council of governors meeting - st richard's hospital · january 2020 15.00 – 18.00 john bull...

Council of Governors Meeting

Thursday, 3rd October 2019 at 15.00

John Bull Room – Worthing Health Education Centre (WHEC), Worthing Hospital

AGENDA

Please note that Any Other Business items should be advised to the Chairman before the Meeting

1 15.00 Welcome, Introductions and Apologies for

Absence Mike Rymer

2 15.05 Declarations of Interests Verbal Mike Rymer

3 15.05 Minutes of Meeting of the Council of Governors held on 4th July 2019 To approve

Enclosure Mike Rymer

4 15.05 Minutes of the Annual General meeting held

on 25th July 2019 To approve

Enclosure Mike Rymer

5 15.05

Matters Arising from the Minutes To note

Enclosure

Mike Rymer

LISTENING AND REPRESENTING

6 15.05 Lead Governor’s Report To receive and agree any necessary actions

Enclosure John Thompson

7

15.10 Membership Committee Report

To receive and agree any necessary actions Enclosure John Thompson

8 15.15 Update from Staff Governors

To receive and agree any necessary actions Verbal Staff Governors

9 15.20 Update from Appointed Governors

To receive and agree any necessary actions Verbal Appointed

Governors ACCOUNTABILITY

10 15.25 Chief Executive update to Council To receive

Presentation

Denise Farmer

11 15.35 Governors Feedback from Working Groups

• Noise @ Night • Outpatients Improvement Project • Reducing Abusive Behaviours

To receive

Verbal John Thompson

12 15.45 External Auditors Report

• Annual Audit Letter • External Assurance on the Trust’s

Quality Report To receive

Enclosure Ernst and Young

13

15.55 External Auditor Performance Report To receive and agree any actions

Enclosure Jon Furmston

14 16.05 Committee Feedback – Audit Committee To receive information on the role of the Committee

Presentation/ Discussion

Jon Furmston

GOVERNANCE

15 16.25 Development of the Trust’s Clinical Strategy To receive and agree any necessary actions

Presentation Oliver Phillips

OTHER ITEMS

16 16.30 Company Secretary Report on Governor, Lead and Deputy Lead Elections To approve

Enclosure Glen Palethorpe

17 16.30 Other Business Mike Rymer

18 16.30 Date of next meeting:

Thursday 16th January 2020 15.00 – 18.00 John Bull Room WHEC, Worthing Hospital, BN11 2DH

Mike Rymer

19 16.30 Questions from the Members of the Public Mike Rymer

Glen Palethorpe Group Company Secretary [email protected] Quoracy of Council of Governors Meetings A meeting of the Council shall be quorate and shall not commence until it is quorate. Quoracy is defined as meaning that the following requirements are all satisfied:

• there shall be present at the meeting at least one third of all Governors (9) • of those present, at least 51% shall be Elected Governors • of whom at least two shall be Elected Public Governors

mailto:[email protected]

Minutes of the Council of Governors meeting held in Public from 14.15 on Thursday 4th July 2019 in Ridgeworth House, 5-9 Liverpool Gardens, Worthing.

Present: Alan McCarthy John Todd Jill Long Anita MacKenzie John Thompson Andrew Ratcliffe Lyn Camps Patricia Peal Pauline Constable Les Willcox Alan Sutton Linda Tomsett Penny Richardson Val Turner Ryan De-Vall Warwick George Moira Whitlock

Chairman Public Governor – Adur Public Governor – Arun Public Governor – Arun Public Governor – Arun (Lead Governor) Public Governor – Arun Public Governor – Arun Public Governor – Worthing Public Governor – Worthing Public Governor – Chichester Public Governor – Chichester Public Governor – Chichester Public Governor – Horsham Appointed Governor - Worthing Borough Council Staff Governor – Scientific, Technical & Professional Staff Governor – Estates & Facilities Staff Governor – Nursing & Midwifery

In Attendance:

Dame Marianne Griffiths Patrick Boyle Mike Rymer Joanna Crane Lizzie Peers Amanda Fadero Alison Ingoe Jennie Shore Tim Taylor Glen Palethorpe Jan Simmons

Chief Executive Officer Non-Executive Director Non-Executive Director Non-Executive Director Non-Executive Director Managing Director Director of Finance HR Director Medical Director Group Company Secretary Corporate Governance Officer (Minutes)

COG/07/19/01 Welcome and Apologies

1.1 The Chair welcomed all new and returning Governors to the meeting.

1.2 Apologies for absence were noted from: Executive Directors: Denise Farmer, Karen Geoghegan, Maggie Davies and George Findlay. Non-executive Directors: Jon Furmston Governors: Stuart Fleming, Gill Yeates, Miranda Jose, Somnath Mukhopadhyay, Jane Ramage and John Bull.

COG/07/19/02 Declarations of Interests

2.1 There were no declarations of interest. COG/07/19/03 Minutes of the Council of Governors meeting held in Public on the

7 March 2019

Minutes page 2

3.1

The minutes of the meeting of the Council of Governors held on the 7th March 2019 were agreed as correct and APPROVED to be signed by the Chairman.

COG/07/19/04 Matters arising from Minutes

4.1 The Matters Arising from previous meetings were received and all noted as having been completed.

COG/07/19/05 Board Report to Council

5.1

5.2

5.3

5.4

5.5

5.6

5.7

5.8

5.9

5.10

As the Council had not met since the Trust’s year end, Dame Marianne Griffiths provided a review of the year and highlighted the following key areas. Quality In relation to the True North quality metric for mortality the Trust aspired to be in the top 20 hospitals with a rating below 100. Marianne was pleased to report that this had been achieved for most of the year with the last rolling average being 91.2% which was much better than across the country. The Trust’s aim for a harm free care for patients was to be in excess of 97%; currently 98% was being achieved. A&E – Marianne explained the Trust performance in the context of the National target and the performance trajectory set by the Trust. As a result of the Trust’s current performance a great deal of work was taking place and the Trust performance for the last year had increased significantly. Friends & Family test – the Trust sees a response rate of three times more than the National average, notably outpatients had improved to over 97%. Marianne went on to say that a huge amount of work had taken place in respect of inpatients. One area of focus had been to reduce noise at night for patients and improvements had been made by the introduction of soft close bins and reducing the number of moves at night. With emphasis on this area continuing this year it was hoped that more interventions would be identified that could help. It was with great pleasure that Marianne was able to announce that the Trust had been named as one of the best hospitals in the country at this year’s CHKS Top Hospitals Awards. Marianne then moved on to report on the 4 key constitutional access targets. A&E The Trust had achieved 95.02% against a trajectory of 95% which was an increase on the previous month. The Trust had succeeded in reaching all of its quarterly A&E targets for the year and as a result had received a further £770k from the Provider Sustainability Funds (PSF). The Trust had 1000 less breaches than the previous year despite an increase in attendances and 50 fewer beds due to no escalation wards being used. Referral To Treatment With regard to patients waiting more than 18 weeks for treatment

Minutes page 3

5.11

5.12

5.13

5.14

5.15

5.16

5.17

5.18

Marianne advised that the Trust had achieved its operating framework target to have a smaller waiting list than the previous year. This had been agreed with the Commissioners and the organisation was ahead of the target and in line to achieve the full constitutional target by this year end. Cancer The outcomes of cancer trajectories during the year had been variable although mainly achieved across the various targets with the exception of the 62 day referral to treatment performance target. The Trust had seen more than a 50% increase in Urology referrals as well as a large increase in Colorectal referrals but lacked the staffing levels to cope with this increase. However, Marianne was pleased to report that at the end of May all the cancer targets were now being met and expressed her thanks to the Core Division for all their efforts that helped to achieve this. Diagnostics The Council was informed that this would be the 20th month of sustainably achieving 1% whilst seeing huge increases in activity. Finance Marianne reported that as the Trust had achieved its control total and A&E performance it had received £17m from the Provider Sustainability Fund (PSF). In addition, extra funds were distributed as other Trusts had not achieved their targets. This increased the Trust’s surplus to £28m. However, this excess PSF money could only be used for capital. Workforce With nursing vacancies within the Trust currently standing at 160, Divisions had been asked by site to determine what single thing would make the most difference to improve their recruitment. With this in mind very specialist areas such as critical care, theatres etc were being targeted and the Trust had just launched its Refer a Friend scheme. The scheme offered a financial incentive for any member of Western Sussex Hospitals staff referring a Staff Nurse, ODP or Midwife to join the Trust. CQC Marianne was pleased to announce that the CQC Use of Resources assessment had taken place during the previous week. The visit had been extremely successful and Marianne was very proud of the phenomenal amount of input by Divisional and Corporate staff. It was anticipated that the results of the inspection would be received in early December. The Council was advised that the Well-Led inspection was scheduled to take place on 20 and 21 August 2019 and the unannounced visit was expected during the next 6 weeks but it was unknown which service would be inspected. Responding to a question from Val Turner around the siting of the hyper acute stroke unit, Marianne said that the consultation for this would be commencing in the summer. The National stroke review had been completed and consideration was being given as to how many of these units were required across the Country. Marianne agreed to ask George Findlay to provide a more formal update on the process at the next Council of Governors meeting in October. ACTION: The October agenda to include time for the receipt of an update on the National Stroke Review

GF/ Agenda

Minutes page 4

5.19

5.20

5.21

A question received from Jane Ramage asked if a review of the longer visiting times had taken place. Marianne replied advising that the review had not yet been undertaken but added that there were differences of opinions as to its positive impact. Heads of Nursing were working with their teams to review the site differences and present a proposal and these would inform the review. It had been agreed that this would be completed in the next three months. Alan McCarthy took the opportunity to extend the Council’s thanks to Roger Hammond, the previous Lead Governor and to wish him well. Alan also expressed thanks to John Thompson for taking over the Lead Governor role following Roger’s retirement. The Council of Governors RECEIVED the Board Report to Council.

COG/07/19/06 Lead Governor’s Report

6.1

6.2

6.3

6.4

6.5

John Thompson presented the Lead Governor’s report and highlighted the following key areas. The Council had received and commended the wonderful news that Mike Viggers, the Trust’s recently retired Chairman, had been awarded a very well-deserved MBE. There had been 805 nominations received this year for the Trust’s STARS Awards including nearly 100 from the Public which was a tribute to the care, dedication and compassion of the organization’s staff. John expressed huge thanks to the staff for the almost unrelenting pressures being experienced across the Trust. The Council of Governors RECEIVED the Lead Governor’s Report.

COG/07/19/07 Membership Committee Report

7.1

7.2

7.3

7.4

John Thompson introduced the Membership Committee report and action plan and highlighted the good progress that had been made as a result of stepping up the focus on recruitment in order to make a bigger and more productive impact. “Having your say” in our hospitals and how they develop in the rapidly changing world of the NHS was the key message in engaging with prospective and existing members. Most GP Surgeries had been contacted with a view to recruiting new members and publicising membership events but this had met with mixed results. However excellent support was received from Coastal West Sussex Clinical Commissioning Group to take this forward. An amazing 68 entries had been received for a logo and poster competition that had been run in a local school; the posters were hoped to be displayed at the Trust’s Annual General Meeting (AGM) later in the month. There would also be an opportunity to recruit new members at the forthcoming Supercar event being run by the Love Your Hospital (LYH) charity. Six new banners promoting membership had been acquired to display at events such as this.

Minutes page 5

7.5

7.6

7.7

Andrew Ratcliffe commented that his daughters had applied for membership of the Trust but to date had not received a welcome letter. Glen Palethorpe advised that this would be investigated. ACTION: This lack of welcome letters being sent to these two prospective members to be investigated. The Council of Governors RECEIVED the Membership Committee Report.

GP/JS

COG/07/19/08 Staff Governor Report

8.1

8.2

8.3

8.4

8.5

Moira Whitlock advised that, with regard to nursing, the focus had been to improve the performance of agency nurses. Responding to a question relating to Patient slide sheets, Alison Ingoe informed the Council that a pilot had taken place and was being evaluated to enable a business case to be presented for approval. Alison would provide feedback directly outside the meeting. Patricia Peal recalled how, during a recent ward visit, she was concerned to see members of staff having to leave a ward to work elsewhere. Amanda Fadero asked to meet with Patricia to discuss this and to learn from her experience. ACTION: Amanda Fadero and Patricia Peal to meet to understand and learn from Patricia’s observations. The Council of Governors RECEIVED the Staff Governors Report.

AI AF/PP

COG/07/19/09 Appointed Governors Report (District Cllrs)

Worthing Borough Council

9.1

9.2

Val Turner reported on the very successful local social prescribing scheme and advised that this was being expanded to a wider area. The scheme is a means of enabling GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services. Val also informed the Council of the Greet the Street scheme that was aimed at getting people active. The Council of Governors RECEIVED the Appointed Governors Report.

