objective 1 - safe – deliver safe, high quality care and

Objective 1 - Safe – Deliver safe, high quality care and improving services which pursue perfection and be in the top 25% of our peers Strategic Theme / Annual priority • Reduce Avoidable Harm Director responsible Chief Nurse

Medical Director

Key Action for 2018-19 objectives and description of any potential significant risk to this priority

1.1 There is a risk that the Trust will not be in the top quartile for safety and continue to improve beyond this benchmark if opportunities to innovate and learn from benchmarked outcome data/peer review are not adopted and implemented.

Initial Risk S4 x L3 = 12

Current rating S4 x L2 = 8

Target risk score S4 x L1 = 4

Target Date 2 yrs

Linked to Risk 1514, 1798, 1903, 1936

Controls in place Gaps in Control • Incidents, complaints, risk and legal services managed through Datixweb (web based

database), allowing triangulation of data. • Regular review of patient safety data including incidents, HSMR, the Safety

Thermometer at ward, divisional, executive and board level • Suite of policies relating to the reporting, management and monitoring of

incidents and safety within the Trust. All policies within date. • Nursing staffing levels benchmarked nationally monitored (care hours per

patient day) and related issues managed daily • National patient safety alerts NICE guidance and other safety related

guidance reviewed, audited and implemented where relevant and appropriate • Quarterly Corporate Serious Incident Review Group in place to ensure that

the Trust is sighted on the issues identified during serious incident investigations.

• IPCAS Team and Group in place, monthly taskforce meetings in place • Variety of national audits contributed to and reviewed • Mortality governance review and reports to Board, Medical Examiners,

Structured Judgment review for LD death • Trust Safeguarding Policy, Mental Capacity Act (MCA), Deprivation of

Liberties (DoLS), Information Sharing Policy, and Governance Policy in place and available on intranet for all staff. Safeguarding Children and Adult Committees exist and are have external representation from partner organisations. Training remains an essential part of the MAST.

• The Trust follows the Surrey Multi Agency procedures relating to information sharing.

• Standard Ward – value stream relating to the management of diarrhoea is now standard work across the Trust

• Developing systems to support safety benchmarking • Data quality and lag for use in improvement programmes • Absence of electronic prescribing • No audits of integrated care record use by hospital • Opportunities exist to triangulate data more effectively • No named doctor for adult safeguarding • Maternity system and Cerner are not compatible and there are discrepancies in

data.

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

• External reports and visits to clinical areas both scheduled and unscheduled o CQC o Genba walks o Service user reviews (LD) o PLACE inspections o CCG assurance visits

• Divisional and Trust level dashboards • SASH + Program • Benchmarking:

o Model hospital reports o GIRFT reports o Incidents are uploaded on a weekly basis to the National Reporting and Learning

System (NRLS). o CQC insight report o Internal benchmarking via Trust scorecard o Right Care data/variation vs peers o 7 days services audit benchmarked with STP o Safety Thermometer data o RCP national falls data o National Audits (e.g. Falls, End of Life, Cancer, LD) o NHS benchmark for Learning Difficulties

• Compliance with NICE guidance audits • Respect tool for advance care plans audit • De-prescribing work in frail and elderly within the polypharmacy AHSN work • Assurance process in place for C. diff / MRSA blood stream infection. • Section 11 compliance is monitored by Surrey and West Sussex Safeguarding • Boards by submission of a self-assessment audit.

• Deteriorating Patient group provides oversight of sepsis, resuscitation and MET calls

Positive (+) CQC Chief Inspector of Hospitals Report (+) RAG rated Green by NHS Resolution (former CNST Level 2) (+) EWS audit, action plan in place including development of electronic systems (+) Datix incident reporting and analysis including increase in reporting (+) Datix linkages to audit and strengthening legal affairs systems (+) Strong evidence of improved SI investigation management and closures (+) Improved reporting of patient falls has enabled the Trust to understand fall profile and revised strategy and action plan in development (+) Antimicrobial prescribing audit reported monthly (GAP) (+) Feedback from CQC (periodic rather than formal report) (+) SHMI Mortality is better than expected for our patient group when benchmarked against national comparators. Ambition is to sustain this. (+) Band 6 ready programme publishes innovation on the I2I factory site (+) Falls and pressure damage incidents are validated monthly (+) No severe harm (Cat 3+) pressure damage since March 2019. (+) Nursing vacancy rate 1% Negative (-) Incidence of pressure ulcers (Grade 2 and below) overall rate increased YTD and improvements in pilot wards not yet achieved across other areas (-) falls with harm need to establish actions to address summer variation in falls (-) GAP audit consistently below expectation (-) HSMR rolling 12 month figure has risen steadily in recent months despite a fall in crude mortality rate.

