public board meeting of the east of england …...mar 11, 2020 · agenda: public session...

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PUBLIC BOARD MEETING OF THE EAST OF ENGLAND AMBULANCE SERVICE NHS

TRUST BOARD ON WEDNESDAY 11 MARCH 2020 AT 12:40 Tudor Kitchen, Bury St Edmunds Guildhall, Guildhall Street, Bury St

Edmunds, Suffolk, IP33 1PR AGENDA: PUBLIC SESSION (Disclosable)

SUBJECT LEAD PURPOSE TIME

1 Welcome Trust Chair - 12:40 -

2 Apologies for Absence Head of Governance - 12:41 -

3 Declarations of Interest To receive any new or amended declaration of interests from Board Members

Board Members - 12:42 -

4 Patient Story Director of Clinical Quality and Improvement

- 12:43 3

5 Report from the Trust Chair Trust Chair Update 12:55 Verbal

6 Report from the Chief Executive Chief Executive Update 13:00 5

7

Minutes To approve the minutes of the previous meeting held on 01 January 2020

Trust Chair Approve 13:10 10

8 Matters Arising Not Addressed Elsewhere on the Agenda To consider the actions checklist from previous minutes

Trust Chair

Update 13:15 20

STRATEGY & BUSINESS PLANNING 10 Horizon Scanning Head of Governance Assure 13:20 21

11 Strategic Objective Setting Head of Strategy and Transformation

Review 13:30 24

12 Annual Staff Survey Report and Plan Director of Communications and Engagement

Assure 13:50 29

PERFORMANCE MONITORING

13 Integrated Performance Report Chief Operating Officer Inform 14:00 60

14 M10 Finance Report and Revised Forecast Outturn

Director of Finance and

Commissioning

Inform 14:15 84

16 Well Led Programme Update Head of Governance/ Trust Chair Assure 14:25 102

17 CQC Quality Improvement Plan Medical Director Assure 14:35 107

18 Committee Reports to Board: Performance and Finance Committee Workforce Committee Quality Governance Committee Audit Committee

Chair of P&FC

Chair of WFC

Chair of QGC

Chair of AC

Assure Assure Assure Assure

14:50 14:55 15:00 15:05

119

GOVERNANCE AND REGULATORY 19 Board Assurance Framework Head of Governance Assure 15:10 132

20 Risk Strategy including Risk Appetite and Financial Losses

Head of Governance Discuss/Assure

15:25 148

21 Standing Orders, Standing Financial Instruction, Scheme of Delegation and Reservation of Powers to the Trust Board

Head of Governance Approve 15:35 185

22 Annual Corporate Governance Review including;

Committee ToR

Agenda Plans

Head of Governance Assure 15:45 292

Trust Board Public Agenda - 11.03.20

1 of 350Public Board Reports - 11.03.2020-11/03/20

East of England Ambulance Service NHS Trust: Public Board Agenda of 2

Declaration of Interests

Register of Seals

CLOSING ADMINISTRATION

23 Items Referred to/from Other Committees Trust Chair - 16:10 -

24 Key Messages and Risks Identified Trust Chair - -

25 Any Other Business Trust Chair - -

26 Questions from the Public -

27 Reflection on Meeting All - -

28

Agenda Items for Next Meeting:

All standing agenda items

- -

Date of Next Meeting: 13 May 2020 Trust Chair

Trust Board Public Agenda - 11.03.20

2 of 350 Public Board Reports - 11.03.2020-11/03/20

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MEETING TITLE

PUBLIC BOARD

Date: 11.03.2020

Report Title: Patient / carer story

Agenda Item: 4

Author: Gillian Langley, PPI and Engagement Officer

Lead Director: Tom Davis, Medical Director

Purpose: Assurance Decision

Discussion X Information X

SUMMARY AND BACKGROUND:

The Trust Board will be shown a short video where Mrs Webster shares her experience of our response when she called in relation to her husband. Sadly, Mr Webster died. Nigel Webster had Acute Myeloid Leukaemia. He returned home from his fourth round of Chemotherapy treatment. The following morning Mr Webster felt unwell and was unable to support himself on the toilet. Mrs Webster describes her experience of calling 999 to the point of the ambulance arriving on scene. She talks in detail about the calls that she made to the Trust. Mrs Webster had initially called Queens Hospital, in Romford. Hospital staff advised that Mr Webster needed to get to hospital. She then called 999 and the call was coded as a category 4. An hour later she called back and informed the call handler that Mr Webster was neutropenic as advised by Queens Hospital. A third call was made as Mr Webster was unable to support himself on the toilet, the call was then recoded to a category 3. Following a call back from an EEAST nurse, it was confirmed that an ambulance was required and recoded to a category 2. The ambulance arrived on scene 2 hours and 43 minutes later. Mrs Webster felt she did not get the appropriate care in time for her husband. She feels that she wasn’t asked the correct questions in order for the call to be correctly categorised for someone with potential sepsis. However, she praises the individual paramedics who attended. The story has a number of lessons for processes of call handling and ambulance dispatching along with timely clinical reassessment and escalation to optimise patient outcomes.

RECOMMENDED ACTION:

At the last Board, it was recommended that we present some more challenging patient ‘stories’ where

care, services and treatment has been identified as not meeting desired standards, so that the learning

from these influences corporate priorities and decision making.

KEY ISSUES IDENTIFIED

To continue to use patient stories not identify and recognise the improvements required in systems and

processes to drive and increase consistency and standards of EEAST services routinely available to

patients.

Patient Story


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DECISION OR RESOURCE REQUIRED:

PREVIOUSLY CONSIDERED BY:

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers]

INDICATE WHICH STRATEGIC RISK THIS REPORT RELATES

SR1: Failure to deliver a timely service to our patients in line with commissioned national standards, to ensure a safe level of service

X

SR2: Failure to achieve continuous quality improvements in the quality of care delivered to our patients

X

SR3: Failure to embed a patient-focussed culture that puts the patient at the heart of everything we do

X

SR4: Failure to deliver an efficient, effective and economic service X

Other: Please Specify

THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE

Provide better care X

Value our people

Value for money

Improve performance X

OTHER:

To ensure effective governance and compliance

LINK TO CQC:

Caring X

Responsive X

Effective X

Well Led X

Safe X

RELEVANT LEGAL OR STATUTORY ISSUES

Patient Story


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MEETING TITLE

Trust Board (Public Session)

Date: 11.03.2020

Report Title: Chief Executive’s Report

Agenda Item: 6

Author: Dorothy Hosein, Chief Executive

Lead Director: Nicola Scrivings, Chair


Discussion Information


The purpose of this paper is to update the Board on issues and matters the Chief Executive has been addressing or involved in since the last Trust Board meeting on 8 January 2020.

RECOMMENDED ACTION:

None


Staff engagement, Corona virus, Executive recruitment


None


NA




x


x


x

SR4: Failure to deliver an efficient, effective and economic service x



Provide better care x

Value our people x

Value for money x

Improve performance x

OTHER:

To ensure effective governance and compliance x

LINK TO CQC:

Caring x

Responsive x

Effective x

Well Led x

Report from CEO


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Safe x


Chief Executive’s Report Corona Virus As you will be aware the Covid 19 Virus situation is changing rapidly. Executive and operational colleagues are taking part in national calls daily. We are following national guidance to ensure we are prepared and ready to protect both staff and patients. Air and Share Events My Executive colleagues and I have visited all areas of the Trust over the last three months to meet as many staff as possible. I am very grateful for the number of people who have attended and provided feedback. We are in the process of collating the themes so that an action plan can be developed and presented to the Trust Board. On 7 February we held an Air and Share workshop focused on well being and welfare, which provided staff the opportunity to follow up on staff feedback and start the process of formulating an action plan. The action plan is being coordinated by our Mental health Lead in partnership with external experts. An initial report demonstrating themes and initial progress will be published in March. Although the Air and Share events have been paused whilst we consider the information we have received, I will of course continue to travel around the region to meet and listen to staff. Independent Investigations You may well have seen reported in the media that the Trust and Regulators have commissioned an investigation into the sad deaths of colleagues at the end of last year. An external expert has started a thorough investigation into these tragic events. In parallel the Trust has instigated an internal review to ensure that any lessons learned are highlighted and embedded in practice. We are also linked in with a national project at the Association of Ambulance Chief Executives (AACE) to participate on the Ambulance Service Suicide Register. This provides the oversight and sharing of data relating to suicide cases whilst alerting AACE in the event of a suicide. This is also intended to inform health and wellbeing initiatives and interventions. The purpose of this process is to record the number of deaths by suicide across the UK whilst creating a consistent data set that will facilitate future research (University of Bristol), with the goal of reducing suicides within the ambulance workforce. The investigation commissioned by the previous Trust Chair in partnership with Regulators following whistleblowing has now been concluded. It would not be appropriate to disclose the full details as it relates to individual cases. The report does reveal some control weaknesses in our approach to termination of contracts. There are also some wider learnings that will be included in our work on culture change. It concludes that actions were taken in isolation without the necessary checks and balances by more senior leaders. A clear system of control is now in place for termination of employment by all managers. The immediate process recommendations from the report are now implemented and an action plan is being monitored by the Workforce Committee.

Report from CEO


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Executive Recruitment Last month John Syson started a 12 month secondment in the role of Interim HR Director. John joins us from Papworth Hospital and has a wealth of experience working in other large NHS organisations. He is a very welcome addition to the team and we are looking forward to working with him over the coming year. Early this month we held the interviews for the new Director of Quality and Safety. We should be in a position to make an announcement about the successful candidate in the coming weeks. I would like to take this opportunity to thank all of those who assisted with the Stakeholder panels. Your feedback is invaluable and it forms an important part of the recruitment process. Coming up Since last summer the majority of our managers have attended leadership development sessions. The next stage of this programme is planned for the coming weeks. Senior leaders will attend next step sessions based on the feedback consolidated from their training sessions and agree actions to improve culture and leadership within the organisation. Plans for the New Year I was delighted to have the opportunity to Chair the BME Network meeting in February. New goals were set for the coming year which are working towards our aim of making the Trust a diverse and inclusive environment to work in. As we approach the end of the final year I am in the process of meeting with Executive colleagues to set budgets for the coming year. Trust accountants have already compiled requests and predictions from local teams and we now meet to ensure that all the decisions made are based on achieving the right balance between patient safety, quality and finances. This coincides with contract negotiations with our commissioners which will set our financial envelope. I would like to take this opportunity to thank all our colleagues in the finance team who are working extremely hard at this time of year. Stakeholder Engagement

Stakeholder Location Date

EEAST Call with staff member to discuss retention ideas Staff Engagement Kempston Ambulance Station Staff Engagement Bedford AOC Call with Bedford AOC Staff member leaver Air and Share event Braintree Air and Share event Chelmsford Air and Share event Chelmsford AOC Air and Share event Southend Meeting with Staff member leaving Bedfordshire Corporate Induction Chelmsford Staff Engagement Bedford AOC Air and share Staff Workshop Staff Engagement Ipswich Ambulance Station Staff Engagement Bury St Edmunds Ambulance Station

10/01/2020 10/01/2020 10/01/2020 13/01/2020 13/01/2020 13/01/2020 24/01/2020 27/01/2020 28/01/2020 03/02/2020 07/02/2020 07/02/2020 11/02/2020 11/02/2020

Report from CEO


of 5

Meeting with Staff from Bedfordshire

14/02/2020

CCG

NHS Trusts Richard Henderson, CEO EMAS National HR Director Meeting (Special event dedicated to Suicide prevention)

20/02/2020 28/02/2020

HOSC

MPs Meeting with Richard Fuller MP

Meeting with Matt Hancock MP, MS (H)

07/02/2020

02/03/2020

CQC Introductory meeting with CQC 28/01/2020

NHSI/E Oversight and Support Meeting NHSI/E Meet with Lynne Wigens, Director of Nursing NHSE/I Call with Nigel Coomber, Martin Hawkings, NHSE/I Meeting with David Sissling NHSE/I Oversight and Support Meeting NHSI/E Call with Ann Radmore, NHSE/I Meeting with Jeff Buggle, NHSE/I

21/01/2020 03/02/202024/02/2020 24/02/2020 25/02/2020 25/02/2020 04/02/2020

UNISON Meet with UNISON 14/02/2020

GMB

Blue Light Partners

Regional Police Forum

Meeting with BJ Harrington, Essex Chief Constable

10/02/2020

17/02/2020

Healthwatch/

CEG

Call with a Patient’s family

Call with Patient

13/01/2020

10/02/2020

Media

Health Education England

Meeting with Phil Storr, Health Education England 22/01/2020

HEI CRN Eastern meeting University of East Anglia 24/01/2020

RAF

HSE

Dept. of Health

AACE AACE Council Meeting and Chief Executives Group

AACE Ambulance Chief Executives Group

23/01/2020

20/02/2020

Other Stakeholders

Meeting with Chair of Bedford Faiths Council Shoeburyness People Scrutiny Committee

10/01/2020 20/01/2020

Report from CEO


of 5

Meeting with Community Response Manager for Beds and Herts to discuss Hatzolah Meeting with Harry Steele, Multi Faith Chaplaincy Service Tracy Nicholls, CEO College of Paramedics

10/02/2020 14/02/2020 20/02/2020

British Heart Foundation

Wellbeing Services

Report from CEO


East of England Ambulance Service NHS Trust

Page 1 of 10 Minutes of Trust Board

The UNCONFIRMED (Disclosable)

MINUTES OF THE EAST OF ENGLAND AMBULANCE SERVICE NHS TRUST BOARD MEETING (PUBLIC SESSION) WEDNESDAY 8 JANUARY 2020 AT 13:00

GROUND FLOOR MEETING ROOM, EEAST HQ, UNIT 3, WHITING WAY, MELBOURN SG8 6NA

Present: Nicola Scrivings Trust Chair Tom Spink Non-Executive Director and Acting Committee Chair Wendy Thomas Non-Executive Director Carolan Davidge Non-Executive Director Neville Hounsome Associate Non-Executive Director Tom Davis Medical Director Dorothy Hosein Chief Executive Officer Marcus Bailey Acting Chief Operating Officer Kevin Smith Director of Finance and Commissioning Alison Wigg Associate Non-Executive Director Gillian Hooper Interim Director of Clinical Quality and Improvement In Attendance: Julie Hollings Director of Communications and Engagement Stephen Bromhall Chief Information Officer Emma De Carteret Head of Governance Esther Kingsmill Deputy Head of Corporate Governance Members of the Public

PUBLIC SESSION (Disclosable) 1.0 WELCOME 1.1 Nicola Scrivings, Trust Chair (TC) welcomed those present to the meeting. She extended her

thanks to those members of the public and staff who were in attendance. 2.0 APOLOGIES FOR ABSENCE

2.1 Apologies were received from Lizzy Firmin, Non-Executive Director (NED-LF) and Ravi

Mahendra, Non-Executive Director (NED-RM). 3.0 DECLARATIONS OF INTEREST 3.1 There were no new declarations of interest.

4.0 PATIENT STORY

4.1 The Interim Director of Clinical Quality and Improvement, Gillian Hooper (DoCQI) presented the

story of a former patient who had required an emergency response to a life-threatening emergency. The patient described the professional, compassionate and respectful care he received, and the supportive attitude of emergency services in supporting his wife over the same period. The story had been used in staff inductions and was positively received.

4.2 The Board reflected on the wider compassionate care, for both patients and their families evidenced in the story. They recognised it was vital to reassure patients and their families during periods of worry and were pleased to note this within the interview. The TC recognised the

Draft Public Board Minutes - 08.01.2020




importance of ensuring staff were trained in teaching and communication skills to support keeping patients informed.

4.3 The DoCQI advised that moving forward she was keen to work with other organisations to provide a range of perspectives of patient care within the Trust. Learning could be sought from patients whose care had not been as expected.

4.4 Non-Executive Director, Tom Spink (NED-TS) suggested it would be pertinent to link Serious Incidents to patient stories to identify themes and trends. The DoCQI advised this was being considered, issues were being pursued with frequent attendees to identify learning, incidents and near misses.

5.0 REPORT FROM THE TRUST CHAIR

5.1 The TC recognised that performance throughout the winter period had been positive and represented an improvement compared to previous years. She extended her thanks to staff for their support and hard work throughout the period. Moving forward, the focus continued to be on governance improvements including building relationships with partner organisations and re-aligning non-executive support to committees and STP’s. Work was underway to align and communicate the direction of the ambulance service with key stakeholders.

6.0 REPORT FROM THE CHIEF EXECUTIVE

6.1 The Chief Executive Officer, Dorothy Hosein (CEO) recognised the significant challenges within

the sector including the increased activity and acuity of patients throughout the winter period. She recognised the support of staff in periods of pressure to maintain patient safety. There had been a reduction in harm incidents as a result of staff who had contributed overtime to support patients and staff. Relationships with partner organisations remained a focus, including potential opportunities for rotational staff posts to encourage greater levels of staff into the service. Dragons Den sessions had commenced and provided an opportunity for staff to present key initiatives for adoption by EEAST, at the last session seven initiatives had been chosen for progression and would report back with progress. Further work was underway with partner organisations to identify how more aligned working could be undertaken including the potential for shared estates and workstreams. Increasing work was underway to improve engagement with staff through air and share and engagement sessions to capture and address concerns.

6.2 Non-Executive Director, Wendy Thomas (NED-WT) enquired how outcomes from Dragon’s Den initiatives would be communicated and progressed. She was advised by the CEO that a plan was being developed to formalise reporting and meeting frequency to ensure each initiative received appropriate support for progression and there was suitable capacity.

6.3 Non-Executive Director, Carolan Davidge (NED-CD) raised concerns regarding gaps in engagement, particularly with local MP’s. She was advised by the CEO MP’s were being mapped and a plan developed for communications – it was anticipated there would be meetings with local MP’s from the beginning of February to formalise the relationship.

6.4 Although NED-TS was pleased to see the adoption of seven Dragon’s Den initiatives he cautioned that it was vital to ensure there was appropriate capacity to progress. The CEO recognised this, she confirmed each executive director had taken the lead for an initiative and would showcase this. The projects were considered critical for progression.

7.0 MINUTES FROM THE MEETING ON 13.11.2019

7.1 The minutes from the meeting on 13.11.2019 were approved with no amendments.





8.0 MATTERS ARISING AND ACTION LOG

8.1 With regards minute 15.2, it was agreed best practice for sickness management would be

reviewed by the Workforce committee. ACTION: Workforce committee to review best practice for sickness absence. Lead: Deputy Director of People and Culture/ Director of HR

8.2 Matters Arising: NED-NH enquired how culture was managed as an action plan. He was advised by the DoCQI that the first draft of the CQC action plan focussed on specific recommendations from the previous CQC inspection, next stages would be to develop this. The CEO confirmed that culture formed part of the well led action plan and would report into workforce committee. It was agreed the CEO and TC would report back to the committee with progress to develop a culture strategy and associated time frames. ACTION: Confirm progress and time frames to develop a culture strategy. Lead: CEO/TC

8.3 The Head of Governance, Emma De Carteret (HoG) confirmed that a draft risk strategy had been developed and required review to incorporate changes as a result of the recovery plan and links to patient safety. This would report to AC and into Trust Board.

9.0 WINTER PLAN

9.1 The Chief Operating Officer, Marcus Bailey (COO) advised that a lessons learnt process was being undertaken internally and in partnership with system providers to compare and contrast how systems respond under pressure, including flex and recovery. The testing of flu plans would also be reviewed based on risk assessment thresholds and staffing/ short notice absences. There had been greater resilience over the festive and winter period from a face to face and 999 response perspective which was associated with incentivisation, reduced annual leave allowances and increased staffing to support demand. This would require compensating during other periods of the year. Patient handover delays were increasing related to continuous and sustained pressure within the system, this was being constructively reviewed with system partners. A lesson learnt report would be provided to Trust Board on 11.03.2020. It was vital to consider de-escalation criteria, as based on the current pressures the system was in a continued state of escalation. Board members were provided with weekly updates on the position, metrics and measurements. A focus was on partnership working between control rooms and operational staff to support effective care delivery. ACTION: Lessons learnt from winter period and patient handover delays to be reported to Trust Board on 11.03.2020. Lead: COO

10.0 HORIZON SCANNING

10.1 The HoG informed the Trust Board that a report had been presented on observations and progress following the WannaCry ransomware attack – planned next steps were for NHSX to launch the Cyber Security Strategy for Health and Care and EEAST to complete the CIO recommendations following the WannaCry attack. Information had been published on Q1 complaints findings from the Health Service Ombudsman which demonstrated that of the investigations concluded, the PHSO upheld or partially upheld 49% of cases. A total of 9 ambulance cases were concluded with two upheld (22%), which was a significantly lower proportion than across the rest of the NHS. None of the cases affected EEAST. A brief was provided on NHS ambitions for Artificial Intelligence which focussed on reducing the pressures





on NHS staff, ensuring access to appropriate tools and information and improving productivity through the use of digital technology. This closed action 13.11.19/9.3.

11.0 INTEGRATED PERFORMANCE REPORT

11.1 The COO introduced the report and recognised the significant work required to ensure the IPR was representing a single set of agreed figures which were accurately tracked, monitored and escalated in an intuitive manner. The top 10 proposed metrics focussed on patient safety, performance and finance in a number of key areas, benchmarked against exemplar IPR’s. Where there was variance from the target an expected forecast outturn position was being developed with trendlines indicating an improvement or deterioration in key measures. The team were considering how PTS was best reflected within the IPR. The first phase of the IPR review was to agree 10 key metrics to monitor until data could be better aligned in a single document. The Trust Board were asked to consider whether the 10 metrics proposed were accurate or required review.

11.2 NED-TS reflected that the 10 key metrics seemed accurate however sought assurance that quality of the PTS service would also be reflected. He also recognised the requirement to ensure accountability for delivery of agreed targets.

11.3 NED-NH suggested a better focus of workforce metrics would be on recruitment, rather than sickness. Non-Executive Director, Wendy Thomas (NED-WT) was concerned there were few quality indicators represented within the escalation criteria. It was proposed patient feedback incorporate quality aspects of service delivery. The COO recognised the challenge and observed that it was vital to consider escalations and the safety thermometer within the IPR.

11.4 NED-AW observed that staff engagement was only measured annually and suggested this should be increased in priority.

11.5 The CEO clarified that the 10 key metrics were a proposal, it was vital executive directors were summarising areas of concern within their relevant sections. The 10-key metrics within the IPR were different to the concerns within the organisation which should be escalated through relevant lines of reporting. These metrics would support concerns escalated to direct the narrative of meetings, supported by supplementary information.

11.6 The COO advised that C1 and C2 internal performance trajectories had been delivered, although this remained a divergence from national standards. C3 performance was also monitored to provide an indication of patient safety whilst waiting medical attendance. Work was underway with strategic commanders to pro-actively manage risks and review thresholds. Significant work had been undertaken to improve C3 response rates in piloting CFR response to patient falls across 20 CFR groups.

11.7 NEW-AW reflected that the trend for hear and treat patients indicated this should be RAG rated red. The COO confirmed that although this was off target there was an improving trajectory.

11.8 The TC advised that as part of the governance review she was keen for each sub-committee to have agreed escalation criteria for Board which would formalise reporting and buffer ranges.

11.9 NED-AW was concerned that people and culture metrics within the IPR had a high proportion of Green Rag rated areas despite concerns regarding the staffing establishment and compassionate conversations target. NED-NH advised that the Workforce Committee would be reviewing the key metrics at each meeting and would provide assurance to Trust Board.

11.10 The Trust Board were advised that complaints outstanding against the timeframe were at 37.17%, an increase and significant concern. Within IPC there was a sound and embedded





approach with an improving trend which was also reflected in clinical audit. There was an improving trend in the closure of Serious Incidents at an earlier date however complaints performance was under 20%, a patient information lead had been appointed to review and draft responses. Mandatory training formed a key aspect of the CQC action plan. Conversations were underway to strengthen and develop the action plan and there had been significant progress.

11.11 NED-TS noted that KPI’s were red across the ambulance service in benchmarking and enquired whether there had been any guidance nationally on when these would be reviewed. The COO advised that the KPI’s reflected revised ambulance standards and there was not public appetite to review. The team were working to identify the capacity gap and align resources to support delivery of national standards.

12.0 M8 FINANCE REPORT

12.1 The DoFC outlined the headline deficit position of £1.3m. Principle costs in month were £1.6m accrual in potential liability for the Flowers case, £1.9m deficit to plan for PTS, £1.9m risk to income related to four CCG’s not on a block contract, £0.7m on expenditure for consultants to support the recovery plan and a shortfall in planned CIP delivery. The Trust was on track to achieve the revised forecast deficit of £7.7m. Potential capital expenditure commitments were £7.9m and would be partly funded through the sale of excess property. However, Atlantic Square had been valued below the book value and was therefore placed on hold. This had been raised with NHSE/I to identify whether there was capital within the system to support.

12.2 NED-NH noted that the outcome on the Flowers case was not anticipated to be finalised until 2021 and enquired whether the Trust was accruing a liability. He was advised by the DoFC this was a continual accrual pending the outcome of the case. These liabilities were based on expected outcomes.

12.3 NED-TS enquired whether the performance of the Bedfordshire and Hertfordshire PTS was worse than forecast. He was advised this was marginally worse than the forecast and was being reviewed to identify causes and actions, however it did not impact the revised forecast deficit as there was an improvement in other areas. Since the contract for Bedfordshire and Hertfordshire had been mitigated, it was not anticipated the position would deteriorate any further.

13.0 REVISED FORECAST OUTTURN

13.1 The DoFC presented the proposal for a revised forecast outturn of £7.7m deficit, which had been shared with NHSI/E and required Trust Board approval.

13.2 The TC reflected positively on the assurance received that the revised forecast outturn was on track for delivery, which was supported by PAF. She was also assured by the validation of the position from external consultants.

13.3 The DoFC clarified he had a high level of confidence in the ability to deliver the revised forecast position, however there remained risks to this delivery in incentivisation through January, which had been considered in the revised position however may exceed assumptions.

13.4 The TC enquired whether the revised forecast plan would impact the financial plan for 2020/21. The DoFC advised that the recovery plan included the assumption of a £7.7m deficit based on non-achievement of non-recurrent CIPs and assumptions on income which were dependent on contractual negotiations. The recovery plan was for two years, and it was vital it was delivered. There was a continued aim to further improve the revised forecast deficit position.

13.5 The Trust Board approved the revised forecast deficit of £7.7m.





14.0 CQC ACTION PLAN

14.1 The DoCQI reminded the Trust Board that the CQC action plan had been reviewed to focus on 13 key areas of ‘must do’ and ‘should do’ actions. The plan outlined the actions, leads, oversight, process and evidence to address each key area of concern which would be shared with stakeholders and CQSG once finalised. Delivery against the action plan was RAG rated and descriptors on how the plan would be communicated both internally and externally.

14.2 NED-TS sought clarity on whether the mandatory training target was 85% or 90%. He was advised by the DoCQI that 85% was the minimum requirement, trajectories were set at 90%.

14.3 The CEO assured the Trust Board that each of the relevant committees would be reviewing in detail metrics from the CQC plan to provide assurance and could request a deep dive if needed.

14.4 NED-TS was concerned that since the CQC plan was being reviewed because it was not considered robust, there was the potential other aspects of the Integrated Improvement Plan were not as robust as required. The CEO recognised the increased focus required on actions however emphasised that this did not undermine work already undertaken to identify actions and focus. The COO clarified that the actions within the CQC plan remained unchanged, however had been reformatted to provide greater clarity.

14.5 The TC proposed a broader point that our governance structure does not provide sufficient focus through Committees to drive transformational change and deliver associated benefits, this was a key factor in the proposal to introduce a separate committee focusing on major change. This proposal would be presented to the February Board.

15.0 DoCQI BRIEFING REPORT

15.1 The DoCQI presented her report which briefed on key aspects within the portfolio including incidents, complaints and safeguarding matters. There was an organisational requirement to implement changes from the learning from deaths review which would be informed by a lesson learnt report. It was vital to address this within the workload whilst also maintaining standards for serious incidents and prioritisation of actions to the benefit of patients. In incident reporting and appraisal analysis there was an increased focus on supporting quality administration processes. IPC were undertaking a lesson learnt review to identify wider learning and how this expertise could be extended through the quality team. An interim complaints manager and support manager had been appointed to cover maternity leave. A simple dashboard was presented outlining performance against complaints which indicated a reducing level of complaints in November - whilst all complaints were acknowledged in 3 working days, despite actions taken the number responded to within 25 days was less than 20%. Clinical audit performance was outlined and had not achieved any of the requirements in month. Actions had been undertaken to raise the profile of clinical audit among staff however it was vital the capacity for audit was not overloaded given the work required on pathways and clinician support including training for local operational managers.

15.2 The TC was concerned that the clinical audit plan was not being met. The DoCQI advised that this was a different process and was judged as failing due to a failure to alert, for instance evidence showed that sepsis was consistently being treated and documented accurately, however audit failed as clinicians did not alert hospitals. The COO clarified there were a number of approaches to clinical audit, including required audits and risk-based audits which would be supplemented by developmental audits of pathways and commitments.

15.3 The DoCQI escalated to the attention of the Trust Board compliance software required to support the team in generating information to support performance improvements. The software license





for health assure was due to expire in March 2020, and alternative options were being pursued including a single reporting tool to improve monitoring at pace. It was vital there was clarity on investment requirements to support safeguarding training. The trajectory for level 1 and level 2 safeguarding training was concerning, whilst staff with level 3 training were very limited.

15.4 NED-TS enquired whether it was feasible to implement a new software system by the Health Assure expiry, or what the plans were if this was not possible. Stephen Bromhall, Chief Information Officer (CIO) advised that the potential new vendor was analysing whether historic data could be migrated however advised it was likely that a waiver would be required to extend the Health Assure system until the new software was fully installed.

15.5 The TC confirmed that NED-WT would be NED safeguarding lead.

15.6 The Trust Board were advised that the investigation into unexpected staff deaths was scheduled to commence on 13.01.2020, the process would prioritise the welfare of staff. A panel was scheduled for 28.02.2020 which NEDs were invited to attend and support.

15.7 The draft ambulance safer staffing resource had been received and the Trust Board were required to nominate a Board level clinician to hold accountability. ACTION: Agree executive clinical lead for safer staffing. Lead: All

15.8 The team had discussed the quality account which had mandated requirements, however EEAST had disclosed in excess of these requirements. It was proposed that the quality account integrate with the annual report and accounts. NED-WT noted that medicines management was assessed as a medium risk and suggested as this was one of the CQC action plan priorities it should be a red risk. The DoCQI advised that each aspect was being independently assessed including evidence to identify actual performance across a range of areas.

16.0 FTSU QUARTERLY REPORT

16.1 The MD presented the Q2 FTSU report and advised that the existing team was comprised of two individuals who were undertaking FTSU duties in addition to their substantive roles, which was not considered feasible in the long term due to capacity issues. Four clinical sessions had been undertaken to raise awareness of FTSU and interest had been expressed for a substantive guardian. The business case for a full time FTSU was approved at ELB and would be released to advert with plans to appoint by April 2020. In the interim a 1 day per week resource was committed from Herts Community Services FTSU guardian to reduce pressures on the existing team. The index released by the national guardian’s office provided an overview of FTSU culture within EEAST compared to other NHS organisations - EEAST was performing 349 out of 350 which was evidence of the significant pressures on the team and substantial work needed to address. Six new cases were received in Q2 with themes focussing on front line A&E operational staff expressing pressures or bullying behaviours. There was a significant theme of power dynamics, and the failure from management to recognise the power differential when engaging with staff.

16.2 NED-TS was concerned to note that the EEAST ranking within the national guardian’s office index was not clearly displayed within the report. The MD recognised this and agreed to review with the team – he advised that the index was publicly available.

16.3 The CEO advised that in air and share sessions a culture shift was evident in how staff were raising concerns with managers, with more openness apparent.

17.0 FLU UPDATE





17.1 It was confirmed that 71% of staff had been vaccinated and 88% of staff had confirmed their

intentions for vaccinations. It was apparent that staff abstaining from vaccinations often did so because of incorrect rationale – it was intended that with the new occupational health provider an educational programme would be undertaken to ensure staff were informed of the facts and patient benefits before the commencement of the next flu campaign.

18.0 COMMITTEE REPORTS TO BOARD

18.1 PAF 16.11.2019: NED-TS observed the assurance received on delivery against the forecast outturn of £7.7m deficit and concerns regarding extended patient handover delays. There had been significant work on CIP planning and execution which was demonstrating improvements. Strong progress had been made to address C1 and C2 performance which evidenced the commitment to actions and associated outputs. Concern was raised regarding the make ready programme which was a major area of financial commitments and had demonstrated limited efficiencies to date. Positive progress was made to develop and action the integrated improvement plan.

18.2 PAF 06.12.2019: 10:10 time had a positive impact in reducing on scene times for time critical patients. There were recognisable concerns regarding the PTS in Luton and Bedford following a deterioration in performance – a deep dive had been requested. There was an improvement in the risk profile for the BAF.

18.3 WFC 20.11.2019: NED-NH advised that WFC had focussed on the resourcing pipeline, there was an ambition to reach full staffing establishment by March 2021 which would require the recruitment, training and deployment of an additional 600 employees. Comparatively, actual NET gain the preceding 6 months had been 171 or 28 employees per month.

18.4 WFC 06.12.2019: five additional resources had been appointed to support recruitment, and 10 staff were undertaking training. There had been an increase in resources to support the recruitment plan however there was no robust forward view. It was anticipated at the January workforce committee there would be a clearer view of the plan and variance. The number of ER cases had reduced from 100 to 40 and was being benchmarked to identify anticipated level of open cases. The committee continued to meet on a monthly basis, given the considerable demand on resources this had, agendas were being assessed to focus on high priority areas.

18.5 AC 20.11.2019: NED-CD highlighted the lack of assurance received on the external audit quality account review. There was disagreement on whether a full external audit was required, or whether the review could be supported by a peer review. The HoG advised that it was best practice to undertake an external review of the quality account on a three-yearly basis. Given the significant pressures to ensure delivery of the recovery plan, the executive team had proposed a peer review in year focussing on priority elements with the audit postponed. Given the refresh considered for the quality account it was suggested it was not pertinent to schedule an external audit at present. It was agreed the HoG would report back to AC with the auditing requirements. ACTION: Report to AC with auditing requirements for quality account. Lead: HoG

18.6 It was agreed that future reports would include the minutes from all meetings. ACTION: Include minutes from sub-committees at Trust Board Lead: HoG

19.0 BOARD ASSURANCE FRAMEWORK





19.1 The HoG advised that following discussions at PAF, escalations and mapping had been included

within the report. All strategic risk scores were unchanged due to significant pressures through winter and interdependencies across risk. Areas of risk, progress and stability had all been discussed within the meeting for operational performance, IPC, recovery plan and reforecast finance position and safeguarding. A thematic review of medicines management was underway. HR policy reviews were escalated from Audit Committee and Workforce committee due to the backlog of overdue policies within the department - the workforce committee were scheduled to receive a trajectory for policy completion at the next meeting. Progress against review of the Performance Management Framework had been delayed due to instability within the HR team, however this was being re-assessed to align with strategy work, to ensure there was a clear process from April 2020.