COG/07/19/10 Governors Feedback from Working Groups

10.1

10.2

10.3

Dementia Strategy Group Patricia Peal explained that the new 3-year Dementia strategy plan aimed to enable patients with dementia to have a less frightening and a shorter stay in hospital. The Council acknowledged and thanked the volunteers for the help they provided to dementia patients and also to the winter warriors, whose support was invaluable. Noise @ Night As one of the Patient First Breakthrough objectives, and an important part of delivering improvements to patient experience, Patricia Peal informed the Council that Governors could become involved in carrying out the

Minutes page 6

10.4

10.5

10.6

10.7

10.8

10.9

10.10

surveys on which this initiative was based and asked for those interested to contact the Trust. Patient Catering John Thompson advised that this was an excellent project that was well on the way to improving the suitability and quality of the meals served to inpatients. The menu was based on a cook chilled process providing greater flexibility. The menu was more varied and suitable for young people and older patients who may want smaller portions as well as including snacks for those who prefer to eat little and often. The project had been delayed by the need to meet a number of Building Regulation requirements; replacing more kitchen equipment than was previously planned and to allow a review of the costs of fitting out the new kitchen at St Richard’s which would serve both hospitals. Full go live was now expected in October. Outpatients’ Improvement John Thompson provided feedback on the Outpatient Improvement project. The Steering Group included staff from both the Project Management Office (PMO), responsible for delivering the cost savings target set by NHS Improvement, and the Kaizen Team who led on delivering the Patient First projects. John advised that the two most interesting aspects were seeing how and why what might appear simple systems were quite complex and the great determination of everyone to work together to effect real improvements as soon as possible. The aim of the project was to increase the number of patients having one booking and one attendance thereby reducing cancellations by both the hospitals and patients. Ryan De-Vall asked if an update on the Outpatients’ Improvement project could be provided to Staff. Amanda Fadero agreed to feed this back to the project group. ACTION: Feedback to be provided to staff on the Outpatient Improvement project. Val Turner enquired as to what impact the recent Listeria issue had on hospital catering. Amanda Fadero advised that the outbreak was sandwich related and had no impact on patient catering. The company concerned had ceased production and the Trust had removed all products supplied as a precaution. The Council of Governors RECEIVED the Governors Feedback from Working Groups.

AF

COG/07/19/11 Committee Feedback – Finance and Performance

11.1

11.2

Lizzie Peers gave a presentation on the purpose and scope of the Finance and Performance Committee, how it sought assurance, its link to other sub-Committees and Board and planned future developments of its cycle of business which was linked to the Trust’s Board Assurance Framework. The purpose of the Committee was to support the Board and to ensure that all appropriate action was taken to achieve the financial and operational performance objectives of the Trust. This was achieved through regular review of financial and operational strategies and

Minutes page 7

11.3

11.4

performance, investments and capital and estates plans and performance. Lizzie added that consideration was still being given to the further development of the committee and how to ensure it provided effective assurance to the Board. The Council of Governors RECEIVED the Finance and Performance Committee feedback.

COG/07/19/12 Report from the Nomination and Remuneration Committee meeting

12.1

12.2

12.3

12.4

12.5

12.6

12.7

12.8

Glen Palethorpe presented the report from the Nomination and Remuneration Committee held on 17th June 2019 and highlighted the following areas: The Committee had received a report from the Trust’s Senior Independent Director (SID) who undertook the appraisal of the Chair. Confirmation was received that the appraisal had confirmed the Chair remained a fit and proper person in accordance with the CQC regulations. There was nothing that needed to be referred to the council in respect of the Chair’s performance. The objectives set for the Chair included a proposed objective set by the Lead Governor on behalf of the Governors, that being “Strengthen relationships with Governors to ensure diversity of feedback and insight from the Council of Governors alongside greater understanding of their work”. The Committee, on behalf of the Governors, had set an Objective for each Non-Executive Director (NED) to “Provide feedback to Council of Governors through both the half yearly Governor and NED meetings and through presentations on their role as Committee Chairs to the Council meetings during the year.” The Committee had received information in respect of the terms of office for the NEDs and recognised that the Chair of the Audit Committee would be retiring in the Autumn. A formal recruitment process would be followed to secure a replacement NED and members of the Council of Governors would be actively involved in this process. The Committee had also received feedback from the Senior Independent Director (SID) on the outcome of governor exit interviews. Whilst the number of Governors taking part in the process was small this time the interviews again confirmed that the retiring governors felt engaged with and that there were opportunities to provide feedback which was always listened to and acted on. The retiring Governors recognised that demands on their time had to be carefully managed as there were numerous opportunities for Governors to be involved with meetings at the Trust. On behalf of the Governors, Alan McCarthy said the Trust were blessed with some very special Non-Executive Directors and thanked them for the huge amount of work they did for the organisation. The Council NOTED that the appraisals did not identify any matters that needed referring to the council for consideration in respect of the Chair or the NEDs failing to remain fit and proper persons.

Minutes page 8

12.9

12.10

The council ENDORSED the Governor set objectives for the Chair and each NED. The Council NOTED that Governors would be invited to take part in the recruitment process for the replacement of the Chair of the Audit Committee.

COG/07/19/13 Governor Strategy Group – Update

13.1

13.2

John Thompson reported that there were now established arrangements for keeping Governors in touch with the development of Trust strategies. Recently Governors, drawing on their contacts in and knowledge of the community, were able to contribute to the Trust’s Annual Plan. Other strategy reviews are planned and Governors would be involved in those, starting with the Clinical Strategy. The Council of Governors RECEIVED the Governor Strategy Group update.

COG/07/19/14 Council of Governors’ Annual Programme of Work

14.1

14.2

14.3

14.4

John Thompson introduced the Council’s Annual Programme of Work that set out the objectives, timetable and mapping of 2019/20 Governor activities to the core expectations of the Council. John added that the Governors welcomed the change to the performance reporting at the bi-monthly public Board meetings and really appreciated the quality of the Governor Information Sessions with presenters going out of their way to make them interesting and informative. A request for more seminars was noted. Penny Richardson pointed out that the date for the attendance at Board on 27th July was incorrect and should be amended to the 25th July. The Council of Governors APPROVED the draft work programme for the council and agreed to receive periodic updates on progress during the year.

COG/07/19/15 Governor Election Report

15.1

15.2

15.3

15.4

Glen Palethorpe presented the report and highlighted the following: The Trust ran an election programme across May (seeking nominations) and June (voting taking place for contested positions). The elections were for 7 publically elected positions, 1 elected patient / Carer position and 2 staff elected positions. The outcome of the elections were:

• John Todd returned as Public Governor for Adur having had a short period where he was not an elected Governor. Only one candidate stood leaving one vacant position.

• Lyn Camps elected as Public Governor for Arun, this being Lyn’s first term having previously been an Associate Governor.

• Andrew Ratcliffe elected as Public governor for Arun, this being

Minutes page 9

15.5

15.6

15.7

Andrew’s first term having been an Associate Governor previously.

• Anita MacKenzie was re-elected as Public Governor for Arun. This was Anita’s second and final term under the current constitution.

• Penny Richardson was re-elected a Public Governor for Horsham. This was Penny’s second and final term under the current constitution.

• Pauline Constable was elected as Public Governor for Worthing. This was Pauline’s first term.

• Warwick George was elected as a Staff Governor for Estates and Ancillary. This was Warwick’s first term.

• Patient / Carer – No one stood for election and the Council was asked to approve the co-opting of Stuart Fleming to fill the vacancy. Stuart had previously been elected to this position and would be a non-voting position.

• Medical and Dental Staff Governor – the Council was asked to support the Trust in seeking a co-opted member of staff who could be recommended to the next Council meeting for approval. This would also be a non-voting position. However Richard Venn had agreed to continue in this position until a replacement was found.

Lead Governor Arrangements: Following the retirement of Roger Hammond the Lead Governor positon became vacant. The Deputy Lead Governor, John Thompson, therefore has filled this role. With John taking on this role the Council were left with no formal Deputy Lead Governor. Jill Long remained a serving Governor and previously held the Deputy Lead Governor role and had agreed to fill this role. The Council would hold elections for the Lead and Deputy Lead Governor positions in October 2019. Appointed Governors: The Trust had been informed of the following changes to a number of appointed Governors:

• Chichester District Council their appointed Governor was now Donna Johnson.

• Arun District Council had appointed Gill Yeates to their vacant

appointed Governor position

• Western Sussex County Council, due to change in member portfolios their position was now vacant. The Trust had asked that they make an appointment to this vacant position as soon as is possible. (Post meeting note: Jacky Pendleton had since been appointed to this position)

The Chair expressed his and the Council’s thanks to Stuart Fleming for agreeing to being co-opted into his previously held Governor role, and to Richard Venn who was temporarily remaining as Medical and Dental advocate until a co-opted Governor could be found and also to John Thompson and Jill Long for agreeing to stand as Lead and Deputy Lead Governors until the October elections.

Minutes page 10

15.8

15.9

15.10

15.11

15.12

The Council of Governors NOTED the outcome of the elections and welcomed the newly elected / returning Governors to the Council. The Council of Governors APPROVED the co-opting of Stuart Fleming to the Patient / Carer vacancy until the next round of scheduled elections. The Council of Governors APPROVED the Trust seeking a co-opted member of staff for the Medical and Dental vacancy and to recommend this person to the next Council meeting in October 2019. The Council of Governors RATIFIED John Thompson as Lead Governor until the lead governor elections which would be undertaken in October 2019. The Council of Governors APPROVED that the vacant Deputy Lead Governor role be filled on an interim basis by Jill Long who previously held this positon.

COG/07/19/16 Any Other Business

16.1

16.2

16.3

Warwick George raised a concern he had with the morale of staff within the facilities department. The Chair invited Warwick George to meet with him to discuss his concerns around staff morale. ACTION: Chair and Warwick George to meet. John Thompson reminded the Council that the AGM would be taking place on 25 July starting at 6pm.

AM/WG

COG/07/19/17 Date of Next Meeting

17.1 It was noted that the next Council of Governors Meeting would take place on Thursday 3 October 2019 in the John Bull Room, WHEC, Worthing Hospital, BN11 2DH.

COG/07/19/18 Questions from the Members of the Public

18.1

18.2

18.3

18.4

It had been noted that neither the Agenda nor Minutes were available on the Trust’s website. Glen Palethorpe said he had been made aware of this earlier on the day of the meeting and it was being investigated. ACTION: Investigation as to the breakdown in the process to load papers ahead of the Council meetings. Heather Duffield asked if there was any cause for concern around the backlog of appointments and the long waiting list for the Eye Clinic in Southlands Hospital. Amanda Fadero replied saying there was always concern when patients waited longer than desired and the Trust were actively recruiting more staff and exploring ways to improve the situation, but each patient waiting is subject to a clinical review Heather went on to express her general concerns about the demands on the NHS including the need for timely identification of Sepsis as highlighted in national news broadcasts. Alan McCarthy replied and acknowledged the issues raised but demand was outstripping funding and

GP/JS

Minutes page 11

18.5

18.6

social care was essential for the system to operate. With regard to Sepsis, Tim Taylor replied saying that nationally a number of patients presenting with Sepsis were not getting the required antibiotics in the prescribed hour. This had been a priority for the Trust and the area continued to be a very active workstream which sees the Trust’s performance in the administration of antibiotics being good. Alan Sutton commented that, as a member of Chichester District Council, he had attended a West Sussex County Council joint meeting to discuss the wider care strategy. Alan felt this had been an extremely positive meeting with full commitment to work together and influence the local social care strategy.

Jan Simmons Corporate Governance Officer July 2019 Signed as a correct record of the meeting …………………………………………………. Chair ………………………………………………… Date

Minutes of the Annual General Meeting of Western Sussex Hospitals NHS Foundation Trust held at 19.40 on 25 July 2019 in the Dinwoodie Lecture Theatre, Chichester Medical Education Centre, St Rirchard’s Hospital, Spitalfield Lane, Chichester, West Sussex, PO19 6SE

Present: Alan McCarthy Chairman Mike Rymer Non-Executive Director

Joanna Crane Non-Executive Director Lizzie Peers Non-Executive Director Marianne Griffiths Chief Executive George Findlay Chief Medical Officer Denise Farmer Chief Workforce & Organisational Development

Officer Maggie Davies Chief Nurse Alison Ingoe Finance Director Amanda Fadero Managing Director Governors John Thompson Public Governor - Arun (Lead Governor) Jill Long Public Governor - Arun (Deputy Lead Governor) John Bull Public Governor - Worthing Lindy Tomsett Public Governor – Chichester Alan Sutton Public Governor - Chichester Anita MacKenzie Public Governor - Arun Andrew Ratcliffe Public Governor - Arun John Todd Public Governor – Adur Gill Yeates Appointed Governor – Arun District Council Jane Ramage Appointed Governor – Friends of WSHT

Hospitals Richard Venn Staff Governor – Medical & Dental Ryan De-Vall Staff Governor – Scientific ,Technical and

Professional Services In Attendance: Glen Palethorpe

Jan Simmons Group Company Secretary Corporate Governance Officer (Minutes)

AGM/19/1 WELCOME AND APOLOGIES FOR ABSENCE

1.1

1.2

The Chairman welcomed all those present to the meeting. Apologies for absence were received from: Executive Directors : Pete Landstrom, Karen Geoghegan Non-Executive Directors : Jon Furmston Governors: Les Willcox, Miranda Jose, Lyn Camps, Penny Richardson, Pauline Constable, Patricia Peal, Stuart Fleming, Moira Whitlock, Jacqui Campbell, Warwick George, Somnath Mukhopadhyay, Donna Johnson, Kate Galvin, Jacky Pendleton, Val Turner.