Gaps in assurance Assurance Level gained: RAG Ability to benchmark in real time and data quality of elements of reporting

Actions Progress (including dates, notes on slippage or controls/

assurance failing. 1. VMI/SASH plus development program 2. Improvement strategies underway:

a. Falls and pressure damage b. IPCAS strategy c. Analysis of qualitative date held with Root Cause Analyses d. Focus on the rise in low harm incidents

3. Embed Structured Judgment review of death for people with LD and establish plans to use this methodology to review all death

4. Communication:

a. Key message in CEO led monthly Team Talk b. Chief Nurse monthly newsletter c. Weekly safety message “Safety pin” d. Serious incident learning events held monthly for Trust wide colleagues in PGC e. Monthly Safety focus ‘ Hot Topic’ being rolled out

5. Monitoring of Duty of Candour compliance and actions from serious incidents to be moved to Performance meetings.

6. Trust Strategy being developed. 7. Review National Patient Safety Strategy (July 2019), identify gaps, action plan

8. Electronic EWS with alert system being rolled out. 9. Potential to benchmark pressure damage against national data. 10. Increase awareness of the change from DOLS to LPS 11. Compliance with the Falls CQUIN is good 12. Improve EPR recording of patient co-morbidities, should benefit HSMR

1 Ongoing 2 Improvement strategies underway:

a. Ongoing b. Ongoing c. Ongoing d. Initial validation provided no immediate explanation –

increase in skin damage incidents noted, this is in line with national policy

3 Process in place for LD deaths, implementation of Medical Examiners role commences April. Review of all deaths remains an aspirational target.

4 Communication: a. In place b. In place c. In place d. Commencing January 2020

5 Commencing January 2020

6 Consultations begin January 2020 7 Reviewed and discussed at ECQR, Trust response under

consideration 8 Live on two wards, phasing in planned programme over 2020 9 Live from April 2020 10 Change effective October 2020 11 CQUIN ends 31st March 2020 12 Complete by end Jan 2020

Update by JD 06/01/20 EC 10/01/20

Date discussed at board January 2020

Objective 2 - Effective – As a teaching hospital, deliver effective and sustainable clinical care, which focus on outcomes, innovation and technology Strategic Theme / Annual priority

• Research, Development and Innovation

• Co-design with patients and partners for better outcomes

Director responsible

Medical Director


2.1 There is a risk that the Trust will not develop the right models of care for chronic conditions management and frail elderly care if it does not embed processes promoting co-design, relevant research and education programmes and an increased focus on outcomes.

Initial Risk L3 x S3 = 9

Current rating L3 x S3 = 9

Target risk score

L2 x S3 = 6

Target Date 2yrs

Linked to Risk 1895 Controls in place Gaps in Control

1) Agreed Education strategy and Board reports 2) Regular Education and Research and Development reports to SQC / Board 3) Monitoring a range of outcome data

1) Metrics relating to co-design / PROMs (outcome measures) / PREMs (experience measures)

2) League tables for CRN KSS do not measure adoption of research outcomes



1) Regulator and commissioner statements of value (e.g. NIHR?CRN, HEEKSS, BSMS, University of Surrey

2) Bespoke patient surveys 3) Director of Outcomes work on triangulating metrics around outcomes 4) Clinical Effectiveness Committee – New interventional procedures 5) Quarterly Research report to Executive Board

Positive (+) GMC Survey Results (+) R+D regional reports on studies and recruitment (+) Case studies of co-design

Gaps in assurance Assurance Level gained: RAG Metrics and strategy milestones to be developed to support assurance

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

1) Agree strategies, metrics and milestones at Exec and Board Ongoing

Update by EC 10/01/20 Date discussed at board January 2020

Objective 2 - Effective – As a teaching hospital, deliver effective and sustainable clinical care, which focus on outcomes, innovation and technology Strategic Theme / Annual priority • Prevention


Directors responsible

Medical Director Director of Corporate Affairs


2.2 There is a risk the Trust will not maximise its potential to contribute to the public health agenda if it does not coordinate its focus on prevention and healthy living with the wider health and social care system.



Target risk score

L2 x S3 = 6

Target Date (2yrs+) from 2018/20

Linked to Risk None identified Controls in place Gaps in Control

1) Monitoring outcomes for patients – • Dr Foster data utilising Co-morbidity risk stratification • Patient demographics including deprivation • Local Clinical Audit Programme

2) National programme outputs (GIRFT, national audits, PROMs) 3) CQUIN for patients focusing on reducing risky behaviour 4) Patient & Public Engagement Strategy which identified seldom heard groups including those with protected characteristics as identified by the Equality Act 2010 (Age, Disability, Gender reassignment, Marriage and civil partnership, Pregnancy and maternity, Race, Religion or belief, Sex / Gender, Sexual orientation)

5) Agreed smoke free SASH strategy

1) Evidence of co-design for improved outcomes therefore new metrics needed. 2) Strategy for health and wellbeing offering to patients and general public still in

development 3) Mental Health strategy and metrics in development with system partners



1) Strategy for improvement in health for patients and staff 2) Vaccination strategy for staff 3) Alignment with JSNA and STP population health priorities 4) Implementation of PPE Strategy and key actions

