activation procedures

• Identification, roles and actions (including action cards) of incident response team

• Identification, roles and actions (including action cards) of support staff including communications

• Location of incident co-ordination centre (ICC) from which emergency or business continuity incident will be managed

• Generic roles of all parts of the organisation in relation to responding to emergencies or business continuity incidents

• Complementary generic arrangements of other responders (including acknowledgement of multi-agency working)

• Stand-down procedures, including debriefing and the process of recovery and returning to (new) normal processes

• Contact details of key personnel and relevant partner agencies

• Plan maintenance procedures

(Based on Cabinet Office publication Emergency Preparedness, Emergency Planning, Annexes 5B and 5C (2006))


Plans and policies are version controlled and dated for review period. The programme of work recognises

this cycle and is directed to keep all of the relevant documents in date. PHE, NHS England and the LHRP

supports identifying key risks areas as well as good practice and guidance. These are included as

references in plans as they are updated. Palns are reviewe in keeping with Trust policy through Board sign

off.

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.

Enable an identified person to determine whether an emergency has occurred

- Specify the procedure that person should adopt in making the decision

- Specify who should be consulted before making the decision

- Specify who should be informed once the decision has been made (including clinical staff)


• Oncall Standards and expectations are set out.

• Include 24-hour arrangements for alerting managers and other key staff.

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.

Decide:

- Which activities and functions are critical

- What is an acceptable level of service in the event of different types of emergency for all your services

- Identifying in your risk assessments in what way emergencies and business continuity incidents threaten the performance of your

organisation’s functions, especially critical activities


New Trust BCM plan provides an algotithm and action cards to support decision making

Arrangements explain how VIP and/or high profile patients will be managed. This refers to both clinical (including HAZMAT incidents) management and media / communications management of VIPs and / or high profile

managementY Y Y Y Y

Plan linked to police Operation Carbon Steeple which is at hand for ED staff.

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 contentY Y Y Y Y Y Y Y Y Y Y

Internally planning is supported through the Trust Resilience Group and with key stakeholders as the need

arises. Externally there are stong links to the LHRP, CCG Providers and Communities. This is the same

with other key partners through the LRF, including Police, Fire , SEACamb and Gatwick; this is through

formal meetings and established networking.

Arrangements include a debrief process so as to identify learning and inform future arrangements Explain the de-briefing process (hot, local and multi-agency, cold)at the end of an incident. Y Y Y Y Y Y Y Y Y Y Y

The full range of debriefing approach is avaliable and used dependent on the circumstances and level of

incident.

Command and Control (C2)

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.

Organisation to have a 24/7 on call rota in place with access to strategic and/or executive level personnel

Y Y Y Y Y Y Y Y Y

The site team provide 24/7, 365 day cover formanaging no notice emergency and business continuity

incidents in the first instance. They are supported by a team of general Managers and Directors who are on

call, this is managed through a rota system. The cascade is supported where needed by the trust

switchboard staff.

Those on-call must meet identified competencies and key knowledge and skills for staff. NHS England publised competencies are based upon National Occupation Standards .

Y Y Y Y Y Y Y Y Y

There is a rolling programme of walkthroughs, briefings, exercises and training sessions.

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 should be proportionate to the size and scope of the organisation.


The establishment of the ICC is detailed in the major incident plan and would be used as the current basis

for a BCM response. As detailed above the Trust level business continuity plan is in draft and awaits

presentation to board for sign off. This will provide addditonal guidnace to establsih command and control

to respond to a BCM event.

Resilience

Manager

Dec-15

Arrangements ensure that decisions are recorded and meetings are minuted during an emergency or business

continuity incident. Y Y Y Y Y Y Y Y Y Y Y

A number of staff are trained as loggists to support activations either of a major incident or business

continuity incident. Training and plans reflect the importance of accurate record keeping in both decision

logs and meetings.

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.Y Y Y Y Y Y Y Y Y Y Y

There is an established reporting process during escalation and the mechanisms for providing key updates

were extensively used during the mortuary capacity meetings in 2014 / 2015.

Business continuity plans are in a cycle to be reviewed and updated on a yearly basis or more frequently if

highlighted through an evetn, debrief and lessons learned. The LHRP risk assessments inform the

planning for the Trust in combination with the National and LRF Risk register. The Trust has copies of the

NHS supplies BCM plan and this has been distributed to support departments BCM planning.

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):

Risk assessments should take into account community risk registers and at the very least include reasonable worst-case scenarios for:

• severe weather (including snow, heatwave, prolonged periods of cold weather and flooding);

• staff absence (including industrial action);

• the working environment, buildings and equipment (including denial of access);

• fuel shortages;

• surges and escalation of activity;

• IT and communications;

• utilities failure;

• response a major incident / mass casualty event

• supply chain failure; and

• associated risks in the surrounding area (e.g. COMAH and iconic sites)

There is a process to consider if there are any internal risks that could threaten the performance of the organisation’s functions in an emergency

as well as external risks eg. Flooding, COMAH sites etc.


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Self assessment RAG







Arrangements to have access to 24-hour specialist adviser available for incidents involving firearms or chemical,

biological, radiological, nuclear, explosive or hazardous materials, and support strategic/gold and tactical/silver

command in managing these events.

Both acute and ambulance providers are expected to have in place arrangements for accessing specialist advice in the event of incidents

chemical, biological, radiological, nuclear, explosive or hazardous materials Y Y

Support and specialist advice is available from Police, SEACamb and PHE (ECOSA).

Arrangements to have access to 24-hour radiation protection supervisor available in line with local and national

mutual aid arrangements;

Both acute and ambulance providers are expected to have arrangements in place for accessing specialist advice in the event of a radiation

incidentY Y

Support and specialist advice is available from SEACamb and PHE (ECOSA).

Duty to communicate with the public

Arrangements demonstrate warning and informing processes for emergencies and business continuity incidents. Arrangements include a process to inform and advise the public by providing relevant timely information about the nature of the unfolding event

and about:

- Any immediate actions to be taken by responders

- Actions the public can take

- How further information can be obtained

- The end of an emergency and the return to normal arrangements

Communications arrangements/ protocols:

Y Y Y Y Y Y Y Y Y Y

The communcations team provides the ability to distibute key messaging both internally and externally. It is

supported by an internal communcations plan as well as information sharing protocols established by the

LRF partnership.


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Arrangements ensure the ability to communicate internally and externally during communication equipment

failures Y Y Y Y Y Y Y Y Y Y YRegular checks are made to ensure that both day to day communication systems are functional as well as

emergency systems.

Information Sharing – mandatory requirements

Arrangements contain information sharing protocols to ensure appropriate communication with partners. These must take into account and inclue DH (2007) Data Protection and Sharing – Guidance for Emergency Planners and Responders or any

guidance which supercedes this, the FOI Act 2000, the Data Protection Act 1998 and the CCA 2004 ‘duty to communicate with the public’, or

subsequent / additional legislation and/or guidance.


There is an established information sharing protocol with the LRF in place and consulatation continues with

the Vulnerable people workstream.

Co-operation

Organisations actively participate in or are represented at the Local Resilience Forum (or Borough Resilience

Forum in London if appropriate) Y Y Y Y Y Y Y Y Y Y

The Resilience Manager attends LRF, LHRP, Gatwick meetings. Also represents on identified task and

finish groups as needed.

Demonstrate active engagement and co-operation with other category 1 and 2 responders in accordance with the

CCAY Y Y Y Y Y Y Y Y Y

The Resilience Manager represents the other Acute EP's at the LRF DG, Climate Change,

Telecommunciations, Reslience Direct workstreams and meetings. Also attends Gatwick Resilience

meetings. Supports training delivery with the LRF at Intro to Emergency Planning and Resilince Direct,

Additinally ad hoc as needed.

Arrangements include how mutual aid agreements will be requested, co-ordinated and maintained. NB: mutual aid agreements are wider than staff and should include equipment, services and supplies.

Y Y Y Y Y Y Y Y Y Y

Contribute to the mutual aid arrangements within the health economy. This occurred during the mortuary

capacity peak deand in 2014 /1 2015. Support he LRF and other partners in line with planning locally.

Arrangements outline the procedure for responding to incidents which affect two or more Local Health Resilience

Partnership (LHRP) areas or Local Resilience Forum (LRF) areas.Y Y Y Y

N/A

Arrangements outline the procedure for responding to incidents which affect two or more regions. Y Y Y N/A

Arrangements demonstrate how organisations support NHS England locally in discharging its EPRR functions

and duties

Examples include completing of SITREPs, cascading of information, supporting mutual aid discussions, prioritising activities and/or services

etc. Y Y Y Y Y Y Y

Requested updates are collated and infrmation returned in a timely manner. This is supported by use of the

nhs.net e-mail.

Plans define how links will be made between NHS England, the Department of Health and PHE. Including how

information relating to national emergencies will be co-ordinated and shared Y

N/A

Arrangements are in place to ensure an Local Health Resilience Partnership (LHRP) (and/or Patch LHRP for the

London region) meets at least once every 6 months Y YN/A

Arrangements are in place to ensure attendance at all Local Health Resilience Partnership meetings at a director

levelY Y Y Y Y Y Y Y

Meeting dates and papers circualted in advance of meetings, COO will normally attend or seek a deputy

when unable to.

Training And Exercising

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

• Staff are clear about their roles in a plan

• Training is linked to the National Occupational Standards and is relevant and proportionate to the organisation type.

• Training is linked to Joint Emergency Response Interoperability Programme (JESIP) where appropriate

• Arrangements demonstrate the provision to train an appropriate number of staff and anyone else for whom training would be appropriate for the

purpose of ensuring that the plan(s) is effective

• Arrangements include providing training to an appropriate number of staff to ensure that warning and informing arrangements are effective


Current training programme identifies key training needs which cover Major Incidents, BCM and CBRNe.

Additional training is developed, sought and delivered as needed.An example of this is a specific input to

redress a gap around 'surviving public enquiries' required for executives and directors.

Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs

future work.

• Exercises consider the need to validate plans and capabilities

• Arrangements must identify exercises which are relevant to local risks and meet the needs of the organisation type and of other interested

parties.

• Arrangements are in line with NHS England requirements which include a six-monthly communications test, annual table-top exercise and live

exercise at least once every three years.

• If possible, these exercises should involve relevant interested parties.

• Lessons identified must be acted on as part of continuous improvement.

• Arrangements include provision for carrying out exercises for the purpose of ensuring warning and informing arrangements are effective


Key workstreams and guidnace from NHS England support the identification and dvelopment of exercising

needs. These are in turn incorporated into exisiting exercisies or bespoke exercises developed as needed.

Demonstrate organisation wide (including oncall personnel) appropriate participation in multi-agency exercisesY Y Y Y Y Y Y Y Y

Major incident exercise to be delivered in September 2015. Further walkthroughs to support on call staff to

be delivered.

Resilience

Manager

Apr-16

Preparedness ensures all incident commanders (oncall directors and managers) maintain a continuous personal

development portfolio demonstrating training and/or incident /exercise participation. Y Y Y Y Y Y Y Y YInternal and external training is provided by the LRF and other providers. This needs aligning and

recording, so indivuduals can demonstrate competence as needed.

Resilience

Manager

Apr-16


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Self assessment RAG







2015 Deep Dive

DD1

Organisation have updated their pandemic influenza arrangements to reflect changes to the NHS and partner

organisations, as well as lessons identified from the 2009/10 pandemic including through local debriefing

• changes since April 2013 are reflected in local plans including formation of NHS England, CCGs and PHE; as well as the move of the

previous PCT public health function into local authorities

• key changes to the national pandemic infleunza strategy (such as de-coupling from WHO, development of DATER phases, and removal of UK

alert levels) as well as relevant local learning is reflected

Y Y Y Y Y Y Y Y Y Y

Plan was published post April 2013

DD2

Organisations have developed and reviewed their plans with LHRP and LRF partners • relevant local partners (particularly other NHS providers/ commissioners, PHE and local authority public health and social care teams where

appropriate) have been engaged in the development of local plans - at a minimum through an opportunity to comment on draft versionsY Y Y Y Y Y Y Y

Plan developed utilising PHE guidance and establishing key links

DD3

Organisations have undertaken a pandemic influenza exercise or have one planned in the next six months • local organisations have held an internal exercise or participated in a multi-organisation exercise since updating their local arrangements to

reflect changes and learning described in DD1

• if this has not taken place, there is a clear plan to deliver an exercise in the next six months

Y Y Y Y Y Y Y Y Y Y

it is understood that a regional exercise is planned in this work area to take place during the last quarter of

2015.