AGM/19/2 DECLARATIONS OF INTERESTS

2.1 There were no declarations of interests to record. AGM/19/3 MINUTES OF THE ANNUAL GENERAL MEETING HELD ON 23rd July 2018

3.1

In the absence of formal minutes relating to the last meeting, the Council • Agreed that it did receive and agree the minutes of the 18th July 2017

AGM as a correct record; • Confirmed that it did receive the Trust’s Annual Report and Accounts for

2017/18; • Confirmed that it did receive an update from the Lead Governor on the

work of the Council during 2017/18 and • Confirmed that questions raised were answered.

AGM/19/4 Presentation of the Annual Report and Accounts 2018/19

4.1 The Council of Governors received the Annual Report and Accounts 2018/19 for Western Sussex Hospitals NHS Foundation Trust.

4.2 Alison Ingoe, Finance Director presented the Annual Report and Accounts for

2018/19 in more detail and gave an overview of the Trust’s financial performance headlines, these being:

• The Trust had delivered a retained surplus of £23.1m. • The financial control total had been delivered and had earned the full

Provider Sustainability Funding (PSF of £16.3m and a bonus PSF of £11m.

• The Trust had a financial risk rating of 1 representing the top possible rating with the least risk.

• There had been cost improvement savings of £18.2m. • Expenditure on capital schemes of £19m. • The Trust had delivered efficiency savings of £18.2m • In 2018/19 there had been 110 separate capital investments totaling

£19.4m.

4.3 For 2018/19 the particular headlines in relation to income for the Trust were : Income from patient care activities increased by £22.3m (5.7%). This included Clinical Commissioning Group income increasing by £16.3m and an increase of £4.5m for specialists services activity. Other operating income included Provider Sustainability / Sustainability and Transformation Fund income of £27.3m (£9.9m 2017/18)

4.4 Alison went on to report that the operating expenditure of the Trust had increased by £18.8m (4.6%). Within this the total pay bill increased by £11.5m (4%). However, the cost of agency staff decreased by £2.2m (a reduction of 16.7%) from £12.9m to £10.7m. Against this backdrop there was an increase of £2.8m for the costs of the Trust’s national clinical negligence insurance, an increase of £1.5m for research and development and an increase of £2.4m for education and training.

AGM/19/5 QUESTIONS AND ANSWERS

5.1 There were no questions received from Members or the Public on the Accounts.

AGM/19/6 Close of Meeting

6.1 To conclude the meeting Alan McCarthy thanked everyone present for attending and for their continued support of the Trust.

Jan Simmons

Corporate Governance Officer July 2019

Signed as a correct record of the meeting

…………………………………………………. Chairman

…………………………………………

MATTERS ARISING FROM PUBLIC MEETING OF THE COUNCIL OF GOVERNORS

MATTERS ARISING FROM THE MEETING HELD ON 4 JULY 2019

Minute Ref Description of Action Responsible Person Deadline Report

COG 03/18/6.5 Lead Governor Survey to be considered in detail at a future meeting of the CoG. JT

December 2019

Effectiveness of the Council survey to be carried out at the end of the year.

COG/07/19/5.18 Stroke Provide a more formal update on the national Stroke Review.

GF January 2020

Deferred to January meeting.

COG/07/19/7.6 Membership Investigate the lack of welcome letters being sent to two prospective members.

GP /JS October 2019

Investigated and resolved. COMPLETE.

COG/07/19/8.4

Ward visit A meeting to be arranged to understand and learn from the observations made by Patricia Peal during a ward visit with regard to staff having to leave a ward to work elsewhere.

AF / PP October 2019

Arrangements being made to liaise with Patricia Peal to learn from her observations. COMPLETE.

COG/07/19/10.8 Outpatients’ Improvement Feedback to be provided to staff on the Outpatient Improvement project.

AF October 2019

Comms requested to liaise with Alison Ingoe to provide a staff update on the Corporate Project. COMPLETE.

COG/07/19/16.2

Estates & Facilities A meeting to be arranged to discuss concerns with the morale of staff within the Facilities department.

AM / WG October 2019

A meeting had taken place. COMPLETE.

COG/07/19/18.2

Website Investigate the breakdown in the process to load papers on the Trust’s website ahead of the Council meetings

GP / JS October 2019

Process reviewed and new arrangements put in place to ensure meeting papers are uploaded to the website in a timely fashion. COMPLETE.

Final version 19.11.18 TH

Agenda Item: 6 Meeting: Council of Governors Meeting Date: 03 Oct 19 Report Title: Lead Governor’s Report Sponsoring Executive Director: John Thompson, Lead Governor Author(s): John Thompson, Lead Governor Report previously considered by and date:

Purpose of the report: Information Assurance ☐ Review and Discussion ☐ Approval / Agreement ☐ Reason for submission to Trust Board in Private only (where relevant): Commercial confidentiality ☐ Staff confidentiality ☐ Patient confidentiality ☐ Other exceptional circumstances ☐ Link to Trust Strategic Themes: Patient Care ☐ Sustainability ☐ Our People ☐ Quality ☐ Systems and Partnerships ☐ Any implications for: Quality Financial Workforce Link to CQC Domains: Safe ☐ Effective ☐ Caring ☐ Responsive ☐ Well-led Use of Resources ☐ Communication and Consultation: Executive Summary: This report provides the Council with an update of activities up to the end of September 2019. Key Recommendation(s): The Council is asked to NOTE this report

LEAD GOVERNOR’S REPORT TO THE COUNCIL OF GOVERNORS OCTOBER 2019

As I write this we are into the autumn – levels of activity made the summer feel more like winter. Again this highlights how wonderful our staff is: our people don’t realise how just good they and our community does always realise how lucky we are to live where we do and, if needed, to be in the hands of such caring and dedicated professionals. And still we all keep smiling – truly amasing. Governors were involved in part of CQC Inspection process, one participant said being a Governor of Western Sussex Hospitals NHS Foundation Trust (WSHT) is an honour – I could not agree more. Why is WSHT like it is? From the above this is an important question. At the moment I am working in another organisation that is in difficulties. The biggest difference between the two organisations is culture. WSHT has a really strong culture allied to sound strategies and well trained people working at every level who are confident that they can challenge, where improvements can be made, and escalate, where they have concerns or improvements are not being delivered fast enough. A big driver of this culture is Patient First and particularly PFIS and the pay back is that everyone is comfortable talking to each other on equal terms: “Culture eating strategies for breakfast”! Happy people producing great results! If one needed evidence of this – look to the real pleasure the “thank you cups” events gave to so many people. New and Departing Govs A warm welcome to our new Governors John Todd, Lyn Fowler and Andrew Ratcliffe, who all made the step up from Associate Governor; Pauline Constable (Worthing), Anna Mathew (Staff – Doctors and Dentists) and Warwick George (Staff – Estates and Facilities). There have been changes to our Appointed Governors too – we welcome Jackie Pendleton (West Sussex County Council); Gill Yeates (Arun District Council) and Donna Johnson (Chichester District Council). And to our departing Governors we thank you for your support in so many and varied ways – Richard Venn, Natalie Matthews, Ashvin Patel and Eileen Lintel. You leave with our best wishes. STARS Awards What a fabulous evening– it is great that so many people were able to attend and enjoy the excitement of the winners. I have already mentioned the honour that it is to be a Governor. One of the great honours of being the Lead Governor is being invited to read the nominations all 800+ of them and contribute to the selection process. Everyone nomination tells a story of compassion and dedication to our patients and the Trust. Quality Care Commission (CQC) Inspection The Inspection is over and waiting for confirmation of the result goes on! As Governors our involvement was in the well-led part of the process. I think like most people who were interviewed we wanted to do our best for the Trust and get over our

messages – challenges facing the Trust; strong engagement at levels of the Trust (Peer Review is a good example); good relations with the Trust senior management (regular meetings and briefings and complete openness) and connections to staff (Governors as volunteers and actively participating on many Project Boards and working groups). The other important area was Governors engagement with the Community (and Members) – Governors have quite extensive and varied networks (including Local councillors, hospital volunteers, members of their GP surgery’s Patient Participation Groups and charity work) that allows them to get feedback on how the Trust is perceived in our community and feed this back into the Trust. Executive Management of Brighton ad Sussex University Hospital Trust (BSUH) It hard to believe that it is nearly three years ago that Governors were asked to support WSHT taking over the executive management of BSUH. That BSUH are out of financial measures and achieved a Good CQC rating is a tribute to all involved. Besides the Executive, staff from all levels and disciplines have had the experience of working with another Trust and shared many ideas and innovations which have benefited both Trusts. Negotiations continue around what will happen after 1st April 2020 when the current agreements come to an end. The Trust is well placed to provide positive influence and strong leadership within the STP. To take one Trust out of financial special measures and through a CQC inspection from Inadequate to Good and other through a CQC inspection in the space of nine months is a Herculean task. Holding Non-Executive Directors (NED) to Account Holding the NEDs to account is a key responsibility of Trust Governors. We see the NEDs at Public Board and Council of Governor meetings. Plus twice a year Governors met the NEDs on their own. Their grasp of detail, willingness to challenge and to share with and listen to Governors is outstanding. Some Governors sit on working groups with NEDs whose contribution is always Trust focused, demanding of strong Governance and supportive to the group delivering its set tasks. We are most fortunate in our NEDs – their passions, skills and experience are invaluable. John Furmston is retiring as NED – he has always been approachable and willing to give us the benefit of his experience. I particular enjoyed working with him on the appointment of the external auditors (a Governors’’ responsibility). A big thank John and all best wishes from the Governors. Trust AGM A major occasion in the Trust calendar and our opportunity to be accountable to our patients and the communities that we serve. Excellent presentations were given by Dame Marianne and the team delivering increased morning discharges of the Trust’s patients. By the Lead Governor who unlike last year managed to control his presentation. Best of all was Alison Ingoe’s Report on the Accounts - succinct and

easy to understand. It is a shame that so few members of the public attend the AGMs and other public meetings. Membership Engagement Committee (@Governors) There is a report on the work of the Membership Engagement Committee later in the Agenda. One of the ways in which Governors engage with Members and the wider community is through the @Governors email address. This along with details of how to become members of the Trust and how to contact the Patient Advisory and Liaison Service is printed on governor business cards and widely distributed. We normally get three or four emails a year. In the last couple of months we have had six. Usually they are about delayed appointments; car parking or a problem with some aspect of care. We always welcome plaudits and it is a pleasure to pass them on to the area concerned. This time we have had one about car parking (the car park concerned was not operated by the Trust!); another was about one of the hospitals flying the Pride flag and one was a heartfelt thank you from a patient who had received outstanding care in A&E at Worthing Hospital. Rainbow Warriors While on the subject of Pride, the Trust launched as a follow on to the Staff Conference, the Rainbow Warriors scheme. Warriors support equality and diversity and signpost anyone seeking advice to whoever might be able to help them – sometimes an outside agency (eg. Stonewall). Patient Engagement and Experience Committee This joint Trust/Governor Committee provides a regular opportunity for Governors to be updated on all aspects of patient care and initiatives to further improve the care we provide to our patients. We get updates on all of these – some of which are mentioned below. We also have an opportunity to ask questions and raise any concerns (not individual cases) of which we are aware. An important part of this Committee’s role is to review the latest Quarterly Patient Experience Report and to hear from colleagues from the Clinical Commissioning Group and Sussex Healthwatch. The next meeting is a couple of days before the Council Meeting at which this report will be taken – any updates will be shared at that meeting. Patient Catering Project Work on the new kitchens at St Richards is progressing at a pace and most building work is complete – new equipment is being installed and main services being linked up. The menus have been signed off by the dieticians and provide an exciting range of fare. One of the important parts of this project is to provide variety and portion sizes to suit all patients. Snacks and grazing food will be available to those patients who like to eat a little at a time. Another objective is to cut down on waste. Outpatient Improvements Project This really exciting project is picking up pace. At a meeting attended by many specialities everyone wanted to be in the pilot testing streamlined ways of making appointments – to reduce the number of cancellations; increase the number of first time referral to appointments and reduce the number of calls to the call centre. The pilot involves all GP Gynaecology referrals with the exception of Hysteroscopy &