Positive (+) CQUIN delivery for health and wellbeing (+) PPE and co-design activity taking place e.g. patient support groups, feedback sessions (+) Governor engagement and involvement in working groups and key areas across the Trust including the Big Health & Social Care conversation (+) Endoscopy patient engagement event (+) Mapping of patient engagement and co-design activities taking place (+) Guidance and support for patients and the public approved (+) Election of four new governors (+) Development of mental health strategy in consultation with patients, the public and key stakeholders. Final draft due to be approved by the Board in the next few months (+) Inclusion conference took place at SASH in Feb 2019 key stakeholders & staff

participated in the event (+)clinical lead for dental and maxillofacial services and consultant in paediatric dentistry presented at the first Surrey Gypsy and Traveller Conference (+)On-going work with Children and Family Health Surrey to form a bespoke care pathway for vulnerable children from Gypsy and Traveller communities (+) Funding approved for PPE Lead – drafting JD & recruitment in Q2 – 2019/20 (+) Governors involved in ward based surveys on elderly friendly quality mark (+) lay involvement in SASH+ and RPIWs (+) PPE lead post being recruited to in Sept 2019 (+) innovative work being undertaken at STP/ICS level in relation to unwarranted variation (+) Review of CoG role and communication & development plan being put in place (+) engagement in Surrey Heartlands with Citizen Engagement (+) Review of PPE Strategy by the Board in Nov 2019 – good progress being made (+) SASH PPE Lead started in Jan 2020 (+) CoG Communication & Development Plan approved and being implemented (+) PPE an important part of national Quality Strategy – SASH will implement in 2020 (+) PEE steering group to be established in Feb 2020

Gaps in assurance Assurance Level gained: RAG 1) Strategy and metrics not yet agreed in relation to ambition for health of non-patient / non staff

“foot fall” 2) Development of an engagement and partnerships strategy 3) Trust-wide roll-out and adoption of PPE and co-design tools, techniques and ways of working 4) Establishment of a PPE steering group


1) Agree strategies, metrics and milestones at Exec and Board 1) March 2019

Update by EC 10/01/20 GFM 27/12/19


Objective 3 - Caring – Develop the compassionate care we provide in partnership with patients, staff, families, carers and community services Strategic Theme / Annual priority • Create best environment for

patients Director responsible

Chief Nurse


3.1 There is a risk that the Trust will not meet its commitment to create the best possible environment for its patients based on equality of service provision and inclusion, if it does not seek to shape patient centred clinical services and learn from all sources of patient feedback.



Target risk score

S3 x L2 = 6

Target Date (1-2yrs)

Linked to Risk 1506,1775

Controls in place Gaps in Control 1) Patient experience committee reviews performance and escalates areas of

work and concerns to Executive Committee for Quality & Risk (ECQR) and Board

2) ECQR receives reports and provides feedback regarding patient experience 3) Clear policy and process for the management of complaints 4) Engagement with the voluntary sector including dementia groups 5) Carers support network, involvement in John’s campaign 6) Open visiting 7) High level indicators agreed at Value stream for Discharge including patient

feedback 8) Cerner solution for Accessible Information Standard in place 9) Review of patient information at Patient Information Review Group chaired by

Director of Corporate Affairs 10) Hospital @night strategy in place. 11) Accessible information standard enabled on Cerner, staff are identifying and

recording the communication needs of patients with sensory disability. 12) Outpatient letters continue to be offered in a variety of formats in line with the

communication preferences. 13) Divisional escalation plan for dealing with inpatient concerns to ensure timely

remedy.

1) Groups and patients which are “seldom heard” including those with protected characteristics as identified by the Equality Act 2010 (Age, Disability, Gender reassignment, Marriage and civil partnership, Pregnancy and maternity, Race, Religion or belief, Sex / Gender, Sexual orientation)

2) YCM response rate is low. In 2020 there will be a structured review of the questions being asked to make the survey more dynamic and relevant to improvement initiatives within the Trust.

Potential Sources of Assurance (documented evidence of controls

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

1. Your Care Matters (YCM) results (including free text comments) 2. FFT scores and free text responses 3. Staff survey 4. Themes from Complaints and Concerns reviewed at Patient Experience

Committee. 5. In 2019 National surveys were monitored by the Patient Experience

Committee and used to review and inform improvement strategies: a. National Cancer survey b. National paediatric survey c. National Inpatient Survey d. Dementia Survey e. Care at End of Life Survey f. PLACE audit

6. Duty of Candour embedded across the Trust 7. Patient feedback incorporated into SASH plus improvement work 8. PROMS rolling out to show we care about patients 9. Involvement of governors and patients in SASH + work, visits to clinical

areas, members of patient experience subcommittee , inclusion group and patient information review group

Positive (+) CQC Inspector report rated Trust outstanding for Caring (+) Carers passport (+) Standards of behaviour and feedback from staff (+) The Carers Steering Group meets regularly and the two carer support organisations are present within the Trust to provide support and guidance for carers of patients and staff who are carers. Negative (-) No clear improvement in YCM or national results relating to discharge or communication around medication and danger signals (-) Work to achieve full compliance with Accessible Information Standard (-) FFT score fluctuates (-) Feedback via complaints highlights areas that require improvement

Gaps in assurance Assurance Level gained: RAG Trust position known - no identified gaps in assurance


1) Outpatient FFT/YCM survey to be structured to support improvement initiatives. 2) Local Resolution meetings in place and learning from these must be shared across divisions, at

ECQR and Patient Safety Briefings. 3) Patient Experience Committee to focus on key actions initially identified as safe keeping of patient

property and available recreational activities. Patient Focus group to be arranged. 4) Review National Survey results: form action plans – aim to improve performance to be top 20%

Trust in future audits.