DD4Organisations have taken their plans to Boards / Governing bodies for sign off • updated arrangements that reflect changes and learning described in DD1 have been taken to Boards or Governing Bodies, and even if they

have not yet have been signed off by such bodies, the process towards this has been started Y Y Y Y Y Y Y Y YBroad consulataion took place when the plan was reviewed and updated and will follow again with any new

guidance this year. Evidence of 'deep dive being researched'.

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Red = Not compliant with core standard and

not in the EPRR work plan within the next 12

months.

Amber = Not compliant but evidence of

progress and in the EPRR work plan for the

next 12 months.



Q Core standard Clarifying information Evidence of assurance

Preparedness

38 There is an organisation specific HAZMAT/ CBRN plan (or dedicated annex) Arrangements include:

• command and control interfaces

• tried and tested process for activating the staff and equipment (inc. Step 1-2-3 Plus)

• pre-determined decontamination locations and access to facilities

• management and decontamination processes for contaminated patients and fatalities in

line with the latest guidance

• communications planning for public and other agencies

• interoperability with other relevant agencies

• access to national reserves / Pods

• plan to maintain a cordon / access control

• emergency / contingency arrangements for staff contamination

• plans for the management of hazardous waste

• stand-down procedures, including debriefing and the process of recovery and returning to

(new) normal processes

• contact details of key personnel and relevant partner agencies

Y Y Y Y Y There is a version controlled Chemical incident Plan in place. Aid memoire's

placed in strategic locations and provided as part of the training to staff during

training sessions. Steps 1-2-3 process is at the core of the CBRNe training for

staff. Locations are pre-determined and trained staff aware of these. Warning

and informing is central to the response to ensure patients and public are

informed as appropriate. The acredited training covers joint working, the use and

process of cordon control, decontamnination of staff, the plans for managing

hazardous waste, stand down and debriefing, as well as key contacts; PHE,

SUrrey Fire and Rescue Service as well as HART.

39 Staff are able to access the organisation HAZMAT/ CBRN management plans. Decontamination trained staff can access the plan Y Y Y Y Y Plans and aid memoir's are available to staff.

40 HAZMAT/ CBRN decontamination risk assessments are in place which are

appropriate to the organisation.

• Documented systems of work

• List of required competencies

• Impact assessment of CBRN decontamination on other key facilities

• Arrangements for the management of hazardous waste

Y Y Y Y Y Central to the training and response.

41 Rotas are planned to ensure that there is adequate and appropriate decontamination

capability available 24/7.

Y Y ED staff planning aijms to ensure sufficient staff with the appropriate level of

training are on duty. Training regieme aims to ensure that refresher and new

courses are run regulkalrly to maintain staffing levels.

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.

• For example PHE, emergency services. Y Y Y Y Y Central to the training and response.

Decontamination Equipment

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.

• Acute and Ambulance service providers - see Equipment checklist overleaf on separate

tab

• Community, Mental Health and Specialist service providers - see Response Box in

'Preparation for Incidents Involving Hazardous Materials - Guidance for Primary and

Community Care Facilities' (NHS London, 2011) (found at:

http://www.londonccn.nhs.uk/_store/documents/hazardous-material-incident-guidance-for-

primary-and-community-care.pdf)

• Initial Operating Response (IOR) DVD and other material: http://www.jesip.org.uk/what-will-

jesip-do/training/

Y Y Y Y Y Trust has equipment in excess of PHE guidnace. ED has an established process

for tracking patients.

44 The organisation has the expected number of PRPS suits (sealed and in date)

available for immediate deployment should they be required (NHS England published

guidance (May 2014) or subsequent later guidance when applicable)

There is a plan and finance in place to revalidate (extend) or replace suits that are reaching

the end of shelf life until full capability of the current model is reached in 2017

Y Y Trust has more suits than required to support the diversity of staff.

45 There are routine checks carried out on the decontamination equipment including:

A) Suits

B) Tents

C) Pump

D) RAM GENE (radiation monitor)

E) Other decontamination equipment

There is a named role responsible for ensuring these checks take place Y Y Equipment is checked on a regualr basis and all checks recirded.

46 There is a preventative programme of maintenance (PPM) in place for the

maintenance, repair, calibration and replacement of out of date Decontamination

equipment for:

A) Suits

B) Tents

C) Pump

D) RAM GENE (radiation monitor)

E) Other equipment

Y Y As above, equipment is replaced as required.

47 There are effective disposal arrangements in place for PPE no longer required. (NHS England published guidance (May 2014) or subsequent later guidance when

applicable)

Y Y All suits are in date to 2017, disposal arrangements for cleaning replacement are

well establsihed.

Training

48 The current HAZMAT/ CBRN Decontamination training lead is appropirately trained to

deliver HAZMAT/ CBRN training

Y Y Training is delivered by an accredited trainer from another Trust.

49 Internal training is based upon current good practice and uses material that has been

supplied as appropriate.

• Documented training programme

• Primary Care HAZMAT/ CBRN guidance

• Lead identified for training

• Established system for refresher training so that staff that are HAZMAT/ CBRN

decontamination trained receive refresher training within a reasonable time frame (annually).

• A range of staff roles are trained in decontamination techniques

• Include HAZMAT/ CBRN command and control training

• Include ongoing fit testing programme in place for FFP3 masks to provide a 24/7 capacity

and capability when caring for patients with a suspected or confirmed infectious respiratory

virus

• Including, where appropriate, Initial Operating Response (IOR) and other material:

http://www.jesip.org.uk/what-will-jesip-do/training/

Y Y Y Y Y All records are kept of risk assessments and training attended. Staff are issued

permit to work cards and can only be used in a deployment if they produce a

current and valid pernit to work card.

50 The organisation has sufficient number of trained decontamination trainers to fully

support it's staff HAZMAT/ CBRN training programme.

Y Y Provided by another Trust currently.

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.

• Including, where appropriate, Initial Operating Response (IOR) and other material:

http://www.jesip.org.uk/what-will-jesip-do/training/

• Community, Mental Health and Specialist service providers - see Response Box in

'Preparation for Incidents Involving Hazardous Materials - Guidance for Primary and

Community Care Facilities' (NHS London, 2011) (found at:

http://www.londonccn.nhs.uk/_store/documents/hazardous-material-incident-guidance-for-

primary-and-community-care.pdf)

Y Y Y Y Y Established as part of the Step 1-2-3 training.

Hazardous materials (HAZMAT) and chemical, biological, radiolgocial and nuclear (CBRN) response core standards

(NB this is designed as a stand alone sheet)

HAZMAT CBRN equipment list - for use by Acute and Ambulance service providers in relation to Core Standard 43.

No Equipment Equipment model/ generation/ details etc. Self assessment RAG

Red = Not in place and not in the EPRR

work plan to be in place within the next

12 months.

Amber = Not in place and in the EPRR

work plan to be in place within the next

12 months.

Green = In place.

EITHER: Inflatable mobile structure

E1 Inflatable frame N/AE1.1 Liner N/A

E1.2 Air inflator pump N/A

E1.3 Repair kit N/A

E1.2 Tethering equipment N/A

OR: Rigid/ cantilever structure

E2 Tent shell

OR: Built structure

E3 Decontamination unit or room

AND:

E4 Lights (or way of illuminating decontamination area if dark)

E5 Shower heads

E6 Hose connectors and shower heads

E7 Flooring appropriate to tent in use (with decontamination basin if

needed)

E8 Waste water pump and pipe

E9 Waste water bladder

PPE for chemical, and biological incidents

E10 The organisation (acute and ambulance providers only) has the

expected number of PRPS suits (sealed and in date) available for

immediate deployment should they be required. (NHS England

published guidance (May 2014) or subsequent later guidance

when applicable).

E11 Providers to ensure that they hold enough training suits in order to

facilitate their local training programme

Ancillary

E12 A facility to provide privacy and dignity to patients

E13 Buckets, sponges, cloths and blue roll

E14 Decontamination liquid (COSHH compliant)

E15 Entry control board (including clock)

E16 A means to prevent contamination of the water supply

E17Poly boom (if required by local Fire and Rescue Service) Partner Agency

E18 Minimum of 20 x Disrobe packs or suitable equivalent

(combination of sizes)

E19 Minimum of 20 x re-robe packs or suitable alternative

(combination of sizes - to match disrobe packs)

E20 Waste binsDisposable gloves

E21 Scissors - for removing patient clothes but of sufficient calibre to

execute an emergency PRPS suit disrobe

E22 FFP3 masks

E23 Cordon tape

E24 Loud Hailer

E25 Signage

E26 Tabbards identifying members of the decontamination team

E27 Chemical Exposure Assessment Kits (ChEAKs) (via PHE): should

an acute service provider be required to support PHE in the

collection of samples for assisting in the public health risk

assessment and response phase of an incident, PHE will contact

the acute service provider to agree appropriate arrangements. A

Standard Operating Procedure will be issued at the time to explain

what is expected from the acute service provider staff. Acute

service providers need to be in a position to provide this support.

Radiation

E28 RAM GENE monitors (x 2 per Emergency Department and/or

HART team)

Yes- checking and tesing regieme on a monthly

basis is in place.

E29 Hooded paper suits Ebola PPE

E30 Goggles Ebola PPE

E31 FFP3 Masks - for HART personnel only N/A

E32 Overshoes & Gloves


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Self assessment RAG







Governance

1 Organisations have an MTFA capability at all times within their operational service area.

• Organisations have MTFA capability to the nationally agreed safe system of work standards defined within this service specification.

• Organisations have MTFA capability to the nationally agreed interoperability standard defined within this service specification.

• Organisations have taken sufficient steps to ensure their MTFA capability remains complaint with the National MTFA Standard Operating

Procedures during local and national deployments.

Y

2Organisations have a local policy or procedure to ensure the effective prioritisation and deployment (or

redeployment) of MTFA staff to an incident requiring the MTFA capability.

• Deployment to the Home Office Model Response sites must be within 45 minutes. Y

3Organisations have the ability to ensure that ten MTFA staff are released and available to respond to scene within

10 minutes of that confirmation (with a corresponding safe system of work).

• Organisations maintain a minimum of ten competent MTFA staff on duty at all times. Competence is denoted by the mandatory minimum

training requirements identified in the MTFA capability matrix.

• Organisations ensure that, as part of the selection process, any successful MTFA application must have undergone a Physical Competence

Assessment (PCA) to the nationally agreed standard.

• Organisations maintain the minimum level of training competence among all operational MTFA staff as defined by the national training

standards.

• Organisations ensure that each operational MTFA operative is competent to deliver the MTFA capability.

• Organisations ensure that comprehensive training records are maintained for each member of MTFA staff. These records must include; a

record of mandated training completed, when it was completed, any outstanding training or training due and an indication of the individual’s level

of competence across the MTFA skill sets.

Y

4Organisations ensure that appropriate personal equipment is available and maintained in accordance with the

detailed specification in MTFA SOPs (Reference C).

• To procure interoperable safety critical equipment (as referenced in the National Standard Operating Procedures), organisations should use

the national buying frameworks coordinated by NARU unless they can provide assurance through the change management process that the

local procurement is interoperable.

• All MTFA equipment is maintained to nationally specified standards and must be made available in line with the national MFTA ‘notice to move’

standard.

• All MTFA equipment is maintained according to applicable British or EN standards and in line with manufacturers’ recommendations.

Y

5Organisations maintain a local policy or procedure to ensure the effective identification of incidents or patients

that may benefit from deployment of the MTFA capability.

• Organisations ensure that Control rooms are compliant with JOPs (Reference B).