Colposcopy. The pilot starts in October and is due to finish by the end of November. Outpatient Clinical Pathway Redesign projects are progressing within: Gastroenterology; Breast Cancer; Gynaecology; Ophthalmology and Vascular Services. Improvements are being made to patient clinical pathways to ensure patients are being seen by the right person at the right time. This will reduce the number of unnecessary follow-ups for patients and enable the hospital to see more patients in a more timely manner. Also greater use is being made of IT to improve communications with patients. Everyone will be a winner.” Noise & Night Project A Patient First Breakthrough Project – this is an important project in delivering improvements in patient experience. Work is underway talking to patients and getting experiences and views. An update will be given at The Patient Engagement and Experience Committee meeting referred to above and to the Council of Governors meeting. Reducing Abusive Behaviours The need for work on handling abusive behaviour by patients and visitors was highlighted in the 2018 Staff Survey. Two Governors have been invited to be part of the project team which has commenced work - with the fruits of its labours expected early next year. Environmental Sustainability The Trust is keen to embrace the reduction in its environmental impacts. Work is being done to improve the Green Travel arrangements; reduce energy usage – Switch me off campaign – better sorting of waste and, with another Trust, a broader approach to reducing the Trusts carbon footprint. A Green Group will be pulling all this work together. Information Seminars There have been two really interesting seminars recently. Get it Right First Time. A pan-Trust project to ensure that each speciality has targets for getting their key activities right first time round. There is already evidence that it is impacting across the Trust – one appointment made, one appointment attended – with the right Consultant. The second which we had just before the CQC meeting with their Inspectors was on this year’s Capital Plan – it was very interesting to learn about how projects get into the Plan. It was also interesting to learn about Six Facet the root and branch review of the whole estate and how it can be manged to meet the demands of the future. The Trust scored very well on the Statutory Compliance and Risk Audit. Governors learn a lot from these events and are grateful to the presenters – Dr Tim Taylor (Medical Director) and Robert Cairney (Director, Capital Projects). Love Your Hospital This is the Trust’s charity which raises over a £1M a year and contributes to projects identified in the Capital Programme and to Staff Development activities. A few

Governors helped at the Race Day at Goodwood Motor Circuit – what a fantastic day and we recruited a few new Members too. Sussex Foundation Trust Governors’ Forum Eight of our Governors meet their opposite numbers in the Partnership and Community Trusts in July. We were able to learn about each other’s Trusts and how Governors worked with their Trusts – some interesting variations. I think we have a good balance, not least because of our strong relationship with your NEDs. We have been offered the opportunity to host the next event. Looking forward how Governors work with NEDs and Trust Boards in the Integrated Care Organisations is an area we need to consider together and with input from NHS Providers who provide support to Trusts and Governors. Elections of the Lead and Deputy Lead Governor These are to take place very soon as the new Lead Governor will take up the reins from 1st November. It is a great opportunity to really get to the heart of out Trust. Please do give it some thought! And finally, this is my last report as your Lead Governor. It has been a privilege to be the Lead Governor: to be invited to contribute to so much of the Trust’s work and to work with so many truly amasing and generous people – definitely patient and always willing to advise and to explain. Thank you all. For me it has been wonderful, rewarding and enriching experience that I would not have missed. John Thompson September 2019

Final version 19.11.18 TH

Agenda Item: 7 Meeting: Council of Governors Meeting Date: 03 Oct 19 Report Title: Membership Engagement Report Sponsoring Executive Director: John Thompson, Lead Governor Author(s): John Thompson, Lead Governor Report previously considered by and date:

Purpose of the report: Information Assurance ☐ Review and Discussion ☐ Approval / Agreement ☐ Reason for submission to Trust Board in Private only (where relevant): Commercial confidentiality ☐ Staff confidentiality ☐ Patient confidentiality ☐ Other exceptional circumstances ☐ Link to Trust Strategic Themes: Patient Care ☐ Sustainability ☐ Our People ☐ Quality ☐ Systems and Partnerships ☐ Any implications for: Quality Financial Workforce Link to CQC Domains: Safe ☐ Effective ☐ Caring ☐ Responsive ☐ Well-led Use of Resources ☐ Communication and Consultation: Executive Summary: This report provides the Council with an update of activities up to the end of September 2019. Key Recommendation(s): The Council is asked to NOTE this report

MEMBERSHIP ENGAGEMENT REPORT

OCTOBER 2019

Since the last report in July there has been steady progress on several fronts. The most important is that we have a more targeted recruitment focus. “Having your say” in the development of our hospitals and how they adapt in the rapidly changing world which is the NHS is a key message in engaging with prospective and existing Members. Against a background of an Outstanding CQC; brilliant Friends and Family Test results; and the plaudits received across the Trust from fabulously well cared for patients and their families it is difficult to pursued people that need to “Have their say”. With ever increasing numbers of patients in our hospitals, coming into A&E and as outpatients our communities are pretty happy with services the Trust provides. I believe the effective delivery of the Membership Strategy is best achieved through partnerships. To that end the Action Plan that underpins the Strategy has elements that are dependent on building relationships: we are already working on: Taking the message into Outpatients Departments Making greater use of the Trust’s well developed social media. GPs Surgeries – recruiting new members and publicising events – most surgeries have been contacted with slightly mixed results – we had excellent support

from Coastal West Sussex Clinical Commissioning Group taking this forward – Practice Managers are busy people and unless there is a personal relationship eg. Through a Patient Participation Group it is proving hard to get traction in this area.

Linking up with outward facing parts of the Trust. With LYH we had a recruitment stand at their Race Day at Goodwood Motor Circuit and are now have shared cotton bags with their message on one side and ours on the other. Taking space in their notice boards is a work in progress

Working with partners is schools and FE colleges. The revised Recruitment Action Plan is also attached: it shows progress since the last Council of Governors meeting. As part of my Chairmanship of the Membership Engagement Committee I have tried to encourage Governors to take a more active lead in delivering the strategy and they have really risen to the challenge. We are also very dependent on the Trust’s Communications Team – particularly Jonathan Keeble and Sue Hughes - both of whom are very supportive, but we are taking on some of this challenge ourselves along with encouraging the staff to be advocates for new members. If just 2% of our staff recruited just one new member we would exceed our target and would need to use the biggest rooms available for the Medicine for All events and our AGMs imagine how that success would look like! The next public event is on the 10th October so please spread the word and encourage those who have an interest in our hospitals to attend John Thompson Chair – Membership Engagement Committee September 2019

A date for your diary

Chief Executive’s Report October 2019

Contents

• Headlines: July, August and September

• Looking ahead

Headlines

£5m investment in IM&T innovations and devices New IT innovations and improvements for both staff and patients are coming thanks to a £4.9 million investment in the trust’s information management and technology (IM&T) this year. This includes £450,000 on new computers and other staff devices; £417,000 on Radiology and Pathology order communications; and £450,000 on a new secure clinical messaging service. A new online portal for patients will also enable them to view appointment letters and results on their phone, tablet or PC.

Refer a friend scheme launched The trust has launched a Refer a Friend scheme as part of its wider recruitment efforts. Existing staff can be rewarded with up to £750 if they successfully refer a staff nurse, operating department practitioner or midwife to come and work with us. The new member of the team will also receive an additional £250, once they have completed their first year. For more information, please visit westernsussexhospitals.nhs.uk/you-trust/careers

Support for mental health patients Improvements are being jointly implemented by the trust and Sussex Partnership NHS Foundation Trust for patients with mental health needs. These include a range of developments - expansion of the Community Crisis response team to 24/7, a crisis lounge in Worthing town centre, psychiatric assessment lounges will be rolled out across Sussex. We have confirmed funding to expand the mental health liaison teams in both A&E departments; and a new clinical director post for mental health to support the implementation of these changes and ensure we get the maximum benefit locally for our patients.

Headlines

Discharge project showcased at AGM The success of the “putting patients first through earlier discharges” improvement project was showcased at the trust’s AGM in July. Over 12 months, 3,600 more patients left hospital before 3pm on their day of discharge, thanks to teams working together in new ways on 16 pilot wards. Attendees also heard a review of the year (18/19) and accounts, which are available on our website.

Nurses receive high praise in survey The high standards set by Western Sussex in last year’s national NHS Inpatient Survey have been maintained in the latest results. Patients were particularly complimentary about the people caring for them, with 93% of comments about nurses being positive, and 73% for staff overall.

Friends celebrate Queen’s award Congratulations and thank you to the Friends of Chichester Hospitals on receipt of their very special award. The Friends and their guests gathered in Chichester’s historic Council Chamber last month to witness the formal presentation of The Queen’s Award for Voluntary Service by Her Majesty’s Lord-Lieutenant of West Sussex, Mrs Susan Pyper.

Headlines

Outpatients improvements A pilot to test a new process for booking Outpatients referrals starts today (30 September), aiming to improve patient and staff experience and reduce cancellation and rebooking of appointments. The pilot will be focussed specifically on gynaecology referrals, with six designated GP surgeries supporting the new process. The ambition is to increase the number of appointments booked right and attended first time from 62% to 95%. Since March, a Redesign of Operational Outpatient Process improvement team has been examining the current system and exploring solutions by using in-depth Lean and other continuous improvement techniques.

Clinical scholars improve patient care Our staff development programme has celebrated the graduation of its second set of Clinical Improvement Scholars. Eight members of staff dedicated two days a week for a year to developing research, leadership and quality improvement skills they can use to support better outcomes and care. The programme, which is the first of its kind in the country, saw nurses, midwives and allied healthcare professionals work to improve patient or staff experience through projects ranging from hydration and reducing mortality to improving outcomes.

Diary highlights

• Meetings with partner organisations

• Sustainability and Transformation

Partnership

• Acute Network

• MPs

• West Sussex County Council

• Graduation, University of Brighton

• CQC Well-led and Core Inspection

• All staff briefings – St Richard’s,

Worthing, Southlands

• Consultant engagement briefing

• Council of Governors meeting

• Thank you events

Looking ahead

Staff flu vaccinations The Trust’s flu campaign launches Friday 11 October with all staff encouraged to take up free NHS flu jab. If you’re a frontline worker in the NHS, you’re more likely to be exposed to flu. Catching flu can be serious. In 2017/18 it is estimated that 26,000 deaths were associated with flu. You can have flu without any symptoms and pass it on to family, friends and patients, many of whom may be at increased risk from flu. Being healthy doesn’t reduce your risk of flu or passing it on. The flu jab is the best way to protect yourself, your family and your patients against flu. Please Get your free flu jab as soon as possible

Care Quality Commission inspection The inspection of our trust began in June with a review of our Use of Resources, carried out by NHS Improvement. Inspections are now formed of three parts and our well-led assessment and unannounced core services inspection are also now complete. We are expecting their report and rating to be published at some point in the next few months. We were last inspected in December 2015, which resulted in the publication of our “Outstanding” CQC report in April 2016. Our improvement programme called Patient First was just beginning then and our staff were proud to demonstrate the many ways this has led to significant improvements across the organisation in the last three years.

STARS 2019

Ref: EY-000092651-01

Western Sussex Hospitals NHSFoundation Trust

June 2019

Annual Audit Letter to the Council of Governorsfor the year ended 31 March 2019

Ref: EY-000092651-01

PageSection 1 Executive Summary 2Section 2 Purpose 5Section 3 Responsibilities 7Section 4 Financial Statement Audit 9Section 5 Value for Money 14Section 6 Quality Report 17

Contents

Western Sussex Hospitals NHS Foundation Trust 1

The contents of this report are subject to the terms and conditions of our appointment as set out in our engagement letter.

This report is made solely to the Council of Governors, Audit Committee, Board of Directors and management of Western SussexHospitals NHS Foundation Trust Foundation Trust in accordance with our engagement letter dated 16 January 2017. Our work has beenundertaken so that we might state to the Council of Governors, Audit Committee, Board of Directors and management of the Trust thosematters we are required to state to them in this report and for no other purpose. To the fullest extent permitted by law we do not accept orassume responsibility to anyone other than the Council of Governors, Audit Committee, Board of Directors and management of the Trustfor this report or for the opinions we have formed. It should not be provided to any third party without our prior written consent.Our Complaints Procedure – If at any time you would like to discuss with us how our service to you could be improved, or if you aredissatisfied with the service you are receiving, you may take the issue up with your usual partner or associate partner contact. If you preferan alternative route, please contact Steve Varley, our Managing Partner, 1 More London Place, London SE1 2AF. We undertake to lookinto any complaint carefully and promptly and to do all we can to explain the position to you. Should you remain dissatisfied with anyaspect of our service, you may of course take matters up with our professional institute. We can provide further information on how youmay contact our professional institute.