19.2 NED-AW noted that Building Better Rotas delivery was a key aspect of addressing SR1 ‘failure to deliver a timely response to our patients in line with commissioned national standards, to ensure a safe level of service’ and requested assurance on progress. The COO advised that two phases had gone live since 06.01.2020. Issues had been encountered in rolling out BBR in Watford as the site was not large enough to support requirements, however all other sites remained on track.

19.3 NED-TS noted that compliance with compassionate conversations was RAG rated yellow and enquired what the likelihood of this being completed by the next meeting was. He was advised this would report to WFC alongside metrics. NED-TS advised that as the date was not considered realistic it was vital to be open with staff and agree a recovery plan. The COO advised that the target would remain the same and continued to be pursued however would be affected by the system position.

19.4 The TC advised that a culture action plan was being developed as an integrated approach to address all areas of concern.

20.0 ITEMS REFERRED TO/FROM OTHER COMMITTEES

20.1 The following items were referred to sub-committees for further discussion:

Workforce Committee would oversee compassionate conversations training and workforce concerns

PAF would oversee the integrated improvement plan including assessment of the current position

QGC would scrutinise the CQC action plan

21.0 KEY MESSAGES AND RISKS IDENTIFIED

21.1 A revised forecast outturn of £7.7m deficit had been approved

The CQC action plan was under revision

The Trust Board expressed their thanks to staff for their support during periods of high pressure

22.0 QUESTIONS FROM THE PUBLIC

22.1 What plans does the Trust have to improve the response rate for individuals expressing an

interest in CFR training, is there any target timescale to offer training and if not, should there be? The COO acknowledged that the Trust had failed to support CFR placements adequately. He advised that there had been an increased focus recently with an appointment made to support volunteer placements. Following the CFR conference, a delivery plan had been developed to support CFR’s based on engagement received. The CEO would take accountability for delivery of the CFR plan. There had been challenges in the resources to support training which was





causing delays. The national framework had indicated a 1-year assessment period for CFR’s which EEAST was progressing to as the national direction of travel, with a view to ensure a quality training provision which did not deter individuals from volunteering. An action plan was in development for training. Additional resource had been applied in administrative functions to support improvements, and there was a commitment to developing the volunteering strategy.

22.2 NED-NH recognised the significant work to implement a volunteers conference and appoint a substantive post to support volunteers. This had all taken place since concerns were raised at the AGM.

23.0 ANY OTHER BUSINESS

23.1 NED-TS was pleased the change in location to support attendance from across the regions and welcomed staff to join the Trust Board for lunch on future dates.

23.2 There was no other business and the meeting closed.



AGENDA ITEM: XX (Disclosable)

Key: red – new items from previous meeting, blue – commentary updates, black – outstanding items, grey – completed items

Meeting Date Reference Action

08.01.20 8.2MATTERS ARISING AND ACTION LOGConfirm time frames and progress to develop a culture strategy

TC/CEO 11.03.2008.04.20

To be discussed at the development session on 08.04.2020

08.01.20 9.1

WINTER PLANLessons learnt from winter period and patient handover delays to be reported to Trust Board on 11.03.2020.

COO 11.03.2013.05.20 Postponed until May

08.01.20 15.7 DoCQI BRIEFING REPORTAgree executive clinical lead for safer staffing. All 11.03.20

Clinical lead for safer staffing is the MD pending substantive appoitnment to DoCQI role.

Proposed for Closure

08.01.20 18.6 COMMITTEE REPORTS TO BOARDInclude minutes from sub-committees at Trust Board HoG 11.03.20

These are included in the reading rooms section of Diligent.

Proposed for Closure

13.11.19 8.5 MATTERS ARISING AND ACTION LOGCIO to undertake complete review and refresh of IPR CIO 11.03.20

The process has been implemented to capture all of the Board metrics. Once these have been captured, this will be reviewed and documented, before reporting to Board on 08.04.2020 with a template.

13.11.19 13.3CQC QUALITY IMPROVEMENT PLANInclude metrics for measuring delivery in the engagement plan for the CQC Improvement Plan.

DoCE 08.01.2011.03.20 Verbal update to be provided in the meeting

13.11.19 15.4 WORKFORCE UPDATECollaborate with NED-CD on staff retention plan. COO/DoHR 08.01.20

11.03.20Defer - to be aligned with NHSI retention submission and HR Enabling strategy

TRUST BOARD PUBLIC: ACTION CHECKLIST ARISING FROM PREVIOUS MINUTES TO BE CONSIDERED BY THE BOARD AT ITS MEETING TO BE HELD ON [DATE]

OUTSTANDING MATTERS FOR FUTURE CONSIDERATION

FOLLOW UP ACTION FROM PREVIOUS MEETINGSACTION BY DEADLINE STATUS

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MEETING TITLE

TRUST BOARD (PUBLIC)

Date: 11.03.2020

Report Title: Horizon Scanning

Agenda Item: 10

Author: E de Carteret, Head of Governance

Lead Director: D Hosein, Chief Executive




Two briefing highlights have been included in this month’s horizon scanning report, for the Board’s information. As a result of the launch of the NHS Patient Safety Strategy in summer 2019, two further updates have occurred since the last report – firstly, a consultation into the progression of ‘Patient Safety Specialists’ in all trusts, and secondly, the publication of the fist pan-NHS patient safety syllabus. The 2019 WRES report has been published for NHS Trusts, and the Trust’s position will be reported on in detail at the Workforce Committee.

RECOMMENDED ACTION:

The board is invited to note the report.


N/A


N/A


N/A. The Horizon Scanning report comes to every public Trust Board meeting


N/A





SR4: Failure to deliver an efficient, effective and economic service



Provide better care

Value our people

Value for money

Improve performance

OTHER:

To ensure effective governance and compliance X

Horizon Scanning Report


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LINK TO CQC:

Caring

Responsive

Effective

Well Led X

Safe


None

Publication of the NHS Patient Safety Strategy (July 2019) – further update https://improvement.nhs.uk/resources/patient-safety-strategy/

Board members will recall the Patient Safety Strategy implementation reported in the September

2019 Horizon Scanning report. In early July 2019, NHS England and NHS Improvement published

the NHS Patient Safety Strategy, which set out a vision of continuous improvements in patient

safety, that are based upon both the needs of the patient and the system priorities. Key points

include:

Three key strategic objectives have been identified to achieve this vision:

o to improve understanding of safety (insight)

o to equip patients, staff and partners with the skills and opportunities to improve patient

safety throughout the system (involvement)

o to design and support programmes to deliver effective and sustainable change in the

most important areas of safety (improvement)

Two further updates were published in January 2020 relating to the implementation of the

components of the strategy; namely:

1) Consultation on the proposal to develop patient safety specialists in all trusts

https://engage.improvement.nhs.uk/policy-strategy-and-delivery-management/patient-safety-

specialists/

The consultation seeks to define requirements for the role and training requirements, to

ensure organisations benefit from the role for their patients

2) Patient Safety Syllabus Publication

https://www.aomrc.org.uk/patientsafety/

On 24 January 2020, the Academy of Medical Royal Colleges (AoMRC), in collaboration

with NHS England and NHS Improvement, and Health Education England published the first

iteration of the first National patient safety syllabus. The syllabus will underpin the

development of patient safety curricula for all NHS staff.

2019 Workforce Race Equality Standard (WRES) Report published



https://improvement.nhs.uk/resources/patient-safety-strategy/

https://engage.improvement.nhs.uk/policy-strategy-and-delivery-management/patient-safety-specialists/

https://engage.improvement.nhs.uk/policy-strategy-and-delivery-management/patient-safety-specialists/

https://www.aomrc.org.uk/patientsafety/

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https://www.england.nhs.uk/wp-content/uploads/2020/01/wres-2019-data-report.pdf

The 2019 WRES report was published in February 2020 and shows that, overall for the NHS, more

black and minority ethnic (BME) people working at board level in the NHS, while the number of very

senior managers from BME backgrounds has increased by 30% since 2016. BME candidates’

likelihood of success in job interviews has improved, and fewer BME staff are going through the

formal disciplinary process than two years ago.

The Trust is reviewing the data and will report on Trust figures via the Workforce Committee and

remains committed to delivering the improvement actions already identified within out WRES action

plan.



https://www.england.nhs.uk/wp-content/uploads/2020/01/wres-2019-data-report.pdf

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MEETING TITLE

PUBLIC BOARD

Date: 11.03.2020 Report Title: Strategic Objective Setting Agenda Item: 11 Author: Nicky Ward, Acting Head of Strategy and Transformation Lead Director: Dorothy Hosein, Chief Executive Purpose: Assurance x Decision x


SUMMARY AND BACKGROUND: As an organisation we have been on a journey of strategy development and objective setting. In October 2019 we launched a ‘conversation starter’ document to our partners, staff and patients, proposing themes, priority actions and ambition for the future of our Trust. Over the next 2 months we consulted and listened to the feedback received and in December a thematic analysis of all the feedback with evidence was provided for the Board workshop, called step 1. The themes from the feedback led to a discussion about the need to refresh the Trust’s vision and goals (strategic objectives) and reinforced the clear support for our existing values. It also allowed the Board to determine what the key enabling strategies the organisation needed to deliver the Trusts direction and goals. The Board then asked that the Executive team develop the enabling strategies to 80% completion and that a new vision and goals were developed and brought back to the February Board (step 2). In step 2 of this process, the Board spent time reviewing the new vision and goals and discussed the purpose of each enabling strategy to ensure that nothing had been missed. In addition, the Board considered how we will measure the enabling strategies and what the key high-level metrics to monitor the achievement of our Trust goals would be. The outputs of this meeting led to further work by the Executive including a launch plan for the corporate strategy and further work on finalising the enabling strategies for committee sign off by the end of quarter 1 2020/21. This plan provides the final vision and goals for the organisation for formal sign off. This is important as the Executive are undertaking a piece of work to refresh the appraisal process for the start of the new financial year and we want the goals to be at the heart of the appraisal process and personal objective setting. In addition, the corporate strategy launch plan is included for assurance. Work on the strategy will be continuous but key milestones are detailed within this plan. In addition to the above the Board are also asked to note that in respect of progress against the development of one of our most crucial enabling strategies for urgent and emergency care. The Executive have held a workshop development session on Monday 2nd March to agree scope and next steps. Background engagement work has also been undertaken and we have agreement from NHSE/I, NHS providers and lead STP/ICS colleagues to hold a regional event on urgent and emergency care where we invite key stakeholders to describe what they want us to achieve with this strategy and what they need from our service in respect of the Long Term Plan. A working group to prepare for this event will be set up following a scoping meeting with NHSE/I on 23rd March. Vision and goals for agreement: Vision Outstanding care, exceptional people, every hour of every day.

Strategic Objective Setting


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Goals • Be an exceptional place to work, volunteer and learn • Provide outstanding quality of care and performance • Be excellent collaborators and innovators as system partners • Be an environmentally and financially sustainable organisation

RECOMMENDED ACTION: To approve the proposed vision and goals and note the launch plan for the corporate strategy

KEY ISSUES IDENTIFIED Continued stakeholder engagement and communication will be key

DECISION OR RESOURCE REQUIRED: To approve the vision and goals

PREVIOUSLY CONSIDERED BY: Board (December 2019 and February 2020)

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers] All

INDICATE WHICH STRATEGIC RISK THIS REPORT RELATES SR1: Failure to deliver a timely service to our patients in line with commissioned national standards, to ensure a safe level of service

x


x


x

SR4: Failure to deliver an efficient, effective and economic service x Other: Please Specify

THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE Provide better care x Value our people x Value for money x Improve performance x

OTHER: To ensure effective governance and compliance

LINK TO CQC: Caring x Responsive x Effective x Well Led x Safe x



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RELEVANT LEGAL OR STATUTORY ISSUES Good practice to have a refreshed corporate strategy



Implementation plan for the EEAST Corporate Strategy

This short paper outlines the steps we will take to publicise the publication of the EEAST corporate strategy, during Spring 2020.

1 Aims

• To outline our direction as an organisation over the coming 5 years, articulating our vision and values and clarifying our goals.

• To engage and update internal and external stakeholders, increasing understanding of what it means for them and their objectives.

• To articulate the context and purpose of the corporate and enabling strategies to all staff of EEAST so that it is meaningful to their activities.

• To ensure the corporate strategy becomes the ‘road map’ for our aspirations and performance enhancement activities in the future.

2 Key activities/channels:

2.1 Commission the design and printing of the Corporate Strategy – as a print item and online document.

2.2 Develop a Strategy on a Page that gives an easily understandable overview of the strategy. This will make use of infographics and imagery.

2.3 Develop an animation or video to be used on the Trust website, intranet and social media channels that generates a sense of excitement about the strategy and the difference it will make to patients and staff.

2.4 Develop a staff engagement programme – similar to the Thank you week – for managers engage their teams in what the strategy means for them and their teams.

2.5 Using the Air & Share roadshows for the Exec Team to reinforce the staff engagement activity.

2.6 Chair and CEO letter to write to key external stakeholders with a copy of the printed strategy; launch the strategy at the EEAST AGM in July 2020.

2.7 Ensure our current meetings highlight the corporate strategy at every opportunity.

2.8. Ensure our managers use the corporate strategy in the 2020/2021 appraisal process.



3 Workplan

Action When Who

Production of the corporate strategy

Draft and edit text; collate photography, images and graphics

Week of 9 March Comms Team

Sign off text with ELB – with particular focus on the overview of enabling strategies

Week of 9 March Comms Team/Exec Directors

Design and production – including print and online copies

Printed copies by 20 April

Comms Team

Manager and staff engagement

Align individual objective setting to the four goals within the Corporate Strategy

First priority will be NEDs and Exec Directors

Use Air & Share events in April and May Dates tbc Exec Directors

Managers to lead small interactive sessions; staff to articulate what the corporate strategy means for them.

May Managers

Produce managers’ guide along with selfie frames and guidance on shooting photographic and video content.

April Comms Team

Promote to key external stakeholders

Public Board meeting – printed copies available and published on the website.

13 May Comms Team

Write to key stakeholders with a copy of the strategy

May CEO and Chair

NEDs and Execs to promote at STP meetings at sector level

May NEDs and Exec Team

Launch the corporate strategy at the Trust AGM 15 July CEO and Chair



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MEETING TITLE PUBLIC BOARD Date: 11.03.2020 Report Title: Staff engagement and communications in relation to the 2019 NHS

Staff Survey results for EEAST Agenda Item: 12 Author: Julie Hollings, Director of Communications & Engagement Lead Director: Julie Hollings, Director of Communications & Engagement Purpose: Assurance x Decision



During autumn 2019, the Picker Institute undertook the NHS National Staff Survey for EEAST. Picker is the survey supplier to 8 ambulance trusts in total. The results for the NHS Staff Survey for 2019 were published on 18 February 2020. Along with the Trustwide scores we also received a breakdown by sector.

This paper sets out:

• The results of the survey – with the 3 top scores for each sector and the key areas for improvement.

• How the results of the survey were communicated internally and externally. • How the results of the survey will be used to improve the staff experience within EEAST. • Our process for engaging with staff and managers to identify the improvements needed. • This will focus on local leadership by managers in reviewing the sector-wide results with their

teams. Creating local action plans for improving engagement will a crucial part of this.

RECOMMENDED ACTION: The Board is asked to endorse:

• Our plan for communicating the results of the survey both internally and externally. • Proposals for how the results of the survey will be used • The process for engaging with staff and managers to identify the improvements needed.

KEY ISSUES IDENTIFIED The need to ensure that developing local action planning is undertaken outside the Winter period so that it can be effectively resourced.

DECISION OR RESOURCE REQUIRED: N/A

PREVIOUSLY CONSIDERED BY: N/A

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers] SR3: Failure to establish a culture of engagement and accountability that is patient focussed




X


Annual Staff Survey Report and Plan



THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE Provide better care X Value our people X Value for money Improve performance

OTHER: To ensure effective governance and compliance

LINK TO CQC: Caring X Responsive X Effective X Well Led X Safe X

RELEVANT LEGAL OR STATUTORY ISSUES N/A



1 2019 Staff Survey methodology and results During October and November 2019, the Picker Institute undertook the NHS staff survey for EEAST. This is a requirement for all NHS trusts. Picker is the survey supplier to 8 ambulance trusts in total. Questionnaires were sent to 4,859 staff.

The results were published at 9.30am, on Tuesday 18 February, along with the results for all NHS trusts. The data was provided to us as Trustwide scores as well as breakdown by individual staff groups, ethnicity and disability. Analysis of the findings by each sector will also made available.

The results are set out in the attached slides.

There was an increase in the response rate from 39% to 47%. The average response for Ambulance Trusts is 54%. Top improved scores: • The number of staff receiving appraisals has shown the biggest increase from 45% to 73%. • 59% of staff believe that the Trust’s top priority is patient care (compared to 54% last year).

The number of staff who receive regular updates on patient feedback is above the average and is one of our most improved scores at 39%. There have been improvements in the number of staff who believe that the Trusts acts on patient concerns (59%) and staff believe that patient feedback is used to make informed decisions in their area.

• The survey reported 70% of staff know who senior managers are, an increase of 5% since last year. Communication between senior managers is also reported as more effective with a 5% increase to 23%.

• Our retention is improving with a small increase in the numbers of staff who are not planning to leave the organisation (from 43% to 47%). In addition, 41% would recommend the organisation as a good place to work (an increase of 5%)

Areas for improvement: • With the largest increase of appraisals being undertaken we now need to ensure a continued

focus on quality in terms of ensuring that appraisal help staff improve how to do their job; and ensure that they feel valued.

• Just over half (53%) of staff with a disability believe that the organisation made adequate adjustment(s) to enable them to carry out work.

• There is a decrease in the number of staff agreeing that the organisation takes positive action on health and well-being.

EEAST is still below average for several of the scores. However, most of them are showing improvement in the 2019 survey. Our focus now is on using the results to drive improvements across the Trust, working closely with our staff.

2 Communications and engagement plan for the publication of the results 2.1 Aims • To engage EEAST staff with the results of the 2019 NHS Staff Survey. • To demonstrate progress since the 2018 survey. • To involve local staff in decisions about the improvements that need to be made. Objectives



• To ensure that results are easily understood and digested by staff • To ensure that each sector agrees an action plan for improvements in that area • To maintain a flow of communications through the year on the improvements underway • To help increase participation for the 2020 survey

2.2 Timetable of activity 18 February – publish survey results internally and externally Internal:

• An email with the key findings was sent to all staff from the CEO • There was also a leadership message from the CEO along with a video • An article was published on Need to Know outlining ‘You said, we did’

External: • A reactive press release was prepared for use with enquiries from the local media. We

received one enquiry from the Eastern Daily Press. 3 Process for using the results of the survey February - March 2020

• Publication and dissemination of the results • The results have been incorporated into key enabling strategies and improvement plans

– namely the Leadership Strategy, Communications & Engagement Strategy and Workforce Strategy. These strategies were shared with the Board on 12 February.

• Analysis of the result by sector and by different staff groups will be made available to managers. The expectation will be that the results are discussed with teams and action plans agreed. A briefing session has been held with senior Operations managers to facilitate this process.

• Analysis of the result by sector and by different staff groups will be made available to managers. The expectation will be that the results are discussed with teams and action plans agreed.

Q1 (April – June 2020)

• The OD & Training Team and Workforce Teams will develop action plans for corporate OD issues.

• Discussions would centre on identifying the top 3 results for each sector and the key 3 areas for improvement.

• The sector results will cross-referred to the themes and issues arising from the ‘Air and Share executive.

• The results will be incorporated into the next round of leadership development training commissioned from the Get Real team.

Q2 (July – Sept 2020)

• Action plans to be delivered in all sectors. Outcomes to be gathered for ‘You said, we did’

Q3 (Sept – Nov 2020)



• Launch of the 2020 staff survey, supported by ‘You said, we did’ information to all staff updating them on the changes being made. This will be done at corporate and sector levels.

4 Process for engaging with staff and managers to identify the improvements needed

• The results by sector or staff group will be made available to all managers. All senior managers will be expected to lead sessions with their teams to explore their top 3 and areas for improvement. They will be then be expected develop an action plan for improving these issues – in conjunction with staff.

• The senior managers for each sector will be required to work with their HR leads and their Executive lead to plan the sessions. Guidance and training will be made available to support with this process.

• Progress on these will be monitored through the Accountability Board meetings. • The second phase of Get Real leadership development workshops will focus on values

and behaviours and the results will be used to help develop training on how managers can best engage their teams



NHS Staff Survey 2019Top scores and areas for improvement

February 2020

Annual S

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NHS Staff Survey 2019

• The National Staff Survey was carried out by Pickerbetween October and November 2019.

• Picker was commissioned by 8 Ambulance Trusts in total. • Questionnaires were sent to 4,859 staff. • There has been an increase in the response rate from 39%

to 47%. The average response for Ambulance Trusts is 54%.

• However EEAST is still below average for many of the scores. The majority are beginning to show improvementin the 2019 survey.

Annual S

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18

963

Historical comparison*

Significantlybetter

Significantlyworse

41% Q21c. Would recommend organisation as place to work

65%Q21d. If friend/relative needed treatment would be happy with standard of care provided by organisation

59% Q21a. Care of patients/service users is organisation's top priority

4928Invited to complete

the survey

4859Eligible at the end of

the survey

47%Completed the survey (2307)

54%Average response

rate for similar organisations

39%Your previous response rate

This document summarises the findings from the NHS National Staff Survey 2019, carried out by Picker, on behalf of East of England Ambulance Service NHS Trust. Picker was commissioned by 8 Ambulance Trust organisations to run their survey – this report presents your results in comparison to those organisations.

A total of 90 questions from the survey can be positively scored. 90 of these can be compared historically between NSS18 and NSS19. Your results include every question where your organisation had the minimum required 11 respondents.

Picker: Executive summary (part 1 of 2)

2

72

16

Comparison with average*

Significantlybetter

Significantlyworse

*Chart shows the number of questions that are better, worse, or show no significant difference

Annual S

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Bottom 5 scores (compared to average)

35% Q8c. Immediate manager gives clear feedback on my work

31% Q19g. Definitely supported by manager to receive training, learning or development identified in appraisal

39% Q4b. Able to make suggestions to improve the work of my team/dept

48% Q8a. My immediate manager encourages me at work

63% Q14. Organisation acts fairly: career progression

Picker: Executive summary (part 2 of 2)

Top 5 scores (compared to average)

58% Q19f. Appraisal/performance review: training, learning or development needs identified

72% Q12d. Last experience of physical violence reported

42% Q13d. Last experience of harassment/bullying/abuse reported

39% Q22b. Receive regular updates on patient/service user feedback in my directorate/department

8% Q11g. Not put myself under pressure to come to work when not feeling well enough

Most improved from last survey

73% Q19a. Had appraisal/KSF review in last 12 months

39% Q22b. Receive regular updates on patient/service user feedback in my directorate/department

59% Q21b. Organisation acts on concerns raised by patients/service users

32% Q22c. Feedback from patients/service users is used to make informed decisions within directorate/department

59% Q21a. Care of patients/service users is organisation's top priority

Least improved from last survey

31% Q19g. Definitely supported by manager to receive training, learning or development identified in appraisal

53% Q28b. Disability: organisation made adequate adjustment(s) to enable me to carry out work

17% Q19c. Appraisal/performance review: Clear work objectives definitely agreed

71% Q16a. In last month, have not seen errors/near misses/incidents that could hurt staff

16% Q19d. Appraisal/performance review: definitely left feeling work is valued

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Top scores• The number of staff receiving appraisals has shown the biggest increase from

45% to 73% with 58% of staff having their training needs identified through their appraisal, which is above average.

• 59% of staff believe that the Trust’s top priority is patient care (compared to 54% last year). The number of staff who receive regular updates on patient feedback is above the average and is one of our most improved scores at 39%. There have been improvements in the number of staff who believe that the Trusts acts on patient concerns (59%) and staff believe that patient feedback is used to make informed decisions in their area.

• The survey reported 70% of staff know who senior managers are, an increase of 5% since last year. Communication between senior managers is also reported as more effective with a 5% increase to 23%.

• Our retention is improving with a small increase in the numbers of staff who are not planning to leave the organisation (from 43% to 47%). In addition, 41% would recommend the organisation as a good place to work (an increase of 5%)

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Bottom scores• There is a decrease to only 16% of staff agreeing that the organisation takes

positive action on health and well-being. This is below the average in Ambulance Trusts of 23%.

• With the largest increase of appraisals being undertaken, we will now focus on the quality to ensure that they help staff improve how to do their job; define clear work objectives and leave staff feeling valued.

• Just over half (53%) of staff with a disability believe that the organisation made adequate adjustment(s) to enable them to carry out work.

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Norfolk & Waveney Top scores – compared to Trust overall

79%Trust score 71%

Patient/service user feedback collected within directorate/department

71%Trust score 65%

Satisfied with amount of responsibility given

63%Trust score 60%

Don't work any additional unpaid hours per week for this organisation, over and above contracted hours

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Norfolk & WaveneyKey areas for improvement – compared to Trust overall

39%Trust score 50%

Immediate manager values my work

21%Trust score 35%

Immediate manager gives clear feedback on my work

9%Trust score 20%

Involved in deciding changes that affect work

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Cambridgeshire & PeterboroughTop scores – compared to Trust overall

65%Trust score 53%

Time often/always passes quickly when I am working

66%Trust score 57%

Not felt pressure from manager to come to work when not feeling well enough

55%Trust score 43%

Not felt unwell due to work related stress in last 12 months

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Cambridgeshire & PeterboroughKey areas for improvement – compared to Trust overall

61%Trust score 73%

Had appraisal/KSF review in last 12 months

41%Trust score 58%

Appraisal/performance review: training, learning or development needs identified

39%Trust score 49%

Staff given feedback about changes made in response to reported errors/near misses/incidents

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Suffolk & North EssexTop scores – compared to Trust overall

91%Trust score 81%

Satisfied with quality of care I give to patients/service users

74%Trust score 58%


73%Trust score 63%

Able to provide the care I aspire to

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Suffolk & North EssexKey areas for improvement– compared to Trust overall

25%Trust score 39%

Organisation treats staff involved in errors/near misses/incidents fairly

16%Trust score 31%

Satisfied with recognition for good work

6%Trust score 20%

Team members often meet to discuss the team's effectiveness

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Bedfordshire & LutonTop scores – compared to Trust overall

48%Trust score 39%

Receive regular updates on patient/service user feedback in my directorate/department

47%Trust score 32%

Feedback from patients/service users is used to make informed decisions within department

59%Trust score 49%

Often/always look forward to going to work

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Bedfordshire & LutonKey areas for improvement – compared to Trust overall

41%Trust score 51%

Immediate manager takes a positive interest in my health & well-being

24%Trust score 53%

Disability: organisation made adequate adjustment(s) to enable me to carry out work

10%Trust score 53%

Had training, learning or development in the last 12 months

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Mid & South EssexTop scores – compared to Trust overall

70%Trust score 59%

Care of patients/service users is organisation's top priority

65%Trust score 43%


38%Trust score 27%

Able to meet conflicting demands on my time at work

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Mid & South EssexBottom scores – compared to Trust overall

40%Trust score 56%

Immediate manager can be counted on to help with difficult tasks

38%Trust score 58%


36%Trust score 52%

Satisfied with support from immediate manager

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Herts & West EssexTop scores – compared to Trust overall

96%Trust score 81%


84%Trust score 63%


49%Trust score 33%

Relationships at work are unstrained

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Herts & West EssexKey areas for improvement – compared to Trust overall

25%Trust score 39%

Able to make suggestions to improve the work of my team/dept

18%Trust score 32%

Feedback from patients/service users is used to make informed decisions within directorate/department

17%Trust score 29%

Immediate manager asks for my opinion before making decisions that affect my work

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AOC (combined)Top scores – compared to Trust overall

76%Trust score 54%

In last 12 months, have not experienced musculoskeletal (MSK) problems as a result of work activities

72%Trust score 53%

Disability: organisation made adequate adjustment(s) to enable me to carry out work

53%Trust score 35%

Immediate manager gives clear feedback on my work

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AOC (all 3 combined)Key areas for improvement – compared to Trust overall

61%Trust score 81%


44%Trust score 63%


28%Trust score 42%

I have a choice in deciding how to do my work

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PTSTop scores – compared to Trust overall

78%Trust score 57%

Not felt pressure from manager to come to work when not feeling well enough

67%Trust score 43%


76%Trust score 53%

Time often/always passes quickly when I am working

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PTSKey areas for improvement – compared to Trust overall

33%Trust score 58%


36%Trust score 49%

Staff given feedback about changes made in response to reported errors/near misses/incidents

56%Trust score 72%

Last experience of physical violence reported

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Support ServicesTop scores – compared to Trust overall

78%Trust score 22%

Don't work any additional paid hours per week for this organisation, over and above contracted hours

71%Trust score 39%

Able to make suggestions to improve the work of my team/dept

53%Trust score 20%

Team members often meet to discuss the team's effectiveness

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Support ServicesKey areas for improvement – compared to Trust overall

76%Trust score 86%

Feel my role makes a difference to patients/service users

74%Trust score 84%

Always know what work responsibilities are

64%Trust score 72%

Last experience of physical violence reported

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Local EngagementSector/Department Workshops1. Sector/Department specific resultsEach sector/department (where possible) will be supplied with specific local results (due at end of February). These will include the Trust score as a comparator. Managers will be asked to look specifically into their top 3 scores and 3 key areas for improvement.

2. WorkshopsThe Communications Team has begun working with HR and AGMs and GMs to design interactive sessions with staff to look at the results and develop action plans in response.HR leads will work with local managers to arrange local workshops (more than one!) to discuss results with team members. Ask team members to share any further insight on the staff survey specifically the top and bottom scores. To create sub teams to focus on the areas for improvement and to contribute to an action plan.

3. Action plansDevelop an action plan to focus on the areas for improvement. The action plan will be monitored though the Accountability meetings. Arrange team meetings to report on the action plan. Run local surveys to see whether staff have noticed any changes.

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Integrated Performance Report

Trust Board – March 2020

January 2020 Data

EEAST: Integrated Performance ReportMarch 2020, January 20 data

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Key IndicatorsTrust (January 2020 data)


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Overview Trust (January 2020 data)

• Fields with no RAG rating currently do not have a plan / target• Average YTD % figures are currently all calculated by adding the monthly data and dividing by the number of months.


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OverviewSTP (January 2020 data)


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Performance – Emergency Operations, AOC & EPRRLead Director: Marcus Bailey


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Performance – Emergency Operations, AOC & EPRRLead Director: Marcus Bailey

SummaryThe summary will form part of an overall summary please highlight any key successes and/or issues in this section

KPI Key Success / Issue Action Progress

ISR performance targets Lower Patient Facing Staff Hours Agreement of a set of key actions including incentive to improve PFSH.

REAP review on a weekly basis.

Reduction in annual leave allocation into mid January undertaken.

Incentive released and all actions being monitored ahead of key winter pressure period.

Surge (demand management) plan reviewed.

ISR performance targets Modelling on performance with current staffing

To under ORH modelling and results to be discussed with commissioners

Modelled internal trajectory targets identified, agreed and released at STP along with Trust level.

Commissioner and regulatory discussion has occurred.

Hospital Handover Increasing Arrival to Handover times at certain acute hospitals

Engagement with regional handover programmes

Regional workshop attended. Draft changes proposed back to NHSE on divert protocol

ISR performance targets Profiling of resources to match demand Implementation of building better rotas Progress on track (2 stations delayed but known).Evaluation of project being planned


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Performance – Patient Transport ServiceLead Director: Marcus Bailey


KPI Key Success / Issue Action ProgressPerformance Poor operational and financial

performanceReview each contract delivery. Commenced January 2020

West Essex Efficient use of resources Trial use of software auto-planning functions

Task and finish group commenced

NEPTS Lack of co-ordination of all business activity for NEPTS

Role established to facilitateorganisational wide operations

Appointment made

Recruitment Lack of training courses Increase planned in training provision for September and October

Good progress with training placed resulting in decrease vacancies.

Key Indicators for 2019/20

Description This Month

Bedfordshire & Hertfordshire PerformanceEmerging performance risk and improvement plan being

developed.

Cambridgeshire and Peterborough PerformanceActivity increase

Performance stabilised

Recruitment 44.61 vacancies (reduced from last month)


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People & CultureLead Director: John Syson


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Description This Month Trend YTD RAG

Short Term Sickness 3.37% h 2.93% i

Long Term Sickness 3.82% h 3.76% h

Professional Update (Staff Training) 89.68% h 77.36%

Statutory & Mandatory Learning (85% rolling compliance)

88.48% h 86.80%

Information Governance Training (95% rolling compliance)

Compassionate Conversations (rolling 95% compliance)

80.12% h 78.00%

Employee Relation Cases 81 h 75

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People & CultureLead Director: John Syson


KPI Key Success / Issue Action Progress

Sickness Absence Long Term Aim is to decrease staff absence which is longer term

Occupational Health contracthas been awarded to Kays Medical.Line by line reviews are taking place with managers and HR for top 20 cases, each with milestones and plans in place

Implemented working groups . Progress is on-going

Sickness Absence Short Term Aim is to decrease staff absence which is short-term

Training has been delivered on Sickness Policy and management of sickness.A group has been created to focus on 'alternate working duties' and compliancy on Return to Work interviews

New Sickness Policy and refresher training for the new sickness policy to be rolled out

Focus and review ongoing.