• With Trusts using Pathways or AMPDS, ensure that any potential MTFA incident is recognised by Trust specific arrangements. Y

6Organisations have an appropriate revenue depreciation scheme on a 5-year cycle which is maintained locally to

replace nationally specified MTFA equipment.Y

7Organisations use the NARU coordinated national change request process before reconfiguring (or changing)

any MTFA procedures, equipment or training that has been specified as nationally interoperable. Y

8 Organisations maintain an appropriate register of all MTFA safety critical assets.

• Assets are defined by their reference or inclusion within the National MTFA Standard Operating Procedures.

• This register must include; individual asset identification, any applicable servicing or maintenance activity, any identified defects or faults, the

expected replacement date and any applicable statutory or regulatory requirements (including any other records which must be maintained for

that item of equipment).

Y

9Organisations ensure their operational commanders are competent in the deployment and management of NHS

MTFA resources at any live incident. Y

10Organisations maintain accurate records of their compliance with the national MTFA response time standards

and make them available to their local lead commissioner, external regulators (including both NHS and the Health

& Safety Executive) and NHS England (including NARU operating under an NHS England contract).

Y

11

In any event that the organisations is unable to maintain the MTFA capability to the interoperability standards, that

provider has robust and timely mechanisms to make a notification to the National Ambulance Resilience Unit

(NARU) on-call system. The provider must then also provide notification of the specification default in writing to

their lead commissioners.

Y

12

Organisations support the nationally specified system of recording MTFA activity which will include a local

procedure to ensure MTFA staff update the national system with the required information following each live

deployment.

Y

13Organisations ensure that the availability of MTFA capabilities within their operational service area is notified

nationally every 12 hours via a nominated national monitoring system coordinated by NARU.Y

14

Organisations maintain a set of local MTFA risk assessments which are compliment with the national MTFA risk

assessments covering specific training venues or activity and pre-identified high risk sites. The provider must

also ensure there is a local process / procedure to regulate how MTFA staff conduct a joint dynamic hazards

assessment (JDHA) at any live deployment.

Y

15

Organisations have a robust and timely process to report any lessons identified following an MTFA deployment or

training activity that may be relevant to the interoperable service to NARU within 12 weeks using a nationally

approved lessons database.

Y

16

Organisations have a robust and timely process to report, to NARU and their commissioners, any safety risks

related to equipment, training or operational practice which may have an impact on the national interoperability of

the MTFA service as soon as is practicable and no later than 7 days of the risk being identified.

Y

17Organisations have a proces to acknowledge and respond appropriately to any national safety notifications issued

for MTFA by NARU within 7 days.Y

18FRS organisations that have an MTFA capability the ambulance service provider must provide training to this

FRS

Training to include:

• Introduction and understanding of NASMed triage

• Haemorrhage control

• Use of dressings and tourniquets

• Patient positioning

• Casualty Collection Point procedures.

Y

19 Organisations ensure that staff view the appropriate DVDs

• National Strategic Guidance - KPI 100% Gold commanders.

• Specialist Ambulance Service Response to MTFA - KPI 100% MTFA commanders and teams.

• Non-Specialist Ambulance Service Response to MTFA - KPI 80% of operational staff.Y


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Governance

1Organisations maintain a HART Incident Response Unit (IRU) capability at all times within their operational

service area.Y

2Organisaions maintain a HART Urban Search & Rescue (USAR) capability at all times within their operational

service area.Y

3Organisations maintain a HART Inland Water Operations (IWO) capability at all times within their operational

service area.Y

4Organisations maintain a HART Tactical Medicine Operations (TMO) capability at all times within their

operational service area.Y

5Organisations maintain a local policy or procedure to ensure the effective prioritisation and deployment (or

redeployment) of HART staff to an incident requiring the HART capabilities.

• Four HART staff must be released and available to respond locally to any incident identified as potentially requiring HART capabilities within

15 minutes of the call being accepted by the provider. Note: This standard does not apply to pre-planned operations or occasions where HART

is used to support wider operations. It only applies to calls where the information received by the provider indicates the potential for one of the

four HART core capabilities to be required at the scene. See also standard 13.

• Organisations maintain a minimum of six competent HART staff on duty for live deployments at all times.

• Once HART capability is confirmed as being required at the scene (with a corresponding safe system of work) organisations can ensure that

six HART staff are released and available to respond to scene within 10 minutes of that confirmation. The six includes the four already

mobilised.

• Organisations maintain a HART service capable of placing six competent HART staff on-scene at strategic sites of interest within 45 minutes.

These sites are currently defined within the Home Office Model Response Plan (by region). Competence is denoted by the mandatory minimum

training requirements identified in the HART capability matrix.

• Organisations maintain any live (on-duty) HART teams under their control maintain a 30 minute ‘notice to move’ to respond to a mutual aid

request outside of the host providers operational service area. An exception to this standard may be claimed if the live (on duty) HART team is

already providing HART capabilities at an incident in region.

Y

6Organisations maintain a criteria or process to ensure the effective identification of incidents or patients at the

point of receiving an emergency call that may benefit from the deployment of a HART capability.Y

7Organisations ensure an appropriate capital and revenue depreciation scheme is maintained locally to replace

nationally specified HART equipment.

• To procure interoperable safety critical equipment (as referenced in the National Standard Operating Procedures), organisations should have

processes in place to use the national buying frameworks coordinated by NARU unless they can provide assurance through the change

management process that the local procurement is interoperable.

Y

8Organisations use the NARU coordinated national change request process before reconfiguring (or changing)

any HART procedures, equipment or training that has been specified as nationally interoperable. Y

9Organisations ensure that the HART fleet and associated incident technology are maintained to nationally

specified standards and must be made available in line with the national HART ‘notice to move’ standard.Y

10Organisations ensure that all HART equipment is maintained according to applicable British or EN standards and

in line with manufacturers recommendations.Y

11

Organisations maintain an appropriate register of all HART safety critical assets. Such assets are defined by

their reference or inclusion within the National HART Standard Operating Procedures. This register must

include; individual asset identification, any applicable servicing or maintenance activity, any identified defects or

faults, the expected replacement date and any applicable statutory or regulatory requirements (including any

other records which must be maintained for that item of equipment).

Y

12Organisations ensure that a capital estate is provided for HART that meets the standards set out in the HART

estate specification.Y

13Organisations ensure their incident commanders are competent in the deployment and management of NHS

HART resources at any live incident. Y

14

In any event that the provider is unable to maintain the four core HART capabilities to the interoperability

standards,that provider has robust and timely mechanisms to make a notification to the National Ambulance

Resilience Unit (NARU) on-call system. The provider must then also provide notification of the specification

default in writing to their lead commissioners.

Y

15

Organisations support the nationally specified system of recording HART activity which will include a local

procedure to ensure HART staff update the national system with the required information following each live

deployment.

Y

16Organisations maintain accurate records of their compliance with the national HART response time standards

and make them available to their local lead commissioner, external regulators (including both NHS and the Health

& Safety Executive) and NHS England (including NARU operating under an NHS England contract).

Y

17Organisations ensure that the availability of HART capabilities within their operational service area is notified

nationally every 12 hours via a nominated national monitoring system coordinated by NARU.Y

18

Organisations maintain a set of local HART risk assessments which compliment the national HART risk

assessments covering specific training venues or activity and pre-identified high risk sites. The provider must

also ensure there is a local process / procedure to regulate how HART staff conduct a joint dynamic hazards

assessment (JDHA) at any live deployment.

Y

19

Organisations have a robust and timely process to reportany lessons identified following a HART deployment or

training activity that may be relevant to the interoperable service to NARU within 12 weeks using a nationally

approved lessons database.

Y

20

Organisations have a robust and timely process to report, to NARU and their commissioners, any safety risks

related to equipment, training or operational practice which may have an impact on the national interoperability of

the HART service as soon as is practicable and no later than 7 days of the risk being identified.

Y

21Organisations have a proces to acknowledge and respond appropriately to any national safety notifications issued

for HART by NARU within 7 days. Y

• Organiations maintain the four core HART capabilities to the nationally agreed safe system of work standards defined within this service

specification.

• Organiations maintain the four core HART capabilities to the nationally agreed interoperability standard defined within this service

specification.

• Organiations take sufficient steps to ensure their HART unit(s) remains complaint with the National HART Standard Operating Procedures

during local and national deployments.

• Organiations maintain the minimum level of training competence among all operational HART staff as defined by the national training

standards for HART.

• Organiations ensure that each operational HART operative is provided with no less than 37.5 hours protected training time every seven weeks.

If designated training staff are used to augment the live HART team, they must receive the equivalent protected training hours within the seven

week period (in other words, training hours can be converted to live hours providing they are re-scheduled as protected training hours within the

seven week period).

• Organiations ensure that all HART operational personnel are Paramedics with appropriate corresponding professional registration (note

s.3.4.6 of the specification).

• As part of the selection process, any successful HART applicant must have passed a Physical Competence Assessment (PCA) to the

nationally agreed standard and the provider must ensure that standard is maintained through an ongoing PCA process which assesses

operational staff every 6 months and any staff returning to duty after a period of absence exceeding 1 month.

• Organiations ensure that comprehensive training records are maintained for each member of HART staff. These records must include; a

record of mandated training completed, when it was completed, any outstanding training or training due and an indication of the individual’s level

of competence across the HART skill sets.



REPORT TITLE: NHS PLANNING GUIDANCE 2016/17 – 2020/21

EXECUTIVE SPONSOR: Michael Wilson Chief Executive

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

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

Action Required:


Purpose of Report: Provide an overview of the new NHS planning requirements for 2016/17 – 2020/21 Summary of key issues As part of the planning process, all NHS organisations are asked to produce two separate but interconnected plans:

• A local health and care system ‘Sustainability and Transformation Plan’, which will cover the period October 2016 to March 2021; and

• A plan by organisation for 2016/17 which will need to reflect the emerging Sustainability and Transformation Plan.

Recommendation:

The Board is asked to note the report and the Trusts plans to work in partnership with the health system to deliver the requirements.



Legal and regulatory impact Ensures the Board are aware of current and new requirements.

Financial impact N/A

Patient Experience/Engagement Highlights national requirements in place to improve patient experience.

Risk & Performance Management Identifies possible future strategic risks which the Board should consider


Includes where relevant an update on the NHS Constitution and compliance with Equality Legislation

Attachment: N/A

2

TRUST BOARD REPORT – 26th January 2016 NHS PLANNING GUIDANCE 2016/17 – 2020/21 1. Introduction The leading national health and care bodies in England recently jointly published ‘Delivering the Forward View: NHS Shared Planning Guidance 2016/17 – 2020/21’ which sets out steps to help local organisations deliver a sustainable, transformed health service and improve the quality of care, wellbeing and NHS finances. Backed up by £560 billion of NHS funding, including a new Sustainability and Transformation Fund to support financial balance, the delivery of the Five Year Forward View, and enable new investment in key priorities. As part of the planning process, all NHS organisations are asked to produce two separate but interconnected plans:

• A local health and care system ‘Sustainability and Transformation Plan’, which will cover the period October 2016 to March 2021; and

• A plan by organisation for 2016/17 which will need to reflect the emerging Sustainability and Transformation Plan.

2. Local health system Sustainability and Transformation Plans (STPs) Every health and care system must come together, to create an ambitious local blueprint for accelerating its implementation of the Forward View. STPs will cover the period between October 2016 and March 2021 and will be subject to formal assessment in July 2016 following submission in June 2016. Organisations have the next six months to develop and deliver core access, quality and financial standards while planning properly for the next five years. Planning by individual institutions will increasingly be supplemented with planning by place for local populations. For many years now, the NHS has emphasised organisational separation and autonomy that does not make sense to staff or the patients and communities they serve. Producing a STP is not just about writing a document, nor is it a job that can be outsourced or delegated. Instead it involves five things:

• local leaders coming together as a team; • developing a shared vision with the local community, which also involves local

government as appropriate; • programming a coherent set of activities to make it happen; • execution against plan; and • learning and adapting.

Where collaborative and capable leadership cannot be found, NHS England and NHS Improvement will help secure remedies through more joined-up and effective system oversight. Success in developing the plans will also depend on having an open, engaging, and iterative process that harnesses the energies of clinicians, patients, carers, citizens, and local community partners including the independent and voluntary sectors, and local government through health and wellbeing boards.

https://www.england.nhs.uk/2015/12/17/nhs-england-allocates-560-billion/

3

As a truly place-based plan, the STPs must cover all areas of CCG and NHS England commissioned activity including:

• specialised services, where the planning will be led from the 10 collaborative commissioning hubs; and

• primary medical care, from a local CCG perspective, irrespective of delegation arrangements.