Ref: EY-000092651-01

Section 1

Executive Summary

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We have summarised the results and conclusions on the significant areas of the audit process for Western Sussex Hospitals NHS Foundation Trust (‘the Trust’) for theyear ended 31 March 2019 below.

Executive Summary


Area of Work Conclusion

Opinion on the Trust’s:

► Financial statements Unqualified – the financial statements give a true and fair view of the financial position of the Trust as at31 March 2019 and of its expenditure and income for the year then ended

► Parts of the remuneration and staff report to be audited We had no matters to report.

► Consistency of the information in Annual Report with the financialstatements

Financial information in the Annual Report and published with the financial statements was consistent with the Financial Statements.


Reports by exception:

► Consistency of Governance Statement The Governance Statement was consistent with our understanding of the Trust.

► Consistency of the Annual Report within knowledge we haveacquired during the course of our audit

We had no matters to report.

► Referrals to NHS Improvement (formerly Monitor) We had no matters to report.

► Public interest report We had no matters to report in the public interest.

► Value for money conclusion We had no matters to report.

Ref: EY-000092651-01 Western Sussex Hospitals NHS Foundation Trust 4

Executive Summary (cont’d)Area of Work Conclusion

Examining the contents of the Trust’s Quality Report and testingof two mandated performance indicators and one indicatorselected by the Council of Governors

We issued an unqualified limited assurance report.

Reporting to NHS Improvement (formerly Monitor) on the Trust’sconsolidation schedules

We concluded that the Trust’s consolidation schedules agreed, within a £300,000 tolerance, to your audited financial statements.

Reporting to the National Audit Office (NAO) in line with groupinstructions

We had no matters to report.

As a result of the above we have also:


Issued a report to those charged with governance of the Trustcommunicating significant findings resulting from our audit.

Our Audit Results Report was issued on 29 May 2019.

Issued a report to Governors on the assurance process for the QualityReport

Our report to Governors on the Quality Report was issued on 29 May 2019.

Issued a certificate that we have completed the audit in accordancewith the requirements of the National Health Service Act 2006 and theNational Audit Office’s 2015 Code of Audit Practice.

Our certificate was issued on 29 May 2019.

We would like to take this opportunity to thank the Trust staff for their assistance during the course of our work.

Paul King

Associate PartnerFor and on behalf of Ernst & Young LLP

Ref: EY-000092651-01

Section 2

Purpose

Ref: EY-000092651-01

Purpose


Purpose of this letterThe purpose of this letter is to communicate to the Council of Governors the key issues arising from our work, which we consider should be brought to the attention ofthe Trust.We have already reported the detailed findings from our audit work in our 2018/19 audit results report to the 23 May 2019 Audit Committee, representing those chargedwith governance. We do not repeat those detailed findings in this letter but instead provide a summary of our key findings.We also make reference to our limited assurance work on the Trust’s Quality Report.

Ref: EY-000092651-01

Section 3

Responsibilities

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Responsibilities


Responsibilities of the External AuditorOur 2018/19 audit work has been undertaken in accordance with the Audit Plan that we issued in January 2019 and is conducted in accordance with the National AuditOffice's 2015 Code of Audit Practice, International Standards on Auditing (UK), and other guidance issued by the National Audit Office and NHS Improvement (formerlyMonitor).As auditors we are responsible for:Expressing an opinion:► On the 2018/19 financial statements;► On the parts of the remuneration and staff report to be audited;► On the consistency of the information in the Annual Report with the financial statements; and► On whether the consolidation schedules are consistent, within a £300,000 tolerance, with the Trust’s financial statements for the relevant reporting period.Reporting by exception:► if the Governance Statement does not comply with relevant guidance or is not consistent with our understanding of the Trust;► on the consistency of the Annual Report with knowledge we have acquired during the course of our audit;► to NHS Improvement (formerly Monitor) if we have concerns about the legality of transactions or decisions taken by the Trust; and► any significant matters that are in the public interest.► forming a conclusion on the arrangements the Trust has in place to secure economy, efficiency and effectiveness in its use of resources.We report to the National Audit Office (NAO) on the Trust’s Whole of Government Accounts return, the Trust Accounts Consolidation schedules, which support the Wholeof Provider account consolidation.We also undertake an independent assurance engagement on the Trust’s Quality Report for the year ended 31 March 2019 and certain performance indicatorscontained within the report. Our review is undertaken in accordance with the NHS Foundation Trust Annual Reporting Manual and supporting guidance and the sixdimensions of data quality issued by NHS Improvement ‘Detailed Guidance for External Assurance on Quality Reports’

Responsibilities of the TrustThe Trust is responsible for preparing and publishing its financial statements, Annual Report and Governance Statement. In the Governance Statement, the Trustpublicly reports on the extent to which it complies with its own code of governance, including how it has monitored and evaluated the effectiveness of its governancearrangements in the year, and on any planned changes in the coming period.The Trust is also responsible for putting in place proper arrangements to secure economy, efficiency and effectiveness in its use of resources.

Ref: EY-000092651-01

Section 4

Financial StatementAudit


Key IssuesThe Annual Report and Accounts is an important tool for the Trust to show how it has used public money and how it can demonstrate its financial management andfinancial health.Our 2018/19 audit work on the Trust’s financial statements has been undertaken in accordance with the audit plan we issued in January 2019 and is conducted inaccordance with the National Audit Office’s 2015 Code of Audit Practice, International Standards on Auditing (UK), and other guidance issued by the National Audit Officeand NHS Improvement (formerly Monitor).We issued an unqualified audit report on 29 May 2019.Our detailed findings were reported to the 23 May 2019 Audit Committee, through our Audit Results Report.The key issues identified as part of our audit were as follows:

Financial Statement Audit

Significant Risk ConclusionRisk of fraud in revenue recognition through managementoverride

Under ISA 240 there is a presumed risk that revenue may bemisstated due to improper revenue recognition. In the public sector,this requirement is modified by Practice Note 10 issued by theFinancial Reporting Council, which states that auditors should alsoconsider the risk that material misstatements may occur by themanipulation of expenditure recognition. We believe this manipulationis possible through both income and expenditure transactions andareas of significant estimation. We also recognised there is a risk thatrevenue expenditure will be inappropriately capitalised within theTrust’s capital programme. There is a further risk that capital fundingcould be transferred to revenue to help manage or manipulate theoverall financial position of the Trust for the reasons set out above.Management is in a unique position to perpetrate fraud because of itsability to manipulate accounting records directly or indirectly andprepare fraudulent financial statements by overriding controls thatotherwise appear to be operating effectively.We identify and respond to this fraud risk on every audit engagement.The NHS as a whole continues to experience significant financialpressures and there is pressure on the Trust to achieve its forecastfinancial position. While the Trust is performing better than most, werecognise that any targeted outturn position produces financialpressures on the Trust and therefore increase the risk of manipulationof the reported financial position in order to achieve that forecastoutturn.

In response, we completed the following procedures:• discussed with management to understand the overall financial position to inform the appropriate audit expectations of the year-end

income and expenditure position;• reviewed and tested revenue and expenditure recognition policies. No evidence of material misstatement was identified;• discussed with management any accounting estimates on revenue or expenditure recognition for evidence of bias. None was

identified;• developed and carried out a testing strategy to test material revenue and expenditure streams;• tested revenue cut-off at the period end date. No material cut-off issues were identified;• critically reviewed Department of Health agreement of balances data to investigate significant differences (outside of DH

tolerances). We did not identify any significant differences outside the DH tolerances;• tested the appropriateness of journal entries recorded in the general ledger and other adjustments made in the preparation of the

financial statements. No evidence of management override or material misstatement was identified;• reviewed accounting estimates for evidence of management bias. No evidence of bias was identified;• confirmed there was no evidence of fraud arising from the business rationale for significant unusual transactions; and,• tested a sample of capital additions to ensure the relevant capitalisation criteria had been met.

Our testing identified no evidence of fraud in revenue recognition or management override of controls.


Financial Statement Audit (cont’d)Other areas of audit focus Conclusion

Valuation of Property, Plant & Equipment

In our Audit Plan, we identified the valuation of Property, Plant &Equipment as an area that was not a significant risk, but was an areaof audit focus due to its complexity and size within the financialstatements. PPE, in particular land and buildings, is the mostsignificant figure in the Trust’s balance sheet. The valuation of landand buildings is complex and is subject to a number of assumptionsand judgements. A small movement in these assumptions can have amaterial impact on the financial statements. We identified a significanterror and adjustment to the financial statements in the prior yearrelating to the processing of the split of impairment figures between theRevaluation Reserve and the SOCI.

In response, we completed the following procedures:

• We reviewed the output of the Trust’s valuer and confirmed that the output was in line with our expectations. We confirmed thevaluers report had been correctly accounted for in the Trust’s financial statements.

• We challenged the assumptions used by the Trust’s valuer by reference to external evidence and our EY valuation specialists andconcluded they were in line with our expectations; and,

• We tested the journals for the valuation adjustments and confirmed they had been accurately processed in the financial statements.

We were therefore satisfied that the Trust had correctly accounted for the valuation of property, plant and equipment in the 2018/19financial statements.

IFRS9 – Financial Instruments

In our Audit Planning Report, we outlined the new requirementsrelating to Financial Instruments. The new requirements change:• How financial assets are classified and measured;• How the impairment of financial assets are calculated; and• The disclosure requirements for financial assets.

In response, we completed the following procedures:

• We assessed the Trust’s implementation arrangements, which included its assessment of the impact of the new standard. We weresatisfied that there would be no significant impact on the Trust accounts beyond new disclosure requirements.

• We confirmed the Trusts accounting policies had been correctly updated for the new standard, and that this new policy had beenappropriately applied.

• We confirmed the additional disclosure requirements had been included within the draft financial statements.

IFRS 15 – Revenue from Contracts with Customers

IFRS 15 is a new accounting standard relevant for the 2018/19financial period. The key requirements of the standard cover theidentification of performance obligations under customer contracts andthe linking of income to the meeting of those performance obligations.

In response to the new standard, we have:

• Assessed the Trusts implementation arrangements for the new standard, confirming there is no material impact of the standard on theTrusts accounts.

• Confirmed the Trusts accounting policies have been properly updated to reflect the new standard.

• Confirmed that the additional disclosure requirements have been included in the financial statements.


Financial Statement Audit (cont’d)

We also identified the following areas where misstatement at a level lower than our overall materiality level might influence the reader. For these areas we developed anaudit strategy specific to these areas. The areas identified and audit strategy applied include:► Remuneration disclosures including any severance payments, exit packages and termination benefits; and► Related party transactions.We applied a materiality level of £1 or to the level of disclosure in the financial statements (e.g. rounded to the nearest thousand) to these items due to their sensitivenature.We evaluate any uncorrected misstatements against both the quantitative measures of materiality discussed above and in light of other relevant qualitativeconsiderations. We identified one uncorrected error which has been rolled forwards from the 2017/18 period, where we disagreed with the Trust’s capitalisation of thePatient First Programme. As this item remained on the Trust’s 2018/19 Balance Sheet as an Intangible Asset, we reported that the balance was overstated by £1.1m.

Control Themes and ObservationsAs part of our work, we obtained an understanding of internal control sufficient to plan our audit and determine the nature, timing and extent of testing performed. Althoughour audit was not designed to express an opinion on the effectiveness of internal control, we are required to communicate to you significant deficiencies in internal controlidentified during our audit.We have adopted a fully substantive approach and have therefore not tested the operation of controls.Our audit did not identify any controls issues to bring to the attention of the Audit Committee.

Department of Health and Social Care Group InstructionsWe are only required to report to the NAO on an exception basis if there were significant issues or outstanding matters arising from our work. There were no such issues.

Item Thresholds appliedPlanning materiality We determined planning materiality to be £4.443m (2017/18: £4.253m), which is 1% of Operating Expenses.

We consider Operating Expenses to be one of the principal considerations for stakeholders in assessing thefinancial performance of the Trust.

Reporting threshold We agreed with the Audit Committee that we would report to the Committee all audit differences in excess of£0.222m (2017/18: £0.213m)

Our application of materialityWhen establishing our overall audit strategy, we determined a magnitude of uncorrected misstatements that we judged would be material for the financial statements as awhole.


Financial Statement Audit (cont’d)Department of Health and Social Care Group Instructions (cont’d)We are also required by NHS Improvement (formerly Monitor) to provide to the Trust a statement that the Trust Accounts Consolidation schedules (TACs) are consistentwith the audited accounts, including a list of inconsistencies greater that £300,000 between the TACs and the accounts. We reported that the TACs were consistent withthe audited statements.

Governance StatementWe are required to consider the completeness of disclosures in the Trust’s Governance Statement, identify any inconsistencies with the other information of which we areaware from our work, and consider whether it complies with relevant guidance.We completed this work and did not identify any areas of concern.