Recruitment Underlying vacancy gap across service line

Projection plans are in place with gap analysis incorporating staff turnover.Recruitment /Vacancy tracker implemented by sector/AGM

Review ongoingAdditional capacity be sourced

Professional Update training Need to ensure PU compliance Revised trajectory required for PU completion from operations

Trajectories in place and monitoring/exception


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Clinical (1)Lead Director: Dr Davis


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*New Reporting due Q4

Description This Month Trend YTD

Patient Safety - Harmful Incidents (Moderate or above)

5 h 49

IPC Compliance - Vehicles A&E -Deep Clean Compliance

96.00% g 96.10%

IPC Compliance - Vehicles A&E -Interim Clean Compliance

75.00% i 72.80%

IPC Compliance - Vehicles PTS -Deep Clean Compliance*

tbc tbc

IPC Compliance - Vehicles PTS -Interim Clean Compliance*

tbc tbc

IPC Compliance -Station Cleanliness Compliance*

94.00% i 96.00%

Outstanding Complaints Against Timeframe

4200.00% h 3830.00%

Outstanding Incidents Against Timeframe

102 h 671

Medicine Management Compliance -Controlled Drug Audit

Not reported in month (1/4

report)>90%

Medicine Management Compliance -Prescription / Pharmacy Audit

Not reported in month (1/4

report)>90%

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Clinical (2)Lead Director: T Davis


KPI Key Success / Issue Remedial Action Progress

IPC A&E overall vehicle cleaning

compliance = 85% against Trust target

of 90% (min standard = 85%) and 74%

(Trust standard = 85%) against

interim cleans (min standard = 75%).

PTS overall vehicle compliance shows

89% (standard = 90%) compliance

against deep clean and 79% (standard

= 85%) against interim cleans.

Total overall fleet compliance has

reduced to 86% from 89% (Trust

standard is 90%) but remains just

above the min standard of 85% and

75% against Trust standard of 85%

(min standard = 75%). This is due to

incentive scheme to support

performance over winter period has

utilised all fleet = impacted on vehicle

cleaning schedules.

Station and vehicle compliance

remain above Trust standards set.

Escalation to COO & MD to support

improvement of current compliance

standards above the minimum and

moving towards the Trust minimum

standards.

A mobile MRO has commenced to seek

out and support cleaning whilst fleet is

maximised to support operational

delivery.

IPC Lead working closely with Trust and

National IPC Leads around Cov-19

management.

Flu programme continues to

improve, current vaccination rate

is at 74% with a stretch target of

80%. Current level of forms

received from staff would

indicate likely maximum

vaccination rate being 79%.

Medicine Management Medicines Centralisation plan has

commenced with trial roll out in line

with the implementation (Jan 2020)

to reduce variation and improve

compliance.

Pharmacy team now reviewing and

coding all medicine datixes to improve

reporting around medicine

management

Supporting Medicine

Centralisation plan and CQC

action plans as required. 32

audits were undertaken in

January that should good

compliance above the Trust

target of 95% (97% achieved).


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Patient Safety – (Serious

Incidents)

7 new serious incident cases reported (3 x

moderate harm 4 near miss/low harm) due to:

WEB162713 – unmanaged airway with foreign

body obstruction until second resource arrived

on scene. Patient passed away following

resuscitation. Moderate harm.

WEB164875 – non-conveyance of an unwell

child. She was later taken to hospital by her

parents having deteriorated. Low harm.

WEB164003 – a patient wasn’t immobilised

following an RTC. She was later found to have

spinal fractures. Low harm.

WEB163957 – a private ambulance service

provided PTS ambulances which were used as

emergency ambulances by EEAST. No harm.

WEB164542 – a delay in a Mercedes ambulance

arriving to transfer a critical care patient to a

specialist centre. Low harm.

WEB164695 – an unrecognised oesophageal

intubation. The patient passed away following

resuscitation. Moderate harm.

WEB162790 – a patient fell whilst getting into

taxi arranged to take her to her dialysis

appointment. The patient suffered a fractured

hip in the fall. Moderate harm.

Outstanding incidents has reduced to 72 from the

SI policy amended and approved

through ELB.

EEAST unable to adopt early

implementation of new lessons

learned framework – therefore

continuing with current processes

until new framework released –

expected Autumn 2020 that will

lead to an overhaul of current SI

procedures.


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Patient Experience -

Outstanding Complaints

Against Timeframe

Complaints average closure has stabilised at 40

days against the 25-day target (previously 41.82

days).

Complaints logged has decreased to 72 from 93.

Currently 14 complaints remain open past the

25-day timeframe which has improved to the

lowest for the previous six months reporting.

Compliments continues to outstrip complaints

and concerns combined with 195 reported in

January 2020.

Complaints Manager position

recruited to internally.

Focus on PTS complaint closure

and review of Trust Policy to

determine quick resolution of

concerns.

Lesson learned process to be

completed by March 2020

detailing recommendations

required to improve PE.

It is anticipated the trajectory is

moving old complaints towards

closure and will improve figures

from March 2020 as focus

switching to PTS from A&E.

Currently 15 complaints overdue

25 day working timeframe.


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Legal Services – Claims 3 new claims received in December are

progressing:

1. Claim ID 25240 – Clinical Negligence claim

– Waveney Locality - Incident type:

Inadequate Clinical Assessment - Patient

was not conveyed to hospital on the first

ambulance attendance and it is alleged that

the attending crew failed to have any or

adequate regard to the patient’s red flag

symptoms of cauda equina syndrome.


– South Cambs Locality – Incident type:

Inadequate Clinical Assessment – Non-

conveyance of a patient who had a 3-day

history of severe headaches and sickness.

Patient conveyed to hospital the following

day, where a CT scan showed a

'triventricular hydrocephalus with suspicion

of mass in third ventricle'. Patient sadly

died a few days later.


– South West Essex Locality – Inadequate

Clinical Assessment – Non-conveyance of a

patient after she had an episode of fainting

and lost consciousness. Patient had a

history of cancer and was going through

Claims Facilitator continues

collating files for NHS R to

determine level of liability

against the cases.

CLIIP reporting remains to be

reviewed by Patient

Engagement/Compliance &

Standard/Risk & Safety Leads to

ensure developing

lessons/learned/outcomes from

incidents in Q4.


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FinanceLead Director: Kevin Smith

Key Indicators for

2019/20

Description This Month YTD

Financial Position – variance to original plan £(1.8)m £(3.2)m

Capital Expenditure £(0.2)m £(4.6)m

Cash Balance £(12.5)m

Financial Forecast £(7.7)m


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Summary

KPI Key Success / Issue Action ProgressCIP Target Revised CIP Action Plan.

PMO in situ to add structure to programmeM10 increase in achievement. M10 achievement £0.6m

CIP Delivery Board Scrutiny, Re-Forecast of likely achievement level has given an improved position. Likely shortfall c£3.7m is in line with revised full year reforecast

Ongoing

Year End Forecast Detailed reforecast has been completedThe Trust has submitted a reforecast full year deficit of £(7.7)m to RegulatorsThis has been approved by Trust Board and has previously been presented to Regulators

Budget monitoring, costing of new initiatives to enable fully informed decision making (e.g. incentives)Work continues on CIP achievement and mitigations for shortfallsTrust Recovery plan WIP

Ongoing

Cash Flow Forecast M10 remains ahead of plan Rolling cash flow forecast reviews weekly BAU

Financial Risk Rating Currently at 3 (Rated between 1&4, top rated would be 1)

Budgetary Control and Management, CIP Action plan

Ongoing BAU

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4: NOC

A13 - C1 NoC / PTQ incidentsThe count of C1 incidents, that NoC identified as C1, and received a response on scene.

For A14 to A16, if the call connect time is not recorded, start from the next earliest time, such as T1.

Calculated where the CAD = C1 Call category, and Time first unit on scene is not null and Time of NOC shown is not null. This selects all C1 responses that have been allocated with a NOC.

A14 - Total time to NoC / PTQ C1Aggregated across each call in A13, the time, in seconds, from call connect, until the call was identified as a potential C1 using NoC / PTQ.

Calculated where the CAD = C1 Call category. Then works out the total time between when the first pre triage question was asked 'Time_of_first_prediction_PTQ' and when the NOC code was assigned to the call 'Time_of_first_prediction_NOC'.

A15 -Mean time to NoC / PTQ C1Across all calls in A13, the mean average time, in seconds, from call connect, until a call was identified as a potential C1 using NoC / PTQ.

Definition: A15 = A14 / A13

A16 - 90th centile time to NoC / PTQ C1Across all calls in A13, the 90th centile time, in seconds, from call connect, until a call was identified as a potential C1 using NoC / PTQ.

Calculated where the CAD = C1 Call category. Then works out the 90th percentile time between when the first pre triage question was asked 'Time_of_first_prediction_PTQ' and when the NOC code was assigned to the call 'Time_of_first_prediction_NOC'.

5: INCIDENTS WITH NO FACE-TO-FACE RESPONSE

A17 - incidents with no face-to-face response

Count incidents with no face-to-face resource.

INCLUDE - HCP accountable to the Trust providing telephoneadvice, decisions supported by clinical decision support softwareor approved triage tool, referring to another organisationworking with the Trust through an agreed contract or ServiceLevel Agreement, or through the Directory of Services. | EXCLUDE- Duplicate, information, cancelled by caller and hoax calls. Alsoexclude deceased patient with no response on scene, demandmanagement, and calls passed to another ambulance service.

When a incident goes through the Heat and Treat pathway our database assigns it with the Hear and Treat CAD reference as well as a call category. We then do a total of all Inicdents of with a H&T CAD.ID. (A18 + A19 + A21 + A22)

A18 - Incidents closed with advice: Non-C4H Count of incidents with a stop code of self-careCaculated where all Inicdents with a H&T CAD.ID is not null and Call category is not C4H.

A19 - Incidents referred to other service: Non-C4H

Count of incidents with a stop code of Refer to GP, Refer to A&E, Refer to Minor Injuries Unit (MIU) / Walk-in Centre, Refer to HCP, Refer to Specific service, or Refer to 111 / out of hours care.

Caculated where all Inicdents with a H&T CAD.ID is not null and Call category is not C4H.

A20 - Incidents with call back before response on scene: Non-C4H

Count of incidents where, before any resource arrived on scene, the patient received additional clinical assessment over the telephone, but the patient still received a response on scene.

Caculated where all Inicdents with a H&T CAD.ID and has a Call Category of C2, C3, C4T, and Time first unit on scene is not null, and ECAT lowcode is not null.

A21 - Incidents closed with advice: C4H

Count of C4H incidents where the patient was given specific home management advice regarding their condition, and did not require any further onward referral

Caculated where all Inicdents with a H&T CAD.ID is not null and Call category is not C4H and ECAT lowcode dispositon is equal to 'Self Care' or 'Triaged by GP in EOC - No ambo required - Self Care'

A22 - Incidents referred to other service: C4H

Count of C4H incidents where an onward treatment path was agreed with the patient; whether the Ambulance Service advised the patient to make their own way

Caculated where all Inicdents with a H&T CAD.ID is not null and Call category is not C4H and ECAT lowcode dispositon is not equal to 'Self Care' or 'Triaged by GP in EOC - No ambo required - Self Care'

A23 - Incidents with call back before response on scene: C4H

Count of incidents originally coded as C4H receiving a response on scene.

Calculated where all Incidents with a H&T CAD.ID and has a Call Category of C4H, and Time first unit on scene is not null, and ECAT low code is not null.

Data DictionaryAmbulance Quality Indicators (2)


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6: RESPONSE TIMES

A24 - Total response time C1The total response time aggregated across all incidents in A8 in the period.

An ARP Response Time and ARP Transport Response Time measure has been created by EEAST to only take calculate responses for transportable resources.

Calculated when Call Category = C1 and Time first unit on scene is not Null then Sum the ARP Response Time for all incidents across the specified period.

A25 - Mean Response time - C1 Across all incidents in A8 in the period, the mean average response time. A25 = A24 / A8

A26 - 90th centile response time C1Across all incidents in A8 in the period, the 90th centile response time

Calculated when Call Category = C1 and Time first unit on scene is not Null then calculate the 90th percentile ARP Response Timefor all incidents across the specified period.

A27 - Total response time C1TThe total response time aggregated across all incidents in A9 in the period.

Calculated when Call Category = C1 and Time first unit on scene is not, and time destination is not null. then Sum the ARP Response Time for all incidents across the specified period.

A28 - Mean response time C1T Across all incidents in A9 in the period, the mean average response time. A28 = A27 / A9

A29 - 90th centile response time C1TAcross all C1T incidents in A9 in the period, the 90th centile response time.

Calculated when Call Category = C1 and Time first unit on scene is not Null and Time Destination is not null then calculate the 90th percentile ARP Response Time for all incidents across the specified period.



A31 - Mean Response time - C2Across all incidents in A10 in the period, the mean average response time.

A31 = A30 / A10

A32 - 90th centile response time C2Across all incidents in A10 in the period, the 90th centile response time.





A34 = A33 / A11




Calculated when Call Category = C4T and Time first unit on scene is not Null then Sum the ARP Response Time for all incidentsacross the specified period.


A37 = A36 / A12


Calculated when Call Category = C4T and Time first unit on scene is not Null then calculate the 90th percentile ARP Response Time for all incidents across the specified period.

A62 - Total response time: HCP 1 hour response The total response time aggregated across all incidents in A58 in the period.

Calculated where the CAD = URG Call Category and the Time first unit on scene is not null. And the response to scene is 60 minutes or less to provide a 1 hour response. Then Sum the ARP Response Time for all incidents across the specified period.

A63 - Mean response time: HCP 1 hour response Across all incidents in A58 in the period, the mean average response time.

A63 = A62 / A58

A64 - 90th centile response time: HCP 1 hour response Across all incidents in A58 in the period, the 90th centile response time.

Calculated where the CAD = URG Call Category and the Time first unit on scene is not null. And the response to scene is 60 minutes or less to provide a 1 hour response. Calculate the 90th percentile ARP Response Time for all incidents across the specified period.

A65 - Total response time: HCP 2 hour response

The total response time aggregated across all incidents in A59 in the period.

Calculated where the CAD = URG Call Category and the Time first unit on scene is not null. And the response to scene is between 61 and 120 minutes or less to provide a 2 hour response. Then Sum the ARP Response Time for all incidents across the specified period.


A66 = A65 / A59

A67 - 90th centile response time: HCP 2 hour response

Across all incidents in A59 in the period, the 90th centile response time.

Calculated where the CAD = URG Call Category and the Time first unit on scene is not null. And the response to scene is between 61 and 120 minutes or less to provide a 2 hour response. Calculate the 90th percentile ARP Response Time for all incidents across the specified period.





A69 = A68 / A60








A72 = A71 / A61






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6: RESOURCE ALLOCATION AND ARRIVAL

A39 - Resources allocated to C1 For all incidents in A8, total count of resources allocated.

Excluded Vehicle Types: 'CSD','ECAT','DEF','CFR','RAF','CDF','FIR','FIRE', 'TEST','COR','POL'

Count when CAD ID = C1 Call Category and Time assigned is not null / A8

A40 - Resources arriving to C1 For all incidents in A8, total count of resources that arrived on scene.

Count when CAD ID = C1 Call Category and Time at scene is not null. / A8

A41 - Resources allocated to C1T For all incidents in A9, total count of resources allocated.

Count when CAD ID = C1 Call Category and Time assigned is not null and Time at Destination is not null / A9

A42 - Resources arriving to C1T For all incidents in A9, total count of resources that arrived on scene.

Count when CAD ID = C1 Call Category and Time at scene is not null and Time at Destination is not null / A9

A43 - Resources allocated C2 For all incidents in A10, total count of resources allocated.



Count when CAD ID = C2 Call Category and Time at scene is not null / A10









A53 - Incidents with transport to ED (see and convey)

Count of incidents with any patients transported to an Emergency Department (ED), including incidents where the department transported to is not specified. Include incidents with non-emergency conveyance to ED.

ED includes stroke and Primary Percutaneous Coronary Intervention units.

Count of CAD ID where Time Destination is not null and Hospital Ward Name = 'A&E'.

A54 - Incidents with transport not to ED (see and convey)

Count of incidents with any patients transported to any facility other than an Emergency Department

INCLUDES - MIU, EAU, MAU, SAU, WIC AND transport from hospital to hospice.

Count of CAD ID where Time Destination is not null and Hospital Ward Name not equal to 'A&E'.

A55 -Incidents with no transport (see and treat)

Count of incidents with face-to-face response, but no patients transported.

INCLUDES - patients who refused treatment, deceased or where patient could not be found. Ambulance Service staff arranged an appointment for the patient, or a follow-up home visit or ambulance service staff attended an incident and gave advice.

Count of CAD ID where Time first unit on scene is not null and Time Destination is null.

A56 - Incidents with face to face responsecount of all incidents with a face to face response. Includes all inclusions for A53, A54 and A55.

A56 = A53 + A54 + A55


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Data Dictionary Clinical Quality Indicators

AMBULANCE CLINICAL QUALITY INDICATORS

Measure Term - Definition Data Source

CARDIAC ARREST -ROSC (OVERALL): % of all patients who had resuscitation (Advanced or Basic Life Support), commenced/ continued by EEAST following an out-of-hospital cardiac arrest who had return of spontaneous circulation (ROSC) on arrival at hospital. AuditOnline

CARDIAC ARREST -ROSC (UTSTEIN): % of patients who had resuscitation (Advanced or Basic Life Support) commenced / continued by EEAST following an out-of-hospital cardiac arrest of presumed cardiac origin, where the arrest was Bystander witnessed and the initial rhythm was Ventricular Fibrilliation (VF), or Pulseless Ventricular Tachycardia (VT). AuditOnline

CARDIAC ARREST - Survival to Discharge (OVERALL): % of all patients who had resuscitation (Advanced or Basic Life Support) commenced/continued by EEAST following an out-of-hospital cardiac arrest who were discharged / transferred alive from hospital alive. AuditOnline

CARDIAC ARREST - Survival to Discharge (UTSTEIN):% of patients who had resuscitation (Advanced or Basic Life Support) commenced / continued by EEAST following an out-of-hospital cardiac arrest of presumed cardiac origin, where the arrest was Bystander witnessed and the initial rhythm was Ventricular Fibrillation (VF), or Pulseless Ventricular Tachycardia (VT), who were discharged or transferred alive. Excluding patients for whom survival is not known. AuditOnline

POST ROSC Care Bundle % of patients who had resusciation (Advanced or Basic Life Support) commenced / continued by EEAST following an out-of-hospital cardiac arrest with a ROSC at Scene who received an appropriate care bundle. AuditOnline

STEMI - Care Bundle: % of all patients suffering a ST elevation myocardial infarction (STEMI) who received an appropriate care bundle (aspirin, GTN and analgesia administered and two pain scores recorded). AuditOnline

STEMI Timeliness % of all STEMI patients who received primary percutaneous coronary intervention (PPCI) following direct admission to a PPCI centre. The Mean Average & 90th centile time from call for help until catheter insertion for angiography AuditOnline

STROKE - Care Bundle: % of all of patients with suspected new onset of stroke or transient ischaemic attack (TIA) who received an appropriate care bundle (FAST assessment, blood pressure and blood glucose measurement). AuditOnline

STROKE Timeliness % of all NEW Onset, Face Arm Speech Test (FAST) positive stroke symptom patients potentially eligible for stroke thrombolysis (within local guidelines) who arrived at a Hyperactive Unit.The Mean, Median and 90th centile Clock Start to hospital arrival. AuditOnline

SEPSIS Care Bundle % of all adult patients with a pre-hospital impression of suspected sepsis with a National Early Warning Score (NEWS2) of 7 or above who received the appropriate care bundle - First set of observations (GCS or AVPU, BP, Blood Pressure, Blood, Oxygen Saturation level and Respiratory Rate), Oxygen Administered, Administration of IV Fluids, and Hospital Pre-Alert recorded. AuditOnline


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Data DictionaryGRS

Measure Term - Definition

Rostered Shifts Funded and agreed shifts (approved by staffside and finance) - what we should be puttuing out

Planned Shifts May be funded for X but due to operational demand may put out for Y where Y is higher, lower or at a different time than rostered

Filled Shifts Actual Worked Shifts - terminology after the fact

Abstractions Absence Data - Lost hours due to Sickness or other factors

Alternate Working Dutied For whatever reason - staff not on normal duty - working different hours or different work type - represents lost hours for A&E

Secondments When working outside of their normal role - e.g. DLO doing an acting SLM role - Differing core duties

Short Term Sick Sickness under 28 Days

Long Term Sick Sickness of 28 days or more

Core Training Training staff must undertake to continue role - e.g PARA training

Non Core Training Optional Training e.g. Firearms Training

Annual Leave Statutory or Contractual Leave including TOIL

TOIL Time Off In Lui

Leave Other Special Leave - Maternity and Paternity - Other

Incidental Overtime Over-run in hours at end of shift as opposed to Planned OT

Planned Overtime Planned and agreed overtime

Rota Cycle 12 Week (for example) Rota Plan - Time taken for staff to complete planned Rota Period

GRS Global Rostering System

SEL Software Enterprise Limited (company responsible for GRS)

GRS Web Online Access For all staff

GRS Main Client Restricted access to the system

Skill Mix Balance of Paramedics to other staff types to allow for planned vehicle use


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Data Dictionary ECAT & Hear & Treat

Measure Term - Definition Data SourceData - Definition / Caveat / Calculation

ECAT Calls C1-C4 calls with a LowCode ID ECAT Report

H&T Incidents C1-C4 incident responses + H&T. Duplicate, hoax, cancelled by caller & information only calls are excluded ECAT Report

H&TECAT call closed with valid locus of care disposition and no physical response at scene. (includes valid non algorithm HCP H&T by CCORD and CH H&T). Duplicate, hoax, cancelled by caller & information only calls are excluded. ECAT Report Defined in AQI guidance.

CQUIN H&T

Same as H&T but excludes HCP and 111 calls. Based on pre-ARP AQI guidance. Duplicate, hoax, cancelled by caller & information only calls are excluded

ECAT Report

Based on old AQI definition. Agreed to keep supplying to commissioners as part of CQUIN.

ECAT Saved

Same as H&T but excludes HCP calls. Duplicate, hoax, cancelled by caller & information only calls are excluded

ECAT Report

Part of CQUIN agreement, was originally created in opposition to old AQI definition to show what the figure would be with 111 included. No longer relevant outside of CQUIN.

ECAT H&T

Same as H&T but excludes CH and CCORD H&T. Duplicate, hoax, cancelled by caller & information only calls are excluded

ECAT Report

Requested by Ops so they could get an idea of how much of the activity was done specifically by ECAT.

CCORD H&T Total non algorithm HCP H&T by CCORD (either within H&T ECAT or H&T AQI as appropriate). ECAT Report

Call Handler H&T Total calls closed as "Call Handler Hear and Treat" within CH H&T code set. ECAT Report

Call Handler No SendNumber of calls (outside of CH H&T code set) that are implemented via the NO SEND surge process (not counted in any ECAT save activity).

ECAT Report


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Data Dictionary Compliance

Measure Term - Definition Data SourceData - Definition / Caveat / Calculation

Driving Licence Checks

All staff need to have a driving licence check once in a 365 day rolling cycle. The report includes administrators and PTS office colleagues. he driving licence procedure applies to all eligible employees of the Trust. It also applies to bank workers, volunteers or those who are authorised to drive a vehicle belonging to or on behalf of the Trust (including leased and hired). All should comply with driving licence checks including employees who use their private vehicle on Trust business claiming mileage expenses.

GRS - Personnel -Driving Licence -Licence Reports -Licence Checks

All staff with a driving licence check completed <365 days ago are counted as compliant

PU Completion All eligible staff to complete a PU within an 18 month cycle (current cycle ends 30.09.2019) OD

Compassionate Conversations

100% compliance in a 12 month cycle (FY 2018-19 cycle ended 31.03.2019) OD

Workbooks 100% compliance in a 12 month cycle (FY 2018-19 cycle ended 31.03.2019) OD

DBS Checks TBC TBC

Paediatric Harnesses 100% compliance for all eligible staff by 28/11/2018 - OVERDUE OD

FFP3 Mask Fitting Operational staff to have an FFP3 mask fitted once in a two year rolling cycle Local Records

DATIXAssigned to an investigator within 5 days, Duty of Candour within 10 days (if applicable), investigation completed within 35 days, finally approved within 5 days of investigation completion

DATIX

Report covers awaiting review, being reviewed, awaiting final approval, finally approved and rejected. Also reports on overdue DATIX current week and previous week.

Planning compliance All relief planning for A&E rosters to be completed 12 weeks ahead on a rolling cycle GRS

Annual leave 75% of annual leave allowance to be booked by month 7 of individual leave year GRS

EPCR 85% EPCR usage in all areas by September 2018 - OVERDUE MedusaNumber of EPCR's Created per SLM area/Number of Responses per SLM area (Excluding PAS)

HSDA All blue light drivers to have a high speed driving assessment once in a 5 year rolling cycleDriver

Training/Local records

A new report is being set up by driver training to better capture data for new starters/staff referred following collisions

IG Training 100% compliance by 31.03.2019 - OVERDUE OD

Safeguarding Training 100% compliance by 31.03.2019 - OVERDUE OD


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MEETING TITLE

TRUST BOARD – PUBLIC SESSION

Date: 11.03.2020

Report Title: Finance Report Month 10 – January 2020

Agenda Item: 14

Author: Heather Madden, Head of Finance

Lead Director: Kevin Smith, Director of Finance and Commissioning




The report is to brief the Board on two items: 1. the Financial Position for the Trust as the end of Month 10, January 2020 2. The forecast position for the end of the financial year 2019-2020. FINANCIAL POSITION The accounts for the end of January 2020 show the Trust reporting a cumulative deficit for the YTD of £(5.0)m, £(1.6)m of this amount during the month of January. This is in line with the trajectory of the revised forecast noted below. The principal items contributing to the deficit are detailed in the report below. FORECAST FOR THE YEAR END 2019/2020 The Trust forecasts a deficit of £(7.7)m for 2019-2020. This is in line with the revised forecast agreed with NHSE&I. The Trust has a good degree of confidence in delivery of this revised forecast; however, some risks still remain that may impact on this position. Principally the risks relate to additional costs to maintain service provision over the reminder of the winter period and emerging issues in relation to Covid19.

Further detail is given in the body of this report.

RECOMMENDED ACTION:

To note the position at M10


Forecast deficit for the Financial Year 2019/2020


None


ELT


SR4, SR1



X


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Provide better care

Value our people

Value for money

Improve performance

OTHER:

To ensure effective governance and compliance

LINK TO CQC:

Caring

Responsive

Effective

Well Led

Safe


Statutory Duty to Break Even

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Month 10 Headlines of the Financial Position

1. The Trust set the plan for 2019-2020 to deliver a deficit financial position of £(1.0)m. This included £2.2m of PSF (provider sustainability funding), therefore an underlying deficit of £(3.2)m.

2. Achievement of PSF is predicated in the achievement of the Trust’s financial plan across the

financial year. PSF is paid across to the Trust on a quarterly basis and for Quarters 1 and 2 the Trust achieved its financial targets and has therefore received £0.8m of PSF. However, risks to the achievement of the financial plan emerged earlier in the year giving significant risk to the ability of the Trust to achieve the amounts due for Q3 and Q4. The Trust did not receive the PSF for quarter 3 and forecasts non-achievement of the remainder of the £1.4m scheduled during Quarters 3 & 4.

3. For Month 10 the Trust reports a deficit of £(1.6)m. This gives an actual position YTD of a deficit of £(5.0)m. This is against the original plan for the Trust to achieve a deficit at this time of the financial year of £(0.5)m so gives the Trust a £(5.5)m adverse variance to plan.

4. The principle items of cost included in the position at Month 10 which were not included in the original financial plan and therefore contribute towards the Trust’s deficit remain as previously reported to the Trust Board and include the following:-

a) £(2.1)m towards the potential liability for the Flowers case concerning holiday pay for

overtime worked.

b) £(2.3)m deficit to plan for PTS Services, mainly the Bedfordshire and Hertfordshire area contract. This contract has recovered its financial performance during Month 10 with a surplus of £40k due to the revised income to EEAST following the renegotiation of the contractual sum due with the Commissioners. There remains additional cost for PAS, agency staff and on taxis and work continues to recruit and stabilise this contract.

c) £(2.4)m reduction to income from the 4 CCGs who are not signed up to the block

contractual arrangements. d) £(1.3)m expenditure with consultants for support in development of the Trusts Recovery

plan, CIP programme and related work. e) January saw CIP achievement of £0.5m, this is in line with the revised trajectory to deliver

CIPs of £6.8m.

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The summary position for the Trust by directorate is shown below NB – variances are shown against the original financial plan.

Detail to the position shown above include - The position for Service Delivery of a deficit to plan of £(4.5) includes the income risk and the PTS position previously mentioned plus the additional pay to front line emergency operations staff in overtime, overtime incentives, bank and agency to cover vacancies and abstractions. - The position for Operations Support of a deficit to plan of £(1.9)m includes £(0.5)m additional expenditure in Estates maintenance due to the work taking place to update and refurbish various properties. The remainder relates to fleet issues due to the delays with the fleet replacement programme, lower than anticipated income from fleet workshops and finally due to additional vehicles being retained to boost the fleet at this time to assist with the rollout of BBR (Building Better Rotas). - The position for the CEO of a deficit to plan of £(0.2)m is due to additional senior resource to support the Trust. - A new line has been inserted to the report for the expenditure on the Recovery strategy (including CIP development) and the £(1.3)m expenditure so far is for consultancy support to the Trust for this matter. - The position for the People and Culture Directorate of a deficit to plan of £(0.3)m is due to costs incurred for legal fees together with agency staff. This has also been impacted during January due to the national change in discount rate for provisions which has affected the costs of the injury benefits and early retirement provisions held. - The deficit position show under Depreciation and Provisions of £(2.1)m includes the provision mentioned above for the Flowers legal case.

Summary by Service Line

Annual

Function Director Budget Budget Actual Variance Budget Actual Variance

Service Delivery Marcus Bailey (100,913) (8,130) (7,784) 346 (84,685) (80,177) 4,509

AOCs Marcus Bailey 24,214 2,030 2,097 67 20,153 19,518 (635)

Strategy & Sustainability Dorothy Hosein 8,162 672 665 (7) 6,791 6,494 (297)

Operational Support Dorothy Hosein 38,597 3,201 3,974 773 32,039 33,984 1,946

Special Operations Marcus Bailey 148 7 (10) (17) 134 (694) (827)

Chief Executive Dorothy Hosein 3,316 235 263 28 2,784 3,027 243

Recovery Strategy ELB 0 0 353 353 0 1,275 1,275

Clinical Quality Tracy Nicholls 3,149 248 239 (9) 2,624 2,652 28

Medical Directorate Tom Davis 2,026 178 228 50 1,670 1,753 82

People & Culture Dorothy Hosein 8,428 636 619 (18) 7,220 7,531 311

Finance Kevin Smith 2,704 229 222 (7) 2,232 2,049 (184)

CQUIN Kevin Smith (1,250) (104) (330) (226) (1,042) (1,776) (734)

Trust CIP Kevin Smith 0 0 0 0 0 0 0

Reserves Kevin Smith 2,608 362 0 (362) 2,509 (787) (3,296)

Depreciation & Provisions Kevin Smith 9,765 814 1,094 281 8,137 10,187 2,050

Grand Total 952 378 1,630 1,252 566 5,036 4,470

EAST OF ENGLAND AMBULANCE SERVICE NHS TRUST - BUDGET STATEMENT

Period 10 - January 2020

Current Month Year to Date

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- The favourable variance for AOCs of £0.6m reflects the difficulties for recruitment in this area although the costs of the incentive for frontline staff has given this area a small deficit during the month of January. - The favourable variance for strategy and sustainability of £0.3m is due to vacancies, mainly in the IT and Information Department. - The favourable variance for Special Operations of £0.8m is due to vacancies with their associated costs. - The favourable variance on Finance of £0.2m is due to one off non-pay measures. - The favourable CQUIN variance of £0.7m is due to the achievement of income for the CQUIN measures with lower than planned costs -The reserves position of £3.3m surplus to plan includes the following:-

a) YTD contingency release of £1.2m (the 0.5% the Trust is obliged to include in its financial plan and which is released into the position on a monthly basis), b) The release of the reserves held for the additional planned training and PAS expenditure - £3.0m at this stage of the year. c) The PSF due of £1.7m at this stage. £0.8m is achieved for Q1&2, which then give a deficit to plan of £(0.9)m.