The STP must also cover better integration with local authority services, including, but not limited to, prevention and social care, reflecting local agreed health and wellbeing strategies. For the first time, the local NHS planning process will have significant central money attached. The STPs will become the single application and approval process for being accepted onto programmes with transformational funding for 2017/18 onwards. This step is intended to reduce bureaucracy and help with the local join-up of multiple national initiatives. The most compelling and credible STPs will secure the earliest additional funding from April 2017 onwards. 3. Agreeing ‘transformation footprints’ The STP will be the umbrella plan, holding underneath it a number of different specific delivery plans, some of which will necessarily be on different geographical footprints. For example, planning for urgent and emergency care will range across multiple levels: a locality focus for enhanced primary care right through to major trauma centres. The first critical task is for local health and care systems to consider their transformation footprint – the geographic scope of their STP. They must make proposals to regulatory bodies by Friday 29 January 2016, for national agreement. Local authorities should be engaged with these proposals. Taken together, all the transformation footprints must form a complete national map. The scale of the planning task may point to larger rather than smaller footprints. Transformation footprints should be locally defined, based on natural communities, existing working relationships, patient flows and take account of the scale needed to deliver the services, transformation and public health programmes required, and how it best fits with other footprints such as local digital roadmaps and learning disability units of planning. In future years regulatory bodies will be open to simplifying some of these arrangements. Where geographies are already involved in the Success Regime, or devolution bids, the expectation is that these determine the transformation footprint. Although it is important to get this right, there is no single right answer. The footprints may well adapt over time. The focus of energies should be on the content of plans rather than have lengthy debates about boundaries. 4. National ‘must dos’ for 2016/17 Whilst developing long-term plans for 2020/21, the NHS also has a clear set of plans and priorities for 2016/17 that reflect the Mandate to the NHS and the next steps on Forward View implementation. Some of the most important requirements for 2016/17 involve partial roll-out rather than full national coverage.

4

The ambition is that by March 2017, 25 percent of the population will have access to acute hospital services that comply with four priority clinical standards on every day of the week, and 20 percent of the population will have enhanced access to primary care. There are three distinct challenges under the banner of seven day services:

• reducing excess deaths by increasing the level of consultant cover and diagnostic services available in hospitals at weekends. During 16/17, a quarter of the country must be offering four of the ten standards, rising to half of the country by 2018 and complete coverage by 2020;

• improving access to out of hours care by achieving better integration and redesign of 111, minor injuries units, urgent care centres and GP out of hours services to enhance the patient offer and flows into hospital; and

• improving access to primary care at weekends and evenings where patients need it by increasing the capacity and resilience of primary care over the next few years.

Where relevant, local systems need to reflect this in their 2016/17 Operational Plans, and all areas will need to set out their ambitions for seven day services as part of their STPs. 5. The Nine must dos for 2016/17 for every local system 5.1 Develop a high quality and agreed STP, and subsequently achieve what we determine are our most locally critical milestones for accelerating progress in 2016/17 towards achieving the triple aim as set out in the Forward View. 5.2 Return the system to aggregate financial balance. This includes secondary care providers delivering efficiency savings through actively engaging with the Lord Carter provider productivity work programme and complying with the maximum total agency spend and hourly rates set out by NHS Improvement. CCGs will additionally be expected to deliver savings by tackling unwarranted variation in demand through implementing the RightCare programme in every locality. 5.3 Develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues. 5.4 Get back on track with access standards for A&E and ambulance waits, ensuring more than 95 percent of patients wait no more than four hours in A&E, and that all ambulance trusts respond to 75 percent of Category A calls within eight minutes; including through making progress in implementing the urgent and emergency care review and associated ambulance standard pilots. 5.5 Improvement against and maintenance of the NHS Constitution standards that more than 92 percent of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment, including offering patient choice. 5.6 Deliver the NHS Constitution 62 day cancer waiting standard, including by securing adequate diagnostic capacity; continue to deliver the constitutional two week and 31 day cancer standards and make progress in improving one-year survival rates by delivering a year-on-year improvement in the proportion of cancers diagnosed at stage one and stage two; and reducing the proportion of cancers diagnosed following an emergency admission. 5.7 Achieve and maintain the two new mental health access standards: more than 50 percent of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral; 75 percent of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, with 95 percent

5

treated within 18 weeks. Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia. 5.8 Deliver actions set out in local plans to transform care for people with learning disabilities, including implementing enhanced community provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy. 5.9 Develop and implement an affordable plan to make improvements in quality particularly for organisations in special measures. In addition, providers are required to participate in the annual publication of avoidable mortality rates by individual trusts. 6. Operational Plans for 2016/17 An early task for local system leaders is to run a shared and open-book operational planning process for 2016/17. This will cover activity, capacity, finance and 2016/17 deliverables from the emerging STP. By April 2016, commissioner and provider plans for 2016/17 will need to be agreed by NHS England and NHS Improvement, based on local contracts that must be signed by March 2016. The detailed requirements for commissioner and provider plans are set out in the technical guidance. All plans will need to demonstrate:

• how they intend to reconcile finance with activity (and where a deficit exists, set out clear plans to return to balance);

• their planned contribution to the efficiency savings; • their plans to deliver the key must-dos; • how quality and safety will be maintained and improved for patients; • how risks across the local health economy plans have been jointly identified and

mitigated through an agreed contingency plan; and • how they link with and support with local emerging STPs.

The 2016/17 Operational Plan should be regarded as year one of the five year STP, and we expect significant progress on transformation through the 2016/17 Operational Plan. Building credible plans for 2016/17 will rely on a clear understanding of demand and capacity, alignment between commissioners and providers, and the skills to plan effectively. A support programme is being developed jointly by national partners to help local health economies in preparing robust activity plans for 2016/17 and beyond. 7. Our approach to the requirements in the planning guidance The Trust has already begun working with our partners across the health system and plans are being put in place for organisations to come together to input, develop and agree a clear process for development and agreement of the STP. CCGs and NHS England are providing guidance on the geographical footprint which will be based on the commissioning intentions and landscape and SaSH will have an important role in agreeing this footprint.

6

8. Timetable

A full copy of the planning guidance can be found at https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf

9. Recommendation

The Board is asked to note the requirements for the NHS Planning Guidance for 2016/17 and beyond and the plans in place to deliver these requirements.

Michael Wilson Chief Executive 26th January 2016

https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf


Date: 26TH January 2016 Agenda Item: 4.4

REPORT TITLE: NHS England Major Incident Assurance Return

EXECUTIVE SPONSOR: Angela Stevenson Chief Operating Officer

REPORT AUTHOR (s): Jamie Hogg Emergency Resilience Planning Manager

REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date) Executive Committee

Action Required:

Approval (√) Discussion Assurance (√)

Purpose of Report: NHS England is seeking assurance of Trusts preparedness in relation to a specific set of questions concerning preparedness for a major incident.

Summary of key issues Executive Summary: The attached document addresses the questions raised with the overall position being that the Trust has adequately prepared to respond and recover to a major incident.

Recommendation:

Agree the assurance provided against the criteria set in the NHS England assurance return.

Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment:

Legal and regulatory impact Legal and regulatory requirements

Financial impact Non-compliance could incur financial penalties

Patient Experience/Engagement Compliant


Risk & Performance Management Compliant

NHS Constitution/Equality & Diversity/Communication Compliant

Attachment: NHS England MI Assurance Return

NHS England Assurance Return Trust Name: Surrey & Sussex NHS Healthcare Trust EPRR Accountable Executive officer: COO Angela Stevenson EPRR Lead: Hazel Gleed Date: 23.12.2015 Part 1: Assurance Statement of assurance

You have reviewed and tested your internal cascade systems to ensure that you can activate support from all staff groups, including doctors in training posts, in a timely manner including in the event of a loss the primary communications system;

• A test of the emergency cascade was conducted by switchboard on Friday the 11th December 2015, it is reported that an adequate number of consultants and doctors responding. New equipment is in place to enable a relocation of the switchboard in the event of a loss of premises. If primary communications are lost, radios are available to the enable co-ordination across the Trust. Clinical areas have reviewed their staff contact lists to ensure these are both complete and current.

You have arrangements in place to ensure that staff can still gain access to sites in circumstances where there may be disruption to the transport infrastructure, including public transport where appropriate, in an emergency;

• The Trust has arrangements within the Adverse Weather which could be used in part to support transport of staff.

• The trust is a prioritised user of a local taxi company with agreement to release taxis for any identified need ahead of other customers.

• A large number of staff do utilise public transport to travel to the site any disruption would have an impact on normal travel arrangements. Plans to help manage this eventuality are being developed.

Plans are in place to significantly increase critical care capacity and capability over a protracted period of time in response to an incident, including where patients may need to be supported for a period of time prior to transfer for definitive care;

• The MI plan allows for us to upgrade some of our beds temporarily whilst waiting to transfer out. However in the event of the system being overwhelmed, our Pandemic flu plan has a graded response from using all our Level 2 & 3 beds for Level 3 patients to expanding into the theatre suite using Recovery and theatres if we are unable to transfer out.

The Trust has given due consideration as to how specialist advice can be gained in relation to the management of a significant number of patients with traumatic blast and ballistic injuries.

• There is a network of experienced clinical staff that has this specialist advice and can be contacted if needed. Arrangements for a seminar are being made to deliver training/briefing to key staff. The target to deliver this is by the end of April 2016.

Date of public Board meeting to present statement of readiness:

28th January 2016



REPORT TITLE: Annual plan 2015/16 update

EXECUTIVE SPONSOR: Sue Jenkins Director of Strategy

REPORT AUTHOR (s): Sue Jenkins Director of Strategy


Executive Committee

Action Required:

Approval Discussion Assurance (√)

Purpose of Report:

The purpose of this report is to provide assurance to the Board that the annual operating plan for 2015/16 has been delivered


The annual plan for 2015/16 was approved by the Board in April 2015. The original annual plan included progress against 107 actions. For quarter 3 this has now reduced to 106 actions. The one that has been deleted is 2.17 which relates to enhanced recovery pathways for breast and C-sections. This work was being led by the AHSN who have decided not to progress this work during 15/16. This will be reviewed for inclusion in the 16/17 plan. Of the 106 actions the status for the quarter is reported as follows:-

Status Q1 – April to June 2015

Q2 – July to September 2015

Q3 – October to December 2015

Red 1 <1% 4 4% 2 <2%

Amber 27 25% 29 27% 26 25%

Green 75 70% 70 65% 66 62%

Blue 4 4%

4 4% 12 11%

This quarter’s performance has generally improved and moved in a positive direction. 11% of the actions have already been completed and 73% are being delivered according to plan or have been completed which is on track for a Q3 position. There are two actions with a red status. These are;

1.15 – Healthcare acquired infection. 31 cases have now been reported against a target of 15. This target reduced from 24 cases last year. The target of 15 relates to those cases which are deemed a lapse of care by both the Trust and CCG. So far 2 cases have been deemed a lapse of care but there are a number of cases which are still to be reviewed in partnership to agree their final status. The



management of diarrhoea has been identified as a value stream for VMI work to better understand the detail and areas for improvement around this.

2.2 – Manage non elective demand. An AMU consultant has started and is developing plans to increase ambulatory capability. Escalation processes to respond to increases in demand include and elective winter plan, plans for the opening of an integrated reablement unit and a length of stay group

Recommendation:

The Board are asked to confirm that this report provides assurance that the annual plan 2015/16 is being delivered




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

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

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

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


The annual plan demonstrates delivery of the organisations strategic objectives

Attachment:

Annual plan 2015/16 Q3 update

Work stream off track and unlikely to

deliver as describedA

Work stream off-track but plans in

place to recoverG

Work stream on track

and to plan

BComplete

RefNew

or bfSource Lead director Lead manager/clinician

Q3 Update RAG

status

1.1 NEW Strategic objectives delivery plan Sue Jenkins - Series of deep dives planned for all specialties from

January to April 2016 G

1.2 NEW Strategic objectives delivery plan Fiona Allsop - Good rating still in place

Included on divisional board agendasG

1.3 NEW Strategic objectives delivery planFiona Allsop/ Des

HoldenKatharine Horner

Medicine, Cancer and WaCH are now producing

regular newsletters that highlight learning from

incidents and complaints. Reporters of incidents now

have the facility to request automatic feedback from

incidents. An e-mail is generated from Datixweb

outlining the action taken by the reviewing manager.