Referral to the RegulatorWe must report to NHS Improvement (formerly Monitor) any matter where we believe a decision has led to, or would lead to, unlawful expenditure, or some action hasbeen, or would be, unlawful and likely to cause a loss or deficiency. We had no exceptions to report.

Report in the Public InterestWe have a duty under the National Health Service Act 2006 to consider whether, in the public interest, to report on any matter that comes to our attention in the course ofthe audit in order for it to be considered by the Trust or brought to the attention of the public.We did not identify any issues which required us to issue a report in the public interest.

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Section 5

Value for Money


Value for MoneyWe are required to consider whether the Trust has put in place ‘proper arrangements’ to secure economy, efficiencyand effectiveness on its use of resources. This is known as our value for money conclusion.Proper arrangements are defined by statutory guidance issued by the National Audit Office. They comprise yourarrangements to:► Take informed decisions;► Deploy resources in a sustainable manner; and► Work with partners and other third parties. Proper

arrangements forsecuring value

for money

Informeddecisionmaking

Working withpartners andthird parties

Sustainableresource

deployment

We identified one significant risk in relation to these arrangements. The tables below presents the findings of ourwork in response to the risks identified and any other significant weaknesses or issues to bring to your attention.We therefore had no matters to report about your arrangements to secure economy, efficiency and effectiveness inyour use of resources.

Significant Risk Conclusion

Delivering Financial SustainabilityThe NHS is under continuing financial pressure and needs to makeongoing efficiency savings and improvements, whilst maintaining aclear focus on the quality of care for patients.The long term sustainability of its finances and the ability todemonstrate good financial health are critical to the future of the Trust.We recognise that as at month 8, the Trust is reporting a deficit of£0.2m, reducing the cumulative position to a surplus of £0.1m. TheTrust has achieved PSF target for Q1 and 2, earning a total of £5.7mPSF income. The Trust has a total of £16.3m of PSF funding availableif it meets all targets for the 2018/19 (30% of PSF is linked to A&Eperformance). The Year End target is for £1.185m surplus.

Reviewing the 2018/19 Outturn Position:The Trust’s draft financial statements have been produced and report a year end retained surplus of £23.836m including core PSFincome of £16.252m and £11.011m of incentive PSF received for achieving the Trust’s control total.After adjustments, the Trust is reporting a control total surplus of £1.195m excluding PSF at year end. This compares favourably to thecontrol total of £1.185m surplus set at the beginning of the financial year (excluding PSF funding), and therefore means the total hasbeen achieved.

Assessing the progress made in delivering the Cost Improvement Programme (CIP) and reviewing the balance of recurrentand non-recurrent savings:We reviewed the progress made in delivering the 2018/19 CIP and note the Trust reported savings of £18.2 million compared to atarget of £18.2 million. This represents 100% of the planned CIP being identified and realised. Underperformance within Core services,Medicine and Surgery were offset by over performance in Back Office & Corporate Support, and Women and Children services.For 2019/20, the Trust has set an efficiency programme of £11.728m. At April 2019, the Trust has identified £8m out of £11.728m ofsavings as being fully identified and costed (green rated), with remaining £2.7m as amber rated and £1m red rated. For 2019/20 theTrust will focus the majority of their savings within Procurement (£2.524m), Medical and Medicine (combined savings of £5.170m).


Value for Money (Contd)

Significant Risk Conclusion

Delivering Financial Sustainability (continued) Reviewing the process for setting the 2019-20 Operational Plan:We reviewed the 2019/20 Operational Plan. The plan appears reasonable and is based on sound assumptions, which have beenreported to both the Finance & Investment Committee and the Trust Board. The plan highlights a control total surplus (before STF) of£2.459 million. The Trust’s plan also outlines an intention to secure PSF funds of £8.341m and includes Marginal Rate EmergencyFunding of £3.262m which the Trust will receive as they have accepted their control total. This takes the control total including PSF to£14.06m surplus.Delivery of the surplus is reliant on the delivery of significant CIP savings of £11.73m, which is £6.6m lower than that achieved in2018/19. Given the historic performances of delivering the CIP savings, and the fact that this figure is lower than in previous years,suggests the 2019/20 figure is not unachievable. The Trust has performed its own risk rating for these plans as noted above. Thoseschemes rated high risk are expected to reduce as plans mature.A review of the plan and the above factors confirms that while a reasonable approach has been taken to setting the 2019/20 plan, theTrust is aware there are several factors which impact the Trust’s ability to achieve the control total. We are satisfied that the Trust hasappropriate arrangements in place to monitor and respond to these.

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Section 6

Quality Report

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ResponsibilitiesWe are required to perform an independent assurance engagement in respect of the Trust’s Quality Report for the year ended 31 March 2019 (the ‘Quality Report’) andcertain performance indicators contained within the report. Our review is undertaken in accordance with the NHS Foundation Trust Annual Reporting Manual andsupporting guidance and the six dimensions of data quality issued by NHS Improvement ‘Detailed Guidance for External Assurance on Quality Reports’.As auditors we are required to:► Review the content of the Quality Report against the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2018/19, which is combined with the

quality accounts requirements in NHS Improvement’s document ‘Detailed guidance for External Assurance on quality reports 2018/19’;► Review the content of the Quality Report for consistency against the other information published by the Trust;► Undertake substantive sample testing on two mandated performance indicators and one locally selected indicator;► Provide the Trust with a Limited Assurance Report confirming that the Quality Report meets NHS Improvements requirements and that the two mandated indicators

are reasonably stated in all material respects;► Provide the Trust’s Governors with a report setting out the findings of our work including the content of the quality report, mandated indicators and the locally selected

indicator.

Compliance and consistencyWe reviewed the Trust’s Quality Report and found that its content was in line with NHS Improvement’s requirements, and it was consistent with other informationpublished by the Trust.

Performance indicatorsWe undertook testing on two mandated indicators:► percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge► maximum waiting time of 62 days from urgent GP referral to first treatment for all cancersIn both instances we found no evidence to suggest that the two mandated indicators have not been reasonably stated in all material respects.

Quality Report


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Performance indicators (cont’d)The local indicator tested was:► Summary Hospital-level Mortality Indicator (SHMI)Consistent with other Trusts, we found that our ability to test this indicator was limited by the fact that it is compiled by NHS Digital using a statistical model. While wefound no evidence to suggest that the local indicator has not been reasonably stated in all material respects, we were unable to confirm:► that the data provided for audit is the same as submitted to NHS Digital for use in the statistical model.► what happens to the data once it has been submitted to NHS Digital to produce the indicator.This is expected and in line with the Quality Report guidance for auditors.

Quality Report (cont’d)


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© Ernst & Young LLP. Published in the UK.All Rights Reserved.

The UK firm Ernst & Young LLP is a limited liability partnership registered in England and Waleswith registered number OC300001 and is a member firm of Ernst & Young Global Limited.

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External Assurance on the QualityReport

May 2019

Western Sussex Hospitals NHS Foundation Trust

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PageSection 1 Executive Summary 3Section 2 Detailed Findings 6

AppendicesAppendix A Limited assurance report – draft 9

Contents

External Assurance on the Quality Report 1

The contents of this report are subject to the terms and conditions of our appointment as set out in our engagementletter dated 20 May 2019.This report is made solely to the Audit Committee, Board of Directors, Council of Governors and management ofWestern Sussex Hospitals NHS Foundation Trust in accordance with our engagement letter. Our work has beenundertaken so that we might state to the Audit Committee, Board of Directors, Council of Governors and managementof the Trust those matters we are required to state to them in this report and for no other purpose. To the fullest extentpermitted by law we do not accept or assume responsibility to anyone other than the Audit Committee, Board ofDirectors, Council of Governors and management of the Trust for this report or for the judgements we have formed. Itshould not be provided to any third-party without our prior written consent.

Ernst & Young LLP1 More London PlaceLondon SE1 2AF

Tel: + 44 20 7951 2000Fax: + 44 20 7951 1345ey.com

The UK firm Ernst & Young LLP is a limited liability partnership registered in England and Wales with registered number OC300001 and is a member firm of Ernst & YoungGlobal Limited. A list of members’ names is available for inspection at 1 More London Place, London SE1 2AF, the firm’s principal place of business and registered office.

Council of GovernorsWestern Sussex Hospitals NHS Foundation TrustLyndhurst RoadWorthingWest SussexBN11 2DH

Dear Governors,

External Assurance on the Trust’s Quality Report

We are pleased to present our findings following our review of the Western Sussex Hospitals NHS Foundation Trust’s (‘the Trust’s’) Quality Report for the yearended 31 March 2019.

The purpose of this report to the Council of Governors is to set out the work that we have performed, our findings and conclusions and any recommendations forimprovement concerning the content of the Trust’s Quality Report and our testing on mandated and local indicators as required by NHS Improvement.

We would like to take this opportunity to thank the staff of the Trust for their assistance during the course of our work.

Yours faithfully

Paul KingAssociate PartnerFor and on behalf of Ernst & Young LLPEnc

20 May 2019

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Section 1

Executive Summary

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Executive Summary


1.1 ResponsibilitiesWe have been engaged by the Trust to perform an independent assurance engagement in respect of the Trust’s Quality Report for the year ended 31 March 2019 andcertain performance indicators contained within the report. Our review is undertaken in accordance with the ‘Detailed Requirements for Quality Reports 2018/19’ issuedby NHS Improvement on 17 December 2018 (‘the Detailed Guidance’).NHS Improvement’s ‘Detailed Requirements for External Assurance for Quality Reports for Foundation Trusts 2018/19’ (‘the Assurance Requirements’) sets out thework that we are required to complete on the Trust’s Quality Report for the year ended 31 March 2019, which is published as part of its Annual Report.As auditors we are required to:► Review the content of the Quality Report against the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2018/19 (‘FT ARM’), which is

supported by the Quality Reports requirements in the Detailed Guidance;► Review the content of the Quality Report for consistency against the other information sources detailed in Section 2.1 of the Detailed Guidance;► Undertake substantive testing on two mandated performance indicators and at least one locally selected indicator (to include, but not necessarily be limited to, an

evaluation of the key processes and controls for managing and reporting the indicators and sample testing of the data used to calculate the indicator back tosupporting documentation);

► Provide a signed limited assurance report in the Quality Report on whether anything has come to our attention that leads us to believe that the Quality Report has notbeen prepared in line with the requirements set out in the FT ARM and Detailed Guidance and/or is not consistent with the other information sources detailed inSection 2.1 of the Assurance Requirements and whether there is evidence to suggest that the two mandated indicators have not been reasonably stated in allmaterial respects in accordance with the FT ARM and Detailed Guidance; and

► Provide a report to Trust’s Council of Governors (‘the Governors’ Report’) of our findings and recommendations for improvements on the content of the QualityReport, the mandated indicators and the locally selected indicator(s).

1.2 Key findingsWe have reviewed the Trust’s Quality Report and found that:► Its content is in line with NHS Improvement’s requirements; and► It is consistent with other information published by/about the Trust.In our detailed findings section of this report (section 2) we have included comments about the content and consistency of the Quality Report.

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Executive Summary (cont’d)


1.2 Key findings (cont’d)We have also undertaken testing on two mandated indicators and one local indicator. The two mandated indicators tested are:► percentage of patients with a total time in A&E of four hours or less from arrival to admission, transfer or discharge► maximum waiting time of 62 days from urgent GP referral to first treatment for all cancersThe local indicator tested was:► Summary Hospital-level Mortality Indicator (SHMI)Consistent with other Trusts, we found that our ability to test this indicator was limited by the fact that it is compiled by NHS Digital using a statistical model. While wefound no evidence to suggest that the local indicator has not been reasonably stated in all material respects, we were unable to confirm:► that the data provided for audit is the same as submitted to NHS Digital for use in the statistical model.► what happens to the data once it has been submitted to NHS Digital to produce the indicator. This is expected and in line with the Quality Report guidance for

auditors.We note that the locally selected indicator is not included in our limited assurance audit report and therefore no modification will be made in respect of it.Further details of our findings are in Section 2.2.As a result of our findings from the work we have performed, we will issue an unqualified limited assurance report to the Trust. This will conclude that nothing has cometo our attention which leads us to believe that:► The Quality Report is not prepared in all material respects in line with the criteria set out in the FT ARM and Detailed Guidance;► The Quality Report is not consistent in all material respects with the sources specified in the Assurance Requirements; and► The indicators identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material respects in accordance with

the FT ARM and supporting guidance and the six dimensions of data quality set out in the Detailed Guidance.A copy of this report is provided in Appendix A.