1) Questions being finalized and process needs to be agreed with Meridian.

2) Options for Trustwide learning are being evaluated.

3) Lost Property policy under review.

4) National Survey action plans to be devised with Divisional Leads.

Update by JD 27/12/19 Date discussed at board January 2020

Objective 4 - Responsive – To continue to be the secondary care provider of choice for the people of our community Strategic Theme / Annual priority • Timely access to services Director

responsible Chief Operating Officer


4.1 There is a risk that continued growth in urgent and emergency demand will have an adverse impact on delivery of elective care, quality outcomes, staff satisfaction, income and expenditure



Target risk score

S3 x L2 = 6

Target Date (2yrs)

Linked to Risk 1491, 1724, 1757, 1838, 1850, 1856/8, 1905/07, 1918, Controls in place Gaps in Control

1) SASH System A&E Delivery Board • Urgent and Emergency Care • System Wide Escalation Plan • Ambulance Conveyance

2) Integrated Discharge Board • Let’s get you home Initiative • Reduction of Super stranded patients

3) Theatre and Angio Productivity Projects 4) GIRFT specialty level reviews and Action Plans 5) Model Hospital Action Plans 6) Kingsfold and Pendleton Teams continuing focus on increasing Same Day

Emergency Care pathways 7) Outpatient Board and associated action plans focused on improving

productivity and reducing wait to first outpatient appointment to less than 12 weeks

8) RTT Recovery Plan 9) Patient Flow Improvement Board aimed at increasing and maintaining flow 10) North System-wide Recovery Plan which has four relevant subgroups

focusing on: • Optimising System Activity Flow and Pathways • Reducing Unwarranted variation • Managing Demand • Managing LOS

1. Financial position across the health system has potential to undermine efforts to deliver RTT

2. Limited prospective cover for specialist elective work 3. Limited CCG ability to arrest growth in urgent and emergency demand 4. Absence of a coherent system wide winter plan which adequately addresses

the capacity gap associated with the unprecedented increase in non-elective activity which is significantly in excess of plan.

5. Limited ability of SecAmb to arrest conveyances from out of area.



1) Integrated Performance Report 2) Benchmarking Report 3) Activity Report 4) Productivity Report 5) Winter Plan 6) SASH Escalation Plan 7) SASH System Escalation Plan

Positive (+) Delivered surplus in 18/19 and on plan in Q1 19/20 (+) Strong elective performance in 18/19 (+) Paper switch off delivered August 2018 (+) Opening of 2 temporary theatres (+) Additional investment in ED (+) CCG have agreed funding of a number of winter resilience schemes (+) CCG have agreed increased funding to support response to increase in activity (+) coordination of possible mutual aid across Surrey Heartlands Negative (-) Increase in super stranded patients (-) Community capacity does not meet demand (in volume or type) (-) Temporary closure of 2 laminar flow theatres (-) Increase in volume and LOS of patients with complex discharge needs (-) Inefficiencies associated with the use of assessment areas as escalation due to excessive demand. (-) the lateness of the decision to fund the winter resilience schemes is likely to hamper the effectiveness of the schemes. (-) the lateness of the decision to increase funding to support response to increase in activity has hampered the efficiency and effectiveness of the necessary changes

Gaps in assurance Assurance Level gained: RAG 1) CCG commitment to increase capacity or to agree use of a winter resilience fund 2) CCG commitment to increase funding to support infrastructure changes required in order to

safely respond to increase in activity.


1) Delivery of all actions both at SASH and system wide 1) Ongoing

Update by AS 23/01/20


Objective 5 - Well Led – To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centered, clinically led leadership model Strategic Theme / Annual priority Integrated health and social care Director

responsible Chief Executive Officer


5.1 There is a risk that the Integrated Care System and Integrated Care Partnerships that the Trust belongs to will not provide a workable strategic framework that allow services to be sustainably delivered.



Target risk score

S3 x L3 = 9

Target Date ( 2yrs) Milestone: January 2020 Target date: January 2021

Linked to Risk None identified Controls in place Gaps in Control 1) Surrey Heartlands Integrated Care System [SH] structure embedded and

SASH now included within this. This includes: a. System Oversight & Assurance Group; b. System Finance Assurance Board; c. Clinical Academy, and; d. A range of other forums and groups.

2) Sussex Health and Care Partnership STP structure and leadership [Exec Board, Operational Delivery Group, Finance Group and Clinical Board, in place (but see “gaps in control” #3).

3) Integrated Care Partnership Director in place (ICP – a building block within the ICS covering the SASH catchment

4) Devolution structure in place for SH and pipeline for ICS development for Sussex being established.

5) Reporting to Board, including Board seminar discussions every other month, huddles with executive team;

6) Trust strategy plans agreed by Board (part of existing Trust process); 7) Commissioning structure established for 2019/20 and 1 April 2020 will see

commissioning move to SH. 8) System Recovery Board (SRB) in SH has replaced financial recovery action in

Sussex STP structure.