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The split between income, pay and non-pay is shown below for information

Summary by Responsibility

Annual

Function Budget Budget Actual Variance Budget Actual Variance

Income

Service Delivery (282,814) (23,535) (23,594) (59) (235,741) (233,098) 2,643

AOCs (1,046) (87) (99) (12) (872) (944) (73)

Strategy & Sustainability 0 0 (5) (5) 0 (5) (5)

Operational Support (2,252) (221) (85) 136 (1,811) (962) 849

Special Operations (10,520) (874) (882) (8) (8,772) (8,931) (159)

Chief Executive 0 0 (6) (6) 0 (74) (74)

Recovery Strategy 0 0 0 0 0 0 0

Clinical Quality (4) (0) 0 0 (4) (3) 0

Medical Directorate (92) (8) (10) (2) (77) (91) (15)

People & Culture (2,549) (243) (361) (118) (1,993) (3,087) (1,094)

Finance (736) (60) (51) 9 (617) (586) 31

CQUIN (3,087) (257) (359) (101) (2,572) (1,917) 655

Trust CIP 0 0 0 0 0 0 0

Reserves (2,248) (262) 0 262 (1,723) (787) 936

Depreciation & Provisions (180) (15) (10) 5 (150) (120) 30

Income Total (305,528) (25,561) (25,459) 102 (254,331) (250,607) 3,724

Pay

Service Delivery 161,820 13,725 13,916 191 134,248 134,868 621

AOCs 24,684 2,070 2,154 84 20,544 19,873 (672)

Strategy & Sustainability 2,491 219 177 (42) 2,027 1,841 (186)

Operational Support 6,531 613 592 (21) 5,305 4,603 (702)

Special Operations 8,018 684 698 14 6,649 6,604 (45)

Chief Executive 2,407 200 233 33 1,944 2,193 248

Recovery Strategy 0 0 0 0 0 0 0

Clinical Quality 2,522 195 186 (9) 2,103 2,142 39

Medical Directorate 844 82 80 (2) 679 632 (47)

People & Culture 6,506 533 622 89 5,437 5,997 560

Finance 2,319 202 204 2 1,901 1,977 76

CQUIN (0) (0) 25 25 (0) 70 70

Trust CIP 0 0 0 0 0 0 0

Reserves 3,031 399 0 (399) 2,431 0 (2,431)

Depreciation & Provisions 0 0 228 228 0 2,131 2,131

Pay Total 221,171 18,921 19,114 193 183,269 182,930 (339)

Non Pay

Service Delivery 20,080 1,680 1,894 214 16,808 18,053 1,245

AOCs 576 48 42 (5) 480 590 110

Strategy & Sustainability 5,671 453 493 40 4,764 4,658 (106)

Operational Support 34,319 2,809 3,467 658 28,545 30,344 1,799

Special Operations 2,651 197 174 (24) 2,257 1,634 (623)

Chief Executive 909 35 36 1 840 909 69

Recovery Strategy 0 0 353 353 0 1,275 1,275

Clinical Quality 631 53 52 (1) 524 513 (11)

Medical Directorate 1,275 104 158 54 1,067 1,212 144

People & Culture 4,470 346 357 11 3,776 4,621 845

Finance 1,122 87 68 (19) 948 658 (290)

CQUIN 1,837 153 4 (149) 1,531 71 (1,460)

Trust CIP 0 0 0 0 0 0 0

Reserves 1,825 225 0 (225) 1,801 0 (1,801)

Depreciation & Provisions 9,944 829 876 48 8,287 8,177 (110)

Non Pay Total 85,309 7,018 7,975 957 71,628 72,714 1,085

Grand Total 952 378 1,630 1,252 566 5,036 4,470

EAST OF ENGLAND AMBULANCE SERVICE NHS TRUST - BUDGET STATEMENT

Period 10 - January 2020

Current Month Year to Date

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Key Performance Indicators to 31st January 2020 (Month 10 FY19/20)

Plan Actual Variance

1 Turnover £m 304.4 305.5 254.2 250.5 (3.7) 299.0

2a EBITDA £m 6.5 6.5 5.7 1.2 (4.5) (0.5)

2b EBITDA % 2.1% 2.1% 2.2% 0.5% (1.7%) (0.2%)

3a Surplus / (Deficit) £m (1.0) (1.0) (0.6) (5.0) (4.4) (7.7)

3b Surplus / (Deficit) % (0.3%) (0.3%) (0.2%) (2.0%) (1.8%) (2.6%)

4 CIP £m 10.5 10.5 8.1 5.9 (2.2) 6.8

5a Pay £m 219.9 221.2 183.3 182.9 0.4 221.3

5b WTE 5,517 5,517 5,517 4,955 (562) 5,075

5c Non-Pay £m 77.8 77.7 65.3 66.4 (1.1) 78.1

6 Capital budget £m Delivery of capital plan 6.1 7.5 4.5 5.2 0.7 7.5

7a Cash balance £m 7.9 7.9 8.9 9.5 0.6 8.9

7b Debtors >90 days £m 0.2 0.2 0.2 0.8 0.6 0.2

7b BPPC % Non-NHS 95.0% 95.0% 95.0% 94.1% (0.9%) 95.0%

8 Rate of return % Asset utilisation 3.5% 3.5% 3.5% 3.5% 0.0% 3.5%

9 Finance & use of resources Risk rating 3

Delivery of revenue plan

Management of working capital

KEY PERFORMANCE INDICATORS

KPI Relevance of indicatorOpening

plan

Year to date position YTD RAG

Rating

F/cast

Outturn

Current

Plan

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Executive Summary - Key Financial Metrics

Plan Actual Variance Plan Actual Variance

£000 £000 £000 £000 £000 £000

Surplus / (Deficit) (378) (1,630) (1,252) (568) (5,036) (4,470)

Suppliers paid within 30 days - NHS 95% 83% (12%) 95% 91% (4%)

Suppliers paid within 30 days - Non NHS 95% 92% (3%) 95% 94% (1%)

3

Supplier Days (No. Invoices paid)

Finance and use of resources risk rating

Month 10 - January 2020Description

Year to Date

(8,000,000)

(7,000,000)

(6,000,000)

(5,000,000)

(4,000,000)

(3,000,000)

(2,000,000)

(1,000,000)

0

1,000,000

2,000,000

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Operating Surplus

2019-20 Actual 2019-20 Plan 2019-20 Forecast

0

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Cash Balance

2019-20 Actual 2019-20 Plan 2019-20 Forecast

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Statement of Comprehensive Income

Plan Actual Variance Plan Actual Variance

Original

Plan Forecast Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000

Income

24,836 25,018 182 Revenue from patient care activities 248,883 245,977 (2,907) 297,289 292,795 (4,494)

716 431 (285) Other Operating revenue 5,348 4,549 (799) 6,987 6,102 (885)

25,552 25,449 (103) 254,231 250,526 (3,706) 304,276 298,897 (5,379)

Operating Expense

(18,921) (19,114) (193) Pay (183,269) (182,930) 339 (219,914) (221,267) (1,353)

(6,384) (7,274) (890) Non Pay (65,306) (66,443) (1,138) (77,826) (78,095) (269)

(25,305) (26,388) (1,083) (248,575) (249,373) (799) (297,740) (299,362) (1,622)

247 (939) (1,186) 5,656 1,153 (4,505) 6,536 (465) (7,001)

1.0% (3.7%) 1151.5% EBITDA margin 2.2% 0.5% 121.6% 2.1% (0.2%) 130.2%

Depreciation & Financial

(510) (575) (65) Depreciation (5,096) (5,043) 53 (6,115) (5,830) 285

(122) (122) 0 PDC Dividend (1,217) (1,217) 0 (1,460) (1,460) 0

10 10 0 Financing Income 99 83 (16) 119 87 (32)

(3) (4) (1) Financing Costs (27) (28) (1) (32) (31) 1

0 0 0 Other Gains & (Losses) 17 16 (1) 0 22 22

(625) (691) (66) (6,224) (6,189) 35 (7,488) (7,212) 276

(378) (1,630) (1,252) (568) (5,036) (4,470) (952) (7,677) (6,725)Net Surplus/(Deficit)

Month 10 - January 2020

Description

Year End Forecast

Subtotal

Subtotal

EBITDA

Subtotal

Year to Date

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Divisional Expenditure

Plan Actual Variance Plan Actual Variance Current Plan Forecast Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000

Service Delivery

15,405 15,809 (404) Emergency Operations 151,059 152,923 (1,866) 181,901 184,787 (2,886)

2,117 2,196 (79) AOCs 21,025 20,463 562 25,260 25,102 158

881 872 9 Special Operations 8,906 8,237 669 10,668 10,261 407

18,403 18,877 (474) 180,990 181,623 (635) 217,829 220,150 (2,321)

Support Services

235 269 (34) Chief Executive 2,784 3,101 (317) 3,316 3,721 (405)

289 272 17 Finance Directorate 2,849 2,635 214 3,441 3,276 166

3,422 4,059 (637) Operational Support Services 33,849 34,947 (1,098) 40,849 41,993 (1,144)

672 670 2 Strategy & Sustainability 6,791 6,499 292 8,162 8,122 40

879 979 (100) People and Culture 9,212 10,618 (1,406) 10,976 12,845 (1,869)

248 239 9 Clinical Quality 2,627 2,655 (28) 3,153 3,407 (254)

829 1,104 (275) Depreciation & Provisions 8,287 10,307 (2,020) 9,944 12,612 (2,668)

153 29 124 CQUIN 1,530 141 1,389 1,836 449 1,387

186 238 (52) Medical Directorate 1,747 1,844 (97) 2,118 2,192 (74)

0 353 (353) Recovery Strategy 0 1,275 (1,275) 0 1,024 (1,024)

624 0 624 Trust Reserves 4,232 0 4,232 4,856 (460) 5,316

7,537 8,212 (675) 73,908 74,022 (114) 88,651 89,181 (530)

25,940 27,089 (1,149) 254,898 255,645 (749) 306,480 309,332 (2,852)

25,562 25,459 (103) Income Memorandum 254,330 250,609 (3,721) 305,528 301,655 (3,873)

(378) (1,630) (1,252) (568) (5,036) (4,470) (952) (7,677) (6,725)


Net Position Memorandum

Full Year

Subtotal

Support Services (inc. Reserves)

TOTAL

Year to Date

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Statement of Position

Mar-19 Nov-19 Dec-19 Jan-20

Actual Actual Actual Actual Plan Variance %

£000 £000 £000 £000 £000 £000

Non Current Assets

Property, Plant & Equip, & Intangibles 56,170 56,634 56,266 56,270 57,389 (1,119) (1.95%)

Investment Property 980 980 980 980 980 0 0.00%

57,150 57,614 57,246 57,250 58,369 (1,119) (1.92%)

Current Assets

Inventories 1,371 1,516 1,414 1,472 1,000 472 47.20%

Trade & Other Receivables 17,052 18,722 15,688 18,007 18,763 (756) (4.03%)

Cash & Cash Equivalents 16,587 10,620 12,458 9,480 8,940 540 6.04%

35,010 30,858 29,560 28,959 28,703 256 0.89%

92,160 88,472 86,806 86,209 87,072 (863) (0.99%)

Current Liabilities

Trade & Other Payables (33,832) (29,936) (29,750) (29,946) (31,145) 1,199 (3.85%)

Provisions (3,971) (2,819) (2,819) (2,819) (2,100) (719) 34.24%

(37,803) (32,755) (32,569) (32,765) (33,245) 480 (1.44%)

54,357 55,717 54,237 53,444 53,827 (383) (0.71%)

Non Current Liabilities

Provisions (5,486) (8,123) (8,769) (8,997) (5,614) (3,155) 56.20%

(5,486) (8,123) (8,769) (8,997) (5,614) (3,155) 56.20%

48,871 47,594 45,468 44,447 48,213 (3,766) (7.81%)

Financed by Taxpayers Equity

Public Dividend Capital 71,461 71,461 71,461 72,071 71,331 740 1.04%

Retained Earnings (25,102) (26,379) (28,503) (30,134) (25,631) (4,503) 17.57%

Revaluation Reserve 3,925 3,925 3,923 3,923 3,926 (3) (0.08%)

Other Reserves (1,413) (1,413) (1,413) (1,413) (1,413) 0 0.00%

48,871 47,594 45,468 44,447 48,213 (3,766) (7.81%)

Jan-20

Total Non Current Assets

Total Assets Employed

Total Taxpayers Equity

Total Current Assets

Total Assets

Net Current Liabilities

Non Current Assets plus/less current

assets/Liabilities

Total Non Current Liabilities

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Cashflow Statement

YTD Move YTD Plan Variance

Nov-19 Dec-19 Jan-20 Jan-20 Jan-20 Jan-20

Actual Actual Actual

£000 £000 £000 £000 £000 £000

10,641 10,620 12,458 16,587 9,947 6,640

Operating Surplus (1,087) (2,009) (1,517) (3,894) 579 (4,473)

(Increase)/decrease in current assets 360 903 (144) (1,194) 1,744 (2,938)

Increase/(decrease) in current liabilities 106 1,938 (2,437) 294 (117) 411

Increase/(decrease) in provisions 224 645 229 2,359 0 2,359

0

(397) 1,477 (3,869) (2,435) 2,206 (4,641)

Returns on investments and servicing

finance 16 13 8 83 99 (16)

Depreciation & amortisation 549 551 577 5,043 5,096 (53)

Capital Expenditure (189) (201) (304) (9,832) (7,678) (2,154)

Impairments & revaluation for surplus 0 0 0 0 0 0

Proceeds from disposal of plant,

property and equipment 0 (2) 0 16 0 16

Dividend paid 0 0 0 (592) (730) 138

PDC received 0 0 610 610 0 610

376 361 891 (4,672) (3,213) (1,459)

Movement (21) 1,838 (2,978) (7,107) (1,007) (6,100)

10,620 12,458 9,480 9,480 8,940 540Closing Cash Balance

In Month Movement

Opening Balance

Cash inflow/outflow from operating

activities

Cash inflow/outflow from financing

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CAPITAL

Items primarily with statement of financial position focus:

Capital Expenditure and Disposals

Plan Actual Variance Plan Actual Variance Plan Forecast Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000

Business as usual Capital Expenditure

306 26 (280) IT Projects and Intangibles 1,930 967 (963) 2,542 2,702 (160)

410 78 (332) Make Ready Projects 2,317 3,335 1,018 2,421 3,437 (1,016)

150 64 (86) Other Building Projects 302 188 (114) 752 556 196

0 0 0 Plant & Equipment Projects 0 0 0 0 0 0

0 0 0 Transport Projects 0 68 68 400 143 257

Additionally funded Capital

0 0 0 ePCR - STP funded 0 0 0 25 25 0

0 415 415 Winter capital centrally funding 0 610 610 0 610 (610)

866 583 (283) 4,549 5,168 9 6,140 7,473 (1,333)

Net book value of disposals

0 0 0 Medical devices - defibril lators 0 (21) (21) 0 (21) 21

0 0 0 Atlantic Square (Investment Property) 0 0 0 0 0 0

0 0 0 Sudbury 0 0 0 0 (180) 170

0 0 0 0 (21) (21) 0 (201) 191

Business as usual: CRL 6,115 = Planned Depreciation for the year

Additional CRL disposals 201 = Identified disposal sites

Suffolk STP - ePCR funding 25 = Anticipated additional funding

Additional Winter funding 610 = Notified Winter Capital Funding achieved

Requested CRL for capital program 522 = Request to NHSE/I

Planned total CRL: 7,473

Spend 7,473

Under/ (over) spend on CRL -

Items primarily with statement of financial performance focus:

Depreciation and Amortisation and Gains/Losses on Disposal

Plan Actual Variance Plan Actual Variance Plan Forecast Variance

£000 £000 £000 £000 £000 £000 £000 £000 £000

135 160 (25) IT 1,329 1,205 124 1,600 1,315 285

109 145 (36) Land & Buildings 1,090 1,152 (62) 1,308 1,308 0

1 1 0 Fixtures & Fittings 19 20 (1) 21 21 0

202 206 (4) Plant & Equipment 2,038 2,040 (2) 2,442 2,442 0

52 53 (1) Transport 520 525 (5) 624 624 0

10 10 0 Amortisation of Licenses 100 100 0 120 120 0

509 575 (66) 5,096 5,042 54 6,115 5,830 285

Asset Disposals

0 0 0 Disposals: loss /(gain) 0 (16) 16 0 (16) 16

0 0 0 0 (16) 16 0 (16) 16

Plan and Forecast Variance: Actual depreciation is currently slightly lower than plan due to the timing of the bringing into use of assets from 2018/19. This is expected to

balance out over the last quarter of the year as assets are brought into use. Minor gains have been achieved on the sale of defibrillators to date.

Year End Forecast

Capital Expenditure


Year to Date

Total

Current month and YTD transactions: Capital expenditure is currently £1m ahead of plan. Development has continued on the Make Ready depots and workshops across

the 10 identified sites which commenced last year. IT expenditure has been on software licenses and the telephone voice recording system, IT spend is currently behind plan

but is expected to ramp up across Q4 which will include significant individual projects like a new telephony system.

£0.61m of Additional Winter funding has been awarded to the Trust to be spent on Estates Transformation work in support of Building Better Rotas and Make Ready.

In furtherance of the estates transformational work commenced in 2018/19, the year to date expenditure on Make Ready reflects the completion of works on 10 depots and

workshops. Two disposal sites have been identified as part of the midyear development of the capital plan instigated by requests from NHSI to review capital spend, such that

utilisation of disposal proceeds on the sale of these properties (Atlantic Square and Sudbury) to enable the Trust's capital plan to continue at pace. The marketting for sale of

Atlantic Square has been postponed such that it is no longer expected to proceed in 2019/20. As a result of this additional Capial Resource Limit is being requested of NHSI.


Year to Date Year End Forecast

STP: The development of ePCR specifications and business cases is expected to be part funded by STP contributions. STP Funding and capital expenditure for the

successful STP bid to transform the estates of the Trust to a make ready service are currently not included in the 2019/20 plan due to administrative and approval requirements

of NHSI and DoHSC.

Total

Capital Disposals

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Divisional WTE

Plan Contract Paid

WTE WTE WTE

Service Delivery

Emergency Operations incl. PTS 4,109 3,636 4,075

AOCs 631 626 715

Special Operations 153 141 149

4,893 4,403 4,939

Support Services

Chief Executive 54 47 47

Finance 60 54 54

Operational Support Services 204 196 220

Strategy & Sustainability 81 45 45

Workforce & OD 141 128 125

Patient Safety 67 60 56

Medical Director 17 19 22

CQUIN 0 3 3

624 552 572

5,517 4,955 5,511TOTAL

Description

Month 10 - January 2020

Subtotal

Support Services

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Trust Cost Improvement Programme The Trust’s original target for the year was £10.5m, however when this was forecast out-turn was revised, full year achievement of CIPs was forecast to be £6.8m At the end of Month 10 the Trust has achieved £5.9m savings, this is in line with the revised forecast.

2019-20 CIP Schemes - Progress Tracker - Month 10

Scheme

ReferenceCIP Scheme

Responsible

Manager(s)

Recurrent /

Non-

recurrent

Pay / Non

Pay

NHSI Plan

M10 £000s

Actual

Achieved

M10 £000s

Actual vs.

NHSI Plan

M10 £000s

NHSI Plan

YTD £000s

Actual

Achieved

YTD £000s

Actual vs.

NHSI Plan

YTD £000s

Corporate and Operations Support Vacancy Slippage

CP1 Vacancy Slippage All NR P 0.0 83.3 83.3 1,500.0 1,460.4 -39.6

Corporate and Operations Support Vacancy Slippage Subtotal 0.0 83.3 83.3 1,500.0 1,460.4 -39.6

Emergency Operations

EO1 Reduction in Arrival to Clear Sector Heads R P 105.0 0.0 -105.0 790.0 0.0 -790.0

EO2 Out of Service Reduction Sector Heads R P 60.0 214.2 154.2 480.0 1,233.9 753.9

EO3 On Scene Time Reduction Sector Heads R P 140.0 0.0 -140.0 560.0 0.0 -560.0

EO4Abstraction Reduction (Sickness, AWD &

3rd Person)Sector Heads R P 120.0 0.0 -120.0 750.0 0.0 -750.0

EO5Operational Impact of Make Ready

ImplementationR Ashford R P 210.0 0.0 -210.0 1,077.0 0.0 -1,077.0

EO6 PAS Utilisation & Efficiency Sector Heads NR NP 35.0 42.4 7.4 230.0 580.6 350.6

EO7 Late finishes / Intelligent X-ray Sector Heads R P 12.5 0.0 -12.5 100.0 159.0 59.0

EO8 Implementation of Building Better Rotas R Ashford R P 80.0 0.0 -80.0 140.0 0.0 -140.0

EO9Suffolk and North Essex Sector - Local

SchemesD Allen R NP 0.0 0.0 0.0 0.0 40.1 40.1

EO10 Beds & Luton - Local Schemes S King R NP 0.0 0.0 0.0 0.0 20.9 20.9

EO11 Herts & West Essex - Local Schemes S King R NP 0.0 0.0 0.0 0.0 8.5 8.5

EO12Cambridge and Peterborough - Local

SchemesP Marshall R NP 0.0 0.0 0.0 0.0 39.8 39.8

EO13 Norfolk and Waveney - Local Schemes T Hicks R NP 0.0 2.0 2.0 0.0 89.8 89.8

EO14 Mid & South Essex - Local Schemes A Whitehead R NP 0.0 0.0 0.0 0.0 0.0 0.0

Emergency Operations Subtotal 762.5 258.6 -503.9 4,127.0 2,172.5 -1,954.5

AOC

AO1 Staff Streamline G Morgan R P 8.0 8.0 -0.0 80.3 80.3 -0.0

AO2 EOC Vacancy Slippage G Morgan NR P 0.0 0.0 0.0 153.6 275.6 122.0

AOC Subtotal 8.0 8.0 -0.0 233.9 355.9 122.0

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2019-20 CIP Schemes - Progress Tracker - Month 10 - Page 2

Scheme

ReferenceCIP Scheme

Responsible

Manager(s)

Recurrent /

Non-

recurrent

Pay / Non

Pay

NHSI Plan

M10 £000s

Actual

Achieved

M10 £000s

Actual vs.

NHSI Plan

M10 £000s

NHSI Plan

YTD £000s

Actual

Achieved

YTD £000s

Actual vs.

NHSI Plan

YTD £000s

Full Year

NHSI Plan

£000s

Special Operations

SO1 EPRR Staff Appointment Slippage J Moore NR P 0.7 0.6 -0.1 173.7 173.8 0.1 175.0

SO3 Special Operations Vacancy Slippage J Moore NR P 0.0 0.0 0.0 72.0 132.0 60.0 72.0

Special Operations Subtotal 0.7 0.6 -0.1 245.7 305.8 60.1 247.0

Operations Support

OS1 Medical Device Product Savings P Henry R NP 5.4 5.0 -0.4 46.0 80.0 34.0 56.7

OS2 Fleet - RRV Replacements P Henry R NP 15.7 27.0 11.3 235.4 270.3 34.9 266.7

OS3 Fleet - DSA Replacements P Henry R NP 30.5 30.0 -0.5 181.6 180.7 -0.9 254.6

OS4 Fleet - Maintenance Tenders P Henry R NP 3.5 3.5 0.0 32.0 33.0 1.0 39.0

OS5 Fuel Card P Henry R NP 1.7 2.0 0.3 14.6 18.0 3.4 18.0

OS6 Business Travel Policy P Henry R NP 13.0 0.0 -13.0 52.0 0.0 -52.0 78.0

Operations Support Sub-Total 69.7 67.5 -2.2 561.6 582.0 20.4 713.0

Estates

E1 Maintenance Contract Management C Radestock R NP 30.0 30.0 0.0 190.0 190.0 0.0 250.0

E2Waste & Energy

Management/ReductionC Radestock R NP 14.0 14.0 0.0 62.0 62.0 0.0 90.0

E4 Rate Reduction C Radestock R NP 0.0 0.0 0.0 50.0 0.0 -50.0 50.0

Estates Subtotal 44.0 44.0 0.0 302.0 252.0 -50.0 390.0

Clinical Directorate

CL1 Medical GasesA Godfrey / C

Radestock R NP 13.4 0.0 -13.4 123.2 34.0 -89.2 150.0

Clinical Directorate Subtotal 13.4 0.0 -13.4 123.2 34.0 -89.2 150.0

Procurement and Finance

PF1 Contract Renewals and Supplies S Dubery R NP 195.0 49.9 -145.1 760.0 491.1 -268.9 1,150.0

Procurement and Finance Subtotal 195.0 49.9 -145.1 760.0 491.1 -268.9 1,150.0

Information Technology

IMT1 BT Meridian Leasing Charges C Chambers R NP 0.0 2.3 2.3 0.0 11.5 11.5 0.0

IMT2 NHS Digital Network Charges C Chambers R NP 0.0 0.0 0.0 0.0 0.0 0.0 0.0

IMT3 Papercut C Chambers R NP 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Information Technology Subtotal 0.0 2.3 2.3 0.0 11.5 11.5 0.0

People and Culture

PC1 Training Efficiencies M Stead R NP 36.0 0.0 -36.0 216.0 168.6 -47.4 300.0

PC2 HR Process Recruitment Director R P 0.0 12.5 12.5 0.0 52.8 52.8 0.0

People and Culture Subtotal 36.0 12.5 -23.5 216.0 221.4 5.4 300.0

Grand Total 1,129.3 526.7 -602.6 8,069.4 5,886.6 -2,182.8 10,500.0

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Trust Forecast The original financial plan set by the Trust was to finish the financial year 2019-2020 with a deficit of £(1.0)m. This included £2.2m of PSF (provider sustainability funding), therefore an underlying deficit of £(3.2)m. However, during the second quarter of 2019-2020 a range of risks to the forecast financial position began to emerge. Detail of those risks include the items listed below. Potential winter activity levels Temporary resource requirements Front line workforce incentive payments The workforce recruitment recovery plan PTS issues, predominately the Beds & Herts contract but also with other contracts Potential worsening of Hospital Delays Potential Patient Safety issues due to the length of waits Temporary resource availability levels – less PAS in the marketplace/less overtime availability from the EEAST workforce Levels of abstraction – especially due to the number of student courses scheduled CIP progress Revenue consequences of the Capital expenditure allocated for make ready The legal case concerning holiday overtime pay Expenditure levels concerning repairs and updates to the Trust Estate Loss of PSF income for Q3 and/or Q4 Expenditure on external resources to support the development of the recovery plan The Trust has considered the potential financial impact of these risks currently known and the Board agreed a revised forecast deficit of £(7.7)m. The forecast amendment was submitted to NHSE&I at M9 at the date for official forecast change submissions which are only available at the end of a quarter. This revised forecast has been agreed by NHSE&I. The Trust has a good degree of confidence in delivery of this revised forecast; however, some risks still remain that may impact on this position. Principally the risks relate to additional costs to maintain service provision over the reminder of the winter period and emerging issues in relation to Covid19. The detail for the forecast across Income and expenditure and also across the Directorates is shown in the tables at Pages 9 and 10 of this report – The Statement of Comprehensive Income and the Detailed Expenditure Tables The YTD performance against the trajectory for the forecast is shown in the table below:

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Financial Trajectory M10 2019-2020

Forecast To M6 M7 M8 M9 M10 M11 M12 Out-turn

£'m £'m £'m £'m £'m £'m £'m £'m

Income -150.4 -25.0 -25.1 -25.1 -24.5 -24.4 -24.5 -299.0

Pay 107.2 19.0 18.9 20.2 18.8 18.6 18.7 221.3

Non-Pay 42.3 7.2 7.5 7.3 7.2 7.0 6.8 85.3

-0.9 1.2 1.3 2.3 1.5 1.2 1.1 7.7

Actuals To M6 M7 M8 M9 M10 M11 M12

£'m £'m £'m £'m £'m

Income -150.4 -24.9 -25.1 -24.8 -25.5

Pay 107.2 18.5 18.9 19.2 19.1

Non-Pay 42.3 7.4 7.4 7.7 8.0

-0.9 1.0 1.2 2.1 1.6

Variance To M6 M7 M8 M9 M10 M11 M12

£'m £'m £'m £'m £'m

Income 0.0 0.1 -0.0 0.4 -1.0

Pay 0.0 -0.5 -0.0 -1.0 0.3

Non-Pay 0.0 0.2 -0.1 0.4 0.8

0.0 -0.2 -0.1 -0.2 0.1

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MEETING TITLE

PUBLIC BOARD

Date: 11.03.2020 Report Title: Governance and Well Led update Agenda Item: 16 Author: E de Carteret, Head of Governance Lead Director: D Hosein, Chief Executive Officer Purpose: Assurance Decision


SUMMARY AND BACKGROUND: This report provides detail regarding the Governance and well-led section (IP4) of the Integrated Improvement Plan. The cycle is now underway with progress in a wide number of areas, most notably:

• Risk management training for managers continues, with a high level of compliance with attendance (99 trained to date, with a further 52 planned in). All teams have either received (or are scheduled) to receive training by 6 April 2020 and following this, there will be a greater number of managers having received training than in the previous financial year. The risk management aspects of the plan have received assurance through the risk reporting and deep dives into the risk registers by the Audit Committee.

• Board level recruitment is progressing positively with interviews for the final two posts (Director of Clinical Quality and Improvement and the Audit Committee Chair Non-Executive Director) scheduled in March.

• Annual review of Board committee effectiveness and the final implementation of the realigned sub-committees and associated escalation triggers are well underway and will be fully implemented following the March Board, in readiness for go live in from April.

• Strategy development is progressing well with the planned launch date at the next Public Board meeting

• Governance Sub-group terms of reference approval is progressing well, with the core groups all approved and rolling out

• The recruitment campaign for the Freedom to Speak Up Guardian has been very successful with a large number of candidates applying for the post – shortlisting is well underway

The majority of actions are green or green-amber. However there are some challenges in certain areas, as follows:

• In spite of the positive progress and delivery of training, risk review compliance still remains lower than desired. As a result, further communications are being cascaded, and group and committee oversight of risks will support a rapid turnaround of compliance.

• The delays in progressing the clinical aspect of the governance sub-groups as noted in previous meetings has resulted in dates slipping for finalisation of this and the sector governance framework, which were due at the end of February. However, there is confidence that all remaining groups will roll out in line with the new Board committees in March and April and as such, whilst this constitutes a delay, this is mitigated

• HR policy review remains amber due to the need for focus and the number requiring review. However there is significant progression with the joint working group with the union, with the intention of approving 20 policies by the end of March. When this target is met, the confidence rating in the overall action will reduce due to evidence of clear traction

It is important to note that the actions within cycle five will be further expanded to include the following, after the Board meeting:

• The actions identified as a result of the Board and Committee effectiveness review, once the actions are agreed at the March Board meeting

• The remaining actions from the Information Governance Action Plan – these will form a new

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objective within the plan • Further actions identified from the Board’s Well led Self-Assessment in April

RECOMMENDED ACTION: • Note the update and areas of progress and concern • Receive updates at subsequent public Board meetings

KEY ISSUES IDENTIFIED Capacity within the Corporate Governance team is extremely limited and the scale of change and improvement under way combines with the known pressure period at the end of year for compliance returns to result in a risk to delivery. Some administrator capacity has been provided for the next 2-3 months to support which should help to mitigate this risk

DECISION OR RESOURCE REQUIRED: None noted at this time

PREVIOUSLY CONSIDERED BY: Governance and Well led plan considered at Board in February and via Improvement Plan

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers] Meeting the requirements of the well led framework will have a positive impact across all areas of the risk register, especially the strategic risks. Risk 1187: Failure to ensure a well governed and accountable Trust that meets inspection standards currently sits at a residual score of 16 in recognition of the Inadequate rating from the CQC. It is still anticipated that completion of the actions planned will enable a reduction in the risk score to 12. However, this reduction in risk score is dependent not only on action reduction but key metrics improving.


x


x


x

SR4: Failure to deliver an efficient, effective and economic service x Other: Please Specify

THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE Provide better care x Value our people x Value for money x Improve performance x

OTHER: To ensure effective governance and compliance x

LINK TO CQC: Caring Responsive Effective Well Led Safe



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RELEVANT LEGAL OR STATUTORY ISSUES Compliance with our statutory and regulatory requirements under the Health and Social Care Act, via the Care Quality Commission’s assessment of the Trust against the Well Led framework



Weekly RAG

Green/Amber

Green/Amber

Green/Amber

Green/Amber

Green/Amber

Green/Amber

Green/Amber

Activity Owner:

CQC Plan Recovery Plan / CIP Strategy

1.1 ✓ Emma de Carteret30/03/2020New date:

30/420

In planning stage- determining who the Chairs are through group and meeting review and will then schedule - capacity prior to end November may be an issue. Booked in for April so date realigns, but will be delivered

Green/Amber Training Complete

% of risks reviewed per month

1.2 ✓ Emma de Carteret 31/3/20

Training dates established and teams scheduled in. Sessions commenced on 25 September 2019 with over 120 managers booked in so far and training for over 85 completed. March focuses on mop up sessions of those teams not yet having received training



1.3 ✓ Emma de Carteret14/02/2020New Date:

20/3/20

Cascaded chase emails reminding core teams. Drafted communications to be released reminding all of the role and the importance, which will correspond to the new risk monitoring approach proposed in the new committee terms of reference



1.4 ✓ Emma de Carteret28/02/2020New Date:

20/3/20

Monthly compliance packs established, and being rolled out from March 2020 Green/Amber Training

Complete



2.1 ✓ ✓ Dorothy Hosein 28/2/20CEO, Chair, COO, and CIO all now confirmed and commenced in post, and the 12 month Interim Director of Workforce has commenced in post - action closes

Green Vacant post filled

2.2 ✓ ✓ Dorothy Hosein 30/4/20 Interviews for the Director of Clinical Quality and Improvement role taking place on 3 March 2020 Green/Amber Vacant post filled

2.3 ✓ ✓ Dorothy Hosein 30/3/20 Audit Chair NED is being interviewed for in the thrid week in March. Following this, all posts filled and action will close Green/Amber Vacant post filled

2.4 ✓ ✓ Dorothy Hosein 30/4/20Day for Board assessment is being finalised and the self assessment document being populated, for circulation in mid-March (anticipated) for review and comment

Green/AmberDevelopment

plans complete

2.5 ✓ ✓ Dorothy Hosein 30/3/20Completed, being tabled at Trust Board in March and action therefore closes - actions identified will be incoporated into this action plan

GreenDevelopment

plans complete

2.6

Ind

uct

ion

✓ ✓Emma de Carteret & Chris Carberry 31/3/20

Scheduled for Board 11 March 2020. Leads for each STP area have been established and approved at Board in February. Action therefore closes

GreenDevelopment

plans complete

2.7

Met

rics

✓ ✓ Dorothy Hosein 13/3/20Underway, metrics and triggers will be within the ToR for the committees which are due for approval at the March Board - action therefore closes as meeting on 11 March 2020

GreenDevelopment

plans complete


3.3 ✓ ✓ Nicky Ward31/01/2020New Date:

16/5/20

Good progress made with Vision, mission, principles and the sub-strategies. Board agreed to approval at the public Board in May, so action timescale will change but on track to be implemented

Green/Amber Strategy approved NA

3.4 ✓ ✓ Nicky Ward 15/4/20 Strategy to commence at the start of the new financial year - on track Green/Amber Strategy launched NA

3.5 ✓ ✓ Nicky Ward

28/02/2020New Date:

16/5/20

Strategy development sessions taking place frequently to support delivery. As per 3.3 above, date will realign for approval at the May Board

Green/Amber Strategies aligned NA


4.1 ✓ ✓ Emma de Carteret28/02/2020New Date:

30/4/20

Drafted, however now coordinating with the metrics being established within the committee terms of reference. Will be in place by end April

Green/Amber Framework Est. NA

4.2 ✓ ✓ Emma de Carteret 31/3/20

Following management meeting review, the next phase includes establishment of all ToR, initiation of the meetings, and refresh of the governance and assurance framework document and all policy references to previous groups and structure. Significant piece of work, currently off track slightly due to capacity, aiming for mid-December

Green/Amber Framework

refreshedNA

4.3 ✓ ✓ Emma de Carteret28/02/2020New Date:

30/4/20

Initial delay due to the pausing of the clinical groups, however this barrier has been resolved and so now focussed delivery underway. Core groups have commenced, with Compliance and Risk Group commencing in March. Groups all to be established by April

Green/AmberFramework

refreshedNA

4.4 ✓ ✓ Emma de Carteret 14/02/20Complete - Board in February approved the committee realignment and committees to commence from April - action closes

GreenFramework

refreshedNA

4.5 ✓ ✓ Emma de Carteret 02/04/20Underway - approval of terms of reference due at Board on 11 March. Schedule is set and planned in. Action will complete by the end of March following Board approval of the ToR

Green/Amber

4.6

Co

mm

's

✓ ✓ Emma de Carteret14/02/2020New Date:

20/3/20Being drafted - will be published by mid March Green/AmberCommunications out to launch meetings and reporting lines

Fram

ewo

rks

Governance and assurance framework refresh

Establish the Sector Governance Framework to ensure consistent oversight and focus of key governance elements

Timelines

Roll out monthly risk compliance packs to teams

Ris

k R

elat

ed C

om

m's

Establish clear metrics and escalation triggers for all committees

Rec

ruit

ing

to D

irec

tor

Vac

anci

esSe

lf-A

sses

smen

t

Release Trust-wide communications to re-focus appropriate use of Risk registers

Recruit to vacancy: Human Resources Executive Director

Recruit to vacancy: Quality & Safety Executive Director

Recruit to vacancy: Non-Executive Director, Chair of Audit Committee

Undertake Board 'Well-Led' assessment

Complete Annual review of Board and Committee effectiveness

Establish Board member STP induction to enable Board level engagement

IP4. Governance and Well Led (1) Key objectives:

Embed rigour and accountability through the implementation of a sound system of control, to ensure a well-governed and risk-based approach to decision making.