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Section 2

Detailed Findings

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Detailed findings


2.1 Content of the Quality ReportCompliance with the requirements of the NHS Foundation Trust Annual Reporting Manual 2018/19We have reviewed the content of the Quality Report against the requirements set out by NHS Improvement in the FT ARM.In all regards we found that the Trust met these requirements.Consistency with other specified documentsThe Quality Report is also reviewed for consistency with the following documents:► Board minutes for the period April 2018 to 29 May 2019;► Papers relating to quality reported to the Board over the period April 2018 to 29 May 2019;► feedback from commissioners, dated 2 May 2019;► feedback from governors, dated 25 February 2019;► feedback from local Healthwatch organisations, dated 13 May 2019;► feedback from Overview and Scrutiny Committee dated 30 April 2019;► the Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated 29 April 2019;► the latest national staff survey, dated 1 February 2019;► the Head of Internal Audit’s annual opinion over the trust’s control environment for 2018/19; and► Care Quality Commission inspection report, dated 20 April 2019.Our review concluded that the contents of the Quality Report published by the Trust are consistent with these documents.

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Detailed findings (cont’d)


2.2 Locally selected indicatorIn 2018/19, NHS Improvement’s guidance also requires the testing of a locally selected indicator. The assurance work on this indicator does not contribute to our limitedassurance report in Appendix A.Governors selected the Summary Hospital-level Mortality Indicator (SHMI). Auditor guidance is clear that the assurance work performed need only concentrate on theinformation provided by the trust which is used in computing the indicator by NHS Digital.The result of our testing of this indicator is detailed below.

Indicator Findings

Summary Hospital-level Mortality Indicator (SHMI). We recognise that in line with auditor guidance, it is not possible for auditors to test the statistical computations completed by NHS Digital to producethe indicator. Our work therefore concentrated on testing the information provided by the Trust to NHS Digital for use in their modelling tool.

While we tested a sample of data and confirmed the reports provided for audit were supported by patient records, we were unable to confirm that thereports provided to us for audit matched those provided by the Trust to NHS Digital.

We therefore recommend the Trust implements a method of recording the data submitted to NHS Digital so that verification can be completed in future.

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Appendix A

Limited assurancereport – draft

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Limited assurance report on the content of the Quality Reports and mandatedperformance indicatorsIndependent auditor’s report to the Council of Governors of Western SussexHospitals NHS Foundation Trust on the Quality Report

We have been engaged by the Council of Governors of Western Sussex HospitalsNHS Foundation Trust (“the Trust”) to perform an independent assuranceengagement in respect of Western Sussex Hospitals NHS Foundation Trust’s QualityReport for the year ended 31 March 2019 (the ‘Quality Report’) and certainperformance indicators contained therein.

This report is made solely to the Trust’s Council of Governors, as a body, inaccordance with our engagement letter dated 16 January 2017. We permit thedisclosure of this report within the Annual Report for the year ended 31 March 2019to enable the Council of Governors to demonstrate that they have discharged theirgovernance responsibilities by commissioning an independent assurance report inconnection with the indicators.

To the fullest extent permitted by law, we do not accept or assume responsibility toanyone other than the Trust and the Trust's Council of Governors as a body, for ourexamination, for this report, or for the conclusions we have formed.

Our work has been undertaken so that we might report to the Council of Governorsthose matters that we have agreed to state to them in this report and for no otherpurpose. Our report must not be recited or referred to in whole or in part in any otherdocument nor made available, copied or recited to any other party, in anycircumstances, without our express prior written permission. This engagement isseparate to, and distinct from, our appointment as the auditors to the Trust.

Scope and subject matter

The indicators for the year ended 31 March 2019 subject to limited assuranceconsist of the national priority indicators as mandated by NHS Improvement:

percentage of patients with a total time in A&E of four hours or less from arrival toadmission, transfer or discharge (page 85)maximum waiting time of 62 days from urgent GP referral to first treatment for allcancers (page 85)

We refer to these national priority indicators collectively as the ‘indicators’.

Respective responsibilities of the directors and Ernst & Young LLP

The directors are responsible for the content and the preparation of the quality reportin accordance with the criteria set out in the ‘NHS Foundation Trust AnnualReporting Manual 2018/19’ issued by NHS Improvement.

Our responsibility is to form a conclusion, based on limited assurance procedures,on whether anything has come to our attention that causes us to believe that:

Limited assurance report – draft


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•the Quality Report is not prepared in all material respects in line with the criteriaset out in the ‘NHS Foundation Trust Annual Reporting Manual 2018/19’(published on 6 November 2018), which is supported by NHS Improvement’s‘Detailed requirements for quality reports 2018/19' (published on 17 December2018) issued by NHS Improvement;

• the Quality Report is not consistent in all material respects with the sourcesspecified in Section 2.1 of the ‘Detailed guidance for external assurance onquality reports 2018/19’ and

• the indicators in the Quality Report identified as having been the subject of limitedassurance in the Quality Report are not reasonably stated in all material respectsin accordance with the ‘NHS Foundation Trust Annual Reporting Manual 2018/19’and supporting guidance and the six dimensions of data quality set out in the‘Detailed Guidance for External Assurance on Quality Reports 2018/19’.

We read the Quality Report and consider whether it addresses the contentrequirements of the ‘NHS Foundation Trust Annual Reporting Manual 2018/19’ andsupporting guidance, and consider the implications for our report if we becomeaware of any material omissions.We read the other information contained in the Quality Report and consider whetherit is materially inconsistent with the other information sources detailed in Section 2.1of the ‘Detailed guidance for external assurance on quality reports 2018/19’. Theseare:• Board minutes for the period April 2018 to 29 May 2019;• Papers relating to quality reported to the Board over the period April 2018 to 29

May 2019;• feedback from commissioners, dated 2 May 2019;• feedback from governors, dated 25 February 2019;• feedback from local Healthwatch organisations, dated 13 May 2019;• feedback from Overview and Scrutiny Committee dated 30 April 2019;

• the trust’s complaints report published under regulation 18 of the Local AuthoritySocial Services and NHS Complaints Regulations 2009, dated 29 April 2019;

• the latest national staff survey, dated 1 February 2019;• the Head of Internal Audit’s annual opinion over the trust’s control environment for

2018/19; and• Care Quality Commission inspection report, dated 20 April 2019.We consider the implications for our report if we become aware of any apparentmisstatements or material inconsistencies with those documents (collectively, the‘documents’). Our responsibilities do not extend to any other information.

We are in compliance with the applicable independence and competencyrequirements of the Institute of Chartered Accountants in England and Wales(ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevantsubject matter experts.

This report, including the conclusion, has been prepared solely for the Council ofGovernors of Western Sussex Hospitals NHS Foundation Trust as a body, to assistthe Council of Governors in reporting Western Sussex Hospitals NHS FoundationTrust’s quality agenda, performance and activities. We permit the disclosure of thisreport within the Annual Report for the year ended 31 March 2019, to enable theCouncil of Governors to demonstrate they have discharged their governanceresponsibilities by commissioning an independent assurance report in connectionwith the indicators.



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To the fullest extent permitted by law, we do not accept or assume responsibility toanyone other than the Council of Governors as a body and Western SussexHospitals NHS Foundation Trust for our work or this report, except where terms areexpressly agreed and with our prior consent in writing.

Assurance work performed

We conducted this limited assurance engagement in accordance with InternationalStandard on Assurance Engagements 3000 (Revised) – ‘Assurance Engagementsother than Audits or Reviews of Historical Financial Information’, issued by theInternational Auditing and Assurance Standards Board (‘ISAE 3000’). Our limitedassurance procedures included, but were not limited to:

evaluating the design and implementation of the key processes and controls formanaging and reporting the indicatorsmaking enquiries of managementlimited testing, on a selective basis, of the data used to calculate the indicator backto supporting documentationcomparing the content requirements of the ‘NHS Foundation Trust Annual ReportingManual 2018/19’ to the categories reported in the Quality Report.reading the documents.

The objective of a limited assurance engagement is to perform such procedures asto obtain information and explanations in order to provide us with sufficientappropriate evidence to express a negative conclusion on the Quality Report. Theprocedures performed in a limited assurance engagement vary in nature and timingfrom, and are less in extent than for, a reasonable assurance engagement.Consequently the level of assurance obtained in a limited assurance engagement is

substantially lower than the assurance that would have been obtained had areasonable assurance engagement been performed.

Inherent limitations

Non-financial performance information is subject to more inherent limitations thanfinancial information, given the characteristics of the subject matter and the methodsused for determining such information.

The absence of a significant body of established practice on which to draw allows forthe selection of different, but acceptable measurement techniques which can resultin materially different measurements and can affect comparability. The precision ofdifferent measurement techniques may also vary. Furthermore, the nature andmethods used to determine such information, as well as the measurement criteriaand the precision of these criteria, may change over time. It is important to read thequality report in the context of the criteria set out in the ‘NHS foundation trust annualreporting manual 2018/19’ and supporting guidance. The scope of our assurancework has not included governance over quality or non-mandated indicators, whichhave been determined locally by Western Sussex Hospitals NHS Foundation Trust.

The scope of our assurance work has not included governance over quality or non-mandated indicators, which have been determined locally by Western SussexHospitals NHS Foundation Trust.



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Conclusion

Based on the results of our procedures, nothing has come to our attention thatcauses us to believe that, for the year ended 31 March 2019:

the Quality Report is not prepared in all material respects in line with the criteria setout in the NHS Foundation Trust Annual Reporting Manual 2018/19 (published on 6November 2018) and the Detailed requirements for quality reports 2018/19(published on 17 December 2018) issued by NHS Improvementthe Quality Report is not consistent in all material respects with the sources specifiedin the detailed requirements for assurance for quality reports; andthe indicators in the Quality Report subject to limited assurance have not beenreasonably stated in all material respects in accordance with NHS Foundation TrustAnnual Reporting Manual 2018/19 (published on 6 November 2018) and the Detailedrequirements for quality reports 2018/19 (published on 17 December 2018) issuedby NHS Improvement .

Ernst & Young LLPApex Plaza,Forbury Road,Reading,RG1 1YE29 May 2019

Notes:1. The maintenance and integrity of the Western Sussex HospitalsNHS Foundation Trust web site is the responsibility of the directors; the work carriedout by Ernst & Young LLP does not involve consideration of these matters and,accordingly, Ernst & Young LLP accept no responsibility for any changes that mayhave occurred to the Quality Report since it was initially presented on the web site.2. Legislation in the United Kingdom governing the preparation anddissemination of financial statements may differ from legislation in other jurisdictions.



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Ernst & Young LLP

© Ernst & Young LLP. Published in the UK.All Rights Reserved.

The UK firm Ernst & Young LLP is a limited liability partnership registered in England and Waleswith registered number OC300001 and is a member firm of Ernst & Young Global Limited.

Ernst & Young LLP, 1 More London Place, London, SE1 2AF.

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Audit Committee Update to Council of Governors Jon Furmston Chair, Audit Committee Sept 2019

Role of the Audit Committee

In other words :

“To test, on behalf of the Trust Board, whether this is a well run organisation”

We do this through four main tools: • External audits – for statutory items • Internal audits – wherever we choose (usually where there is higher risk) • Counter Fraud Services • Executive reports and challenge

To scrutinise the governance, risk management and internal control arrangements put in place

to ensure achievement of organisational objectives.

1. External Audit

Perform audit work and then provide an opinion on: Financial Statements and Annual Report Value for Money Conclusion Quality Report Quality Indicators (2 mandated & 1 local) EY present their report today so I won’t repeat their findings…

2. Internal Audit

Substantial Assurance (“Stretch”) • Release of information Moderate Assurance (“On Target”) • Divisional Governance • Data Quality • Medical revalidation • Key financial systems • IT asset management • Business Continuity

Area of Limited Assurance (“Threshold”) • Consent

No audit findings were “Below Threshold” Two advisory assignments • Risk Maturity Assessment • Medicine Division: Medical staffing

3. Local Counter Fraud Service Counter Fraud help us to deter, prevent, detect and hold to account anyone trying to commit fraud against the Trust. They have also been challenged to find extra value-add opportunities. They benchmarked how frequently we don’t follow normal procurement processes of getting several quotes from suppliers – i.e. a ‘single tender waiver’. This can be an indicator of weak financial controls and may make fraudulent procurement more possible We benchmark very well

4. NED Challenge

Some of the areas we have sought assurance from management: Business Case Development and Post Project Reviews DocMan, Southlands Opthalmology Security Executive Group Board Assurance Framework Financial and other Process Controls Accounts Preparation - lessons learnt, Tender Waivers, Special Payments, Declaration of Interests Audit Committee Hotspots Identifying known/unknown possible issues and checking there is a route to testing and hence gaining assurance

Audit Committee Presentation

Thank you for listening and any questions ?