This went live 21/9/15 and will be monitored over the

coming months.

In medicine division, comms folders, safety briefings

and lessons learned are shared across teams

G

1.4 NEW Strategic objectives delivery plan Des Holden - Fully signed up. Leads for emergency laporotomy

and sepsis identified. Attended all relevant events G

1.5 NEW Strategic objectives delivery plan Mark Preston Janet Miller

Achievement Review compliance is at 74%. New

risk 1740 added to the Trust risk register recognising

the impact of embedding the Trust values and

behaviours and the ability to pilot the '9 blocker' for

8As and above. Communication on 2nd year to

commence January 2016

A

1.6 NEW Quality account Fiona Allsop Kim Rayment

The strategic project meetings have taken place as

scheduled. Q3 report submitted to Patient Safety

Committee and Executive Committee for Quality and

Risk meetings in January 2016 as planned. G

1.7 BFClinical strategy

Divisional plansDes Holden Barbara Bray

SSIs are discussed monthly at Divisional Board.

Every orthopaedic infection has an RCA that is

reported to Divisional Board. Woodland elective

beds are not consistently ring-fenced.

G


Divisional plansAngela Stevenson Ben Emly

ED

Oct 95.5% Nov 92.9% Dec 95.5% Q3 94.6%

2 week rule

Oct 90% Nov 93.3% Dec 94.3%

31 days

Oct 98.2% Nov 96.6% Dec 92.4%

62 days

Oct 85.6% Nov 88.3% Dec 85.8%

A

RR

Annual plan 2015/16 v1.4 - Q3 update

Actively participate in national Patient Safety Collaborative in Kent,

Surrey and Sussex area

Demonstrate improved learning from incidents across the Trust

Meet all access targets including ED, 2 weeks referral, 31 days and

62 days

SO1 - Safe - Deliver safe services and be in the top 20% against peers

Action

Complete deep dive process for all relevant specialties

Maintain a CQC inspection rating of good or outstanding

Maintain the low incidence of surgical site infections

Implement achievement review and include safety goals for all staff

Evidence compliance with Sign up to Safety

1.9 NEW Quality account Des Holden Jonathan Parr

ERP performance much improved and meeting

targets for 2/3 pathways. COPD pathway having

data collection issues, but data completeness now

rising. Plans have had to be put in pace to cover

Demetia Specialist Nurse who is leaving the Trust in

Janaury to ensure delivery of programme whilst post

vacant. Some risks around Sepsis which is not yet

reaching the required 90% target for screening and

antibiotic administration.

A


Divisional plansFiona Allsop Michelle Cudjoe

Staffing requirements to achieve Maternity Ratios

added to WACH Business Plan

Currently recruiting to senior midwife post and

expected to have in post by April 2016

G

1.11 NEW Quality Account Des Holden Sue Jenkins

Part 2 of Advanced Lean Training completed in

November and both candidates were succesful

Trust Guiding team completed trip to Seattle in

October 2015

Executive sponsors agreed for 3 value streams

Cardiology inpatient flow, outpatients and

management of diarrhoea

Value stream sponsorship team recruited for

Cardiology

Improvement workshop agreeing current state value

stream map and future state value stream map

completed for Cardiology in December 2015

G

1.12 BFQuality Account

Quality strategy

Avoidable falls/ falls resulting in

harm

Demonstrate further improvement

in number of fallsFiona Allsop Francis Fernando

The number of falls in Q3 fell by 8% compared to

Q2. Although the percentage of falls with harm

increased in Q3, from 28% to 31%. But this only

equates to an increase of 2 falls with harm compared

with Q2. Low harms constituted 92% of all the falls

with harm in Q3. The remaining 8% of all the harms

in Q3 were severe and one death. This death is

being investigated at present. Falls care bundle

being reviewed at present to reflect the results of the

1st National In-patient Falls Audit and to comply with

the NICE CG 161 (2015). Annual falls data (January-

December 2015) showed a 50% reduction in

moderate harms, 35% reduction in severe harms

and a 22% reduction in Serious Incidents compared

to the same period in 2014.

A


Quality strategyPressure damage

Maintain achievement of no

hospital acquired major pressure

damage and aim to reduce

hospital acquired minor damage

Fiona Allsop Louise Evans

Year to date we have had 35 minor pressure

damage incidents against a target of 40. Despite

some of these being unavoidable incidents we are

unlikely to meet our target this year. We still are on

track to have no avoidable major pressure damage.

G

Deliver CQUIN plans for 2015/16:-

Local - Discharge to Assess (Sue Jenkins)

Local - Improving Discharge (Angela Stevenson)

Local - Enhanced Quality (Jonathan Parr)

Local - Ward accreditation (Fiona Allsop)

National - Acute Kidney Injury (Phil Williams)

National - Sepsis (Julian Webb)

National - Dementia and delirium (Steve Adams)

National - Avoid emergency admissions Angela Stevenson)

National - Improving diagnosis of mental health patients in ED

(Julian Webb)

Monitor compliance with national midwifery staffing guidance

Explore opportunities of improving the safety journey by learning

from international best practice i.e. Virginia Mason


Quality StrategyDementia

Develop community facing

approach to dementia careFiona Allsop Steve Adams

Work is progressing as described previously. The

"comfort blankets pilot scheme is being managed by

Pamela Trangmar Physicians Associate, `who has

been instrumental in trying to establish the project

and seeking engagement with community services.

Dementia lead nurse is leaving the Trust at the end

of January. Successor has been appointed who will

commence in April. Handover plans are in place in

the interim.

G

Meet the DH central infection

control targets of <15 Cdiff cases

and no preventable MRSA blood

stream infections

31 cases against a target of 15 which the CCG jusge

as a lapse of care. Currently only 2 have been

confirmed as a lapse of care by CCG and most are

awaiting review

R

Continue to screen patients for

MRSA and administer MRSA

suppression treatment in a timely

way

1 MRSA has been reported in a baby

A

NEWImprove completion of assessment

on dischargeDes Holden -

VTE group established. VTE nurse appointment

increased from temporary part time to substantive

full timeG

BFContinue risk assessment on >

95% of patients on admissionDes Holden -

Q2 was met and Q3 is currently being validatedG


Quality strategy

World Health Organisation

(WHO) safer surgery checklist

Continue to audit quality of safer

surgery processesDes Holden Barbara Bray

Theatre continuously audit the performance of the

WHO checklist and review the results at the Theatre

Management Group. Performance remains good.

The WHO checklist is one of the National Safety

Standards for Invasive Procedure(NatSSIPs) and the

Division of Surgery has a working group to review

and update all their safety processes to ensure they

are consistent with the national standards. The

progress of this is monitored through the Division

and reported to the NatSSIP steering group.

G

Maintain and further improve timely

admission and operative

intervention

A

Improve length of stay for #NOF AImprove follow up data collection To improve SSNAP audit

performance to at least a B ratingDes Holden Ben Mearns

Currently a band C and action plan being progressedA

Improve use of safety information

at divisional meetings

Dashboard used live in the Patient Safety sub-

committee in September. Dashboard is still being

developed and refined.

G

Increase number of audits that

impact on patient safety

Progress made in registration of audit projects and

assessing impact of audit on patient safety. Update

presented to SQC in November.G

Make patient safety data more

transparent for staff and patients

Patient safety dashboard show compliance with

metrics at service level for staff.G

1.21 BF CQC improvement plan Angela StevensonNatasha Hare

Linda Judge

New Governance agreed and implemented,

including a weekly operational meeting (Delivery

Group)and a monthly strategic group (OP Board);

ToR approved December 2015. Medical Director

confirmed as VMI executive sponsor.

A

BF

Further improve scanning time

Ashley Flores

Des Holden

BFQuality Account

Quality Strategy

Barbara Bray

Ben Mearns

Healthcare acquired infection

Quality Account

Quality StrategyIncident reporting

Des Holden

Progressing well against time to theatre.

4 hour standard to ward is not as good although

sometimes this is because patients go directly to

theatre from ED

CT in ED being progressed which will seek to

improve positionA

Fiona Allsop

1.19

1.18

Quality Account

Quality Strategy

1.20

Patients admitted with stroke

Quality Account

Quality strategy

Clinical strategy

Divisional plans

Des Holden

BF

Venous thromboembolism

(VTE)

Fractured neck of femur (hip)

1.16

BF

Deliver outpatients improvement plan

1.15

Quality Account

Quality strategy

Katharine Horner

Jonathan Parr

DCNs

1.22 BF CQC improvement plan Ian Mackenzie Phil Stone Work starts on site in January 2016 G

1.23 BF CQC improvement plan Jim DaveyCompleted Q1 - Plan delivered and savings realised

B

1.24 BF Quality Account Angela Stevenson David Heller

Cerner e-discharge letter pilot now to commence in

Feb 2016

EpMA project business case to be included in roll

out of acceleration of EPR work

MaPPs leaflets still in use and continued

reinforcment of their importance is maintained with

staff

G

1.25 NEW Quality Account Safety thermometer

Maintain compliance of 95% and

increase average compliance to

97% from January to March 2016

Fiona Allsop Vicky Daley

The Safety Thermometer continues to be monitored

and discussed at the Patient Safety and Clinical Risk

sub-committee. 95% compliance for harm free care

(new harm) for November 2015. Medicines Safety

Thermometer piloted in 6 wards in November 2015.

G

1.26 NEW Quality Account Fiona Allsop Vicky Daley

As per the previous quarter, infection control remains

as a standing item at the PSCRC and the NMPC. In

addition, the Infection Control Tasforce meeting

continues on a weekly basis to discuss operational

and strategic issues pertinant to improving and

maintaining standards of cleanliness. Formal CCG

cdi review meetings continue. Since the last update,

a CCG Clostridium Difficile Lapse in Care

Assessment tool has been agreed, inclusive of a

RAG rating criteria to determine the application of

sanctions. Noise at night remains on the inpatient

survery action plan, which is monitored via the

Patient Experience sub-committee.

G

RefNew

or bfSource Lead Director Lead Manager/clinician

Q3 Update RAG

status

2.1 BFIBP service development

Estate strategyAngela Stevenson -

Build complete and unit fully operationalB

2.2 BFIBP service development

Strategic objectives delivery planAngela Stevenson -

AMU consultant started and developing plans to

increase ambulatory capability

Escalation process includes elective winter plan,

plans for integrated reablement unit, LOS group

R

2.3 BF Strategic objectives delivery plan Sue Jenkins -AMU consultant to support ED in key times

Summit planned with CCGsG

2.4 NEW Strategic objectives delivery plan Ian Mackenzie -Completed Q1 - Procurement was completed in

October 2014B


Divisional plansDes Holden Ben Mearns

Continuing to work with Surrey and Stroke networks

to develop whole system pathway for stroke G


Divisional plansDes Holden Ben Mearns

Further developing the frailty pathway

A


Divisional plansDes Holden Virach Phongsathorn

Completed Q1 - High dependency respiratory bay

developed on Tilgate Annexe and now operational B


Divisional plansDes Holden

Debbie Pullen

Michelle Cudjoe

Utilisation of BU continues to be in excess of 20%

per month G

Continue participation in wider health system transformation forums

to influence development of new models of care

Develop plans to support re-procurement of EPR and EPMA

Redesign service to create HDU respiratory beds

Action

Continue to maintain high standards of cleanliness and to ensure

patients are not disturbed unnecessarily

Redesign the pathways in elderly medicine to create seamless

patient care across all providers including early supported discharge

Redesign of service to ensure that the birthing unit provides intra-

partum and postnatal care for 20% of women booked for maternity

services at East Surrey hospital

Develop second cardiac angiography suite

Redesign the stroke pathway to create a seamless in and out of

hospital patient centred pathway across all providers

Deliver Dictate IT improvement plan

Manage non elective care

Improve communications and information around medication on

discharge

Deliver medical records improvement plan

SO2 - Effective: Deliver effective and sustainable clinical services within the local health economy



Ed Cetti

Mo Luqman

Actions being followed up in Radiology at the

'Seniors team meeting' as standard agenda item.