1. Fully embed risk management across core business

2. Establish a stable and effective Trust Board

Week 3

Responsibilities 3. Drive sustainable transformation of the organisation in line with strategy

Executive Owner Dorothy Hosein, Chief Executive Officer 4. Build and embed robust Governance systems and processes that enable good decision making

Senior Leader Support Emma de Carteret, Head of Governance

5. Drive a culture of personal and corporate responsibility, with clear lines of accountability

6. Embed the Freedom to Speak Up (FTSU) process, aligning with Best Practice

Overall workstream rating

Date of update Week Ending 28th February 2020

Progress Update against key objectives:

1. Fully embed risk management across core business

Milestone or Action ref.

numberMilestones Required:

(Sub

-title

) Action aligns with:

Due Date (Priority colour): Comments/Update: Delivery

ConfidenceDefinition of

DeliveryMeasuring

Delivery

Establish training for Senior Leaders (Group Chairs) to enable risk focus in meetings.

Roll out risk management training for 4Risk users Ris

k Tr

ain

ing

Definition of Delivery

Measuring Delivery

2. Establish a stable and effective Trust Board



(Sub

-title


Activity Owner: Due Date (Priority colour): Comments/Update: Delivery

Confidence


Measuring Delivery

Tru

st S

trat

egy

Pro

cess

3. Drive sustainable transformation of the organisation in line with strategy



(Sub

-title


Activity Owner: Due Date (Priority colour): Comments/Update: Delivery

Confidence

Board Sub-Committee re-alignment proposal to be approved

Final approval and implementation of sub-committee

Strategy Approval

Strategy Launch

Alignment of all plans and underpinning strategies

4. Build and embed robust Governance systems and processes that enable good decision making



(Sub

-title


Comments/Update: Definition of Delivery

Measuring Delivery

Due Date (Priority colour):

Delivery ConfidenceActivity Owner:

Completion of Terms of Reference approval




5.1 ✓Emma de Carteret 30/4/20

Current plan agreed by ELB and Workforce Committee - work in partnership with Union underway tpo review and approve 20 policies by the end of March. First suite of policies were presented at SPF in the last week in February

Green/Amber Policies Reviewed NA

5.2 ✓ Marcus Bailey 31/3/20For consideration after core actions completed. COO attending a system workshop in November on Outcomes Based Accountability for planning purposes

Green/Amber TBC NA

5.3 ✓Emma de Carteret TBC

Once meeting review has been completed, this will be established. Meeting framework approved at Board in November, now approving Terms of reference and transferring into Sector framework, and realigning the governance and assurance framework. Off track slightly due to capacity but still aiming for

Green/Amber Framework est. NA


6.1

Rec

ruit

✓ Tom Davis TBC Recruitment underway, significant level of interest in the post and a high number of applicants. Shortlisting underway for interview. Green/Amber

6.2 ✓ Tom Davis 1/4/20 Priority following appointment of new Guardian. Green/AmberVision est. NA

6.3 ✓ Tom Davis 1/4/20 Priority following appointment of new Guardian. Green/Amber

Process embedded NA

6.4 ✓ Tom Davis 1/4/20 Priority following appointment of new Guardian. Green/Amber Intranet updated NA

6.5 ✓ Tom Davis 1/4/20 Priority following appointment of new Guardian. Green/AmberDevelopment

needs est.NA

6.6 ✓ Tom Davis 1/4/20Established buddy arrangements with ambulance network in place. Developing relationships with wider EoE regional Guardians.

AmberBuddy

arrangement est.NA

6.70 ✓ Emma de Carteret 31/3/20

New self-review guidance has been launched. To undertake self-review on Q4, enabling recruitment of FTSU Guardian before undertaking the action. Date realigns

Green/AmberScheduled

completionNA

Measuring Delivery

HR Policy review

IP4. Governance and Well-Led (2)

5. Embed a culture of personal and corporate responsibility and accountability, to ensure delivery



(Sub

-title


Activity Owner: Due Date:

Outcomes Based Accountability development

Decisions and escalations framework

Comments/Update: Delivery Confidence


Recruit to FTSU guardian position

6. Embed the Freedom to Speak Up (FTSU) process, aligning with Best Practice



(Sub

-title


Activity Owner: Due Date: Comments/Update: Delivery Confidence


Measuring Delivery

Act

ion

s fo

r n

ew F

TSU

Gu

ard

ian

Establish FTSU buddy arrangement and undertake an audit with buddy of case feedback to progress future improvements

Refocus the FTSU agenda through the People and Culture Committee and Trust Board, scheduling in completion of the self-review

Update all FTSU related content on the intranet

Establish individual development needs and objectives for FTSUs through the compassionate conversation process

Establish the vision and strategy statement for FTSU

Establish and embed a process for proactively and retrospectively quality assuring cases



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MEETING TITLE TRUST BOARD Date: 11.03.2020 Report Title: Care Quality Commission Improvement Plan Agenda Item: 17 Author: Lewis Andrews, Head of Quality Improvement Lead Director: Dr Tom Davis Purpose: Assurance Decision


SUMMARY AND BACKGROUND: This report provides in full the improvement plan established to address the must do and should do recommendations as outlined in the CQC’s report into EEAST’s 2019 regulatory inspection. The Board should note that the plan was submitted to and discussed at the Quality Governance Committee on 5 February 2020, for in depth scrutiny as per the Trust’s governance processes. Board members will be aware following discussions in the January Board meeting of the additional time taken prior to publication of the CQC action plan. The time taken relates to ensuring that the format of the plan demonstrates clear alignment of the actions with the recommendations set out by the CQC, via the opportunity for the Executive team to undertake a review of the original plan’s status. It is important to note that the time taken to achieve the final version of the action plan has not delayed progression of the actions and improvements required to respond to the Must Do and Should Do actions identified by the CQC – both Quality Governance Committee and Board have received updates both in the committee, via the Integrated Improvement Plan and Board discussions that actions have been underway since the CQC published their inspection report. Key aspects in terms of functionality of the plan is as follows:

• The actions are clearly aligned to the recommendations – Must do and Should do – within the CQC report to demonstrate compliance with the CQC requirements

• The plan captures a summary of all actions – including those completed prior to publication of this plan to the committee, to afford oversight of the substantial improvement progress made between July and the current status.

• The RAG rating is a three-level approach, which is different to the five-level framework within the integrated improvement plan

• There are two RAG elements – one on delivery of the action, and one relating to the impact this has had on the outcome.

In terms of Executive Oversight:

• The Executive Directors are leading and owning the plan collectively, in order to ensure clear lines of responsibility and accountability for each of the recommendations.

• Each delivery lead has been involved in ensuring the actions align to the recommendations to deliver the outcome required

• The Executive Leadership Board have collectively, with the delivery leads, undertaken a line by line review of the plan and progress, giving cross-functional challenge and scrutiny to ensure assurance is received.

• The Medical Director, supported by the Head of Quality Improvement has overseen evidence collection to ensure that where progress is stated, this is backed up by tangible evidence.

• The CQC plan will undergo a full line by line review by the Executive Leadership Board and delivery leads every month to ensure no slippage. There is however also a weekly escalation option established, should the Medical Director be concerned with progress.

CQC Improvement Plan


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Key messages: • The Executive oversight process has afforded confidence in the progress of a large proportion of

actions and clarity on the area requiring focus • Good progress has been achieved in terms of delivery of actions, with the remainder tracking as

amber. • Two areas of concern in terms of tangible outputs are recruitment and retention within Emergency

and Urgent care and complaint timescale completions. Whilst to date there has been insufficient progress in improving outcomes, the Executive Leadership Board are assured that there is a clear plan in place for both recommendations to bring about a positive change.

RECOMMENDED ACTION: • Note the CQC plan and progress made. • Note and discuss any areas escalated from the Quality Governance Committee meeting on 5

February 2020 • Gain assurance with the approach adopted and the progress made to date.

KEY ISSUES IDENTIFIED N/A


PREVIOUSLY CONSIDERED BY: Executive Leadership Board, 26 February 2020 Quality Governance Committee, 5 February 2020

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers] All, but predominantly SR2


X


X


X

SR4: Failure to deliver an efficient, effective and economic service X Other: Please Specify X

THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE Provide better care X Value our people X Value for money Improve performance X

OTHER: To ensure effective governance and compliance X

LINK TO CQC: Caring X Responsive X



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Effective X Well Led X Safe X

RELEVANT LEGAL OR STATUTORY ISSUES CQC compliance under the Health and Social Care Act



Date of update 02-Mar-20

Date of next update 13-Mar-20

Executive Team

RAG

Ref. no. Focus Recommendation Delivery Lead Exec. Lead Oversight RAGAction

Evidence of Achievement (to be identified when available)

RAGOutcome RAG Outcome descriptor

Next steps - what will be done with

trajectory/timescalesOrganisational development manager

Organisational development manager



Organisational development managerOperational managers

Clinical lead for Education


Operational managersHeads of departments

Safeguarding Lead

Safeguarding Lead

Safeguarding Lead

Safeguarding Lead

Safeguarding Lead

Safeguarding Lead

Clinical Lead

Clinical Lead

To be at or above agreed trajectories and achieve position

of 90% or above by 31.03.20

OD reports matched with operational trajectories to March 2020, monitored for

progress monthly

February 2020: Level 3 training commenced

Ongoing compliance monitoring to embed the medicines management process. Further develop

processes for PGD compliance

To be at or above agreed trajectories and achieve position of 90% or above by 31.03.20 for

Level 1, 2 and 3 training

Demonstrate systems and processes to safely administer, store, prescribe medicines is in

place. A 10% reduction in administration errors by

31.08.20. A 5% reduction on medicine cost by 31.12.20

2 Corporate

The trust MUST ensure all staff consistently complete safeguarding training in line with

the trust target. (Safeguarding L1, 2 & 3 all - 90% of appropriate roles)

Key link with statuary/mandatory training

1. Provide a consistent approach for ordering and restocking off all medicines from a single supplier by 31st Jan 2020

2. Produce a standard protocol for restocking of medicines to be approved by 31.01.20

6. Identify other appropriate roles that require L3 training

1. Review learning from safeguarding activity during 2019 to identify priorities by 21.01.20

2. Define local standards for L3 training and above by 31.01.20

3. Present clear proposals to ELT regarding delivery of training to meet agreed standards by Feb 2020

4. Develop local multi professional training package to deliver locally, by March 2020

5. Deliver L3 training in cohorts March - April

3 Corporate

The trust MUST ensure that systems and processes to safely administer, store,

prescribe medicines is consistently applied across the trust

1. Initial lessons learnt review has been documented and considered by safeguarding meeting 14.01.20 and presented to CQSG 28.01.20

Level 1 training currently 82.96% with Level 2 (completed on PU programme and linked to point 1) at 92.28%, which is an increase on the previous month

2.Online HEE L3 training for adults being commenced for appropriate roles from February 2020

3. Long term L3 proposal is to be presented verbally at CQSG on 28.01.20 in order to determine direction of travel for ELT decision

4. Online HEE L3 training for adults being commenced for appropriate roles from February 2020. Long term L3 proposal presented verbally at CQSG on 28.01.20 in order to determine direction of travel for ELT decision

5. To be implimented once agreed process agreed at ELT. Point 3 refers.

6. 40 key roles have been identified for consideration to undertake external L3 training by April 2020

Lessons learnt documentL3 option paper Safeguarding compliance report as of 04.02.20

1. Suppliers reduced to a primary single independent supplier with resilience in contracts to allow additional medicine source for specialist meds and business continuity from alternative independent suppliers: In place Dec19/Jan20

2. Restocking SOP drafted surrounding project implementation presented at MMG 23.01.20

Medical Director

Clinical Effectiveness group

Quality governance committee

Senior Leader Support Head of Quality Improvement

Executive Owner

4 To ensure delivery of all new regulatory requirements as they are communicated..

Governance Process

The role of the Delivery Lead will be to update action plans, progress reports and RAG rate the delivery of actions on a weekly basis.

The role of the Executive Lead will be to test and challenge the update provided by the delivery lead and RAG rate the achievement of the outcomes sought, confirming these by the end of the second week each month.

The role of the Head of Quality Improvement will be to facilitate and support delivery leads in developing and implementation of action plans ensuring formal updates of this CQC action plan are available to the DCQ&I by the third week of the month.

The role of the Executive team will be to clarify an overall assessment of the level of assurance offered regarding delivery of the plan and recommend specific actions to mitigate risks to achieving strategic priorities, presenting these for consideration at the third week of each month, prior to circulation to committees and the Trust Board on a monthly basis.

Key to RAG Rating for actions

The action will be delivered successfully on time, within budget and to the level of quality required. There are no

major problems or barriers that threaten delivery.Successful delivery is feasible, but significant issues and

risks exist that require focussed attention to ensure delivery remains on track and risks do not materialise.

Successful delivery of the action appears in doubt due to significant risks in a number of key areas. Urgent action is

required to determine if these issues may be resolved.

Key to RAG Rating for outcomes

The outcome sought is being achieved at both the pace and extent expected.The outcome sought is delayed or at a lesser extent than that expected.

Successful delivery of the outcome appears unachievable. There are major issues which do not appear to be manageable. The outcome needs re-basing or its viability re-assessing

Progress

1 CorporateThe trust MUST ensure all staff consistently complete mandatory training in line with the

Trust target. (Mandatory - 90%)

1. Refresh and provide a clear definition for mandatory training for both patient facing and non patient facing Trust staff with associated metrics by 31.01.20

2. Produce a defined reporting process for compliance to be reviewed at Executive Leadership Team (ELT) meeting to ensure the Trust uses data and defines how we are reporting standards by 28.02.2020

3. Refresh and define process for reporting compliance to service line managers which will be presented at Education & Learning Group by 31.01.20

New CQC Improvement Plan

Responsibilities:

Key objectives:

1 To ensure delivery of all regulatory MUST DO recommendations as published by the CQC July 2019.

2 To ensure delivery of all regulatory SHOULD DO recommendations as published by the CQC July 2019.

3 To ensure delivery of all regulatory suggested improvements as published by the CQC July 2019.

4. Define the governance process for mandatory training requirements to be presented at Education and Learning group by 31.01.20

5. Finalise and implement recovery plan for PU in each sector/department. to be submitted to SDAG in support of PU, plan to be monitored through the accountability review committees

6. Agree 2020/21 content for Pu programme - Essential Care Skills Programme (ECSP) in Q3. launch TTT in Q4 for launch in April. Set ECSP (PU) Trajectory for each sector/Department

7. Release newest version of the Statutory Mandatory online assessment

8. Heads of Departments/Service Delivery/AOC to submit a PU implementation plan to SDAG to support the roll out of ECSP by April 2020

Action Plan

7. Released through Evolve October 2019.

8. Plans in progress, to be presented at SDAG once final detail of programme is confirmed

1. Definition completed and attached

2. Reporting process for compliance defined and reviewed at ELT

3. Process for reporting compliance to service line managers refreshed and defined and presented at Education & Learning Group on 28.01.20. Fortnightly reporting to Heads of Departments ongoing

4. Governance process defined and presented at Education and Learning Group on 28.01.20

5. Recovery plans in place and monitored through accountability review committees (latest review 27.02.20)

6. Programme content complete. PU Trajectories in place for each sector & department

EEAST: CQC Action plan Report - OD 13/01/2020, V1 contains detail for points 1,2 and 3Point 4 confirmed as complete.Point 5 SDAG paperPoint 6 updated reviewed form ODPoint 7 released through EvolvePoint 8 to be presented in SDAG paper

Head of Improvement Programmes

Workforce CommitteeELTAccountability Meetings

Highlight report 16.12.19 and exec briefing reviewed to support

evidence.All documents have been reviewed which align to the actions required.

Minutes from MMG.Minutes from QGC

Medical Director Compliance and Risk Group

Quality Governance Committee

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Clinical Lead

Clinical Lead

Clinical Lead

Clinical Lead

Head of Estates

Clinical Lead

Clinical Lead

Clinical Lead

Clinical Lead

Clinical Lead

Clinical Lead

Clinical Lead

Head of Performance

Head of Performance

Recruitment Manager

Recruitment Manager

Head of Performance

Head of Performance

Senior Operations Centres Manager

Head of Performance

Head of Performance

Chief Operating Officer

Recruitment Manager

Recruitment Manager

PTS Service Delivery Lead

Ongoing compliance monitoring to embed the medicines management process. Further develop

processes for PGD compliance

Develop a governance and improvement framework for

PTS (February 2020)

Development of the 20/21 ORH trajectory (early view in March 2020). Develop a plan

for hear and treat enhancement and continue

negotiations with commissioners

Demonstrate systems and processes to safely administer, store, prescribe medicines is in

place. A 10% reduction in administration errors by

31.08.20. A 5% reduction on medicine cost by 31.12.20

5 PTSThe trust MUST ensure it improves response times in patient transport

services

3. Recruitment to address vacancies is monitored through workforce planning

4. The top 10 long waits are identified and scrutinised continually but formally reviewed each month, areas for actions and improvements identified and relevant changes implemented

3. Implementation of recruitment plans with the remaining rota gaps to be filled through intelligent use of flexible resources, aligned to demand

4. Complete a 'deep dive' for the top ten long waits and identify learning and implement changes as appropriate on a monthly basis

To be at or above commiosner set trajectories reviewed monthly

and working towards national standards

1. Appoint service delivery lead for PTS focussing on transformation and improvement

2. Produce a regular report detailing current vacancies within PTS to track improvement

1. Service Delivery Lead appointed December 2019

2. Vacancies continue to reduce to 3.7% (December 2019). Current vacancies are reported monthly through our governance structures


Performance and finance committee

ELB

To meet contract standards and demonstrate a 5% monthly reduction in complaints by

31.08.20.

Chief Operating Officer Performance and Finance

committee4 E&UCThe trust MUST ensure it improves

response times in emergency and urgent care

The following points are to support progress in capacity, demand and efficiency

6. Reduce gap between planned capacity and profiled capacity - monthly

7. To deliver a trajectory to improve Hear and Treat to 10% by August 2020

8. To deliver a range of operational efficiencies that improve our response to patients, in areas of job cycle time, loss of hours from out of service and dispatch process's

9. Effective use of staff aligned with patient facing staff hours (PFSH) requirements.

1. Completed for 2019/20 The Trust has successfully improved response times in line with our improvement trajectory agreed with regulators

2. As of January 2020 86% of rota's have been implemented

3. Recruitment to address vacancies in all areas is monitored through workforce planning (section 9)

4. Recruitment plans identifying gaps will be filled through intelligent use of flexible workforce. 80% of 2020/21 Private Ambulance Service tender is aligned specifically to BBR gaps

5. Level 1 signals for noise (SFN) performance meetings now embedded

6. Over 80% of building better rotas have now been implemented with the reminder by end of March 2020

7. Plan is being developed that identifies key enablers to delivery, for example technology and reviewing the triage process and increases available capacity within clinical function to improve H&T

8. An integral part of our recovery and QCIP programme is to deliver these operational efficiencies, further detail can be found in the recovery workbooks and sector dashboards

9. This is successfully monitored centrally through planning teams and targeted use of flexible resources

1. Define and provide trajectory from revised ORH modelling on a monthly cycle

2. Report monthly on implementation of all Building Better Rotas rosters (BBR)

3. Ensure recruitment plan is focused to vacancies in all areas with documented monthly updates

4. Ensure clear plans are in place to address capacity gaps that are updated monthly to support any gaps in BBR due to vacancies ahead of recruitment

5. Implement performance improvement methodology ('Signals from Noise') at Level 1 performance meetings

12. PGD review embedded as part of the MMP. Timetable being created and embedded on health assure for monitoring. Team have just had HA refresher training. Medicines team responsible for PGD creation and will utilise ad hoc working groups as required via clinical leads

13. Medicines Audit and Compliance lead recruited on development opportunity to mitigate against risk register action. Administration compliance SOP drafted to assist in administration issues. New lead will assist meds team in developing processes for PGD compliance. Currently PGD reviews undertaken via QA8 submissions

8 Review ToR membership and work plan for MMG - Feb 20

9. Provide a process for consistent, sustainable and long term approach for the restocking and tagging of medicines bags by 31.01.20

10. Produce draft standard operating procedure and associate business case for the monitoring of ambient temperatures for all stored medicines by 31.01.20

12. Produce a protocol to ensure a timely review for PGDs by 31.1.20

3. Provide a protocol for consistent approach for auditing medicines by 30.11.19

4. Introduce monthly spot checks of drug bag records during station visits completed by the medicine management team

5. Introduce medicines bag loading lists by 30.11.19

6. Produce business case to ensure a consistent approach of use of CCTV for Medicines Management security by 31.01.20

7. Undertake detailed analysis of Datix reports relating to medicine errors by 31.01.20

3 Corporate

The trust MUST ensure that systems and processes to safely administer, store,

prescribe medicines is consistently applied across the trust

11. Produce process to ensure a consistent approach of local stock checking of medicines. By 31.01.20 - implemented new SOP due for sign off 31.01.20

13. Produce process for monitoring drug administration compliance against PGD's, protocols

3. Audit online adjusted and update process created and disseminated. New process allows for greater feedback and compliance monitoring which was completed in December 2019

4. Spot checks have been embedded as part of Delivery SOP and Audit Online created for compliance recording. Complete and in place Jan 2020

5. New meds loading list created and disseminated for action Oct 19. Compliance being monitored in spot checks and assistance in implementing as part of project roll out

Medical Director

Clinical Effectiveness group

Quality governance committee

6. Work in progress and consulting with estates regards new build needs and consistent approach for use of CCTV. Business case element added to plan in Dec 19 and being worked up, being drafted ready for wider consultation

7. Datix deep dive undertaken with report presented at MMG, CQSG and CGC in Jan/Feb 2020

8. Comparison being undertaken to evaluate actions against governance groups awareness. MMG ToR created and ready for sign off at next MMG

9. Long term project designed and implemented and went live in stage 2 on the 8.1.20. Highlight report demonstrates progress to date with regular updates provided to QGC

10. Policy and procedure created and drafted ready for MMG sign off 23.1.20. Business case for replacement process removed and can be revisited later subject to integration as required to ELB approved RFID use

11. Local stock checks in place as per MMP2018. Policy under revision in line with project re-alignment and new SOP being written for MMG sign off 23.1.20

Highlight report 16.12.19 and exec briefing reviewed to support

evidence.All documents have been reviewed which align to the actions required.

Minutes from MMG.Minutes from QGC

Review of IIP #4 and associated actions and evidence.

ELB paper 6.11.19 reviewed, along with strategic, Performance and capacity notes November 2019.Operational performance reports reviewed which support evidence

and have been presented to Performance and Finance

committee

Detailed breakdown can be found in published weekly integrated report -

Performance

Service delivery lead in post who is leading on actions. Recruitment

information dashboards available and reviewed. Monthly updates have ben

supplied and reviewed. Long wait deep dive reports and will request

learning . Contract reviews on going with updates provided in IIP

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Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Head of Governance

Develop a governance and improvement framework for

PTS (February 2020)

Board and committee phase 2 governance proposalBoard and committee effectiveness reviews

Board well led self assessment

Establish escalation and triggers for Committee and

Board oversightEmbed ED and NED STP engagement approach and

information flowQuality assure embedding of

safety huddlesComplete HR policy reviewEmbed new governance

group framework and renew Governance and Assurance

Framework accordinglySenior managers to have risk

as an annual objectiveConsideration of band 7

training for 2020/21

A 20% increase in the compliance with monthly risk

review 6 Corporate

The trust MUST ensure that governance and risk management processes are

embedded in all areas

Chief Executive Officer

Compliance and Risk group

Quality and governance committee

16. Specific areas of risk are highlighted in the Committee Chair’s

report to Trust Board

17. In-house training on risk management is in place and 2019/20 is the second financial year that this has been implemented. It is now an annual requirement for all teams. 110 managers in 18/19 and 93 in 19/20 to date have undergone training, with a further 57 scheduled

18. The risk escalation process was established and circulated to managers in quarter three and the risk team are currently building a compliance pack for teams to support escalation

19. Any omission or delays in completion of statutory and mandatory training is monitored and escalated to the relevant Director

20. All Accountability Committee meetings are required as per the template to report on their risk register and their high-risk areas. This ensures consistency and proving to be effective

11 .Accountability Committees for AOC are now in place (Q3 2019/20)

12.. Resilience and Special ops commencing in February 2020

13. The Sector Governance framework has been delayed in implementation due to the requirement to realign the governance meeting structure but is drafted and likely to roll out in the next 3-4 weeks

14. The Audit Committee ensures that the improvements in operational risk management are supported and since September, the Board Sub-Committees have reported into Audit Committee on risk assurance pertaining to the strategic risks and their risk remit

15. Operational support presented at February 2020 committee with finance to be presented at May's committee. Rolling plan in place

6. Charitable Funds committee and an improved Corporate Trustee approach was implemented in quarter three to maximise compliance

7. A process of ‘Safety Huddles’ has been implemented with the

transformation team in place to support the embedding process

8. The Corporate governance group framework has been fully reviewed and approved at Board. Good progress with finalising the Terms of Reference with the aim to complete by end of February

9. A policy management process has been reviewed adopting a lessons learnt approach with a new checklist and process in place

10. Whilst HR policy review has been slow to gain traction, there is now a clear trajectory in place being monitored through the Workforce Committee, with a plan to have 20 policies complete via collaboration with staff side by the end of March

1. All actions taken to embed organisational governance have been supported by a robust Board governance approach. The Fit and Proper Person’s policy has been reviewed and updated with annual

checks in accordance with this policy2. The Deloitte action plan was completed and closed, with ‘next

steps’ actions being embedded within the Integrated improvement

plan3. All reports from Committee Chairs have been standardised in approach enabling clarity of decisions re achievement of full / partial / limited assuranceA template is now in place for cover sheets for Board and Committee papers to ensure consistency4. Management Assurance Group was implemented and effective, and has been realigned to the Compliance and Risk Group which commences in February 20205. Efficient oversight of high-risk areas are now an integral part of Workforce and Performance & Finance Committees since the summer 2019. Workforce Committee and assurance on delivery remains the key area of focus

16. Inclusion of risk within Committee Chair’s reports to Board

Embedding operational risk management:17. Risk management training for band 8 managers and above through team risk surgeries

Embedding strategic governance:1. Review and update Fit and Proper Person’s policy

2. Completion of Deloitte review action plan

3. Establish clear Committee and Board cover sheets, including Committee Chairs report template

4. Complete realignment of Executive sub-groups

5. Increase oversight pertaining to workforce, finance and performance

18. Risk escalation process implementation

19. Completion of statutory training (e-learning) on Health and Safety (includes risk)

20. Ensure risk is featured with Accountability committee meetings

11. Establish Accountability Committee meetings for AOCs

12. Establish Accountability Committee meetings for Resilience/special operations

13. Implement corporate governance group for sufficient oversight and scrutiny

Embedding strategic risk management:14. Embed Committee risk assurance reporting to Audit Committee

15.Quarterly deep dive on risk registers to each Audit Committee meeting

6. Establish clear charitable funds approach and oversight

Embedding operational governance:7. Embed Safety Huddles across all operational areas

8. Implement sector governance framework

9. Review and strengthen policy management process

10. Complete review of all HR policies

5 PTSThe trust MUST ensure it improves response times in patient transport

services5. The Service delivery lead for PTS is undertaking a contract by contract review with Bedfordshire and Hertfordshire now completed and a plan for review of the remaining contracts

6. An integral part of our recovery and QCIP programme is to deliver these operational efficiencies, further detail can be found in the recovery workbooks for PTS. This is successfully monitored centrally through planning teams and targeted use of flexible resources

7. PFSH is continually monitored by planning teams to match demand to resources as effectively as possible within the contracted capacity. This process prioritises Cancer, Renal and End of Life patients

5. Contracts to be reviewed to ensure deliverability, effectiveness and quality of patient care

The following points are to support progress in capacity, demand and efficiency.

6. To deliver a range of operational efficiencies that improve our response to patients, in areas of job cycle time, loss of hours from out of service and dispatch process's

7. Ensure the effective use of staff aligned with patient facing staff hours (PFSH) requirements



ELB

To meet contract standards and demonstrate a 5% monthly reduction in complaints by

31.08.20.

Service delivery lead in post who is leading on actions. Recruitment

information dashboards available and reviewed. Monthly updates have ben

supplied and reviewed. Long wait deep dive reports and will request

learning . Contract reviews on going with updates provided in IIP

Fit and Proper Persons policy and MAG minutes

Deloitte action plan closure papersCorporate governance internal auditChair’s report template and reports

since September 2019Cover sheets for Board

Committee agendas and scheduleCharitable funds terms of reference,

agendas and minutesCorporate governance group papers

to ELB and BoardApproved group Terms of ReferenceAnnual report outlining safety huddles

CQC presentation 2019 – safety

huddlesTransformation team information

held on safety huddlesPolicy management process and the

PDPD. Policy Checklist and reports to MAG

and Audit CommitteeHR policy report to workforce

committee Approved new terms of reference –

compliance and risk groupAudit Committee agendas and

minutesAudit papers – Committee

assuranceRisk deep dive presentations

Committee Chair’s reports to Board

Risk training paper- audit committeeRisk presentation slides

Risk escalation process and emailAccountability committee reports and

presentationsStatutory/mandatory training

compliance figures

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Clinical lead for Education


Recruitment manager in partnership with Head of Improvement programmes





Recruitment managerin partnership with Head of Improvement programmes






6. By increasing staffing levels in the recruitment team will improve efficiency

7. Recruitment Manager to meet with regional Head of Operational Managers to establish individual recruitment plans against vacanciesEstablished monthly meetings with regional Head of Operations and PTS Managers using escalatory framework for local recruitment leads/COO to identify and address any barriers

8. Designated HR resource identified to review Recruitment Policy

9. On going monitoring using TRAC reports

10. Established monthly meetings with regional Head of Operational Managers and weekly meetings between Team Leads and the Recruitment Specialists

11. Workforce dashboard will inform to update and adapt local recruitment plans

Deputy Director of Human

Resources

Ongoing recruitment and monitoring of retention

Continued rigorous monitoring of 19/20 compliance

trajectories by ELB and accountability meetings

monthly

To be at or above agreed trajectories and achieve position

of 90% or above by 31.03.20

4. Revise and agree local recruitment plans

5. Provide definition of time to recruit and time to hire

6. Improve from point of contact time to recruit by reducing the time to hire by 10% by 31.03.20

7. Implement escalatory framework for local recruitment leads/COO to identify and address any barriers

Improvement in recruitment has been clearly demonstrated with vacancies in PTS continuing to reduce with a position of 3.7% vacancies in December 2019. Current vacancies are reported monthly through our governance structures.1. Workforce dashboard now produced on a monthly basis which identifies vacancy numbers by core service

2. Established weekly meetings between Team Leads and the Recruitment Specialists to review recruitment and retention process.

3. Approval to recruit 8 additional resources and is currently underway.Established weekly meetings between Team Leads and the Recruitment Specialists

4. Recruitment Manager to meet with regional Head of Operational Managers to establish individual recruitment plans against vacancies

5. Established defined parameters of time to recruit and time to hire

8. Review of Recruitment Policy completed by 28.02.20

9. Monitor time to recruit using TRAC

10. Weekly conference calls with HR, recruitment Leads, T&E and Ops

11. Net staff increase target to meet current vacancies

Staffing levels are at contractually agreed parameters

with vacancy rate to be maintained below 5% on a rolling

basis

7 Corporate

The trust MUST ensure that processes in place for appraisals and supervision are

consistently applied and demonstrate that staff are competent for their roles - target

90%

Head of Improvement programmes

1. Define vacancy numbers by core service

2. HR lead carries out review on recruitment and retention process to identify barriers and provide agreed actions to address shortcomings by 29.02.20

5. Clinical lead education and learning to provide the process which will support the implementation for a consistent process for supervision via clinical managers in operations by 31.03.20

1. Target agreed, trajectory for emergency operations, PTS and AOC established. Other directorates being produced

2. Trust wide figures for compassionate conversations have remained static from August 2019 through to February 2020 at around 80%. Trajectory for emergency operations, PTS and AOC established. Other directorates being produced

3. Continuous monitoring of Compassionate Conversations (Appraisals) and Training Completion including Mandatory Training through monthly accountability meetings

4. Proposals for sustainable supervision model drafted for discussion with executive and workforce groups

5. Proposals for sustainable supervision model drafted for discussion with executive and workforce groups

1. Executive team to review and agree performance for appraisal target (90 %) for 2020/21 by 31.01.20

2. Organisational development manager and Operational managers agree trajectory for appraisal completion for 2020/21

3. General managers review monthly reporting which is reviewed at Accountability meetings

4. Consult and agree model of supervision

8 PTS

The trust MUST ensure it improves recruitment and retention to have enough

staff to provide a safe and responsive service in PTS

(recognised as a critical underpinning requirement to all other PTS areas of

improvement)

Workforce committee

Accountability meetings

3. Increase HR capacity to support recruitment

OD reports Compliance report 04.02.20

PQRM November reviewed recruitment part of action log.