1) Although the SH ICS structure is embedded and has been operating for over a year prior to SASH joining, the nature of governance arrangements and decision making (notably aspects requiring Board sign off) are not wholly satisfactory to the Trust;

2) Although the nominal local ICP has now been named Crawley, East Surrey and Horsham (CRESH) losing the ‘East Surrey ICP’ epithet, the announcement of new Sussex CCG structures strengthens the ambiguity regarding the “place” and how practically organisations will work across the SH and Sussex boundary. A question is also raised by these changes over the status of CRESH as an ICP in a formal sense.

3) The ICP partnership Board has met, but TORs, chair and ICP governance structure not yet agreed - development of ICP strategy and contribution to ICS planning not yet structured

4) Financial position across the CRESH system is problematic – this is being addressed by the SRB (left) but action not yet agreed + affordability problem against control totals

5) Commissioning reshape in progress but future commissioning arrangements not yet known [CCGs likely to retain current statutory responsibility]. It is clear that the SASH contract will be commissioned through SH, however.

6) Potential for conflict with organisational objectives and strategic ambitions within the Sussex and SH systems – cf #2 and the conversation about ICP status;

7) Lack of national formality around STP/ICP operations, authority and accountability 8) Interpretation of 2020/21 planning guidance (and availability of it) 9) Long Term Plan submission by ICS includes ambitious financial savings that will

nominally balance to regulator trajectories in 2 years, rather than 4. These have not been agreed at an organisational level.



1) ICS meetings, reporting and outputs 2) SASH involvement in ICS work streams and core governance 3) NHS Long Term Plan Implementation plans (Place based plans) 4) Board understanding and input into ICS solutions 5) System Recovery Board with supporting implementation plans 6) Engagement and communication plan in place with stakeholders 7) Engagement of relevant stakeholders 8) Feedback from NHSE/NHSI, NAO and others

Positive (+) SH ICS is a Wave 1 ICS, and achieved relevant targets in 2018/19; (+) Board states it is adequately briefed on STP/ICP - IA report provided assurance about Trust processes and engagement with ICS/STP; (+) A&E Delivery Board meets monthly and as the only forum with all system partners included development plans are being progressed through this route; this is however more reactive than strategic and will not met the needs of developing future strategies (+) Working approach and culture in SH ICS is positive (+) SASH moved into Surrey Heartlands ICS and participating fully in a variety of workstreams taking forward innovation and service transformation Negative (-) please see gaps in controls – several of these items are significant; (-) ICS financial position is worsening in 2019/20 and action in LTP plans is not agreed between partners

Gaps in assurance Assurance Level gained: RAG Several – please see gaps in controls articulated above. Commissioning reform will be needed around the move to SH commissioning. The Trust is establishing its engagement and routine with the new ICS.


1) Continue working positively with the ICS and local partners, including Director engagement in workstreams (ongoing)

2) Influence the ICS Executive through engagement (ongoing) 3) Adapt reporting to Board as work progresses (ongoing) 4) Work with both ICS and ICP to ensure that governance processes are transparent and

embedded and that Trust Board decisions are timetabled with as much advance notice as possible.

Actions proceeding to plan.

Update by AAP08/01/20 PS 31/12/19


Objective 5 - Well Led – To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centered, clinically led leadership model Strategic Theme / Annual priority • Integrated health and social care Director

responsible

Chief Finance Officer


5.2 There is a risk to the Trust’s short term financial stability if the annual income plan is not achieved and/or if divisional spending exceeds budget.



Target risk score

S3 x L2 = 6

Target Date (1 year)

Linked to Risk 1663, 1688, 1689 Controls in place Gaps in Control 1) Business Plans & budgets (activity/ financial) waste reduction & productivity

plans. 2) Control Total agreed with Regulators 3) Contract management process in place with CCGs. 4) Financial reporting, including periodic forecast scenarios, is in place and

effective – the first detail forecast went to Board in July (Q1), the 2nd in October (Q2), with the 3rd due in January (Q3).

5) A&E Delivery Board operating 6) NHSE/I Performance Meetings: 7) COO has established “boards” to oversee productivity delivery, patient flow, &

outpatients

1) There is continued overspending (2019/20) in all clinical Divisions and (noting the success of the recruitment) on overseas nurse recruitment

2) Significant increases in ED attendances provide a substantial organisational issue operationally and financially.

3) There are demand increases with several income areas but capacity is restricted by emergency activity.



1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board (including CQUIN reporting process).

2) Performance Review and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process

3) Outputs and reporting from contract and information teams 4) Output and reporting from health system management (e.g.: A&E Delivery

Board/System Improvement Board) 5) Output of Contract Management Process. 6) Agency and roster PMOs.

Positive (+) Trust delivered an overall (and underlying) surplus in 2018/19 and agreed an income settlement with CCGs. (+)Control Total agreed with regulators (reduced by £5m), although £14m surplus target (including PSF) is challenging (+) Cash position is now “normal” after substantial sustainability funding payments in both 2017/18 and 2018/19. At M09 the cash position is strong (+) Nurse agency has reduced significantly [but significant cost from overseas recruitment of nurses] (+) M08 position [just] favourable to Plan. (+) Apart from Cancer & Diagnostics, divisional overspending is set off by income from increased activity. Negative (-) There is continued overspending in all clinical Divisions (despite set off from

income) (-) Emergency activity pressures remain prevalent and have increased in 2019/20 – ED attends are c9% higher than planned causing significant operational disruption (-) Too much non elective activity, not enough elective – risk remains over emergency demand (-) M04 position had a significant favourable variance to plan that has eroded each month to M08 – there is risk to M09. (-) Commissioners around the Trust have significant financial risk – YTD adverse variances are reported in Sussex and Surrey Heartlands.