Group meets every 2 weeks to progress action plan.G

2.10 BF

Clinical strategy

Divisional plans

Estate strategy

Angela StevensonEd Cetti

Mo Luqman

FBC Approved in Dec. Build started with completion

expected Mid Feb 16 G



Ed Cetti

Mo Luqman

OBC approved by TDA late Dec 15. Progressing

works to FBC following feedback from TDA on OBC.

Still working to implementation date of April 16A

Focus on categories of death

rather than individual and make

recommendations via clinical

effectiveness committee to make

improvements

Roll out enhanced review of all

patient deaths

Maintain “better than expected”

rating for mortality by Dr Foster

Latest report reports Trust no longer 'better than

expected' in latest 12 month rolling report (Oct 2014 -

Sep 2015)A

2.13Quality Account

Quality strategyReadmissions

Undertake review of one month’s

clinical readmission data and

implement any lessons learned

Jim Davey -

Completed in Q3

B


Quality strategy(NICE) technology appraisals

Increase statement compliance.

Audit against NICE technology

appraisals and post on audit

intranet

Des Holden Jonathan Parr

No further progress with other audits identified.

A

Reduce LOS ChiefsLOS action plans being developed as part of

business planning process A

Maintain core hospital at home

beds all yearPaula Tooms

Capacity increased in line with planG

Review pathways to develop

alternatives to admissionJim Davey

Black escalation summit to take place in New Year

Growth being considered as part of SRG plans G

2.16 BF 7 day working SDIP Sue Jenkins -Audit results received

G

2.17 NEW Quality account Enhanced recovery

Commence enhanced recovery

pathways for breast and C-

sections


The AHSN has decided to no longer lead a project

for both pathways for 15/16N/A

2.18 NEW Quality account Enhanced quality

Commence new enhanced quality

pathways for COPD, fractured

neck of femur and emergency

laparotomy


Trust represented at #NoF meetings and data

collectionnow underway. Emergency Laparotomy

regional meetieng attended by Trust leads. COPD

reporting slightly behind schedule due to coding

issues, but plan in place to get data back up to date

and achieve minimum data completeness

A

RefNew

or bfSource Lead Director Lead Manager/clinician

Q3 Update RAG

status

3.1 BF Strategic objectives delivery plan Des Holden Jonathan Parr

Progress made in registration of audit projects and

assessing impact of audit on patient safety. Update

presented to SQC in November.G

Implement a managed equipment service which is supported by a

rolling equipment replacement schedule

SO3 - Caring - Ensure patients feel cared for and cared about

Mortality Group continue to meet and reports being

received by specialties on learning. Group has also

recommended specific work to be done around NIV

and impact of winter pressures A

BF

2.15

Demonstrate that audit plans include issues raised by YCM, FFT

and inpatient survey

Redesign of service to support the installation of a digital

mammography machine on the ESH site

Mortality

To consider recommendations from the strategic review of radiology

services undertaken in autumn 2013 and agree and implement

action plan

Implement 7 day working for all relevant specialties

Angela Stevenson

Quality Account

Quality strategy

Reducing need for admission

Action

Jonathan Parr2.12 Des Holden

BFQuality Account

Quality strategy

3.2 BFStrategic objectives delivery plan

Nursing & Midwifery strategyFiona Allsop

Vicky Daley

DCNs

Maintaining safe levels of nursing care is an ongoing

key focus. Safe and effective care is of a better

standard when provided by permanent members of

staff that are experienced in the speciality of the

ward/department and familiar with the Trust's

policies and procedures. In line with the the

TDA/Monitor requirements to reduce agency spend

and keep hourly rates below a cap, the organisation

continues on a significant programme or recruitment

both locally and overseas. Their induction and

development is supported by the PD team and 2

Clinical Support Nurses appointed in Q3 2015/16.

In addition, the Trust has been awarded funding by

HEKSS to recruit a Band 7 Practice Development

Nurse for Career Development and a Band 6 Clinical

Support Nurse for Elderly Care with a view to

developing and retaining our existing experienced

nursing workforce. The band 7 post holder

commences on the 22nd February, with the band 6

post still to be filled.

G

3.3 NEW Strategic objectives delivery plan Fiona Allsop Cathy White

Focus groups have been undertaken among

endoscopy patients. Carers discussions took place

in October 2015 and a maternity listening event was

completed in November

G

3.4 NEWStrategic objectives delivery plan

Nursing & Midwifery strategyFiona Allsop DCNs

Nursing documentation review still to be progressedA


Divisional plansAngela Stevenson Jane Penny

Centre opened and launch to take place in January

2016 B

Continue to ensure there are no

mixed sex breachesAngela Stevenson -

No mixed sex breaches for Q3G

Share and implement learning

from Breaking the CycleAngela Stevenson -

Monthly breaking the cycles have been in place

throughout winter. Last ones planned the first week

of January and FebruaryG

Participate in 5th National Audit of

Care of the Dying patient

The Trust participated in the audit, we have

submitted organisational data and reviewed 80 sets

of notes and still awaiting the results.

B

Complete internal audit of end of

life care documentation

Audit completed and submitted to the audit

department , presented to cancer division October

15

B

Develop and introduce second

version of SaSH end of life care

plan

Second version of Care Plan developed and in use

on the wards. To be reviewed later in 2016.B

3.8 NEW Estates strategy Ian Mackenzie Shaun CunninghamCompleted in Q3

B

Establish and undertake a programme of patient listening events

End of life care

Review and develop scheme to modernise East Entrance

environment and facilities including additional retail outlets.

Quality Account

Quality strategyRight bed, right time

3.7Quality Account

Quality strategyFiona Allsop Jane Penny

Demonstrate delivery of “Provide safe and effective care in all that

we do” objective from nursing and midwifery strategy at safety and

quality committee

3.6

Demonstrate that nursing review and assessment reflects individual

needs of patients

Work with Olive Tree, Friends of east Surrey and Macmillan Cancer

Support to develop and implement a Cancer Information and

Support Centre at East Surrey Hospital

NEW

BF

3.9 NEW Quality Account Des Holden Mili Doshi

MCM team have completed phase 1 ( training all

wards in ES) . There have been improvement in the

mouth care of patients but only 31% have a fully

completed mouth care form. The team are

developing new incentives to engage staff but there

is a need for senior nursing support. We will be

managing the roll out of MCM initially across 11 sites

in KSS. A work shop is being held on 27.1.16 and

we have a representative form each trust.

G

3.10 BF Quality Account NutritionContinue to make improvements to

protected meal timesFiona Allsop Vicky Daley

Protected mealtimes remains as a regular item at

the Oral Nutrition and Hydration Group. Spot checks

continue to be taken on ward areas to determine

levels of compliance.Results are variable in some

areas.Discussion around improving protected

mealtimes. Revised Oral Nutrion and Hydration

Policy ratified and uploaded in January 2016. Policy

includes a section on protected mealtimes and the

new MUST tool which has been widely

communicated to clinical staff.

G

Seek ways to broaden how we get

feedback from wider communityFiona Allsop

Vicky Daley

Cathy White

Continue to promote FFT and YCM

and make changes on basis of

feedback

Fiona AllsopVicky Daley

Cathy White

RefNew


Q3 Update RAG

status

4.1 NEW Strategic objectives delivery planGillian Francis-

Musanu

Laura Warren Plan greed and in place.G

4.2 BF IBP service development Anglea Stevenson Jane Penny

Currently paused awaiting discussion with

Macmillan as their structure has changed and there

is increased pressure on their finances. Macmillan

Head of Service Development for South and Eastern

England visit planned for April 17.

A

4.3 BFStrategic objectives delivery plan

Membership strategy

Gillian Francis-

Musanu

Laura Warren

Colin Pink

The first meeting of theShadow Council of

Governors has been held and terms of reference

agreed. Membership enegagement group plans

developed to meet early q4

G

4.4 BF

Clinical strategy

Divisional plans

Estate strategy

Angela StevensonBill Kilvington

Barbara Bray

The completion of the final stage which is the theatre

reception area is due to commence on 18 January

2016 and be finished by 8 February 2016G

4.5 BF Market Development strategy Paul Simpson Larisa Wallis

Trust applied for AQP for Non-Invasive Ventilation

and AQP for Non-Obstetric Ultrasound Service

(NOUS) and currently awaits the outcome of the

qualification process on both AQPs.

G

To maintain market share through excellent service provision and

securing AQP contracts where CCGs have given notice on the

service that was previously part of the acute contract

G

The Patient Experience Sub-Committee meets on a

monthly basis, and there are standing items on the

agenda on FFT and YCM. A series of hot topic

events provide an opportunity for attendees to give

feedback and seek clarification on relevant service

areeas. An option also exists for patients and the

public to feedback direct on our website.

Patient feedback

Establish CoG and demonstrate meaningful engagement which

shapes our services

Complete refurbishment of and open theatres

3.11

Implement oral healthcare initiative and demonstrate improvement

of patient and clinical care

Chemotherapy service development

Action

Quality Account

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

NEW

Develop programme of engagement activities with patients and

members


Plans for additional elective activity have been

compromised by high levels of non elective activity

and 18 weeks backlog. The numbers of elective

patients seen this year are higher than last year.

Integrated Reablement Unit (IRU) has been built and

opened on 21st Jan-16 as a result of tripartite

partnership of Surrey County Council, East Surrey

CCG and SASH. The aim of the unit is to provide

step-down / rehab beds for those patients who no

longer need acute care but who cannot be

discharged due to the delays in social care

packages.

A


Second Cardiology Angio Suite will be opening in

February which will enable the Trust to repartriate

some NHS activity and to expand Cardiology private

patient activity which are currently send away to

other NHS and private providers. The project plan is

being worked up for the start in April 2016.

A


BSUH/SaSH joint venture for pathology services

progressing. New name agreed as Frontier. Final

business case to be considered by both Boards later

this yearG


New Cardiology Angio lab went live on 28th Sept-15

but income from additional activity was compromised

by waiting list activity which was the first priority to

clear.

Second Cardiology Angio Suite will be opening in

February which will enable the Trust to repartriate

some NHS activity and to expand Cardiology private

patient activity which are currently send away to

other NHS and private providers. The project plan is

being worked up for the start in April 2016.

A

4.10 BF QGAFDes Holden/ Fiona

AllsopColin Pink

Delivery of specific elements of QGAF proceeding as

planned, outstanding elments focus on delivery of

data quality stratgeyG

RefNew


Q3 Update RAG

status

5.1 BF Strategic objectives delivery plan Paul Simpson Larisa Wallis

Market Share Report for 6 months of 2015-16 is

being prepared and shared with Divisions and

Finance & Workforce Committee to show the trends

and shifts in Trust's market share for elective,

emergency and outpatient activity.

A

Action

To expand market share for elective activity by working with CCGs

and other providers to repatriate elective activity from distant tertiary

providers where this is clinically appropriate

Deliver QGAF action plan

To expand market share for elective activity targeted market that

have traditionally referred patients to other providers

To explore opportunities for further joint ventures/partnership

arrangements to continue to develop the East Surrey Hospital

campus so that local patients can receive an increasing range of

specialist services at ESH whether provided by SASH or a partner

organisation

To move to new markets, such as private practice, where this is

clinically and financially viable and supports the long term strategic

intentions of the Trust

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

Demonstrate increase in market share due to repatriation of

services

5.2 BF Strategic objectives delivery plan Fiona AllsopSue Carr

DCNs

31 European nurses arrived between October and

December 2015. 26 now have their NMC PIN

number

18 nurses on the overseas nursing programme have

received their NMC PIN number

European recruitment continuing with Skype

interviews booked for January 2016. Trust has

engaged a second recruitment partner in order to

improve fulfilment.

First of Phillipino nurses arriving on 15 January.

Succesful Bank recruitment for nursing assistants

continues with a proportion of applicants who are

student nurses from across the region and students

on the access to nursing course from East Surrey

College.