Workforce update standing agenda item. Weekly meetings between

team leads and recruitment specialists. Approval to recruit to 8

additional resources to support function. Workforce dashboard now in placed and reviewed. Internal E-

zine now re-established

Workforce committee


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Resources

Ongoing recruitment and monitoring of retention

Monitoring of delivery against training plan

9 E&UC

The trust SHOULD ensure it improves recruitment and retention strategy to have enough staff to provide a safe service in

E&UC

(recognised as a critical underpinning requirement to all other areas of

improvement)


Resources

5. Revise and agree local recruitment plans

6. Provide definition of time to recruit and time to hire

7. Improve from point of contact time to recruit by reducing the time to hire by 10% by 31.03.20

1. Workforce dashboard now produced on a monthly basis

2. Training plan for 2020/21 produced

3. Established weekly meetings between Team Leads and the Recruitment Specialists to review recruitment and retention process

4. Approval to recruit 8 additional resources and is currently underway

5. Recruitment Manager meets with regional Head of Operational Managers to establish individual recruitment plans against vacancies

6. Established defined parameters of time to recruit and time to hire

7. By increasing staffing levels in the recruitment team will improve efficiency

8. Established monthly meetings with regional Head of Operational Managers using escalatory framework for local recruitment leads/COO to identify and address any barriers

9 . Complete with on going monitoring

10. Pilot on track for course starting February 2020 for Ambulance Nurses

1. Define vacancy numbers by core service

2. Require training plan for 2020/21

Workforce committee


40 WTE month on month net gain until agreed workforce

numbers are reached

3. HR lead carries out review on recruitment and retention process to identify barriers and provide agreed actions to address shortcomings by 29.02.20

4. Increase HR capacity to support recruitment

8. Implement escalatory framework for local recruitment leads/COO to identify and address any barriers

9. Ensure staff are fully trained to operational standards at the time of finishing training school

10. Specific initiative to recruit ambulance nurses in Hertfordshire

15. Internal Ezine re-established

12. Revised exit questionnaire developed, electronic version pending

13. Production of Quarterly Reports with additional reports for each sector collating exit interview data

14. Executive led air and share programme underway

13. Continual monitoring process that collates exit interview data to inform action plans to support retention

14. Improve staff engagement to capture themes - programme of Executive Led Air and Share staff engagement sessions in progress

15. Improve communication of internal vacancies

12. Review themes/trends of staff leaving -questionnaire developed to support exit interviews; data available for 2019/20; reviewing provision of electronic questionnaires by 31.03.20

Staffing levels are at contractually agreed parameters

with vacancy rate to be maintained below 5% on a rolling

basis

8 PTS

The trust MUST ensure it improves recruitment and retention to have enough

staff to provide a safe and responsive service in PTS

(recognised as a critical underpinning requirement to all other PTS areas of

improvement)

Workforce committee


PQRM November reviewed recruitment part of action log.

Workforce update standing agenda item. Weekly meetings between

team leads and recruitment specialists. Approval to recruit to 8

additional resources to support function. Workforce dashboard now in placed and reviewed. Internal E-

zine now re-established

Workforce dashboard observed (monthly). Established weekly meetings with team leads and

recruitment specialists. Recruit 8 additional resources to support team underway. Time to recruit definitions

have been provided and used for reporting. Monthly meetings

established between regional head of operations managers and HR. Exit interview data reviewed and reports

produced quarterly. Revised exit being developed. ' E-zine' relaunched

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Head of Estates in partnership with Head of infection, prevention and control

Head of infection, prevention and control

Head of infection, prevention and control

Operational Sector leads in partnership with Head of infection, prevention and control

Chief Operating Officer in partnership withMedical Director



Continued implementation to reach 90% by end March 2020

95% by end May 2020 and 100% by end of August 2020

A sustained reduction in handover delays which is

monitored with system partners

Meeting in planning stages to convene a regional best

practice workshop in collaboration with NHSE/I and

commissioners

Monitoring of delivery against training plan

11 E&UCThe trust SHOULD continue to work with system partners to ensure that handover

delays are reduced at acute hospitals



1. Training delivered by EEAST to the Norfolk commissioners, formal offer made to the commissioning consortium meeting for further training which a Norfolk CCG member attended to describe the benefits to the CCG for undertaking this training

2. System wide winter room supported by EEAST tactical commanders is in place. Winter plan enacted. 24/7 escalation in real time following escalation policy. Norfolk winter room supported through staffing with EEAST tactical support

3. Medical Director escalates to medical director colleagues across systems as required. Good collaboration through QGARD - AACE

1.Provide commissioners training and support to manage delays effectively

2.EEAST to provide targeted support to most highly challenged systems

3.Trust medical Director to liaise with Medical Directors across the system to ensure a consistent approach is taken

E&UC

The trust SHOULD ensure that sharps boxes are consistently labelled

Compliance and risk group

Quality and Governance committee

Compliance of 90% by end of March , 95% by end of May and

100% by end of August 2020

4. Improve staff awareness through huddles, posters and peer review

1. Waste Policy has been reviewed taken to specialist group IPCG and is being prepared for formal approval at MAG

2.Checks included within the IPC audits for stations, vehicles and staff and included within the IPC reporting, alerts are generated for non-compliance

3. Audit results for January indicate station checks 72 from 76 (94.7%) were complaint, for DSA 302 out of 339 were compliant 89.1% and RRV's 84 out of 94 (89.4%). Overall compliance for December 90% and was 89.98% for January, (target from NPSA for cleanliness of vehicles is 85%, the Trust aims for 95%). Head of IP&C and Head of estates reviewing target specifically in relation to this area

4. Awareness raised and refreshed, posters at point of issue and part of peer review discussions

1. Review waste management & IPC policy/procedures and revise if required

2. Incorporate sharps box checks into current audit programmes including safety walkabout audits

3. Review outcomes from audit results monthly and Datix incidents

9 E&UC

The trust SHOULD ensure it improves recruitment and retention strategy to have enough staff to provide a safe service in

E&UC

(recognised as a critical underpinning requirement to all other areas of

improvement)


Resources

10

13. Clinical lead - education to develop framework for clinical development of existing staff

14. Improve staff engagement to capture themes - programme of Executive Led Air and Share staff engagement sessions in progress

11. Revised exit questionnaire developed, electronic version pending

12. Production of Quarterly Reports with additional reports for each sector collating exit interview data

13. Work underway to provide a paper for framework for clinical development of existing staff

14. Executive led air and share programme underway.

Key actions are progressing but as this is the Trust's highest risk area the RAG rating reflects the need for the full strategy implementation

11. Review themes/trends of staff leaving -questionnaire developed to support exit interviews; data available for 2019/20; reviewing provision of electronic questionnaires by 31.03.20

Workforce committee


40 WTE month on month net gain until agreed workforce

numbers are reached

12. Continual monitoring process that collates exit interview data to inform action plans to support retention

Workforce dashboard observed (monthly). Established weekly meetings with team leads and

recruitment specialists. Recruit 8 additional resources to support team underway. Time to recruit definitions

have been provided and used for reporting. Monthly meetings

established between regional head of operations managers and HR. Exit interview data reviewed and reports

produced quarterly. Revised exit being developed. ' E-zine' relaunched

Review of IP&C update Dec 19. Evidence noted of changes to peer

review - station assessment document Jan 20 along with vehicle

spot check forms. Audit results reviewed for December 2019. Safety walkabout audit for Q3

identifies sharps bins labelled on vehicles has improved from 94.1% to 95.3% in Q3, sharps bins on stations

has dropped from 91% in Q2 to 87.7% in Q3

Winter plan reviewed. Regular attendance at A&E delivery boards - Minutes requested. Review of PQRM

minutes and action log Nov 19 . Minutes reviewed oversight and

support meeting 26.11.19. Operational productivity regular

review and monitoring of arrival to handover times and impact. Paper

reviewed increasing HALO provision. Operational instructions reviewed,

drop and go, corridor care along with cohorting guidance and emergency

department ambulance risk assessment - patient handover

19.12.19. 16 On call directors/senior managers on collaborative training

programme. Engagement and visits hosted by 3 acute hospitals ED

Depts: Norfolk and Norwich Hospital, Norwich / Queen Elizabeth Hospital / James Paget and IC24 (111 & Out of

hours)

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Patient experience lead









Service delivery lead - PTS



A sustained reduction in handover delays which is

monitored with system partners

Meeting in planning stages to convene a regional best

practice workshop in collaboration with NHSE/I and

commissioners

The trust SHOULD ensure that complaints are investigated and resolved in a timely

manner

7. Audit and target reduction - reopened complaints

8. Review response template to ensure includes qualitive response

9. Provide training for LOMs/investigating managers to promote resolution

Revision of transformation plan by new service delivery

lead for PTS13 PTS

The trust SHOULD ensure that progress with the transformation programme

continues


Performance & Finance Committee

To reach and maintain that 75% of complaints are responded to

in 25 working days

Workshop agenda and agreed outputs: Feb 20

Agreed workplan – across

Patient Experience Lead and Manager roles agreeing

priorities: Feb 20Result of benchmarking: Feb

20Proposed action plan

addressing current and planned activities: Feb 20

1. Recruit Service Delivery Lead - Patient Transport Services (PTS) to lead on PTS transformation

2. Service delivery lead to review and provide a current position of the PTS transformation plan

3. Service delivery lead to identify key risk's and barriers in continuing and completing the transformation PTS plan by 31.01.20

1.The service delivery lead for PTS is in post from December 2019 with a focus on transformation

2.Transformational plan has been reviewed

3.This is a challenging requirement given the timescales and the extent of the transformation programme required as the plan itself requires revision, this work has commenced.To note these actions are closely aligned to section 5

Transformational plan completed and all associated actions closed

by 31.08.20

12 E&UC Medical Director

11 E&UCThe trust SHOULD continue to work with system partners to ensure that handover

delays are reduced at acute hospitals



5. Ensure EEAST learn from best practice.

4. HALO provision has been increased across the region despite late requests made, drop and go and corridor care processes completed and implemented

5. NWAS requested to provide every minute matters work to assess current practice against this work.

This important area of concern (hospital delays) and the risks has been taken to NHS E/I by EEAST for escalation.

4.Increase HALO provision if required to support system flow, communications with the acute services and provide cohorting capacity if required

Action plan to be developed further following FT appointment of Head of Patient Engagement 1st Feb 2020

1. Develop comprehensive complaints dashboard to evaluate performance

2. Daily sitreps created for Patient Experience Lead to monitor and expedite closure of out of date complaints

3. Post now offered to start once post backfilled (March 2020)

4. Changes to process being developed to offer people immediate resolutions for concerns – Currently all complaints and concerns

managed via the same process

5. Workshop to be held within Feb across directorate to discuss, map, streamline and agree current processes / responses across all areas of feedback to enable theme analysis and a focus on learning form response

6. Stocktake planned across all sites to ascertain what training IO’s

have received and where the gaps are. Next Steps to develop a solution to address the gaps either via buddying, coaching and or training

Patient experience lead in post is interim with advert out for

substantive. Dashboard ongoing with monthly reporting to operational

teams. Additional dashboard highlighting overdue complaints is also produced monthly for Director

Clinical Quality & Improvement. From January 2020 compliance and

standards leads communicates directly with sector heads relating to both PTS and U&EC. Shortlisting for

Patient experience manager has been completed with interviews due Feb 20. An outstanding item is the review of learning from compliant

activity

1. Complaints dashboard in place and shared monthly with teams across the organisation

2. Recruit to patient experience lead

3. Recruit to patient experience manager to appoint Jan 2020

4. Review learning from complaints activity during 2019 to identify priorities

5. Review and streamline process, focusing on early conversations to resolve issues

6. Team and sector training to ensure qualitative responses

Quality and Governance Committee

7. Wider benchmarking of other complaints handling processes with other trusts nationally. Currently achieving the statutory 3 days acknowledgement of complaint – 100% across the last quarter - but

not the non-statutory days to respond timeframe.% of complaints resolved to within 25 days for January was 23.5% which was an improvement on the previous month

8. Having addressed delays within system, workshop to be held to critique process and resources including quality of templates and responses

9. Stocktake planned across all sites to ascertain what training IO’s

have received and where the gaps are. Next Steps to develop a solution to address the gaps either via buddying, coaching and or training

Review of IIP actions and associated evidence. Evidence of ongoing

contract reviews for each contract and discussed at meeting. Work on

going to support control room functions and relationship with

operational staff. Monthly meetings established between control room

and operational staff in PTS. Control room function improved, additional portacabin on site Bedford and use

of meeting room 1

Winter plan reviewed. Regular attendance at A&E delivery boards - Minutes requested. Review of PQRM

minutes and action log Nov 19 . Minutes reviewed oversight and

support meeting 26.11.19. Operational productivity regular

review and monitoring of arrival to handover times and impact. Paper

reviewed increasing HALO provision. Operational instructions reviewed,

drop and go, corridor care along with cohorting guidance and emergency

department ambulance risk assessment - patient handover

19.12.19. 16 On call directors/senior managers on collaborative training

programme. Engagement and visits hosted by 3 acute hospitals ED

Depts: Norfolk and Norwich Hospital, Norwich / Queen Elizabeth Hospital / James Paget and IC24 (111 & Out of

hours)

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Aviva: Public

Report title: Report from Performance and Finance Committee – 15.01 2020

Report author(s): Tom Spink, Non-Executive Director

Purpose: Decision Assurance For information Disclosable X

X Non-disclosable

Matters for Escalation: The impact of increasing hospital handover delays on patient safety and the performance of the Trust

Other Key Matters Considered: The Interim Head of Strategy and Transformation presented the update on the CIP programme. In month delivery was £0.41m, off plan but in line with forecast outturn of £6.8m. Confidence remained high that the 2019/20 forecast will be achieved and attention was focussing on plans for 2020/21 where £8.05m had been identified out of a required total of £11.5m.

Progress was positive with the rollout of the 10:10 initiatives across five key clinical areas which should improve on scene times without negatively impacting patient outcomes.

Hospital delays continued to be an increasing threat to the performance of the Trust with Essex, Peterborough and Norfolk all under increased pressure. The COO confirmed the issue was a system wide pressure.

TRUST BOARD (public session) 16.11.2019 AGENDA ITEM

Related Trust strategic objective(s):

Provide better care X Value our people Value for money X Improve performance X

Other:


Legal implications None

Regulatory requirements None

Equality and diversity impacts None

Report Title

18

Committee Reports to Board


Aviva: Public

The DoFC confirmed that initial figures for M9 indicated circa £0.5m ahead of forecast in month, mainly as a result of reduced take up of overtime incentives. It was likely that the additional sums would be used to bolster PFSH in the run up to Easter. However it was also confirmed there was an increased level of confidence in achieving the forecast deficit of £7.7m.

The COO explained that the Bedfordshire and Hertfordshire PTS contract had been agreed with the consortium. This would help mitigate any further losses on this contract.

Concerns were raised about the overall performance of the PTS contracts. The COO confirmed that in addition to the new Beds and Herts agreement, it was anticipated the West Essex contract was a manageable risk and that diagnostic work was underway for the Cambridgeshire and Peterborough contract.

Encouragingly, although there had been a national increase in flu like cases, there was no suggestion these were reaching pandemic levels.

The Infrastructure and Estates Programme Lead presented a summary of the infrastructure and estates programme. Although it was clear there had been a great deal of progress, the Committee were unable to reconcile progress against the original business case. In particular, concerns were shared around how the benefits would be monetised.

The CEO gave her thanks and appreciation on behalf of EEAST to the DDoOS for his 37 years of service.

Key Decisions Made and Actions Identified:

To assist the Committee to focus on the important areas of performance, it was agreed that key metrics, escalation points and triggers would be agreed for future reporting against.

It was recognised that reporting of the PTS contracts was somewhat fragmented and so it was agreed it would become more integrated helping to achieve greater management accountability

As a result of the review of the CQC improvement plan (as part of the Integrated Improvement Plan) the relevant sub committees were asked to review their element of the IIP to ensure it was still fit for purpose. The Committee took some reassurance from the fact that 82 of the CQC improvement plan remained the same post review.

The IEPL committed to bringing clarity around the timelines for delivery of the estates and infrastructure together with a clear articulation of how the benefits mapped against the original business case. A key focus would be how these benefits would be monetised.

Risks: The risks relating to the delivery of the financial recovery plan were discussed. The P&FC were assured the forecast outturn of a deficit of £7.7m could be achieved.



Aviva: Public

The increase in hospital handover times was recognised as a system wide issue with a corresponding impact on the level of resources EEAST needed to deploy to help mitigate the risks to patient.

Assurance: Full Assurance: Finance Report Operational Performance Report CIP plans

Partial Assurance: Integrated Improvement Delivery of anticipated benefits from the Infrastructure and Estates programme

Lack of Assurance (and next steps): None

Referrals to Other Committees: Review of Integrated Improvement Programme by sub committee

Meeting Details: Meeting Chair: Tom Spink, Non-Executive Director Lead Director: Kevin Smith, Director of Finance and Commissioning

Yes No Was the Meeting Quorate? X



Aviva: Public

Report title: Report from Performance and Finance Committee – 19.02.2020

Report author(s): Tom Spink, Non-Executive Director


X Non-disclosable

Matters for Escalation: A significant part of the savings generated from the Estates and Make Ready programme are currently non-cash releasing. With pressure on the Trust’s cost base, it is important we find a method to monetise these savings.

Other Key Matters Considered:

The Interim Head of Strategy and Transformation presented the update on the CIP programme. In month delivery was £0.61m, off plan but in line with forecast outturn of £6.8m. Confidence remained high that the 2019/20 forecast will be achieved and attention was continuing on increasing the confidence and quantum of opportunities for 2020/21 where £8.8m (an increase of £0.75m since last month) had been identified out of a required total of £11.5m.

The DoF confirmed that M9 financial performance was a deficit of £1.8m to the original plan but ahead of forecast by £0.2m. It was confirmed that the Trust should hit the year end forecast deficit of £7.7m albeit there remain risks around any potential impact of the Coronavirus.

Although we are seeing an increase in patient handover delays, the PFSH were in line with the critical path and encouragingly, the internal performance trajectories continue to be met.


Related Trust strategic objective(s): Provide better care X Value our people Value for money X Improve performance X

Other: To ensure effective governance and compliance X

Legal implications None

Regulatory requirements None

Equality and diversity impacts None

Report Title

18



Aviva: Public

We continue to see under performance against ACQI targets but the rollout of the 10:10 programmes should drive improvements in the future.

It was pleasing to see call pick up times in the AOC improve substantially to 11 sec for the 95th percentile. It was also encouraging to see the ECAT H&T performance continue to be above target for the month.

The Service Delivery Lead for NEPTS presented the deep dive on PTS. The plans are well developed and gave the Committee a good level of assurance that the performance of PTS will continue to improve.

Progress with the EPCR project is positive and the new Telephone System has been ordered from BT. Planning for deployment is underway.

The DOFC presented the Capital Report. Although forecast for year-end is showing £750k overspend, an application for an increase to the CRL has been made to NHSI/E.

Cycle 4 of the integrated improvement plan showed on-going progress albeit hampered by winter pressures on resourcing. Lessons continue to be learned and changes to the programme are then made to drive continuous improvement.

The Committee debated the BAF. The residual score for SR1 remained the same reflecting the positive improvements made by the Trust but also recognising the additional pressures due to winter, system wide pressures and possible virus prevalence. SR4 residual score remained elevated due to demand in the recovery plan but also the risks associated with potential slippage. It was also agreed to review the method for RAG rating to allow the Committee to better understand partial and full mitigation of risks.

The Sustainability and Environmental Strategy was presented. This was a good, comprehensive document. It was agreed that in future, key targets and milestones would be shared to enable the Committee to be assured of future progress.

The Make Ready Infrastructure Transformation project was presented. It was clear a great deal of work has been done and encouragingly, the projected total forecast savings are ahead of the original business case. More work is still required to agree how to translate the c. £2.7m non-cash savings into tangible benefits.

A paper was presented and agreed on how the procurement team can ensure appropriate policies and procedures are in place for future contracts so that the use of waivers can be significantly reduced.


It was agreed the PTS improvement plan was comprehensive but that the Committee needs visibility of key milestones to enable full assurance of progress to be given

The Made Ready Estates Transformation programme was welcomed but the Committee still require the comparison of key assumptions underpinning the original; business case to be detailed.



Aviva: Public

Risks: The risks relating to the delivery of the financial recovery plan were discussed. The P&FC were assured the forecast outturn of a deficit of £7.7m should be achieved. The increase in hospital handover times was recognised as an on-going system wide issue with a corresponding impact on the level of resources EEAST needed to deploy to help mitigate the risks to patient.

Assurance: Full Assurance: Finance Report Operational Performance Report CIP plans Integrated Improvement Sustainability Strategy

Partial Assurance: Delivery of anticipated benefits from the Infrastructure and Estates programme

Lack of Assurance (and next steps): None

Referrals to Other Committees:

Review of Integrated Improvement Programme by sub committee

Meeting Details: Meeting Chair: Tom Spink, Non-Executive Director Lead Director: Kevin Smith, Director of Finance and Commissioning




Report title: Report to Board from the Workforce Committee – 16th Jan 2020

Report author(s): Neville Hounsome, Associate Non-Executive Director


X Non-disclosable

Matters for Escalation: The main Board will receive a workforce plan update twice per annum. It will also receive the results of this year’s employee survey when they are available.


1. The Committee received a training plan for this year and until March2021. The plan anticipates being 337 Paramedics short by it’s end. Thiscompares with a current establishment of 1,454 (23% short). We arecurrently 232 Paramedics short of establishment (16% short).

2. The shortfall in Paramedics will be balanced by 260 AEMT Techniciansover the present establishment of 454 (plus 57%) and by an excess of 86Care Support Workers over the current establishment of 194 (plus 44%).



Provide better care Value our people X Value for money Improve performance X

Other:


Legal implications The committee overseas compliance with our legal responsivities relating to safeguarding and employment.

Regulatory requirements The committee seeks to provide a good level of governance and reassurance regarding the recruitment, education, training and general employment of Trust staff.

Equality and diversity impacts The Executive are realigning sponsors for each network and clarifying time off arrangements. HR are still looking into the impact of the 3 year national pay deal on equal pay gaps.

Report Title

18



The executive reassured the Committee that revised skills mix was both practicable and desirable.

3. The Committee now seeks a fuller resourcing plan (recruitment, trainingan deployment) by month and skill to support this direction of travel.

4. A plan to catch up on HR policy reviews was reviewed. Positive relationswith staff partners are critical to the rate of progress.

5. The staff survey process was welcomed and reviewed.


The Committee accepted the proposed move to a greater use of Technicians and Support Workers.

Risks: The committee considered SR3 and elevated risk 526. They were assured that these were reflective of the risks and issues within workforce however further assurance was required to demonstrate improvements.

Assurance: Full Assurance: Equality and Diversity Update, Get Real Change Programme Update

Partial Assurance: BAF, Workforce Metrics and Priorities, PPI and CEG Update, Education and Training Progress Report, ET and ER cases

Lack of Assurance (and next steps):


None

Meeting Details: Meeting Chair: Neville Hounsome Lead Director: Marcus Bailey




Report title: Report from the Quality Governance Committee meeting on 05.03.2020

Report author(s): Wendy Thomas, Committee Chair


X X Non-disclosable

Matters for Escalation: Safeguarding – 25 open cases being progressed via the Local Authority Designated Officer (LADO) route – involve staff members – CC is now sighted on all. Mandatory training compliance at 76% - needs to be at 90% by year-end. Level 3 training and requirement by role needs to be clarified.


Quality reports – concern re: complaints and timeliness of response but agreed not a high strategic risk – work on going however to replace team members and improve timeliness of responses Safeguarding cases – there appears to have been a dramatic reduction in cases recently but committee accepted these were not cases specific to EEAST (may have been multi agency) Now closed at conclusion of EEAST investigation to enable focus on open EEAST cases for active management and subsequent learning. Clinical Strategy – Good progress toward identifying and developing draft KPIs within the Trust

TRUST BOARD (public session) 11.03.2020 AGENDA ITEM 18


Provide better care X Value our people X Value for money X Improve performance X

Other:


Legal implications

Regulatory requirements Compliance with the Health and Social Care Act via the CQC Key Lines of Enquiry

Equality and diversity impacts

Report Title




Commitment of Committee members to participate in Quality Assurance visits. Methodology to be presented to April 20 meeting. Safeguarding – CC to receive details of the LADO cases from MD every 2 weeks to gain assurance on trends, root causes and lessons learnt Claims – lessons learnt from claims to be considered and reported back to a future meeting – consider for June 20 Clinical Quality Steering Group – agreed disbanded (as agreed in Governance Review approved by Board in November 19) – Expect report form Compliance and Risk Group to April 20 meeting.

Risks: Coronavirus but assurance as prepared as can be.

Assurance: Full Assurance: Emergency preparedness for Coronavirus outbreak Medicines Management

Partial Assurance: Clinical audit activity. 3 areas - Essex and Luton & Beds assurance expected at April Committee meeting Safeguarding – Assured re: new process for closure but concern, specifically LADO cases & mandatory training compliance. CQC Action plan – only 2 areas rated green but assurance that many areas will see significant progress during February and then will be green.

Lack of Assurance (and next steps): IPC – Make ready non compliance with action plan and trajectory so deep dive for April 20 meeting.


Safeguarding - Workforce Committee receives updates on closures or ER cases.

Meeting Details: Meeting Chair: Wendy Thomas Lead Director: Tom Davis




Report title: Audit Committee – Chair’s Report

Report author(s): E de Carteret, Head of Governance

Sponsoring director:

C Davidge, Non-Executive Director


X X Non-disclosable

Matters for Escalation: The Trust’s Standing Orders, Standing Financial Instructions, Scheme of Delegation and Reservation of Powers to the Trust Board were all reviewed as per the annual approvals process. There were limited changes to the documents, with the exception of the proposed removal of the sub-Board level Chair’s approval. The Board are asked to note these items are to be found for approval on agenda item 21, and Board are asked to receive the Committee’s recommendation for these to be approved and accepted.

The Committee undertook the annual review of the Risk Management Strategy and noted minor changes only to job titles and templates within the appendices. The Committee supported the re-refinement of the risk appetite relating to financial risk, to realign with the Recovery Plan. The Board is asked to note this item is to be found for approval on agenda item 20, and Bord are asked to receive the Committee’s recommendation for this to be approved and accepted.

TRUST BOARD (public session) 11 March 2020 AGENDA ITEM 18


Provide better care Value our people Value for money Improve performance

Other:


Legal implications Compliance with statutory and regulatory frameworks for financial probity and governance

Regulatory requirements CQC well led Key line of enquiry

Equality and diversity impacts None noted

Report Title




The timeline for the annual accounts were received and noted, with no issues foreseen. Information Governance metrics and indicators were discussed and approved for bi-annual monitoring by the committee. Progress against the IG Data Security Protection Toolkit for 2020/21 was noted with a large proportion of indicators now completed. Outstanding Internal Audit actions were considered by the Committee and anticipated completion for all three will be the end of March. Failure to complete these prior to the next Committee meeting will result in escalation to the Board. Update reports on Internal Audit, External Audit and Counter fraud were noted with no concerns raised. Indicative annual plans for Internal Audit and Counter Fraud were tabled for consideration, and will be factored in to planning for the next financial year in line with the tender process for the contracts.


A full task and finish group review of the scheme of delegation, including benchmarking with others is to be undertaken in 2020/21 to ensure these are fully fit for purpose and user friendly in the coming financial year. The Committee discussed the item referred back to the Committee regarding the query on external assurance of the annual Quality Account. Based on the lack of requirement for ambulance trusts to do this, it was agreed that this would not form a part of the cycle for the 2019/2020 account, but would be considered for the 2020/21 period. The Committee agreed a proposed uplift in fee of the External Audit providers in private session. The fee has been increased to £70,000 from £60,150, and reflects the challenges faced within the audit landscape, the additional workload and legislative requirements since the contract was commenced.

Risks:

The Committee noted a risk to end of year compliance with the Information Governance toolkit relating to the levels of IG training compliance. Whilst there was 7% improvement required prior to the end of the financial year, clear escalation plans were narrated to mitigate this risk and achieve compliance by the end if the financial year.

Assurance:

Full Assurance: Good assurance was received as a result of the risk deep dive into the Operations Support risk register, which demonstrated clear understanding and application of the framework, as well as provision of assurance on the risk management training implemented. The Committee took full assurance from the risk assurance from sub-committee process that had been implemented over the course of the last two quarters, and the improved ability to gain assurance over strategic risk management. From this, assurance was taken that the Board Assurance



Aviva: Public

Framework content reflected the level of risk to the Trust’s strategic objectives, with plans in place to mitigate. Partial Assurance: Good levels of assurance have continued to be noted in the ongoing reduction of waivers and non-compliant procurement processes, as per the improvement plan. The Committee recognised that further improvements were required, but the sustained positive movement remains in line with the agreed trajectory. Limited assurance was received from the Quality Governance Committee on progression of the CQC action plan, which can be tested in Board agenda item 17. Freedom of Information and Release of Information timescale compliance were noted as poor, and off-trajectory from that set 12 months previously. A deep dive was undertaken and whilst there was a lack of assurance regarding compliance, actions were clearly highlighted to improve the situation in the coming months. Lack of Assurance (and next steps): None Noted


None Noted

Meeting Details: Meeting Chair: Ravi Mahendra, Chair and Non-Executive Director

Lead Director: Kevin Smith, Director of Finance and Commissioning




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MEETING TITLE

TRUST BOARD (PUBLIC)

Date: 11.03.2020

Report Title: Board Assurance Framework

Agenda Item: 19

Author: E de Carteret, Head of Governance

Lead Director: D Hosein, Chief Executive




The document provides detail on the four strategic risks agreed by the Board, in line with the current organisational

Strategic Objectives.

The function of the Board is to consider the Strategic Risks in relation to the following:

Consideration of the Strategic risks when receiving information regarding elements of Trust business, to consider the potential impact decisions may have

To seek assurance – or challenge – the mitigating actions identified, based upon information received through other reports and channels, and assurance via the committees

To utilise the Board Assurance Framework to assist in the planning of Board meetings and intended business

To gain assurance that the Board Assurance Framework demonstrates sound risk management principles Pages 3-4 outline the summary of assurances in regards to risk management from the Audit Committee in February 2020. Pages 5-7 contain a summary overview of the strategic risk profile, including a progress update against key mitigating actions for each risk as well as a rationale for the current score. Pages 8 to 16 provide more detail as to the risk context and full listing of mitigating actions underway for each of the BAF risks and includes the anticipated date to reach the target score. All strategic risk scores remain the same this month, due to the pressure of winter and the interdependencies across the risks.

RECOMMENDED ACTION:

To note the Board Assurance Framework and its contents. To consider areas of focus required, either at Committee or Board level


N/A


N/A


All Strategic risks are reviewed monthly by the Executive Directors. Each committee also reviews the strategic risks associated with their terms of reference and strategic objectives SR 1 and 4 with the associated corporate risks were reviewed by the Performance and Finance Committee on 19 February 2020 SR2 and the associated corporate risks was reviewed by the Quality Governance Committee on 5 February 2020 SR3 and the escalated recruitment risk will be reviewed by the Workforce committee on 16 January 2020

LINKS TO THE BAF AND KEY RISK AREAS:

BAF report – all strategic risks and those principal risks escalated to the Board Assurance framework are in included



X

Board Assurance Framework


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SR2: Failure to achieve continuous quality improvements in the quality of care delivered to our patients X

SR3: Failure to embed a patient-focussed culture that puts the patient at the heart of everything we do X




Provide better care X

Value our people X

Value for money X

Improve performance X

OTHER:


LINK TO CQC:

Caring

Responsive

Effective

Well Led X

Safe X


Legal Implications - Health and Social Care Act Equality and Diversity Impacts - None identified



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Board Assurance Framework Assurance from Audit Committee: The Audit Committee reviewed the Board Assurance Framework in February; this included detail on risk activities undertaken by the other Board Sub-Committees. Broadly, there were good levels of assurance afforded across each of the strategic risks and committee portfolios. In summary by Committee: Performance and Finance Committee (SR1 and SR4)

Full assurance:

The strategic risks clearly reflect the level of risk pertaining to performance and finance, with

appropriate residual scores. The Committee agenda and papers fully aligned to ensure sufficient

oversight and coverage of the high-risk areas as outlined within the Board Assurance Framework,

with clear actions in place to support mitigation

Good levels of assurance noted on the planning and preparation of CIPs and the delivery to date in

several areas

Good assurance on achievement of performance in relation to the critical path was noted and it as

agreed to circulate weekly performance summaries to Board members for increased visibility over this

period.

Full assurance on the finance report and capital planning and delivery

Partial Assurance:

Concerns were raised relating to clarity on delivery of benefits on one of the regional level CIPs – the

make ready programme. This was subsequently subjected to a deep dive in January to seek

additional assurance

Assurance on the detail in the improvement plan was provided however the committee expressed

some concerns on the risk to delivery and the need to ensure sufficient focus.

Quality Governance Committee (SR2)

Full assurance:

The strategic risks clearly reflect the level of risk pertaining to quality and safety, with appropriate

residual scores. The Committee agenda and papers aligned to ensure sufficient oversight and

coverage of pertinent areas, as outlined within the Board Assurance Framework

Full assurance on the progress in relation to medicines management and progression to a controlled

drugs licence.

Progress on establishment of the clinical strategy

Full assurance on progress on flu vaccination programme

Partial Assurance:

Progress against the CQC plan was not as advanced as the committee had hoped. The Committee

noted the incoming Interim Director of Clinical Quality and the review of this for the next meeting

Workforce Committee (SR3 and recruitment risk)

Full assurance:



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The strategic risk and Principal risk on the BAF clearly reflect the level of risk pertaining to workforce

and culture, with appropriate residual scores. However, members have requested a focussed deep

dive in the November meeting to ensure sufficient oversight of all the causative factors

Full assurance on the Equality and Diversity progress, as well as the Get Real Change leadership

programme

Partial Assurance:

Delivery of the mitigating actions within the BAF designed to provide risk control – whilst assured

these were the right actions, there was limited assurance on deliverability and the committee outlined

the need to ensure sufficient focus on delivery of these actions.

Partial assurance on workforce metrics and priorities (trajectories required); PPI and CEG update

(requires alignment to future strategy); Education and Training (further assurance required on course

fill, the pipeline and confidence around achievement of the target

Good assurance was afforded to the continued reduction in ER and ET cases, however further

assurance is required in relation to the changes and improvements in the process to support a

sustainable way forwards

Audit Committee referred to Workforce the issue relating to HR policies. Workforce Committee received a

report on this issue along with a trajectory of policy review completion, prioritised according to risk, by April

2020. The workforce committee are reviewing progress at each meeting and are assured on the detail of the

plan – however delivery is essential prior to assurance being given.