Gaps in assurance Assurance Level gained: RAG Amber – contracts are signed, but risks remain from levels of demand.


1) Performance reviews to facilitate income through productive work processes and cost control to be exercised by Divisions (ongoing)

2) Particular attention in Cancer & Diagnostics (ongoing) 3) Review nursing staffing changes, agency and bank usage and look to agree any changes to the

overseas recruitment process

Actions proceeding to timetable.

Update by PS 31/12/19 Date discussed at board January 2020


responsible Chief Finance Officer


5.3 There is a risk to the Trust’s longer term financial stability if it is unable to deliver its medium term financial plan.



Target risk score

S4 x L2 = 8

Target Date (2yrs)

Linked to Risk 1603 Controls in place Gaps in Control 1) Items referred to in 5.2 above 2) NHSi Plan submitted in April 2019 and accepted – Control Total agreed 3) Waste reduction plan process in place (including QIA structure)

1) Items listed above (5.2) are applicable here, and also impact of ICS aspects in 5.1;

2) Detail of 2020/21 operating plan not yet published 3) Reliance on centrally determined rules for tariff & wider NHS finance regime. 4) Risk over capacity from other operational pressures 5) Overall health system financial view describes significant financial pressures,

some with a structural basis 6) Central actions over NHS spend may have an adverse impact on Trust because

of manner of application (e.g. withholding capital and cash). 7) Financial recovery plan for CRESH not yet finalized and agreed with regulators.



1) Production of 2019/20 budget, financial model, business plan documentation,

and delivery against them 2) Output from ICS LTP planning process 3) Output from Financial Recovery Board 4) Agreed contracts with commissioners describing realistic demand and

acceptable financial values 5) Sign off of 2020/21 Plan, provider sustainability funding with NHS

Improvement in 2020/21…not due until later in the year.

Positive (+)Trust delivered a surplus in 2016/17 and in 2017/18 it had an underlying surplus. The Trust ended 2018/19 with a surplus of £11.6m and forecasts ending 2019/20 with a surplus of £14.0m (+) Trust’s liquidity position has moved to a [generally] positive ratio – this and the underlying surplus are providing the strongest financial base the Trust has had in its history. (+) new “trajectories” provide a more reasonable financial target for the Trust (+) LTP return for ICS completed which delivers multi-year required financial trajectory

Negative (-) overall health system loss of resource through structural reasons…health system in overall deficit – system recovery plan necessary to recover financial position (-) At M08 risk to delivering control total estimated as c£12m

Gaps in assurance Assurance Level gained: RAG Amber recognising risks to set against the starting position for 2020/21.


1) Please see mitigating actions listed for #5.2 : 2) The 2020/21 Operating Plan needs to be incorporated into planning and operating plan

submissions made to regulators in February 2020

Actions proceeding to timetable

Update by PS 31/12/19 Date discussed at board January 2020


responsible Director of Information and Facilities Chief Finance Officer


5.4 There is a risk of impact on patients from the delivery of the Trust’s capital programme caused by national / local availability and priority of capital resources if it does not effectively prioritise and manage its resources.



Target risk score

S4 x L1 = 4

Target Date (2yrs)

Linked to Risk 1976 Controls in place Gaps in Control 1) Business Plans, Capital Plan (including 5 year plan) & capital budgets. 2) Capital allocation process in place and embedded with monthly Capital Group 3) Chiefs involved in decision making process for capital budget prioritisation

(through weekly Chief’s meeting); 4) Capital and financial reporting to Execs, FWC and Board (at least monthly) 5) NHSi notification of capital resource and cash limits, and NHSi reporting 6) Patient safety and quality reporting and risk registers 7) Clinical informatics Board and EPR programme management 8) Individual capital scheme project groups

1) Agreement of capital loans effectively suspended by NHSE/i and DHSC 2) An alternative approach delivering the same clinical benefits as the electronic

patient record digitise project would be difficult to create and there is a clinical opportunity cost from not having EPR digitise (safety for sepsis, drug administration, AKI and other areas would be improved by the programme)

3) Central management of capital is very reactive [late release of capital in 2019/20]. 4) Press interest may misinterpret the contents of Board reporting about capital

funding availability



1) Capital and financial performance reporting to Exec Committee, Finance &

Workforce Committee and Trust Board 2) NHSi notification of capital resource limit 3) Safety and Quality reporting to Exec Committee, Safety & Quality Committee

and trust Board. 4) Clinical informatics Board and EPR programme management reporting 5) Individual capital scheme project group reporting

Positive (+)Trust has delivered its capital resource limit every year, and did so again in 2018/19 (+) Trust’s liquidity position has moved to a positive ratio, and it is making surpluses that provide additional cash (+) robust prioritization process, which identifies schemes if funding becomes available (+) additional capital secured for 2019/20 funded from cash reserves, and also from central PDC. (+) progress with Surrey Trusts on a shared approach to EPR may secure funding for the EPR, removing the need for the much-delayed loan (+) EPMA funding was released, but as it is late in the year we can only accept part of the amount [likely to be available again in 2020] (+) capital spend projected to be on plan for the year – an underspend is very unlikely

Negative (-) There is still no formal output about the EPR digitise loan and although elements of that project have been funded piecemeal there is still a gap in the overall funding for the project. There are clinical quality benefits that are therefore delayed.