A

5.3 NEW Strategic objectives delivery plan Paul Simpson Catriona Tait

The final handover meeting with GE took place and

the Chief Operating Officer is developing a proposal

for taking SLM forward within the organisation.G

5.4 NEWStrategic objectives delivery plan

IBP service developmentSue Jenkins Natasha Hare

Business case due in Q4 following completion of

demand and capacity exerciseG

5.5 NEW Strategic objectives delivery plan Mark Preston Sarah Wood

Agreed additional questions added to SF&FT in Q 4.

These are:

How strongly do you agree or disagree with the

following statements:

1. There are clear expectations of how staff should

behave whilst working in the Trust

2. I've observed staff quickly answering a ringing

telephone and pro-actively helping the caller

Five point scale: Strongly agree to strongly

disagree, plus ‘don’t know’ option

Review of effectiveness to be undertaken with a view

to tailoring questions each quarter to develop a multi

source feedback system for staff.

G

5.6 BF Strategic objectives delivery plan Des Holden Colin Pink

Culture champion network maturing, Trust wide

'Standards of Behaviour' developed and agreed

during Q3.G

5.7 BF Strategic objectives delivery planGillian Francis-

Musanu-

CompleteB

5.8 NEW Strategic objectives delivery planGillian Francis -

MusanuColin Pink

Stable governance system in place including

strengthened divisional and speciality level reporting. G

5.9 NEW Membership strategyGillian Francis -

MusanuLaura Warren

Engagemnt plan agreed at initial Shadow Council of

Governors meeting, initial steps taken to implementG

Hold election for Council of

Governors

Gillian Francis -

MusanuLaura Warren

Election to the shadow Council of Governors

complete with all seats filled, Selection of nominated

governors 98% complete.G

Complete induction for CoGGillian Francis -

Musanu-

CoG Induction currently in progress due for

completion by end of Q4G

Establish CoG meetings and

effective engagement and

communications strategy

Gillian Francis -

MusanuLaura Warren

Engagement plan agreed at initial Shadow Council

of Governors meeting, initial steps taken to

implementG

5.11 BF IT strategy Ian Mackenzie Peter Hodgetts Completed in Q3 B

5.12 BF IT strategy Ian Mackenzie Peter Hodgetts Plan being developed for implementation in 2016 G

Upgrade of end-of-life Trust operating systems

Establish multisource feedback system for all staff

Governance processes adapted to support clinical leadership model

and remain effective

Develop nurse recruitment plan, monitor delivery and report to

workforce committee

Complete delivery of Foresight board development programme

Provide upgraded email solution

5.10

Establish and deliver engagement and communications strategy for

members following FT authorisation

NEW Council of Governors (CoG)

Develop and implement SLM model with clinical leads

Complete delivery of SaSH plus GE clinical leadership programme

Develop plans for new outpatient facilities

Membership strategy

IBP

5.13 BF IT strategy Ian Mackenzie Peter Hodgetts

permission to proceed to business case developed

and to be approved in Q4. Aim will be to accelerate

the implementation of EPRG

5.14 BF Estate strategy Ian Mackenzie Shaun Cunningham Ongoing and on track G

5.15 NEW Quality AccountDes Holden

Mark Preston

Adam Stacey-Clear

Janet Miller

Focus in Q3 has been on compliance against targets

and audit and analysis will be undertaken in Q4. A

5.16 BF Workforce and OD strategy Mark Preston Nathaniel Johnston

Work has been on-going to develop a multi-

disciplinary education strategy which will include

embedding the Healthcare Leadership Model (HLM).

As part of this work, we will explore how we utilise

the HLM into all professional leadership

development, and we will look to phase out the

medical L.E.A.D.E.R tool that is being used currently

by our medical workforce. Next steps in this process

include a meeting between Dr Sarah Rafferty, Chief

of Education and Nathaniel Johnston, Head of

Workforce Development at the end of January 2016,

to develop this further and agree an action plan for

delivery.

G

5.17 BF Workforce and OD strategy Mark Preston Janet Miller

Business Planning Guidance includes reference to

Workforce Plans.

ESR project commenced to validate Establishment

for each service area prioritising medical and nursing

staff as a starting point. SOPs for agreeing changes

with Service/Finance/HRBP. Divisional Workforce

Plans to be generated following Business planning

seminar in Q4 27/1/16.

Divisional Workforce Plans to be generated following

Business Planning seminar 27/1/16

G


The Induction Programme has been revised and is

being re-launched in April 2016. Changes to the

programme include hosting a marketplace in the

atrium for staff to meet different departments, (for

example Occupational Health and Libraries). The

'Exec Welcome' has been brought forward in the

Induction Programme to open the day rather than

being held after lunch. Capacity has been created in

the Induction Programme for a Values Workshop,

which will be an interactive session where new staff

will be asked to consider the SaSH values and how

they will role model them in their work. The staffs

stories will then be collected to help understand what

our staff think about our Values.

GRefocus of induction to support OD intervention around behaviours

and values.

Develop integrated workforce plans (demand and supply) at

divisional/ business unit level - identifying workforce changes

required for 24/7 working in appropriate areas

5.18

• harness productivity gains identified in service developments -

advances in medical/surgical innovations e.g. telemedicine,

Complete Network Upgrade

BF Workforce and OD strategy

Continue to embed the setting of personal goals that effect the

quality of service for all staff in annual achievement reviews

Launch the Leadership Framework and an effective assurance

process for the organisation to assess how each line manager is

performing against the key people performance requirements

-

Focus on increasing workforce productivity

Angela Stevenson• realise the benefits of technological business processes across

the Trust

Project manager for eroster recruited and

implementation has commenced

Permission to proceed to business case being

developed to support acceleration of EPR

programme

Deliver estates capital programme

G

5.20 BF Workforce and OD strategy Mark Preston Janet Miller

Stress related absence reduced although it is still

consistent in the top 5 reasons for absence through

Q3. Continue with actions introduced.

Wellbeing Strategy revision behind schedule but

completion by end Q2 (16/17) achievable. Well

being Group to focus on arranging Wellbeing Day in

Q2 of 16/17.

Significant Flu immunisation undertaken during Q3.

G


Following a focus on our brand at recruitment stage,

work begins on developing our "brand" as an

employer that is passionate about developing and

training our workforce. We are currently developing

an infographic to showcase our work in education

and training to use as part of our marketing and

communications materials. Further to this we are

working on a multi-professional plan to increase our

community engagement by visiting schools and

colleges as well as increasing our profile with

universities. In addition, we are building the Trusts

profile on multi-media sites (eg Facebook / Linked

In), in order to help share information with local

online networking/community groups

G

5.22 NEW Workforce and OD strategy Mark Preston Nathaniel Johnston

In February 2016 we will launch the HEKSS suite of

leadership e-learning modules, the Edward Jenner

online programme and we continue to promote the

regional/national leadership programmes to staff via

our communications channels. We have a multi-

disciplinary leadership Expo planned for March 2016,

facilitated by Dr Jean Arokiasamy, Medical

Leadership Tutor, that will showcase paired working

between professional groups. Future leadership

development will be explored through the

development of the education strategy.

G


We are working with the HEKSS leadership

collaborative to align our local talent tools and

resources with those that are being developed at a

national level. The purpose of this is to ensure we

are utilising recognised tools, endorsed by

regulators/national organisations, making us

'Champions for Talent' within our region. The 9-

blocker, or its equivalent, will be piloted at band 8a

and above following the completion of band 8a

Achievement Reviews in line with the achievement

review cascade.

G

Create the SaSH identity and brand so that we are recognised as

the ‘Employer of Choice’

Ensure access to a range of leadership programmes, to cover the

range of levels and focused on leading our values and behaviours.

Develop a Talent Management framework and succession planning

tool to help identify potential leaders to fill key positions within the

organisation.

Have in place a range of interventions to reduce the top reasons for

absence such as workplace stress musculoskeletal disorders

(MSD), flu.


The Workforce Development Team is actively

working with the Kaizen Promotion Office (Sash+

Programme) who will deliver service improvement

training in line with the Virginia Mason value

streams/ methodology. The KPO team will deliver

our service improvement module on the 'Essentials

of Management' Programme to ensure all staff

understand /utilise the same methodologies. In

addition we are designing a programme to embed

Human Factors at SaSH, supported by the AHSN/

HEKSS.

G


The Trust's new Conflict Management programme

was developed and will be launched in January

2016. The programme will be delivered in house by

Alexandria Dyer, Workforce Development Advisor.

Conflict resolution will be included on the MaST

programme, and delivered to teams on a bespoke

basis. Topics include emotional intelligence and

resilience, which have been identified as learning

needs in the wider "conflict resolution" sphere.

Programme content has been aligned to the Core

Skills Training Framework.

G


The Workforce Development Team continue to

engage with our local FEI/HEIs to create

opportunities for students to learn about and/or work

at the Trust. For example we have a cohort of health

and care students at East Surrey College coming to

the Trust on placement and we have opened up

opportunities for hospitality (non-health) students to

support with ward hostessing/ meal times. The

Recruitment Team are developing our profiles on

social media to engage local communities. We now

have a "work for us" banner outside the main

entrance and another in reception which can be seen

by the public when they visit our campus.

G


We have developed, for a January 2016 launch, an

Apprenticeship/Work Experience page on the

external internet site and our Apprenticeship Advisor

is working with the Trust's HR Business Partners to

engage Managers in the organisation to support

apprentices and work experience. Members of the

Workforce Development Team continue to work with

our universities, schools and colleges to promote

placements/work experience opportunities in the

Trust.

G

Ensure effective processes are in place for the prevention and

management of violence and aggression against staff.

Promoting schemes to recruit local people into the NHS careers and

posts.

Positively engaging parents, young people, careers advisors,

university advisors, through individual contact and Trust initiatives.

Develop knowledge and skills vital for innovative thinking and

service improvement

5.28 NEWIBP service development

IT strategyPaul Simpson Bruce Stewart

New LIMS procurement is included with the

procurement for a new laboratory build, the OBC for

which is currently under preparation and is subject to

the Trust Boards agreeing (in Q4 2015/16) to

proceed on the basis of a Pathology JV FBC

addendum laying out the re-worked 10-year

finances. Planned go-live has been put back by at

least 6 months from March 2017 due to the time it

has taken in 2015/16 to re-work and agree the JV

finanical plan.

A

Joint venture for pathology - As part of the proposed pathology

development with BSUH procure laboratory system that meets long-

term Trust requirements.

Minutes of the Finance and Workforce Committee Held on 15 December 2015 at 8.30am In AD77, East Surrey Hospital, Redhill

PUBLIC

Present Richard Durban Paul Biddle Paul Simpson Angela Stevenson Ian Mackenzie Gillian Francis-Musanu

Non-Executive Director (Chair) Non-Executive Director Chief Finance Officer Chief Operating Officer Director of Information & Facilities Director of Corporate Affairs

In attendance Alan McCarthy

Sue Jenkins Janet Miller Ben Emly Peter Burnett Alison James (part meeting) Julian Webb (part meeting) Charminia Fletcher (part meeting) Mohammad Luqman (part meeting) Catriona Tait

Chairman Director of Strategy Deputy Director of Human Resources Head of Performance Deputy Chief Finance Officer Associate Director, Medicine Division Clinical Lead for Emergency Medicine Service Manager, Medical Specialties Radiology Services Manager Head of Costing and SLR (Committee Secretary)

1 MINUTES AND ACTIONS OF THE PREVIOUS MEETING The minutes of the 27th October 2015 were approved. The Committee sought an answer to the change in the non-pay in relation to a reduction in non-pay variance on page 8 of the Financial Performance M06 report. This has subsequently been confirmed to have been caused by the rephrasing of the TDA Plan. Review of Actions The action tracker was presented. Janet Miller confirmed that the current rate of completion for Achievement Reviews is 72%. A hierarchical view of compliance will be presented to the next meeting. Angela Stevenson confirmed that the risk and benefit sections for the Integrated Discharge Unit FBC would be updated for next month’s meeting. All other items due for November are included on the agenda.