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Board Assurance Framework Summary – March 2020 (Third Line of Defence)

The following table gives an overview of the Trust’s strategic risks, their current status and the anticipated date when the risk will be mitigated to the required

level. It also provides a narrative update on progress in regard to the mitigating actions and rationale for the residual risk score:

Risk Title Owner Committee Inherent Residual Target Risk Review Details

SR1: Failure to deliver a timely response to our patients in line with commissioned national standards, to ensure a safe level of service

Marcus Bailey - Chief Operating Officer

Performance and Finance Committee

I = 5 L = 4 20 (20)

I = 5 L = 4 20 (20)

I = 5 L = 2 10 (10)

Latest Review Date: February 2020 The residual score of SR1 remains the same, in light of the mid/long-term challenges being addressed by the Trust’s Recovery Plan. Whilst it is important to note that performance delivery is in line with the internal trajectory set, the risk remains high due to winter pressures, factors impacting staffing and activity levels such as winter virus prevalence, and system-wide pressures. High level of assurance received via Performance Committee on critical path and planning for delivery against the trajectory.

SR2. Failure to achieve continuous quality improvements and high quality care delivery

Dr Tom Davis – Medical Director


I = 5 L = 4 20 (20)

I = 4 L = 3 12 (12)

I = 3 L = 2 6 (6)

Latest Review Date: February 2020 This month the score remains the same, with IPC compliance increased and a number of additional actions identified to strengthen mitigation and monitoring. Delicacies in relation to performance related risks could result in deterioration in quality and safety performance and as a result is being monitored carefully. Review of the CQC action plan in terms of ‘must do’ and ‘should do’ has been completed and a clear plan in place, for presentation to the Board in March. Good levels of assurance in relation to safeguarding was noted at the Quality Governance Committee

SR3. Failure to establish a culture of engagement and accountability that is patient focussed

Dorothy Hosein – Chief Executive Officer

People and Culture Committee

I = 4 L = 4 16 (16)

I = 4 L = 4 16 (16)

I = 4 L = 2 8 (8)

Latest Review Date: February 2020 Risk reviewed and score remains the same, in light of the need to continue to progress some longer standing areas of focus. Significant improvement on ER casework volume has been evidenced in workforce committee giving assurance on progress and correct areas of focus. Good progress relating to

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Governance and Well Led domains which strengthen control of this risk. Progression of Freedom to Speak Up Guardian recruitment also progresses us to further mitigation of this risk. Results of the Staff survey are under review with a range of positive findings and areas for continued improvement, which will result in a review of the risk at the end of the financial year by the new Workforce Director.


Kevin Smith, Director of Finance and Commissioning


I = 5 L = 5 25 (25)

I = 4 L = 5 20 (20)

I = 4 L = 2 8 (8)

Latest Review Date: February 2020 Risk reviewed and score stays the same, although significant progression has taken place and discussions were held in Performance and Finance Committee regarding a potential reduction in score, once 2020/21 QCIP plan and the A&E contract are finalised. There has been good progress on recovery planning, with the 20/21 provisional target of £11.5m set (subject to budget setting and contract negotiations). Of the £11.5m target, £8m has already been identified with schemes now being progressed through the gateway process. Good progress on contract negotiations to date.

Ability to recruit the numbers of staff required

Dorothy Hosein, Chief Executive Officer

Workforce Committee

I = 5 L = 5 25 (25)

I = 4 L = 4 16 (16)

I = 4 L = 2 8 (8)

Latest Review Date: February 2020 Last Review Comments: Risk reviewed, and score remains the same, as the highest risk area impacting upon the strategic objectives. Progression in recent weeks on establishment of the workforce projections which has enabled clarity on the training plan, to achieve a target of full establishment by March 2021. Review of clinical supervision and the pipeline from recruitment through training and out onto the frontline is ongoing, but it is anticipated that greater levels of assurance will be afforded to the recruitment and retention processes in the next two months. Incoming Director of Workforce will undertake a review by the end of the financial year for onward reporting, mitigation and assurance.

The key for delivery confidence rating of actions in the main section of the BAF (pages 6-13) is as follows. It should be noted that this confidence rating relates to the confidence in completion of the action and establishment of an additional control, as such does not necessarily indicate an improvement in metric as the action is underway, i.e. the control is not yet in place:

Green The action will deliver successfully on time, within budget and the level of quality required. There are no major problems or barriers that threaten delivery

Green/Amber Successful delivery of the action is probable, but constant focus is required to ensure it remains on track and risks do not materialise

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Amber Successful delivery is feasible, but significant issues and risks exist that require focussed attention. However, these appear resolvable and can be managed with the action still running to time and within budget.

Amber/Red Successful delivery of the action in doubt due to significant issues and risks in key areas. Urgent action needed to determine whether can be resolved.

Red Successful delivery of the action unachievable. Major issues do not appear to be manageable. The project needs re-basing or its viability re-assessing

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Risk Description Strategic Objective

The Trust has in place a six-year contract to enable delivery of the requirements outlined in the Independent Service review, which includes workforce growth, operational efficiencies and rota conversions, in order to support a timely response to all of our patients. The workforce plan and building better rotas programmes are in situ to reduce the capacity gap and deliver the patient facing staff hours in the long term; however the long-term nature of these programmes and the challenges associated with recruitment and retention result in the need to focus on interim mitigation to ensure a safe staffing level that delivers safe and timely care. Operational efficiencies are also essential to maximise delivery of a timely service to patients, through improved usage of the workforce. The current risks underpinning SR1 include staffing levels, ratio of RRVs to DSAs, abstractions, increased activity acuity, arrival to handover delays, and financial capacity, as well as reputation considering the national context. The high-risk nature of the service includes the pressures within the control rooms, including management of patients waiting, surge and times of peak demand, and the need to balance all of the risks to ensure safe decision making through consistent leadership and behaviours.

Putting into place a new responsive operating model to deliver sustainable performance and improved outcomes for patients

Owner Committee


Performance and Finance

Risk Score Detail to Date Assurance of controls Target Risk Score Post-Mitigation

Likelihood Impact Score Likelihood Impact Score

Inherent 4 5 20 Moderate

When mitigated 2 4 8

Last month 5 4 20 Mitigated score to be achieved by March 2021

This month 5 4 20

Mitigating Actions Owner Due

Deliver the clinical workforce plan against the trajectory (ISR). Recruitment progression has seen improved course fill rates and the rate of leavers has reduced, but the workforce gap remains significant. Workforce projections now available to enable the build of the proposed training and development plan (complete). The plan supports achievement of the goal of zero workforce vacancies by March 2021, and is due for review at Workforce Committee in January.


March 2021

Implement make ready programmes to maximise efficiencies. Clear programme plan and oversight in situ with 5 sites completed and a further two imminent. Recruitment to AFA posts and capital works progressing well. Currently reviewing rate of efficiencies and savings and when benefits will be realised, through Performance and Finance Committee. Assurance received on progress, further work on plan to release savings required for the March Committee meeting (after Board meeting, so action remains)


March 2020

Complete Fleet transformation process to provide increased ambulances and a sustainable fleet. Next phase is the total new fleet to 111 by the end of quarter three, with plan on track. This includes a combination of replacement of existing fleet and additional new vehicles. Current action now complete, but planning for next phase into the new financial year in line with budget setting


April 2020

Increase the level of productivity across service delivery, to maximise operating capacity. A core component of the improvement plan, this is being progressed and includes make ready site implementation and on scene times and behaviours. Action ongoing. Review of PVSH undertaken and action plan being produced. AACE peer review of dispatch functions post ARP implementation - action plan to be developed for ELB review. This action will continue to the end of the financial year as part of the QCIP programme


April 2020

Identify and implement operational efficiencies to deliver required productive patient facing staff hours. Implementation of make ready over coming months will further support greater efficiencies and improved responsiveness. Sectors have established local efficiency plans


April 2020

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which are being monitored through Accountability Committee and QCIP delivery group. Success and traction varied with some high performing and some at risk QCIPs, as reported to P&F via deep dives in previous meetings. Activities identified and incorporated within the CIP recovery workstreams. These will be combined with Lightfoot and Carter metrics review in due course along with peer reviews completed.

Maximise use of the flexible workforce to minimise delays to patient care. This is an ongoing action through the year to mitigate the risk whilst longer term programmes such as building better rotas and the workforce plan are progressed. It includes utilisation of PAS, managed overtime, and use of agency staff. NHSP reviewed and option appraisal completed – not cost effective at this time and so internal option for bank to be progressed. CIP recovery workstream incorporating effective use of flexible workforce.


March 2020

Implement Lightfoot Performance processes using robust change methodology, focussed upon ways to improve performance across three distinct areas of geographical difference – rural, semi-rural and urban. Delayed due to capacity and current contract ending. New proposal and paper to ELB


April 2020

Embed innovation and transformation culture to maximise patient care through efficiencies. Transfer of knowledge is underway to the change agents. Head of PMO recruited to bring capacity to deliver, and further recruitment to the PMO is underway. PWC contract extended til the end of the financial year to give continuity and skills transfer to the PMO – action will then close

Head of Strategy and Transformation

March 2020

Review and deliver benefits realisation from rota realignment and establish planned implementation date for Watford area. Chief Operating Officer

September 2020

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Inability to successfully focus upon safety and quality improvements due to pressures financially and operationally would limit the progress made by the organisation in relation to governance, clinical quality and patient safety. This could lead to an inability to provide safe, consistent and high-quality care to patients across the region. This would have regulatory and reputational implications for the organisation. Current risks include the skill mix and relatively inexperienced clinical scope of the workforce, difficulty with clinical supervision, lack of aligned IT systems to support monitoring, repeat incidents, and the ability to be compliant with training requirements are all significant factors to our ability to deliver quality improvements and reduce variation in practice.

Provide Better Care

Owner Committee

Medical Director Quality Governance

Risk Score Detail to Date Assurance of controls

Target Risk Score Post-Mitigation




Last month 4 3 12 Mitigated score to be achieved by November 2020

This month 4 3 12


Gain approval of the Clinical Strategy for the Trust, including metrics for measurement of improvement and ensure a robust implementation plan – Report received in July and progressing, as per the agenda and outline of priorities. On track and aligned with corporate strategy development, with Board strategy workshop in February. Approval due in line with Corporate Strategy in May

Medical Director May 2020

Pilot and then roll out a clinical supervision model for all clinicians, to facilitate both students and the longstanding workforce have appropriate levels of support and supervision for continuous improvement. Ongoing development of draft model, to be aligned with the operational model and advancing practice and budget setting. There is a new national workstream on clinical supervision that will inform the work. On track to be in place for the new financial year

Medical Director, Chief Operating Officer

April 2020

Redesign the Professional Update course to maximise learning and enable successful delivery and compliance with the programme, whilst delivering the core service. Proposal to move from PU to CPD model has been approved and implementation plans are being finalised. On track to be in place for implementation in April.

Medical Director April 2020

Embed medicines management procedures, including audit and reporting, into business as usual delivery. Pilot of a centralised medicines stock and supply process is taking place to support consistency and reduce variation. Roll out commenced in January and following initial lessons learnt, the overall rollout timeframe has been extended through to June – date realigns to reflect accepted project realignment alongside other competing priorities. Progressing, as noted in Quality Governance Committee

Medical Director June 2020

Improve time-based clinical targets to deliver sustainable clinical performance, in line with make ready and workforce trajectories. Anticipating a deterioration in time based targets due to the four month-lag in data, but internal indicators such as out of service time improvements via the 10:10 scheme and safety huddles are seeking to make sustainable improvements. Anticipate date is likely to slip in terms of seeing tangible improvements and the need for some IT solutions to improve the reflection of practice

Medical Director March 2020

Establish Safe Staffing outline proposal. National Quality Board has released the draft Ambulance safe staffing resource which is being reviewed by ELB in January 2020. Deferred due to changes in personnel – date realigns to enable substantive Director to be recruited

Medical Director July 2020

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Undertake lessons learned review of 2019/20 complaints to support a policy framework review. This will further support immediate improvements implemented to the complaint process, timeliness, complainant experience and the opportunity for learning. Due to change in personnel, date realigns


Scope training proposal for frontline managers on clinical indicators to raise awareness and support standardisation of clinical practice across all areas. Due to change in personnel, date realigns


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Failure to develop a just culture that focusses upon the patient and our staff has the potential to cause avoidable patient harm, incorrect decisions, low staff morale and issues with retention of our workforce. A lack of just – or safety – culture can lead to inconsistent practice and a lack of confidence in the leadership across the organisation, leading in turn to patient safety and staff welfare issues. Whilst the CQC’s rating of ‘outstanding’ for care demonstrates that staff continue to deliver consistently high standards, the staff survey and well led aspects of the CQC inspection (2018) shows that there are clear cultural issues requiring redress. Current risks include inconsistent practices and management approaches, repeat ER casework and limited preventative work through a lessons learnt or an analysis approach, inconsistent documentation and transparency regarding decision making, lack of collective responsibility towards patients, lack of a performance management framework, backlog in employee relations cases, varied leadership and insufficient staff engagement.

Guarantee we have a patient-focussed and engaged workforce

Owner Committee

Interim Director of People and Culture & Medical Director

Workforce Committee




Inherent 4 5 20 Low


Last month 4 4 16 Mitigated score to be achieved by September 2020

This month 4 4 16


Form professional standards panel Not yet progressed due to focus on clinical staff support actions and interim senior roles. Informal process is in place currently to support registrants at Director level. Date realigns to fit with substantive directors coming in to place, and work on a formalised process can then commence.


Ensure all staff receive a compassionate conversation and appraisal. The expectation is to meet 90% completion by January and then maintain on a month by month basis – amber confidence rating due to winter but monitoring through Accountability committee


March 2020

Deliver ER process improvement actions to ensure an efficient and effective process. Actions underway include frequent HR lead review of all cases, improved links on police cases and rapid hearing arrangements

Deputy Director of People and Culture

March 2020

Deliver the outputs within the improvement plan: well-led and governance – Moves to cycle five so date now realigns. CQC action plan under final review and therefore subject to amendment. Good progress against Board-identified well led actions. Board effectiveness review undertaken which will result in further actions

Head of Governance

May 2020

Implement the recommendations from the Freedom to Speak Up review – actions delayed to realign with appointment of Freedom to Speak Up Guardian, which slips into quarter four. FTSU Guardian recruitment is underway with plan to commence in post in May. Board workshop on self-assessment completed in February with ongoing support from NHSE/E. Once new Guardian in post, remaining actions will be progressed.


Complete HR policy update Clear trajectory and project plan now in place, monitored through Workforce Committee. Commitment from working group to undertake review into 20 policies by the end of March.

Deputy Director of People and Culture

March 2020

Undertake meeting and decisions framework review to reduce avoidable components, improve capacity across the Trust and improve timeliness of decisions. ELB and Board approved, approval of ToR underway. The majority have commence under the new ToR with the remain to commence in April.

Head of Governance

April 2020

Establish culture action plan via Board workshop and strategy progression, reviewing the findings from the Get Real Change Chief Executive May 2020

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programme. Officer

Refresh and Relaunch the Raising Concerns Forum Group Terms of reference reviewed, forum met in December. January meeting has been deferred in order to realign following the outcome of the Board FTSU self assessment. Date therefore realigns and confidence score reduces, although plan in place to deliver.


Complete transfer of remaining staff onto electronic system and manually check DBS records to ensure future oversight of all staff

Deputy Director People and Culture

March 2020

Establish a performance management framework for the organisation. Date realigns due to current focus on recruitment and policy compliance. Work to align with strategy development, to ensure clear objective setting and cascade. To be monitored via the workforce committee

Chief Executive April 2020

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Following agreement of the contract post ISR, 2019/20 was intended to be the first year of full delivery of the ISR targets. However, the workforce challenge and the scale of transformation and risks associated with successful delivery have impacted on the ability to meet the targets within the anticipated timescales. As a result, the Trust anticipates being off-plan financially at the end of the 19/20 year, and so development of a robust and effective Recovery Plan spanning two financial years to bring financial stability and long-term sustainability and efficiency, is underway. The two-year timescale for delivery of the recovery plan take into consideration the significant interdependencies between delivery of the workforce plan, workforce needs, and the transformation required to ensure patient safety during the recovery period. The Trust needs to continue to undertake rapid large-scale change throughout all areas, in order to transform its systems and processes safely; this must be done as efficiently as possible, maximising the value of the public pound. Risks include the cost of transformation and the capacity pressures in situ as a result of a lean support structure under the Carter target, as well as the challenge to seeking viable efficiencies and confidence in overall delivery. A current, mid-term risk relates to the uncertainties surrounding next year’s contract, and the potential to lose block contract and more to an increased proportion of cost and volume. It should also be noted that the recovery plan and mitigation of this risk is also dependent on successful mitigation of SR1 and the escalated recruitment risk.

Delivering innovative solutions to ensure we are an efficient, effective and economic service

Owner Committee

Director of Finance and Commissioning

Performance and Finance







This month 4 5 20


Establish PMO functionality fully in house to enable long term application of the embedded governance process. New action, Head of PMO recruited, other posts underway. In the interim, PWC are supporting the embedding of the CIPs and recovery plans, with clear focus throughout all management levels. On track, through til the end of March will focus on robust induction into the programme governance framework and skills transfer from PWC


March 2020

Develop Corporate Strategy and five-year plan with interim milestones of September Board for launch of consultation and collaboration with the wider health economy on system plans. Date realigns to March following December Board workshop. February workshop has been scheduled to finalise the strategy proposals and review underpinning strategies. On track to allow strategy approval at the next public Board


May 2020

Develop Commercial Strategy in line with corporate strategy, to establish clear business intent for the Trust. Underpinning strategies are due for drafting in quarter four. Proposal for short term (12 month period) Commercial services team discussed at ELB to ensure appropriate infrastructure to support the proposed strategy.

Director of Finance & Commissioning

May 2020

Identify and implement operational efficiencies to deliver required productive patient facing staff hours. Implementation of make ready over coming months will further support greater efficiencies and improved responsiveness. Sectors have established local efficiency plans which are being monitored through Accountability Committee and CIP delivery group to bring recurrent efficiencies and improve unit hour production; schemes in consideration vary but include stock control and out of service work. Progress continues with oversight through performance and finance committee. Mixed results to date, but real focus via CIP delivery group and accountability committees


March 2020

Implement make ready programmes to maximise efficiencies. Clear programme plan and oversight in situ as evidenced via committee deep dive. Good progression of the project, current focus is on quantification of the efficiencies and cost improvements to be released, and


March 2020

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when.

Standardise the Trust’s Procurement Processes to improve financial management and bring efficiencies. Initial focus via the improvement plan on purchase to pay and materials management solutions. Full business case has been reviewed and completion date extends to align with the availability of capital resources – becomes a 2020/21 project.


October 2020

Embed Recovery Plan implementation within core business delivery. Recovery plan is for implementation in April, with decision and approval of the final plan scheduled for February 2020. On track with schemes and progression through the gateways, processes embedded in preparation for implementation.


April 2020

Conclude financial negotiations within the current contract for the 2020/21 year. Commissioning intent submitted, awaiting publication of national guidance documents. Good indicative progress to date.


March 2020

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526: Ability to recruit and retain the numbers of staff required to meet contractual and performance requirements


The recognised shortfall of clinical workforce as evidenced within the Independent Service Review demonstrates the need to recruit a significant number of additional clinicians over and above attrition over the next two-year period. Re-profiling of the workforce plan has demonstrated a re-basing of the second year due to a shortfall in workforce growth by the end of Q4 2018/19. Factors include the national shortage of paramedics, limited resources internally to deliver the training places required, and turnover of existing staff, which includes the desirability of Paramedics in other sectors of healthcare. The risk of non-delivery of the workforce numbers required impacts upon the ability to deliver the patient facing staff hours required to deliver a safe and timely service to patients, in line with performance standards. It also impacts the ability to ensure financial sustainability due to the cost of training combined with using temporary resource to support operational delivery.

Owner Committee


Workforce







This month 4 4 16


Recruit to a minimum of 85% utilisation rate of all training courses, to maximise course fill and support delivery against the workforce trajectory. Training pipeline now worked to ensure clarity, next step to ensure flow through from recruitment to operations


September 2020

Complete review of data to enable robust reporting to Board and Committees against trajectory – this action was identified and agreed at Workforce Committee and will result in a clear trajectory and goal to monitor against. Trajectories being established to support oversight and assurance and action can close once complete. Date realigns to March Workforce committee due to deferment of meeting

Chief Operating Officer March 2020

Complete Training and Education Improvement Plan to maximise quality of courses and ensure compliance with regulatory requirements. Good progress against actions regarding apprentice training and establishment of the pipeline. Action continues

Chief Operating Officer March 2020

Establish Recruitment and Retention Improvement Plan with NHSE/I support as per national improvement collaborative. Underway with four areas – career development, wellbeing and resilience, staff engagement and flexibility in working. Draft plan will be presented to February Workforce Committee


March 2020

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MEETING TITLE

PUBLIC BOARD

Date: 11.03.2020 Report Title: Risk Strategy including Risk Appetite and Financial Losses Agenda Item: 20 Author: E de Carteret, Head of Governance Lead Director: D Hosein, Chief Executive Officer Purpose: Assurance Decision


SUMMARY AND BACKGROUND: Audit Committee have reviewed the Risk Management Strategy, to gain assurance that this is still relevant and applicable to the Trust. The Committee approved continuation with the strategy, which is attached as an appendix. The following minor changes were made, as follows:

• Changes to responsibilities to reflect the changes to job titles in year • Realignment of the need to ensure focus on financial risk and impact as per the recovery plan • Reference to the Portfolio Office for oversight on CIP and project risks • Removal of KPI 8 (RIDDOR reportable incidents) – monitored via Health and Safety • Replacement of old Equality impact assessment with the new version • Replacement of appendix E with new QIA template in use as per the Recovery Plan

RECOMMENDED ACTION: • Accept the Audit Committees recommendation and approve the strategy • Note the Audit Committee’s request for Board to review the risk appetite in the 2020/21 Board

workshop for risk management – to ensure ongoing alignment with the Corporate Strategy and Sub-Strategies

KEY ISSUES IDENTIFIED None noted


PREVIOUSLY CONSIDERED BY: Audit Committee February 2020

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers] Risk management strategy – relates to all risks


X

SR2: Failure to achieve continuous quality improvements in the quality of care delivered to our patients X SR3: Failure to embed a patient-focussed culture that puts the patient at the heart of everything we do X SR4: Failure to deliver an efficient, effective and economic service X Other: Please Specify X

THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE Provide better care X Value our people X Value for money X Improve performance X


Risk Management Strategy


of 2

LINK TO CQC: Caring Responsive X Effective Well Led X Safe X

RELEVANT LEGAL OR STATUTORY ISSUES Audit Committee requirements Well-Led framework



EEAST: Risk Management Strategy and Policy V1.0

Risk Management Strategy and Policy

Document Reference To be assigned by Corporate Records Manager Document Status Approved Version: V3.1

DOCUMENT CHANGE HISTORY Initiated by Date Author (s) Audit Committee January 2017 Emma de Carteret, Head of Portfolio Office Version Date Comments (i.e. viewed, or reviewed, amended

approved by person or committee) Draft V0.1 December 2017 Merging of two separate documents – Risk

Management Strategy (V10) and Risk Management Procedure (V3)

V0.1 17 January 2018 Approved at Senior Leadership Board V0.1 25 January 2018 Approved by Executive Leadership Board V0.1 31 January 2018 Approved by Audit Committee V1.0 28 March 2018 Board Approval V1.1 1 February 2019 Minor amends and risk appetite statement inclusion V2 27 March 2019 Approved at Trust Board V3.1 6 February 2020 Minor amends and Audit Committee annual review Document Reference Health & Social Care Act 2008 (Regulated Activities) Regulations

2009 Directorate: Strategy and Sustainability

Recommended at Date

Audit Committee 6 February 2020

Approved at Date

Trust Board

Review date of approved document

March 2021

Equality Analysis 26 January 2020 Linked procedural documents Governance and Assurance Strategy and Framework

Health and Safety Policy Manual Handling Policy Violence and Aggression Policy Fire Safety Policy Major Incident Plan Business Continuity Plan Infection, Prevention and Control Policy Investigation Guidance Management of Incidents Policy



Risk Management Strategy and Policy V3.1


Serious Incident Policy Complaints Policy Whistleblowing Policy Information Governance Policy Medicines Management Policy Counter Fraud and Corruption Policy Safeguarding Policy

Dissemination requirements All managers and staff, via email and intranet Part of Trust’s publication scheme

Yes

The East of England Ambulance Service NHS Trust has made every effort to ensure this policy does not have the effect of unlawful discrimination on the grounds of the protected characteristics of: age, disability, gender reassignment, race, religion/belief, gender, sexual orientation, marriage/civil partnership, pregnancy/maternity. The Trust will not tolerate unfair discrimination on the basis of spent criminal convictions, Trade Union membership or non-membership. In addition, the Trust will have due regard to advancing equality of opportunity between people from different groups and foster good relations between people from different groups. This policy applies to all individuals working at all levels and grades for the Trust, including senior managers, officers, directors, non-executive directors, employees (whether permanent, fixed-term or temporary), consultants, governors, contractors, trainees, seconded staff, homeworkers, casual workers and agency staff, volunteers, interns, agents, sponsors, or any other person associated with the Trust.

All Trust policies can be provided in alternative formats.





Contents Paragraph Page 1. Introduction 5 2. Purpose 5 3. Duties 6 3.1 The Board 6 3.2 The Executive Leadership Board 6 3.3 Assurance Committees 6 3.3.1 Audit Committee 7 3.4 Executive Leadership Sub-Groups 7 3.5 Chief Executive 7 3.6 Executive Directors 8 3.7 Heads of Department and Equivalent 8 3.8 Head of Governance 8 3.9 Trust Specialists 9 3.10 Safety and Risk Lead 9 3.11 All Staff 9 4. Risk Appetite 9 5. Definitions 11 6. Risk Management Strategy and Aim 14 7. Implementation of the Risk Management Strategy 14 8. Risk Management Policy 15 8.1 Risk Identification 16 8.2 Risk Assessment 17 8.2.1 Determining Inherent Risk Score 18 8.2.2 Determining Key Controls 18 8.3 Mitigating Actions 19 8.4 Determining the Residual Risk Score 19 9. Development and Management of Risk Registers 19 9.1 Risk Registers 19 9.2 The Board Assurance Framework 20





Paragraph Page 9.3 Monitoring and Management of Risk Registers 20 9.4 Management of Risks and Risk Appetite 21 9.5 Escalation, De-escalation and Removal of Risks 22 10. Responsibility for Managing Different Levels of Risk 22 11. Service Changes, Projects and Cost Improvement Programmes 23 12. Key Performance Indicators 23 Appendices

Appendix A Monitoring Table 25

Appendix B Equality Impact Assessment 26

Appendix C Risk Matrix 29

Appendix D Risk Assessment Template 33

Appendix E Quality Risk Assessment Template 34





1. Introduction Risk Management is the process of identifying, assessing, analysing and managing all potential risks and when done correctly, assists organisations in successful business planning and management to ensuring the delivery of key and strategic objectives. Risk management is part of every managers day to day responsibilities, it informs judgements about the appropriateness of policy options or service delivery methods, and as such should be integral to both strategic and operational management. The East of England Ambulance Service NHS Trust Board (the Board) recognises that risk management is an integral part of good governance and management practice and to be most effective, should become part of the Trust’s culture. The Board is, therefore, committed to ensuring that risk management forms an integral part of its philosophy, practices and business plans rather than viewed or practised as a separate programme and that responsibility for implementation is accepted at all levels of the organisation. The Trust aims to take all reasonable steps in the management of risk with the overall objective of protecting patients, staff and assets. To achieve this objective, the Trust has adopted a proactive approach with a programme of risk management that aims to preserve its assets and reputation and to provide protection against preventable injury and loss to patients, the general public and employees. Significant work has already been undertaken in regards to risk management within the organisation through training, monitoring and embedding risk within business as usual. Next steps therefore focus upon ensuring risk-based decision making is the norm for all aspects of our business. 2. Purpose This document comprises of both the Risk Management Strategy and Policy, in order to provide a single in-depth file for risk management. The aim of the Risk Management Strategy is to set out the way in which successful risk management will be achieved by the organisation, which will assist in the delivery of the Trust’s strategic objectives. The purpose of the risk management policy section within this document is to provide detailed guidance to Trust managers and staff regarding the operation of the risk management system. It highlights the process to be followed and the responsibilities of those involved in the functioning of the Trust. This document explains how the Trust systematically assesses and treats all types of risks across the organisation. Risk Management forms a core component of good governance and business delivery and as such, adherence to this policy is integral to compliance with the Trust’s Governance and Assurance Framework.





3. Duties 3.1 The Board The Board is accountable for internal control. The Board is required to produce statements of assurance that it is doing its reasonable best to manage the Trust’s affairs efficiently and effectively through the implementation of internal controls to manage risk. In line with Building the Assurance Framework: A practical Guide for NHS Boards, the Board will: • Establish the Trust’s objectives • Establish the Risk Appetite of the organisation • Identify the strategic risks that may threaten the achievement of these objectives • Identify and evaluate the design of key controls intended to manage these strategic risks with

rigour • Set out the arrangements for obtaining assurance on the effectiveness of key controls across all

areas of strategic risk • Identify positive assurances and areas where there are gaps in controls and/or assurances to the

Principal Risks • Put in place plans to take corrective action where gaps have been identified in relation to strategic

risks • Maintain dynamic risk management arrangements including, crucially, a well-founded risk register. 3.2 Executive Leadership Team The Executive Team provides executive leadership to the Trust and is responsible for managing the everyday business affairs of the Trust. They are therefore responsible for ensuring Risk Management is employed throughout all strategic decision making. Other responsibilities include: • Implementation of the strategies and policies of the Trust as determined by the Board • Consideration of both upside and downside risks in decisions relating to potential new business • Monitoring the operation of all Trust services, both front line and back office, against objectives and

action / project plans • Ensuring implementation of risk management systems in accordance with this document and the

associated Governance and Assurance Framework • An awareness of the likelihood and potential impact of risks materialising • Reducing the incidence of impact on the organisation of risks that do materialise • Management and mitigation of the Strategic Risks, as well as those Principal Risks escalated

through the groups in the Governance and Assurance framework • Collective ownership of the Board Assurance Framework • Oversight of the Principal Risks and responsibility for ensuring their direct reports actively seek to

mitigate these 3.3 Assurance Committees The committees are responsible for seeking assurance on behalf of the Board in relation to the risks relevant to that committee, in order to assure the Board that the Trust is on course to deliver against its





strategic objectives. The Board Assurance Framework highlights which committee is responsible for the oversight of which risks. The Committees are also responsible for receiving and reviewing key risks and actions in place to mitigate those risks, highlighted through the assurance and escalation process set out in the Governance and Assurance Strategy and Framework. 3.3.1 Audit Committee The Audit Committee is responsible for providing an independent overview on the effectiveness of the Trust’s risk management and internal control systems, in order to assist in assessment of the way in which the Trust is implementing the Risk Management Strategy. The Audit Committee is also responsible for considering evidence from other areas of the business to enable the provision of robust assurance to the Board that the Trust has a robust and effective risk management system in place – this includes evidence from areas such as internal audit and counter-fraud. 3.4 Executive Leadership Sub-groups The Sub-Groups of the Executive Leadership Team are responsible for considering all risks relevant to their Terms of Reference. The remit is to seek assurance that controls and actions in place are successful in risk mitigation, and escalating risks unable to be managed at that level to the Compliance and Risk Group. The Sub-Groups are also responsible for providing assurance to the relevant Committees on the management and mitigation of the risks pertaining to their Terms of Reference. 3.5 Chief Executive The Chief Executive has overall responsibility for ensuring that an effective risk management system is in place within the Trust and for meeting all statutory requirements and adhering to guidance issued by the Department of Health in respect of governance. The Chief Executive is also accountable to the Board and has responsibility for maintaining a sound system of internal control and will be responsible for preparing the Annual Governance Statement (AGS) that supports the achievement of the organisation’s policies, aims and objectives. The Chief Executive is the Accountable Officer for ensuring that the Trust has a programme of risk management that includes:

• A process for identifying and quantifying risks and potential liabilities engendering among all levels of staff a positive attitude towards the control of risk

• Management processes to ensure all risks and potential liabilities are addressed including effective systems of internal control, cost effective insurance cover, and decisions on the acceptable level of retained risk

• Contingency plans to offset the impact of adverse events • Audit arrangements including; internal audit, clinical audit, health and safety reviews





• Decisions on which risks shall be insured • Arrangements to review the risk management programme

Whilst the strategic development of risk management and its associated activities lies with the Chief Executive, this responsibility is discharged through the departments and respective directors and senior managers as described. 3.6 Executive Directors The Directors are responsible for owning, monitoring and acting upon the Strategic Risks with the intention of mitigating the risks to an acceptable level, in order that the Trust is able to achieve its Strategic Objectives. Directors will take individual ownership for the Strategic Risks based upon the Strategic Objective the risk most relates to. Directors are also responsible for ensuring that Strategic Risks are discussed and key decisions are taken as a collective, as it is recognised that these risks often impact across the Trust and are interdependent. The executive Directors are responsible for ensuring their respective Directorates comply with the Risk Management Strategy and Policy. 3.7 Heads of Department and equivalent Staff at all levels must understand and implement the Trust’s Risk Management Strategy and Policy. Additionally Heads of Operations, Heads of Department and their equivalents are responsible for: • Ensuring that appropriate and effective risk management processes are in place within their

designated areas and scope of responsibility. • Preparing specific directorate and departmental policies and guidelines to ensure all necessary

risk assessments are carried out within their directorate/department in liaison with appropriate expert advisors where necessary.

• Implementing and monitoring any identified and appropriate risk management control measures within their designated areas and scope of responsibility through the maintenance of directorate and local risk registers.

• In situations where potential principal risks have been identified and where local control measures are considered to be potentially inadequate, they are responsible for bringing these risks to the attention of the relevant Director and the risk team, if local resolution has not been satisfactorily achieved.

• Ensuring that all staff are made aware of the risks within their work environment and of their personal responsibilities and that they receive appropriate information, instruction, and training to enable them to work safely. These responsibilities extend to any one affected by the Trust’s operations including sub-contractors, members of the public, visitors etc.

• Ensuring all new staff attend relevant and timely induction programmes and, where appropriate, organising exit interviews, and reporting and addressing any risk areas identified.