(-) Pressure on capital is restricting developments and improvements

Gaps in assurance Assurance Level gained: RAG Rated amber because of late release of additional capital, but there are now routes to complete most of the Trust’s intended capital programme


Complete capital programme to time and within budget (March 2020) Actions proceeding to timetable

Update by PS 31/12/19 IM 20/01/20


Objective 5 - Well Led – To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centered, clinically led leadership model Strategic Theme / Annual priority • Integrated health and social care

• Recruitment & Retention Director responsible

Director of Organisational Development & People


5.5 There is a risk that the Trust will not meet its objectives if it does not implement the workforce strategy that drives the recruitment and retention of talent across all staff groups that meets patient needs.



Target risk score

L2 x S3 = 6

Target Date 5 year strategy

Linked to Risk 1633, 1748, 1895, 1938 Controls in place Gaps in Control 1) Trust’s five year ‘People & Organisational Development Strategy: 2018 – 2023’

approved by the Trust Board in July 2018 2) The Strategy covers six key themes:

Recruitment & Retention Leadership Staff Health Training & Professional Development Staff Engagement & Involvement Workforce Planning

3) Over-arching strategy links to other workforce related strategies, (e.g. Multi-disciplinary Education & Training Strategy; One Team Inclusion Strategy; Retention Strategy) 4) SASH Leadership framework being developed which will support formal leadership development, succession planning and talent management

1) Acknowledged national and regional shortage of key groups of staff (e.g. nurses, doctors, Allied Health Professionals)

2) Recruitment issues for medical staff contributing to high temporary staffing spend 3) Operational activity levels in the Trust stated as reason by line managers for non-

compliance with corporate targets 4) External issues outside of SASH control (e.g. Brexit)



1) Progress towards Trust’s Workforce Strategy objectives is reported monthly to the Trust Board and the Finance & Workforce Committee 2) The quarterly Annual Plan report to the Board also includes People & OD Strategy updates 3) Workforce planning confirmed with NHSi as part of the 2019/20 Operating Plan 4) Key Workforce Indicators (e.g. recruitment, establishment, sickness, turnover, AR compliance, etc.), reported on a monthly basis to the Trust Board and Finance & Workforce Committee

Positive (+) Significant success with nurse recruitment scheme – vacancies for N&M now at 1.8% (end November 2018). We still have an active pipeline of over 150 nurses (+) Month on month reduction in overall agency spend on temporary staffing for N&M (+) Vacancy rates remain on an overall downward trend – this is against a month on month increasing establishment (vacancy rate at end of November 2018 was 4.3%) (+) Achieved a 65% response rate for the 2019 National Staff Survey – national benchmarked results are due in February 2020

5) CQC Inspection – CQC Outstanding rating for Use of Resources 6) CQC Inspection – CQC Outstanding rating for Well-led

(+) Five key themes have been identified as part of our Best Place to Work programme and we are developing ways to continue our ‘conversation’ with staff about these (+) We are analysing the data from out three pilot Talent Review Boards (Executive reports; Modern Matrons and Service Managers) (+) We have run two cohorts of our health and well-being programme - Jump Start. Feedback has been very positive and we have three further cohorts scheduled for 2020 (+) We have received feedback from NHSEI regarding the 2018 WRES data – this confirms we are meeting our expected targets for the number of BME staff in bands 8a and above Negative (-) Vacancies for medical staff have increased along with associated spend on temporary medical staff (-) Consequences for workforce due to Brexit still to be determined

Gaps in assurance Assurance Level gained: RAG Ongoing work to improve staff experience of physical violence and bullying – feedback from ED has been positive


1) Implementing actions agreed in 5 year action plans in the People & OD strategy for the six key themes 2) Action planning from the Best Place to Work on-going 3) Pro-active recruitment planning in place 4) SASH Leadership Framework being developed and pilot schemes being held

1) Trust Board approved People & OD Strategy 2) SASH Leadership framework pilot groups held 3) International nurse recruitment campaign has been successful to date

Update by MP 23/12/19 Date discussed at board January 2020

Objective 5 - Well Led – To be a high quality employer of choice and deliver financial and clinical sustainability around a patient centered, clinically led leadership model Strategic Theme / Annual priority • Technology as an enabler


Director of Information and Facilities Medical Director


5.6 There is a risk that the Trust will not fully maximise the opportunities to use technology in innovation and as an enabler either due to capability and/or investment.