2

BUSINESS CASE INVESTMENT

ED CT and Resus Full Business Case (FBC) Alison James presented the CT and Resus in the Emergency Department Full Business case. The Committee was advised that the cost of the project had reduced by £80k from the OBC and that it would deliver patient safety and quality improvements to Emergency patient by providing 24 hour access to a CT within the Emergency Department. Richard Durban asked about the recruitment of staff and the costs in the business case for staffing. Mohammad Luqman replied that the department had had issues recruiting Radiographers but this is now improving. Alison James added that the Trust would have 8 months from the approval of the business case to recruit the staff. Richard Durban asked about the quantifiable benefits of the investment. Alison James responded that these could be added to the business case and circulated. Action: Benefits of the business case to be updated are circulated to the Committee AS Sue Jenkins asked if the 9-5 option of additional hours is reflective of when the activity increase will be. Julian Webb confirmed that the out of hours scanning will now all the done in ED and the resource change is to have both the current CT in Radiology and the ED CT running between 9-5. The Committee approved the business case MES Update Paul Simpson provided a verbal update on the Radiology Managed Equipment Service and the Managed Print Service. Paul Simpson advised that the Radiology Managed Equipment Service OBC is with the TDA Capital Committee for approval. Issues with the scheme due to VAT rule changes have been shared with the preferred provider and will be reviewed as part of the FBC process. Paul Simpson confirmed that the Managed Printer Service full business case is being finalised following a review of the Trust print requirements. The OBC had a value of £1.3m but the FBC is expected to be less than £1m over the 5 year contract. It was agreed therefore that if the cost is less than £1m the FBC can be approved by the Trust Executive Committee rather than the FWC.

3 FINANCE Financial Performance M08 The finance performance paper was presented by Paul Simpson and noted that the Trust had an adverse variance of £0.6m against the M6 forecast. The other highlights included:

At Month 8 the Trust had YTD I&E deficit (after donated asset technical adjustment) of £4.8m which is £2.2m adverse to revised TDA plan

The reasons for the financial performance remain the same, an increase in Emergency

activity that is impacting on Elective activity and driving up costs, notably agency costs.

The Trust forecast position remains a £1.6m surplus but this will be discussed at the December Trust Board meeting.

The Trust’s cash position at the end of November 2015 was £5.0m.

The capital spend forecast this year remains £17.1m Paul Simpson stated that the Trust is now significantly adverse to the TDA resubmitted plan and the reasons for the performance remain the same. Paul Simpson advised that the position has not improved as forecasted and the elective activity is now going against plan tracking The Committee noted the worsening position and the impact on the M8 Forecast due to be discussed at the Private Board. The Trust is having conversations with the TDA over a capital to revenue transfer for 2015/16, this may total some £3m. Paul Simpson will provide a brief on the impact on the capital programme and advised that the conversion of working capital facilities to loans is also being discussed. Paul Simpson advised that the Trust was still experiencing delays with CCGs on cash receipts but that advances had been agreed. Paul Simpson stated that the TDA and the DH are requiring Trusts to convert their working capital facilities to loans and that the Trust is planning to make an application to the ITFF Board at the beginning of 2016. Paul Biddle asked if that cash request would be to fix the cash shortfall for the year or just in the short term as the Board, as responsible for ensuring the Trusts going concern, needs to ensure cash resources until March 2017. Paul Simpson replied that the application would be for £18m as this is the recognised gap in the Trusts balance sheet position. 2015/16 CIP Update Paul Simpson presented the 2015/16 CIP Update to the Committee and highlighted that the CIPs are not delivering and there had been an adverse movement due to operational pressures. Year to date £2.8m of CIPs have been achieved aided by £0.6K of non-recurrent contingency savings. The forecast is to deliver £4.6m (including the £0.6m contingency) against a target of £8.2m, a worsening of £0.35m since Month 7. 2016/17 Budget Update Paul Simpson presented the 2016/17 budget update. For the tariff deflator prudence has been applied to the modelling with 3% efficiency requirement being used. There was full discussion around the risks to delivering a largely cost reduction based CIP and the benefits of the inclusion of Productivity related CIPs. The Committee noted the indicative CIP for 2016/17 as presented.

4

WORKFORCE AND ORGANISATIONAL DEVELOPMENT Workforce and Organisational Development Report M08 The report was noted by the Committee.

5 CAPITAL AND ESTATES

Capital & Estates Report M08 The report was noted by the Committee.

6 IT IT Report M08 The report was noted by the Committee.

8 GENERAL Date of next meeting Monday 25th January 2016 3.30pm – AD65

Audit & Assurance Committee Page 1 of 6 Minutes November 2015 An Associated University Hospital of


AUDIT & ASSURANCE COMMITTEE

Meeting held on Tuesday 10th November 2015, 10:00am – 13:00pm Venue: Room AD77, Trust HQ, East Surrey Hospital

Present: Paul Biddle PB Committee Chair / Non Executive Director Richard Durban RD Non Executive Director

Richard Shaw RS Non Executive Director In attendance: Paul Simpson PS Chief Finance Officer Fiona Allsop FA Chief Nurse (Item 3.1) Jamie Bewick JB External Audit Nick Atkinson DM Internal Audit

Sarah Pratley SP Local Counter Fraud Specialist Djafer Erdogan DE Head of Financial Accounts Colin Pink CP Head of Corporate Governance

Action by

1 1.1 Welcome and Apologies for absence

The Chair welcomed members and attendees to the meeting. Apologies for absence had been received from GFM.

1.2

1.3

Minutes of last meeting

The Committee reviewed and agreed the minutes of previous meeting were as a true record.

Actions from previous meetings:

The action tracker was reviewed and the Committee noted that actions 2.1 and 3.2 had been closed prior to the meeting.

Action 3.1, relating to workforce controls, is not due until May 2016.



2 2.1 Review of Board Assurance Framework

PS introduced the BAF for review prior to the November Public Board meeting, highlighting that no changes had been made since the October Public Board meeting.

The Committee discussed the IT related strategic risk. PS

highlighted that an updated IT road map would be presented at the

IT Strategy meeting on the 13th November. PS went on to provide

reassurance that actions to meet the first phases of the road map are

occurring. The Committee asked that the relevant BAF risk be

updated to reflect output of the strategy meeting. Action CP and IM

The Committee discussed the Trust’s main financial risks in detail,

noting that both the Trust’s forecast and gross risk is expressed in

Board papers. The Committee requested that PS reconsider the risk

score agreeing that the plan to meet the forecast had been well

described in board papers. Action PS

The Committee asked for assurances that efforts to improve quality

and productivity within the Trust’s Outpatient’s services are on track.

The Committee was assured that the issue was not a safety risk and

that appropriate management focus is in place, including VMI work

stream focus and productivity reviews.

The Committee noted the overall improvements in risk management

which facilitates conversations at Executive level and has

strengthened Trust governance overall. Noting that the BAF included

assurances from third parties and had recently received a further

green Internal Audit.

The Committee focussed on the Trust’s liquidity position challenging

management on the detail that supports its description of risk and

noting that restrictions to access to extra cash had started to be

enacted, making the process of application harder. PS highlighted

that the TDA and DOH are both aware of the Trust’s financial

position, that the issue was not materially worsening and was

dependant on the income the Trust received.

PS went on to state that the Chief Executive had formally written to

Sussex CCG to request a rebase of indicative plans. As such

CP and IM

PS



contractual activity is due to start shortly. There have also been

meetings to start to resolve issues of non-payment.

The Chair brought the discussion to a close stating that the issue of

the Trust’s liquidity would be raised at the Public Board meeting.

The Committee noted the report.

2.2 Review of Significant Risk Register

PS introduced the SRR for review prior to the November Public Board. The Committee raised no issues for discussion that had not been included in early Board Assurance Framework conversations. The Committee noted the report.

3 3.1 Internal Controls RS presented management’s review of internal controls relating to

patient systems, highlighting that the paper had been discussed at

SQC, which had provided good assurance. RS went on to highlight

that the main issue of action related to training for safeguarding, but

there was evidence of good improvements in overall compliance.

FA described how actions to improve training compliance for

children’s safeguarding are being monitored both internally and

externally and is on track. The Committee noted that the Trust had

chosen to provide the highest level of training to all relevant staff

(Level 3).

The Committee noted that the patient property policy was due for

review and took assurance that this was in hand.

PS highlighted the factual error relating to the named management

lead for ‘private and Overseas patients’, this should read Ruth Blanc.

The Committee took assurance from the report.



3.2 Losses and Comps DE presented the Trust’s midyear position for losses and comps, highlighting the error in the coversheet that should read a total of 19 special payments rather than a total of 16. DE went on to highlight that year to date there had been 93 cases where a loss or special payment had been made, totalling £178k. This compares to 140 cases totalling £375k for the full 2014-15 financial year. The main payments so far relate to write off of overseas debt (£77k) and payments made under legal obligation (£65k). DE stated that the large waiver recorded in the paper related to the development of the new Re-enablement Unit. The Committee challenged the detail of the paper and took

assurance from both the detail of the controls in place and the

forecasted reduction in number of losses, based on the cases in the

pipeline.

DE highlighted that the overseas debts position was similar to

previous years, however he went on to highlight that recovering

overseas debt was becoming more administratively challenging.

The Committee took assurance from the paper and noted that the

overall value of losses was high.

4 4.1 Internal Audit Progress Report NA introduced the report, highlighting the amount of activity that was underway towards completing audits detailed in the annual plan. Noting in particular the pharmacy stock review, mortality systems audit and right bed first time audit. The review of the Board Assurance Framework had been completed which had included one low level recommendation and action relating to the recording of healthcare acquired infections controls on the BAF. NA went on to highlight the actions still outstanding on the action tracker which relate to procedural issues and temporary staffing controls.



4.2 External Audit Report JB introduced the paper which highlighted the need to set an ‘Auditor Panel’ to facilitate appointment of External Audit from 2017, changes in format of annual report and changes to assessment of ‘value for money’ opinion. The Committee discussed the need for the Trust to appoint an ‘audit panel’ and responsibility to recommend to the Shadow Council of Governors the appointment of the Trust’s External Auditor. The Committee agreed to request that the Board approve the AAC committee membership as the Trust's Audit Panel Action PB. JB highlighted that the National Audit Office code of practice had been amended to include a new definition of ‘value for money’. The Committee noted that the assessment will be based on proper practice and arrangements, including independent decision making, sustainability and working in partnership. The Committee discussed the proposed agency price caps noting that temporary staffing agencies willingness and capability to join national frameworks would be the key issue in determining the success of the national imperative. The Chair thanked JB for the valuable emerging issues report.

PB

4.3 LCFS Report SP introduced the report highlighting specific investigations and their issues and outcomes (successful dismissal and the striking off of a biomedical scientist). These cases included potential time sheet fraud and allegations of staff working whilst on sick leave. The Committee asked for details of the value that the Trust had successfully reclaimed in recent years. SP indicated that this detail was in the annual report. The Committee asked for an update on what actions the team are taking to raise awareness of the success of the team. SP highlighted that all campaigns are based on an assessment of likelihood of fraud and potential effectiveness of awareness campaign. Highlighting e-bulletin stories, staff magazine articles and training events.



The Committee went on to discuss issues relating to overpayments and plans to strengthen controls supporting leavers and starters that do not commence work but are paid in error. PS commented on the work carried out in radiology which had highlighted some good practice and was no longer a counter fraud issue. The Committee discussed SBS’s involvement in these matters and the Trust’s effort to resolve issues. RS queried the case relating to an illegal worker and asked for assurance that appropriate DBS checks had been carried out. SP assured the Committee that this was an issue over eligibility to work and there was no suggestion that the background check had failed. The Chair thanked SP for the report.

5 5.1 Draft Annual Report to Board CP introduced the first draft of the annual report to Board. This was based on the previous year’s report and include key updates on internal controls and the possibility of including a self-assessment based on the ‘Good Governance Institutes’ maturity matrix for Audit Committees. The Committee discussed the draft report and asked for amendments to be made prior to review at the January meeting. Action CP to amend draft report as detailed.

CP

5.2 AOB PS announced that the Trust had been selected to be involved in the national reference cost audit carried out by PricewaterhouseCoopers. The expectation is that the report will be ready in January 2016 and will be reviewed by the Finance and Workforce Committee. No further AOB was raised.

6 6.1 Date of Next Meeting: 15th January 2016, 09:30 pre-meet, 10:00 meeting start.