Approach to refreshing the Clinical Strategy Council of Governors – 3rd October 2019 Oliver Phillips

Background

• The Trust’s previous 5-year Clinical Strategy was approved in 2014; significant change has happened since this time

• Development of a new five year Clinical Strategy has been agreed as a priority for the Trust and is a corporate project;

• We are refreshing our Clinical Strategy from a position of strength – the Trust provides a wide range of clinically excellent services and will continue to do so

• Refreshing the Clinical Strategy is an opportunity to review each of our clinical services and to ensure that they are placed on a sustainable footing in order to maintain our excellent clinical services

• Programme led by George Findlay as Executive Sponsor with Oliver Phillips as SRO and Tim Taylor as Clinical Lead

Our approach to developing the Clinical Strategy

• Frame – to confirm the scope and the ‘strategic boundaries’ of the refresh

• Diagnose and Forecast – collect information on our current services, the impact of demographic and other changes (such as national policy)

• Generate Options and prioritise - what changes are therefore required and how to we prioritise

• Confirm Strategy – via Executive Steering Group to Board

• Deliver – ensure implementation plan is robust and fed into business planning

Stage Public/Patients Staff Governors/Non-Executive Directors

Commissioners GPs + IPC Statutory Partners/ STP Voluntary Services

Frame/ Diagnose/ Forecast

Collate feedback from patients and public from a range of sources including feedback, engagement and consultation activities carried out by the Trust, CCG and STP

Use a range of approaches to seek people’s views:

• Electronic survey of Trust staff;

• Staff engagement via Divisions;

• Focus groups including with staff groups who have protective characteristics

• Liaise with Unions and Joint Local Negotiating Committee

Feed in views of governors and Non-Executive Directors; Seek ideas about how to promote public engagement in developing the strategy

Use commissioner held information to inform frame, diagnose and forecast; Meet with commissioners to ensure they are engaged and updated, and there is alignment of Clinical Strategy proposals with wider system plans and commissioner expectations

Seek the views of GPs and Innovations in Primary Care through a range of media

Early engagement with the chair of Health and Adult Social Care Select Committee and Children and Young People's Services Select Committee and the Health and Wellbeing Board to advise of Clinical Strategy development and seek views Meet with Statutory Partners to understand their views and how the Clinical Strategy can complement wider place and system based planning;

Seek views of the Voluntary Services organisations via Community Works and Voluntary Action Adur and Chichester (VAAC); Seek views of Voluntary Services directly working with the Trust, e.g.: Carers Support West Sussex

Generate Options

Use the above insight to inform the assessment process

During the above engagement provide opportunity for staff to suggest ideas for change; DDOs, Chiefs of Service, Clinical Directors, Heads of Nursing, Deputy DDOs, CGMs and Matrons attend workshops

During the above engagement provide opportunity for Governors and Non-Executive Directors to suggest ideas for change

During the above engagement provide opportunity for commissioners to suggest ideas for change

During the above engagement provide opportunity for people to suggest ideas for change

During the above engagement provide opportunity for other statutory partners to suggest ideas for change

During the above engagement provide opportunity for people to suggest ideas for change

Prioritise Use the above insight to inform the assessment process

DDOs, Chiefs of Service contribute to prioritisation exercise; Feedback decisions to staff and support understanding why specific choices have been made

Provide opportunity for Governors and Non-Executive Directors to make suggestions for selection criteria; Feedback proposed clinical strategy priorities to Governors

Feedback proposed clinical strategy priorities to Commissioners and enable understanding/ support for specific choices

Feedback decisions and support understanding why specific choices have been made

Feedback decisions to statutory partners and support understanding why specific choices have been made

Feedback decisions to voluntary sector and support understanding why specific choices have been made

Communication and Engagement Some prioritised proposals may then require formal public engagement and consultation

Strategic Boundaries

• ‘Strategic Boundaries’ are agreed limits to what the Trust needs to consider when refreshing its Clinical Strategy; they are ‘fixed points’ around which the refreshed strategy can be designed

• The Executive Team have proposed strategic boundaries for the Strategy which has been reviewed by the Executive Steering Group; these were onformed by The Clinical Co-dependencies of Acute Hospital Services: A Clinical Senate Review;

• These have been carefully considered so as not to limit opportunity to

explore fundamental change where needed;

• The review looked specifically at • Could the current service configuration be sustained? • Is it technically feasible (in terms of capacity) to make any

change? • Could we secure political support for the change?

Strategic Boundaries

As a result of this review the following services are considered fixed points and therefore make up the ‘Strategic Boundaries’ for the Trust as it develops its Clinical Strategy

1. Full Type 1 A&E Services on both the Worthing and the St. Richard’s

site

2. Consultant-led Obstetric services at both the Worthing and St. Richard’s site

3. To continue to provide and enhance outpatient and day case services at Southlands Hospital

Diagnosis - Data and Information Speciality Speciality

Speciality Speciality Speciality

Element theme Element Patient Trust Friends and Family

Recommend %

Complaints Cancelled appts/ theatre sessions

Quality HSMR (Dr F) Mortality (Dr F) Complications (Dr F) Adverse events (Dr F) Compliance to national standards

Our People Vacancy rate Use of temporary staffing Staff recommend rate

Sustainability Demand - Predicted percentage growth (e.g.: -5 to 0; +1 – 5; 5+ etc.)

Market Share (Dr F) Service line reporting Spend outside of budget WAU (Model Hospital) Length of stay - long (Dr F) Length of stay - average (Dr F) Readmissions (Dr F) OP follow ups (Dr F)

Performance/ System and Partnerships RTT Diagnostic wait times

Governance

Trust Board

Trust Executive Committee

Clinical Strategy Programme Board

Work stream 1: Diagnose and Forecast

Work stream 2:Generate Options,

Prioritise and Confirm Strategy

Work steam 3:Deliver/ Monitor

Analytics Function

Stakeholder and public engagement

Estates and Infrastruture

Divisional Engagement

Financial Support Quality team support Communications

Key

Governing Bodies

Coordinating processes

Working Teams

Workforce

Prioritising options Emerging Proposals

True North Considerations Proposal 1 Proposal 2 Proposal 3 Proposal 4 Patient Improves patient

outcomes

Improves patient Experience

Responds to Public Engagement

Our People Addresses workforce gaps and pressures linked to Clinical Sustainability

Quality

Improves patient safety

Improves performance

Directions from Regulators

Sustainability Addresses financial pressures

Systems and Partnerships

Views of Commissioners

STP and place based plans


Questions?

Agenda Item: 16 Meeting: Council of Governors Meeting Date: 3 October 2019

Report Title: Governor Elections Report Presenter: Alan McCarthy Chair Author(s): Glen Palethorpe – Group Company Secretary Report previously considered by and date:

Purpose of the report: Information ☐ Assurance ☐ Review and Discussion ☐ Approval / Agreement Reason for submission to Trust Board in Private only (where relevant): Commercial confidentiality ☐ Staff confidentiality ☐ Patient confidentiality ☐ Other exceptional circumstances ☐ Link to Trust Strategic Themes: Patient Care Sustainability Our People Quality Systems and Partnerships Any implications for: Quality Financial Workforce Link to CQC Domains: Safe ☐ Effective ☐ Caring ☐ Responsive ☐ Well-led Use of Resources ☐ Communication and Consultation: Report: Council of Governors At the last Council meeting it was agreed that the Medical Director would support in securing a co-opted member of staff for the Medical and Dental vacancy. This approach has proved successful and Anna Mathew a consultant paediatrician has agreed to be co-opted to a non-voting position to allow a medical and dental voice to be maintained within the Council. Both the Chair and Lead Governor have met with Anna to discuss the role. West Sussex County Council has appointed Cllr Jacky Pendleton as their representative on the Council. This leaves the Council with one vacancy within Adur. Lead Governor Arrangements At the last meeting the Council agreed to hold elections for the Lead and Deputy Lead Governor positions in October 2019, following the appointment of John Thompson and Gill Long to the positons of Lead and Deputy Lead Governor following the retirement of Roger Hammond.

Process for Lead and Deputy Lead Governor elections. A pack requesting nominations for either position will be sent to Governors in line with the following timetable, nominations along with a short accompanying statement need to be provided to the Group Company Secretary who will then oversee the election process. A Nomination and Remuneration Committee meeting will be held on 7 November 2019 to approve the appointment of the Lead and Deputy Lead Governor, which then will be ratified at the next Council Meeting in January.

Timetable for the election of Lead and Deputy Lead Governor

Dates Action Who by 4 October 2019 Send out requests for

nominations

Glen Palethorpe

11 October 2019 Responses of nominations returned to Glen Palethorpe, Group Company Secretary BY 17.00

Governors

15 October 2019 Responses of nominations collated and sent out to Governors as voting packs

Jan Simmons

28 October 2019 Votes returned to Glen

Palethorpe, Group Company Secretary BY 17.00

Governors

29 October 2019 Votes counted Glen Palethorpe

Jan Simmons

29 October 2019 Successful Governors

notified

Glen Palethorpe

29 October 2019 Unsuccessful candidates

notified

Glen Palethorpe

30 October 2019 All Governors informed of outcome of the vote

Jan Simmons

7 November 2019 Appointments approved at Governor Nomination & Remuneration Committee

Alan McCarthy

7 November 2019 Appointments commence

16 January 2020 Ratification and next Council

of Governors meeting: Alan McCarthy

Key Recommendation(s): The Council of Governors is asked approve the co-opting of Anna Mathew to Medical and Dental vacancy until the next round of scheduled elections. The Council of Governors to note the timetable for the election of the Lead and Deputy Lead Governors. Appendix 1: Lead and Deputy Lead Governor role description

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Lead & Deputy Lead Governor

Role Description

Accountability: The Lead and Deputy Lead Governors are accountable to the Council of Governors collectively as a serving Member of the Council. The Role:

• To be an external point of contact for NHS Improvement (formerly Monitor) where it may be considered inappropriate for the Chairman or his nominated deputy, or for the Company Secretary to deal with a particular matter.

• To facilitate communications and a good working relationship between the Governors and the Executive Board and Trust Board including acting as the principle independent channel for communications between the Governors and Executive Board and Trust Board through the Chairman, Chief Executive, Company Secretary or Senior Independent Director.

• To consult routinely with the Governors, Chair and Company Secretariat regarding the

planning and preparation of the Council of Governors agenda.

• To be a member of the Nominations and Remuneration Committee.

• To contribute to the appraisal of the Chairman by the Senior Independent Director, supported by the Company Secretary, in accordance with the process determined by the Council of Governors including the collation of input from other Governors and the Nominations and Remuneration Committee on the performance of the Chairman.

• Contribute to the determination of the appraisal process of the Non-executive Directors to

be undertaken by the Chairman and supported by the Nominations and Remuneration Committee.

• To recommend to the Council of Governors on behalf of the Nominations and Remuneration Committee any appointments/reappointments of Chair; Non-executive Directors and/or the Chief Executive.

• To take an active role in the activities of the Council of Governors and to meet with the Chairman and Company Secretariat on a regular basis to discuss relevant issues.

• Support the Chairman and Company Secretary in any action to remove a Governor due to

unconstitutional behaviour in accordance with the Code of Conduct.

• To be involved in the induction process for any newly appointed Public Governor.

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• The Lead Governor may call upon the support of the other Governors, the Chairman, the Company Secretary and the Senior Independent Director to carry out their role effectively to the benefit of the Council of Governors.

• In liaison with the Chairman and Company Secretary, support the development of the skills

and strengths of the Council of Governors and raise public awareness of all Governors.

• To chair meetings of Council of Governors where the Trust Chair, Vice-Chair or other Non-Executive Director cannot chair the meeting due to a conflict of interest.

• Where approved by the Council and/or the Chairman speak for and represent the Council at the AGM and on other occasions

• Other duties as requested by the Council of Governors or the Chairman.

• Chair the Pre-Council of Governors meeting and any informal meetings.

The Person: To fulfil this role effectively, the Lead Governor will need to:

• Be a publically elected Governor

• Have the confidence of Governor colleagues and members of the Executive Board and Trust Board

• Be able to forge constructive working relationships with colleagues

• Understand NHSI’s role, the available guidance and the basis upon which NHSI may take regulatory action

• Be committed to the success of the Foundation Trust and understand the Trust’s Constitution

• Have the ability to influence and negotiate

• Be able to present a well-reasoned, unbiased argument

• Demonstrate ability to maintain confidentiality of information.

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The Appointment: The tenure is one financial year with the option for re-election annually in accordance with due process, for up to the full tenure period of the elected Governor’s ‘appointment’. In accordance with a process agreed by the Council of Governors, the Company Secretariat will administer an annual nomination and election/re-election procedure that will require: -

• Submission of an expression of interest (for re-election and for new election candidates) • Submission of a statement for support of no more than 250 words supporting candidature

(only for NEW nominations and/or contested elections);

• Election by ‘show of hands’ or by secret ballot as determined by the relevant Council meeting.

Additional:

The Lead Governor will work closely with and be supported and deputised for by a Deputy Lead Governor whose appointment will follow the same procedure above. It is anticipated, where terms of office accord, that the Deputy Lead Governor will put themselves forward for Lead Governor position when that position becomes vacant, remaining subject to the appointment process above.

council of governors meeting - st richard's hospital · january 2020 15.00 – 18.00 john bull...

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