Target risk score

L2 x S3 = 6

Target Date (2yrs)

Linked to Risk 1656, 1798, 1820 Controls in place Gaps in Control

1) Nice TA / CG compliance statements 2) Digital Maturity Index 3) EPR Digitise FBC approved by The Board

4) NHS innovation accelerator and innovation and technology tariff program run nationally to promote uptake new technical solutions with evidence to support adoption

5) Digital strategy approved 2019

1) League tables for uptake of innovation (e.g. uptake of NHS innovation accelerator and innovation technology payment) to be developed

2) Peer comparison



1) ‘Patient Knows Best’ in inflammatory bowel disease 2) Skype and secure video conference for relatives on ward rounds 3) Internal report on TTP and NIA uptake (un-bench marked) 4) Vitals roll-out in 2019/20 5) Paper-lite in key areas e.g. ED, Kingsfold and Pendleton 6) Development of Surrey Care Record 7) ICS Collaboration in Surrey Heartlands

Positive (+) Development of plans to implement EPR (+) Procurement output related to technology procurement (+) Effectiveness committee new procedure approval (+) EPR pilot work including monitoring of vital signs (+) Paperless systems implanted in ED and Kingsfold Unit (+) Stroke telemedicine service supporting ‘out of hours’ care (+) Addi5tional £1.5m of capital funds spent in 2018/19 on Hardware, Single Sign-on and Vitals Link (part of Digitise programme). (+) Proposed Surrey ICS EPR Programme (+) Surrey Care Record Programme

Gaps in assurance Assurance Level gained: RAG

1) New risk against medium term strategy demand vs. capacity and workforce need therefore many gaps that need to be understood and reduced.

2) Some technologies require EPR.


1) Work with STP and AHSN to develop league tables of tech adoption 2) Digital strategy to be developed by February 2019 3) Progress pilot work with NHSI for virtual outpatient clinics (five clinics initially) 4) Develop GDE Bid within ICS

1) Ongoing 2) Complete 3) December 2019 4) March 2020

Update by EC 10/01/20

IM 20/01/20 Date discussed at board January 2020


• Well-being and rehabilitation Director responsible

Director of Information and Facilities


5.7 There is a risk that the Trust will not capitalise on the opportunity to develop its estate and sites if it does not seek to ensure the developments meet the growing and changing needs of the local population.

Initial Risk L3 x L3 = 9

Current rating L3 x L3 = 9

Target risk score

L3 x L2 = 6

Target Date (2yrs)

Linked to Risk None identified Controls in place Gaps in Control

1) Establishment of the East Surrey Hospital Site Development Working Group with clear ToR

2) Monthly reports to the Trust Board in private 3) Revised Estates Strategy approved

1) None identified at present



1) Compatibility with the wider health and social care system estates strategy 2) Work within relevant legal frameworks 3) Amend governance arrangements for the ESH as plans develop 4) Development of site strategy

Positive (+) Clear strategic direction and its supporting data, analysis and reasoning (+) Translation of the strategic direction into a set of development options/opportunities for the ESH site (+) Trust actively engaged with RBBC Local Plan Development (+) Removal of site from green belt (Oct 2019)

Gaps in assurance Assurance Level gained: RAG 1) Development of an ESH Site Master plan

Actions Progress (including dates, notes on slippage or controls/

assurance failing. 1) Executive’s exploration of these development opportunities 2) Proposals in relation to the ESH site before recommending to the Board for discussion and

decisions 3) Alignment with JSNA, population health, needs and future workforce pre; STP health and social

care themes & priorities

Working group in early stages of development and implementation of actions

Update by IM 20/01/20 Date discussed at board January 2020




Medical Director Chief Operating Officer


5.8 There is a risk the Trust will not maximise its potential to support peoples mental health needs if it does not coordinate its resources and pathways with local mental health providers.



Target risk score

L2 x S2 = 4

Target Date (2yrs)

Linked to Risk 1732 Controls in place Gaps in Control

1) Commissioning standards from CCGs 2) Templates for staffing vs population size 3) SASH System AEDB 4) North System-wide Recovery Plan which includes a focus and likely

subgroup on mental health 5) Surrey Heartlands ICS new governance structures

1) Gap analysis is not routinely performed 2) Strategy for improvement is not finalised 3) Inadequate mental health practitioner cover out of hours 4) Trusted assessor model not in place 5) No agreed system strategy 6) Capacity for emergency care does not meet demand 7) Pathways for 136 patients not robust 8) CAMHS capacity does not meet demand and there is no out of hours support 9) No escalation process for inpatient emergencies 10) Inpatient psychiatric care 11) No Trust level or divisional level metrics



1) Assurance statements on outcomes from local mental health providers and commissioners

2) Audit information for patients with mental health 3) Patient stories 4) Mental Health strategy published in draft for input from public, staff and

partners

Positive (+) Escalation Process agreed with MH partners (+) Peer review complete- key issues identified (+) CSESCA board to board in Sept 2018 with SASH identified MH as a joint priority (+) Mental Health Data collection exercise commenced on 7th January (+) ‘Core 24’ funding agreed and additional staff recruitment in progress as per agreed plan.

Gaps in assurance Assurance Level gained: RAG

1) Board not sighted on controls and assurances


1) Finalise strategy with commissioners and MHPT to satisfy controls and therefore provide assurance

2) Develop Mental Health dashboard in progress

1) Draft mental health strategy reviewed at Board Seminar Oct 2018

2) Draft Mental Health Strategy consultation concluded April 2019, Strategy being finalised.

Update by AS 23/01/20

EC 10/01/20 Date discussed at board January 2020

objective 1 - safe – deliver safe, high quality care and

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