3.8 Head of Governance The Head of Governance is responsible for ensuring Risk Management training is appropriate to support delivery of the Risk Management Strategy, ensuring overall compliance with the Strategy and





Procedure and escalating issues and non-compliance to the Executive Leadership Board and Executive Directors. Other responsibilities include:

• The provision of advisory and practical support to Directors and Managers in risk management issues, actions and policy.

• Administration and review support to the 4Risk system • Conducting and supporting the risk assessment process for new schemes and changes • Development, implementation of and monitoring compliance with the Risk Management

Strategy and Policy • Coordination of the Board Assurance Framework for the Trust Board and associated sub-

committees • Development of the training needs assessment for risk management and provision of risk

management training, in line with the risk management training plan 3.9 Trust Specialists Trust Specialists (for example Safeguarding Lead, Medicines Management Lead, Infection, Protection and Control Lead etc) are responsible for ensuring that relevant risks are escalated to the relevant Sub-Group of the Executive Leadership Team for review, discussion and action. 3.10 Safety and Risk Lead The Safety and Risk Lead is responsible for providing Health and safety training, audits, advice to ensure compliance with Health and Safety at Work Regulations, advice on policy development, fire safety training, advice on fire hazards and on policy development. They provide a coordination function for clinical risk assessment, management and reporting to the relevant Executive sub-groups and provide resilience to the risk remit of the Head of Governance. 3.11 All Staff Staff must adhere to policy and ensure changes to policy or practice are implemented, to ensure safety of staff, patients and the public in all instances. Other responsibilities include:

o Reporting accidents/incidents and near misses in accordance with the Trust’s Management of Incident Policy, to enable the Trust to learn and put improvements in place.

o Raising with their line manager, or via the Trust’s ‘risk’ email address, any areas of potential risk that they have recognised.

o Being aware that they have a duty under legislation to take reasonable care for their own safety and the safety of all others who may be affected by the Trust’s business.

o Complying with Trust rules, regulations and instructions to protect the health, safety and welfare of anyone affected by the Trust’s business.

o Being familiar with the Trust’s Risk Management Strategy and Policy, together with other Trust policies and procedures, including health and safety and fire safety, and comply with these.

4. Risk Appetite

The Trust Board has worked to establish a risk appetite for the organisation, in order to assist with determining the level of risk and risk areas requiring focus. The definition of risk appetite is:





The amount of risk an organisation is prepared to accept in the pursuit of its strategic objectives. This is a complex concept to define within an organisation, and the Board therefore has a different appetite for different types of risk (for example finance, safety).

The Trust Board has identified ten risk categories and has assigned each a qualitative risk appetite value. East of England Ambulance Service has very low appetite for safety risk exposure that could result in loss of life or substantial harm to any individual – safety drives all major decision-making within the organisation. In the pursuit of its strategic objectives, the Trust recognises that delivery of the recovery plan, including the financial recovery, is essential to long term delivery of safe and high quality care and as such, financial impact must be considered within any risk mitigation, in line with the recovery plan.

The following table identifies the level of risk appetite within each category of risk. This gives the level of risk the Trust is willing to accept within that category, in pursuit of objectives:

Category Risk Appetite

Notes

Quality Moderate Quality is a key objective for the Trust and should therefore be treated as such; however focus upon safety is the over-riding priority and actions to improve quality must be balanced against this and financial capability.

Safety Very Low Safety must be prioritised within any activities – for patients, staff and the public – this includes security and health and safety.

Workforce Moderate Workforce culture, development and wellbeing are all areas of focus for the Trust and improvements should be actively pursued, but focus on safety, financial capability and statutory requirements must be considered and mitigated first.

Performance Moderate Performance is a priority and should be treated as such; however focus upon safety is the over-riding concern and actions to improve performance must be balanced against financial capability.

Finance Low Efficient use of public monies is essential and should be prioritised, although must be balanced with safety.

Statutory requirements

Very Low Pursuit of all objectives must seek to support compliance with statutory and legislative requirements.

Transformation Moderate Due to its nature, the Trust is willing to accept a moderate level of risk in regards to the progression of transformation schemes; however other areas such as safety and finance must be balanced in pursuit of transformation.

Commercial Low The Trust is keen to progress and expand commercially, however risks arising from commercial progress must be minimised with a reasonable level of confidence in delivery, prior to proceeding. Commercial advances must not adversely impact upon the Trust’s core areas of business.

Reputation Moderate Reputation is important to the Trust and so efforts should be made not to adversely impact reputation. However, application of risk appetite in regards to safety, finance and statutory requirements and will positively impact upon our reputation.





Informatics and Technology

Moderate Data and technology is essential to our business and must therefore be prioritised, but pursuit of improvement in this area must be balanced against safety, financial capability and statutory requirements.

How risk appetite is applied can be found in section 9.4 of this document.

5. Definitions

Appropriate definitions in relation to risk management are important. This strategy will use certain phrases within this document and on 4Risk which are defined as follows: 4Risk: The software system currently utilised by the Trust for the documentation and storage of risk registers. This is populated by managers to demonstrate the risk, its score, controls in place and actions to be taken. This should be updated by risk leads and owners monthly to ensure currency. Assurance: Assurance is the level of confidence the Board has in the Trust’s ability to manage the risks to business delivery and achievement of the strategic objectives. Executive Directors and managers are required to provide assurance to the Board, which can be through a range of methods including internal audit, surveys and evidence based updates to action plans. Board Assurance Framework: This term is used to describe the document which holds the Strategic risk register, or summary of all of the strategic risks, their scores and what mitigating actions are being taken. The Board Assurance Framework (BAF) is reviewed monthly by Directors, and submitted formally to every Board and sub-committee meeting for review and monitoring. It is a key governance tool that enables the Board to gain assurance that the strategic risks are being effectively managed. Consequence: This phrase is used interchangeably with impact (below). This provides a score out of five which demonstrates the level of effect a risk will have, should it occur. Control: A risk control is a system, process or other tangible thing which has been put in place to better manage a risk. Examples could be training, a procedure or equipment which reduces either the likelihood or the impact of a risk. If the control is not yet in place but is being developed, it is a risk action until implemented. Downside Risk: The majority of risks assessed and managed by the Trust. Downside risks relate to the loss of something, harm, or not meeting a target. Escalation: How a risk or issue is raised through the reporting structures of the organisation, in order to ensure sufficient oversight, scrutiny and action. In terms of risk management, risks from local and directorate risk registers can be escalated to the Senior Leadership Board. In turn, the Senior Leadership Board can escalate risks to the Executive Directors and the Board Assurance Framework. Gap in assurance: This term relates to an inability to provide assurance that a risk is being suitably managed to minimise occurrence, or the impact of the risk. This often relates to either insufficient controls being in place, or a lack of evidence to demonstrate that controls are effective. This term can also relate to a lack of confidence in delivery of the actions required to create mitigating controls and manage the risk.





Governance: The mechanisms, systems and processes within the Trust that ensures robust control and management of the way in which the organisation goes about its business. This incorporates specialist fields of governance, for example clinical, information, financial and project. Please refer to the Governance and Assurance Strategy and Framework for more information. Hazard: A danger, or the source of a risk. It has the potential to cause harm if the hazard is not managed or removed. Whilst the term hazard is often used interchangeably with ‘risk’’, a hazard is best described as the cause of a risk, rather than the risk itself. Impact: This phrase is used interchangeably with consequence (above). This provides a score out of five which demonstrates the level of effect a risk will have, should it occur. Incident: An incident is something which has occurred, for example a risk which has materialised. These should be reported by staff using the Datix incident reporting system so that an investigation can occur and action can be taken to prevent an occurrence. Inherent Score: The score of the risk if there were no mitigating controls in place. This demonstrates the worst position that would be caused through the risk materialising. Likelihood: The probability of the risk occurring. Based upon a percentage or ratio, for example the risk is likely to occur on 10% or 1 in 10 occasions. There are five levels of likelihood set out in the risk matrix. Mitigation: to put in place something which reduces either the impact or likelihood of a risk occurring, through the adding of controls. Operational Risks: Risks encountered in the everyday work of managers and staff. Operational risks may be linked to strategic risks if they could impact on the strategic objectives. They are not limited to service delivery but encompass all areas of the Trust and its business. Principal Risks: The risks residing on the Corporate Risk register. These are not identified by score, but by the nature of the risks and the required methods for mitigation. Principal risks can be described as risks that can effect achievement of the Trust’s priorities, which impact across directorates, and require collaborative working between directorates to resolve in an effective manner. Project Management: A strict discipline of initiating, planning, controlling, and closing a specific piece of work that achieves specific goals. A project will result in a clear product or output that can then be utilised within the business as usual environment. These outputs often facilitate control of risks. Project management includes a clear risk management approach to maximise the likelihood of success of the project. Programme Management: The process of managing several related projects together, in order to ensure that delivery is successful. Programmes are intended to improve an organisation’s performance. As with projects, programme management includes a clear risk management approach to maximise the likelihood of success of the programme.





Project and Programme Risks: Risks that are only associated with the specific project, programme, or delivery of the project output. As such, these risks do not impact the Trust’s business as usual state. Project risks are scored in regards to their impact upon the project rather than the Trust as a whole and as such, can result in higher scores. As a result, they are not escalated beyond the project unless they have a direct impact upon the strategic objectives. Red Risks: This is a term often used to describe the collective risks that the Trust has with a residual risk score of 15 or above, based upon assessment of the impact and likelihood Residual Score: The score of the risk after controls have been identified and working effectively. This is the current score assigned to the risk, and demonstrates whether the controls that have been put in place are working effectively to reduce the risk Risk: The chance of something happening that will have an impact on objectives. It is measured in terms of impact and likelihood. Risks may be strategic, operational, clinical, environmental, financial, economic, political or reputational. Simply put, a risk is the probability that exposure to a hazard – or risk cause – will result in a negative consequence occurring. Risk Action: An action that is taken to reduce either the likelihood of the risk occurring, or to reduce the impact/consequence, should a risk occur. Actions put in place should be set out using SMART principles, with a clear action owner and timescale for completion. They must also be proportionate to the risk itself. Risk Appetite: The amount of risk an organisation is prepared to accept in the pursuit of its strategic objectives. This is a complex concept to define within an organisation, and the Board will have a different appetite for different types of risk (for example finance, safety). Risk Assessment: The systematic review of all strategic and operational activities to identify hazards and develop control measures that eliminate or mitigate the risk. The risk assessment process is a step by step method to ensure all factors are considered and to ensure that the correct actions are taken to help reduce or control the risk. Risk Lead: The person that the Risk Owner feels is better placed to manage the risk on their behalf and to regularly update and report back on progress and mitigation. The Risk Owner ultimately has overall responsibility for the risk, but the Risk Lead takes day to day responsibility and has the most influence in terms of completion of the mitigating actions required. Risk Management: The process of identifying, assessing, analysing and managing all potential risks. Risk Matrix: The mechanism / chart through which all risks are rated and scored using a 5 x 5 matrix with definitions for the impact and likelihood (Appendix C). Risk Owner: The person with overall responsibility for the management of a particular risk. Strategic risks (as per the definitions above) are always assigned to a Director with Principal risks to a Senior Leadership Board member. Risk Register: A management tool that enables the Trust to understand its comprehensive risk profile and is the hub of the internal control system. It includes all strategic and operational risks and they are





stored on an electronic risk management system called “4risk”. The Trust Risk Register is sub-divided into a number of directorate risk registers to ensure there is ownership and management of risks relevant to that area at a local level. Strategic Risks: Risks that may prevent achievement of the Trust’s strategic objectives. These are identified, assessed and managed by the Board and are reviewed at each Board meeting. Upside Risks: The opposite of a downside risk. These relate to the uncertain possibility of gain and often relate to projects or commercial delivery. Upside risks describe the risk being taken to gain the benefit, or upside.

6. Risk Management Strategy and Aim

The overriding aim of the Risk Management Strategy is to maintain and continually seek to improve the quality of healthcare provided by the Trust through the minimisation of risk and harm. To do this, the organisation must ensure that all activities – planned or undertaken – are adequately assessed to ensure that risks have been identified and evaluated, and that appropriate controls and actions are in place to minimise either the likelihood or impact of the risk. It is essential that the organisation not only considers the risks of carrying out an activity, but also those actions that the organisation decides not to take. Objectives underpinning this aim are:

• Ensure that risk management is linked to the implementation and achievement of the Trust’s Strategic aims and objectives.

• Identify and control risks which may adversely affect the Trust’s operational ability • Provide and maintain a safe and secure environment for patients, staff and visitors • Encourage and support innovation and service developments within clear frameworks for risk

management and governance • Protect the services, finances and reputation of the Trust through risk evaluation, control,

elimination or transfer of risk. Otherwise ensure the organisation openly accepts the remaining risks

• Create awareness throughout the Trust about the importance of actively managing risk and how this improves safety for staff, patients and the public

• Ensure risk management systems and processes are clear and understood by all staff • Provide a systematic approach to risk discussions to ensure a ‘no surprises’ culture from

operational staff through to the Board

7. Implementation of the Risk Management Strategy

The Risk Management Strategy and Policy will be applied through a number of methods, including: • Implementation of and adherence to the Risk Management Policy, as set out within this document • Implementation and adherence to all policies in use in the organisation • Establishment and application of a Risk Appetite statement by the Board • Utilising the governance and assurance framework, ensuring flow of risk information through all

groups and committees • Ensuring that all formal Trust groups and committees discuss risks at each meeting





• Provision of risk management training according to the role of the staff member • Ensuring that staff and managers have adequate knowledge and/or access to all legislation

relevant to their area and, as advised by appropriate experts, ensure that compliance with such legislation is maintained.

• Ensuring that adequate resources are made available to provide safe systems of work. This will include making provision for risk assessments, appropriate control measures, raising outstanding concerns, ensuring safe working practices and continued monitoring and revision of same.

• Ensuring that all staff are aware of the system for the reporting of accidents / incidents and near misses. This includes ensuring that all incidents and near misses are appropriately reported, investigated, actioned and feedback provided to enable lessons to be learnt.

• Ensuring that concerns, complaints and claims are managed and investigated appropriately to enable lessons to be learnt

• Ensuring that staff attend all appropriate mandatory training e.g. Health and Safety, Fire Safety, Moving and Handling, Conflict Resolution, Resuscitation Training etc. and that mandatory updates are maintained.

• Ensuring that good practice is shared and disseminated across the organisation to facilitate the continuous improvement of services

• Utilising data from incidents, claims, complaints, concerns and other information to identify issues, risks and concerns and develop plans to resolve these within a timely manner.

• Promoting greater risk management health and safety awareness amongst all staff and ensuring that properly trained and competent staff are responsible for assessing risks and determining adequate control measures within the working environment.

• Making arrangements for the development and testing of procedures to ensure that fire and other emergency situations are appropriately dealt with.

• Monitoring clinical performance, health and safety standards including risk assessments, infection control measures; use of personal protective equipment etc and ensuring that these are reviewed and updated regularly, with appropriate actions taken.

8. Risk Management Policy

The following sections provide detail in relation to the Risk Management Policy, the Trust’s approach and the way in which risks should be assessed, documented, managed and reported throughout the organisation. Adherence to the policy will ensure that a continual, systematic approach to the management of risks and issues is followed throughout the organisation. The following flow chart provides an overview of the risk management process, which is broken down in more detail in subsequent sections:





8.1 Risk Identification The first step in risk management is to identify the risks that could impact upon the objective intending to be met. Risk identification should be a continuous process, as new risks and hazards could become known at any given time. Risk identification can occur in two main ways – proactively and reactively.

• Proactive risk identification occurs throughan individual actively considering all possibilities. A key part of this approach will be to ‘horizon scan’, reviewing trend data or national publications, in order to estimate factors – or risks – that could have an adverse impact on the Trust.





Organisations with a high level of risk maturity identify the majority of risks in this way, as they are invested in preventing an occurrence

• Reactive risk identification is when a risk is recognised after an incident has occurred – i.e., when a risk has materialised. Recognition that the incident could happen again initiates the risk identification and management process.

It is important to consider and document the source of the risk, as this enables the organisation to identify which risks have been identified proactively or reactively. Examples of sources include:

• Discussions at team meetings • Single incidents, serious incidents, complaints or claims • Trends and themes demonstrated through analysis of data • Internal and external audits • Surveys • New guidance or national best practice

8.2 Risk Assessment The Trust requires that risk assessments are carried out in relation to the below types of risk:

• Strategic risks • Operational risks • Projects/programmes • Clinical risks • Non-clinical risks • Any proposed service changes

By assessing these types of risk, the Trust can ensure all categories of risk are considered. The risk assessment should include consideration of all questions highlighted in the risk assessment section of the flow chart in section 7. The risk assessment is a fundamental step in successful risk management – if it is not undertaken in a detailed manner, incorrect actions or ineffective controls could be established which do not help to manage the risk, and can incur unnecessary cost. It is therefore essential that this stage of the process in conducted in an organised manner. Key points to note:

• Ensure the risk is suitably described so that others can understand the problem • Identify a clear owner for the risk • Ensure that all hazards/causes of the risk are captured and considered, as these are required to

determine what mitigating actions are needed • Identify all of the effects that the risk would have if it materialised, in order to assist with the

scoring of the risk. This must include detailing who, or what, is at risk When carrying out a risk assessment the template at appendix D may be used to ensure a systematic approach is followed through the organisation; however it is recognised that all areas of a risk





assessment are covered when entering a risk onto the Trust’s risk register and as such, completion of the risk assessment template is not essential. 8.2.1 Determining the inherent risk score It is important to note that the risk score must be based upon the impact to the organisation as a whole, not to a specific team. The exception to this relates to project risks, which are measured according to the impact upon the project. The inherent risk score demonstrates the likelihood and consequence that a risk would have, before any controls are put in place. It is the level of risk that is apparent at the point of the first risk assessment. Determining the inherent risk score is important as it allows the organisation to understand how significant the risk is, how much effort and resource should be utilised to control the risk, and how effective management of that risk is over time. The inherent risk score is calculated by giving a 1-5 score for both likelihood and consequence, and multiplying them together to give a score out of 25. Definitions for each level of likelihood and consequence can be found in the 5x5 risk matrix in appendix C. 8.2.2 Determining Key Controls Controls are the things put in place to reduce either the likelihood or consequence of a risk. There are a range of controls that can be applied to risks, designed to either prevent, treat, or direct the risk faced. Preventive controls must either eliminate or remove the risk, or substitute it with something less risky to the organisation. Examples of preventive controls would be pre-employment screening, or use of pre-filled syringes to remove the ability for maladministration. Corrective controls treat the risk, and most often reduce the likelihood. Examples of corrective controls include passwords and other access controls, or personal protective equipment. Directive controls are system and processes put in place that are designed to give a specific outcome, through controlling the risk and evidence based practice. Examples would be training, policies and procedures. It is important to note that a control is only in place if it is embedded in practice – for example, recognition that a policy is required is not a control – it is an action. Once the policy has been written, approved, disseminated to staff and implemented, it then becomes a control. It may be necessary to have more than one control to successfully mitigate a risk to an acceptable level and this would be determined through the initial risk assessment, and regular monthly reviews of the risk. Controls can require change, or can become defunct as the risk or systems progress and so regular consideration of the effectiveness of each control should occur. Similarly, controls may only be partially effective – for example implementation of a training course is only effective for those staff who have undertaken the course. Gaps in control should be considered and actions put in place to fill those gaps and maximise the effectiveness of those actions. In the





example of a training course, an action may be delivery against a clear training trajectory to ensure all staff are suitably trained. If something is put in place that does not reduce the score of the risk in terms of either likelihood or consequence, it is not a control. 8.3 Mitigating Actions Following a risk assessment and determination of the key controls in place, consideration should be given to the actions required in order to reduce the likelihood or consequences of the risk occurring. Actions should be designed to form controls upon their completion, must be cost-effective and bring about a reduction in the risk score. Actions should follow the SMART principles of specific, measurable, achievable, realistic and timed. 8.4 Determining the Residual Risk Score The residual risk score demonstrates the likelihood and consequence that a risk would have, at the current time. It is the level of risk that is apparent, with the existing controls currently in place. Determining the residual risk score is important as it allows the organisation to understand how effective management of that risk has been to date, and the level of further effort required to mitigate the risk. The residual risk score is calculated by giving a 1-5 score for both likelihood and consequence, and multiplying them together to give a score out of 25. Definitions for each level of likelihood and consequence can be found in the risk matrix in appendix C. 9. Development and Management of Risk Registers Risk registers are an essential tool the Trust employs to document, assess and manage risks the organisation faces. Risk registers are therefore in a consistent format using a standardised approach. 9.1 Risk Registers The Trust Risk Management System (4Risk) is a tool used to effectively identify, prioritise, monitor and manage risk, and will comprise of the following parts:

• Strategic Risks (Board Assurance Framework) • Corporate risk register, comprising of the principal risks • Director risk registers • Sector Business Unit risk registers, as a sub-section of the Directorate register to better manage

ownership and reporting Projects have project-specific risk registers embedded within the project workbooks and associated documentation, in line with good project governance. As such, only project risks which impact upon business as usual will be entered onto and managed within the 4Risk system.





Each directorate within the Trust will establish a systematic approach to manage their own risks. Risk assessments will be carried out where hazards or risks are identified All risks are recorded on the Trust’s electronic risk management and are assigned to the relevant directorate or local risk register. All risk registers should be reviewed monthly. Those risks deemed to be a principal risk (regardless of score) through the meeting of the following criteria are assigned to the Deputy Director for that area and are escalated to the Corporate risk register, for greater pan-organisation oversight, action and scrutiny:

• Are likely to affect achievement of the Trust’s priorities • Impact across multiple directorates • Require collaborative working between directorates to resolve in an effective manner

The directorates are responsible for the whole process of identifying, recording and managing their risks, taking suitable action within the scope of their responsibility, to ensure that these risks are constantly monitored and updated. In addition when a principal risk is identified they are responsible for escalating the issue to their Deputy Director and for alerting the Head of Governance. Each directorate is required to maintain their own risk register by monitoring actions taken to mitigate risks and reviewing risk assessments. On occasions where it may be possible that the risk has increased, the risk assessment should be reviewed. Risks that are identified within one directorate but cross boundaries with more than one directorate or service, should be bought to the attention of those Deputy Directors and Heads of Department the risk may impact. 9.2 The Board Assurance Framework The Board Assurance Framework (BAF) comprises of the strategic risks agreed by the Board, in regards to delivery against the Strategic Objectives. The BAF is an essential document which enables the Board and its associated sub-committees to gain assurance on risk management and progress towards strategic objective achievement, as well as to inform Board and Committee agenda planning. Executive Directors own the Strategic Risks, with the Head of Governance responsible for coordinating and updating the BAF document. This is undertaken through monthly risk review meetings with Executive Directors and a core component of this function is to challenge quality of the controls and mitigating actions that have been put in place. The Trust Board and each of its sub-committees will receive the BAF at each meeting. 9.3 Monitoring and Management of Risk Registers The risk registers, as part of a living document, are subject to constant review and update; however directorates will be required to review and update their registers on at least a monthly basis. Directors and those with delegated responsibility for maintaining risk registers are encouraged to seek advice





from the risk team if there are any questions or clarifications required to assist in the maintenance of the risk register. The BAF and corporate risk register will be reviewed and monitored by the Executive Leadership Board. The Audit Committee will review these documents to provide assurance to the Trust Board that the risk management system is in place and is effective. 9.4 Management of Risks and Risk Appetite Following risk identification, assessment and determination of the controls in place and the current risk score, there is a need to identify the course of action to take in relation to the risk. Broadly, there are four actions:

• Treat • Tolerate • Transfer • Terminate

The risk owner is responsible for identifying the most appropriate approach to take for each risk, with the Trust Board establishing the appropriate approach for the strategic risks. It is essential that the Trust’s risk appetite statement be considered when determining the course of action. The following table outlines the recommended action regarding risks, based upon the organisation’s risk appetite: Assessment Description of potential effect What does this mean? High Risk Appetite

The Trust is willing to accept the risks that may result, but may choose to mitigate further.

Risks tolerated, or treated by exception. If exception and for mitigation, monitored through ELB sub-group. Risks can be logged on 4Risk, with controls added and the current score determined and then closed by the owner.

Moderate Risk Appetite

The Trust is willing to accept some risks in certain circumstances. Subject to the circumstances, the Trust will otherwise seek to proportionately mitigate the risk.

The majority of these to be treated and monitored through relevant ELB sub-group. Risks can be logged on 4Risk, with controls added and the current score determined and then closed (<15) by the owner. Scores of over 15 need closure by the sub group.

Low Risk Appetite

The Trust is not willing to accept (except in very exceptional circumstances) these risks. Subject to the prevailing exceptional circumstances the Trust will seek to mitigate the risk as far as practically possible.

All risks to be actively treated and monitored through the relevant ELB sub-group, until target score met





9.5 Escalation, De-escalation and Removal of Risks Risks are live; as such, it is important to recognise that risk scores, detail, causes, controls and actions are all subject to change. Risk register design is such that risks can be easily escalated, de-escalated or closed (and then reopened) at any point in time. Options for movement in relation to risks are as follows:

• Escalation to another risk register – risks can be moved from a local or directorate register up to the Corporate register, if deemed to be a principal risk. This decision is taken by the Deputy Director. Similarly, a principal risk can be escalated to the Board Assurance Framework, should the Executive Leadership Board consider it to be a sufficient threat to delivery of Strategic Objectives.

• De-escalation to another risk register – risks can be moved from the Corporate register to a local risk register, in cases where the risk has been controlled to an acceptable level, or when pan-organisation actions have been completed and the risk can be managed in a more local forum. This decision is taken by the risk owner

• Closure of a risk – in scenarios where the risk has been terminated, or the risk is residually green or yellow with no further suitable action to be taken, the risk can be closed (score of 6 or below, or in line with the risk appetite statement as outlined in section 9.4). Risks should only be closed when the risk owner has sufficient assurance to be confident that no further action can be taken to mitigated the risk further, or where the Trust has accepted the risk.

• Ongoing monitoring of a risk – there will be a number of risks that are unable to be mitigated further, but remain at a residual score of 8 or higher. These should remain open on the risk register and reviewed monthly to ensure no change, or no further actions are able to be taken/required

Only the Trust Board can determine the need to remove a Strategic Risk from the Board Assurance Framework. 10. Responsibility for Managing Different Levels of Risk Once a risk has been scored, it will be graded and managed in line with the grading process below:

• Low Risks (green and yellow) – are identified as those scoring 6 or less using the Risk Scoring Matrix and can normally be managed through local action by line managers who will be expected to agree control measures and can be closed once no further mitigating actions are deemed necessary. Decisions should be taken and agreed locally as to the level of review required.

• Moderate Risks – are any risks that score of 8 to 14 and must be reviewed/investigated by the appropriate Head of Department. All risks with a residual moderate score should be reviewed at every directorate meeting.

• High Risks – are any risks that score higher than 15. These must be owned by the Deputy Director and be reviewed at least monthly. All risks with a residual moderate score should be reviewed at every directorate meeting and the relevant Executive Director should be informed of the risk and what actions are being taken to mitigate it.





• Principal Risks – are any risks that reside on the corporate risk register regardless of score. These must be owned by a Head of Department or higher and be reviewed and updated at least monthly.

• Strategic Risks – are the risks determined by the Board that could impact delivery against strategic objectives. Strategic risks will be owned by a pre-determined Executive Director, regardless of the score. Strategic risks must be reviewed and updated monthly by the Director.

11. Service Changes, Projects and Cost Improvement Programmes All proposed service changes, projects and Cost Improvement Programmes should have a full risk assessment, taking into account the potential impacts upon quality, prior to approval and initiation. This risk assessment must be carried out on either a standard risk assessment template (service changes and projects – appendix D) or a Quality Risk Assessment template (Cost improvement programme – appendix E) and then submitted to the relevant governance group for approval:

• CIP Delivery Group for Cost Improvement Programmes and efficiency schemes • Clinical Quality and Safety Group for service changes impacting clinical care, operational

delivery, pathway changes, or for proposed changes to medical equipment or medication products. This includes any changes within operations, EOC, Primary Care and Patient Transport.

• Executive Leadership Board for restructure proposals or new business • If none of the above apply, discuss with the Head of Governance for the correct approval

process Please refer to the Governance and Assurance Strategy and Framework for greater clarity on the correct Executive sub-group pathway for the approvals process. Projects, Cost Improvement Programmes or service developments should have their own individual risk registers that are managed within the process change, in line with project governance. Risks should be reviewed and monitored at every project planning meeting. However, if a project risk may impact upon business as usual, or prevent the overall delivery of the project then it will be necessary to escalate the risk to the appropriate directorate risk register. For the full approval process for service changes, projects and Cost Improvement Programmes, please refer to the Portfolio Office. No service change, Cost Improvement Programme or Project should be initiated without documented approval from the relevant group. The project must have sufficient risk monitoring in place and have clear contingencies in place should it be unsuccessful, with an escalation process. 12. Key Performance Indicators The Trust’s performance in the management of risk will be monitored through: • Internal and External Audit and Assessment reports, including a risk maturity audit • Risk Register reports • Board Assurance Framework reports • Risk management key performance indicators (KPIs).





The aim of the risk management KPIs are to provide some measure of the total risk exposure of the Trust coupled with the effectiveness of the application of the risk management strategy. The Trust recognises that overall effectiveness will also be informed by other assurance arrangements, such as reviews by Internal Audit, and therefore the KPIs cannot be viewed in isolation. However, the set of KPIs determined below provide an immediate picture of risk and control at the Trust, which can be tracked and investigated further as required. The KPI’s will be reported every six months to the Senior Leadership Board. The following key performance indicators will be used: • KPI 1: Inherent / Residual Risk Profile – how many of our inherent Red 15 + Risks have

reduced to either amber / green scores due to mitigating controls and actions and how many remain as Red 15+ risks as a proportion of the total risks on 4Risk.

• KPI 2: Strategic Risk Review – the number / percentage of our Strategic Risks that have been reviewed and updated with Directors every month

• KPI 3: Principal Risk Review – the number / percentage of our Principal Risks that have been

reviewed and updated by Senior Leadership Board members every month

• KPI 4: Operational Risk Review – the number / percentage of our operational risks on directorate risk registers that have been reviewed and updated by risk owners every month

• KPI 5: Principal Risk Assurances – the proportion of Principal Risk controls with recognised gaps in assurance.

• KPI 6: Principal Risks Outstanding Actions - the number of actions created for the Principal

Risks that are overdue and outstanding on 4risk as a proportion of all actions created.

• KPI 7: Operational Risks Outstanding Actions – the number of total actions created that are overdue and outstanding on 4risk across the directorate risk registers as a proportion of actions created.




Appendix A - Monitoring Table

What Who How Frequency Evidence Reporting arrangements Acting on recommendations

Change in practice and lessons to be shared

Appropriate mitigation of the Principal Risks

The Board Each Committee

Review of the Board Assurance Framework

Three times per year (Bi-monthly). Quarterly (Bi-monthly)

The BAF report and the Board/Committee minutes

The BAF report and the Board/Committee minutes

Head of Governance and Risk Owners

Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate.

Successful implementation of Risk Management and the BAF

Internal Audit (Deloittes)

Internal Audit Every other year Audit Report Analysis of the Audit Report by the Executive Leadership Board and Audit Committee

Required actions will be identified and completed in a specified timeframe.

As above

Appropriate Committee and Group discharge of risk management related duties

Head of Governance

Review of the Terms of Reference

Annually Committee and Group Minutes

Board approval of Terms of reference

Committee and Group will act accordingly as required

As above

Assessment of risk and control within the Trust

Head of Governance

Assessment of Risk KPIs

Bi-annually KPI report Reported to the Executive Leadership Board

The Executive Leadership Board will determine actions required

As above

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Appendix B – Equality Impact Analysis

Equality Impact Assessment

EIA Cover Sheet Name of process/policy Risk Management Strategy and Policy Is the process new or existing? If existing, state policy reference number Existing

Person responsible for process/policy Head of Governance

Directorate and department/section Corporate Governance Name of assessment lead or EIA assessment team members Emma de Carteret, Head of Governance

Has consultation taken place? Was consultation internal or external? (please state below):

Internal – Board workshop on risk management strategy annually. Wider consultation on initial creation – no material changes since

Internal Board

The assessment is being made on: Please tick whether the area being assessed is new or existing.

Guidelines Written policy involving staff and patients patients x

Strategy x

Changes in practice

Department changes

Project plan

Action plan Other (please state) Training programme.





Equality Analysis What is the aim of the policy/procedure/practice/event? To ensure that the Trust conducts business on a risk based approach to maximise the safety of patients, staff and the public. Who does the policy/procedure/practice/event impact on? Race Religion/belief Marriage/Civil Partnership Gender Disability Sexual orientation Age Gender re-assignment Pregnancy/maternity

Who is responsible for monitoring the policy/procedure/practice/event? Head of Governance and Audit Committee What information is currently available on the impact of this policy/procedure/practice/event? Demonstration of impact through risk assessments, risk registers, and committee reports on the management of risks to reduce impact or likelihood of an adverse event. Do you need more guidance before you can make an assessment about this policy/procedure/ practice/event? No Do you have any examples that show that this policy/procedure/practice/event is having a positive impact on any of the following protected characteristics? No, If yes please provide evidence/examples: Race Religion/belief Marriage/Civil Partnership Gender Disability Sexual orientation Age Gender re-assignment Pregnancy/maternity

Please provide evidence: No positive impact identified Are there any concerns that this policy/procedure/practice/event could have a negative impact on any of the following characteristics? Yes/No, if so please provide evidence/examples: Race Religion/belief Marriage/Civil Partnership Gender Disability Sexual orientation Age Gender re-assignment Pregnancy/maternity

Please provide evidence: No negative impact identified Action Plan/Plans - SMART





N/A

Evaluation Monitoring Plan/how will this be monitored? Who: Head of Governance and Audit Committee

How: bi-annually reporting of impact via KPIs

By Head of Governance

Reported to Audit Committee





Appendix C: Risk Matrix

Purpose

The purpose of the risk matrix is to provide a consistent approach to the grading of risks arising within the Trust, however and from wherever, they are identified. This means that risks, whether identified from, e.g. a health and safety risk assessment or a clinical incident or a legal claim or a controls assurance self-assessment, may be graded in the same consistent manner against the same generic criteria. The Trust Board (and its sub-committees) can then be confident that, when considering risks within the same grading band, that these have been graded using the same method and the same criteria. This will allow for comparisons between different types of risk and for judgements and decisions to be made on that basis.

Method

The accepted formula for grading risk is: Consequences x Likelihood

This involves making a judgement both as to the Consequences to the person(s) involved and the Trust if the risk is realised, and the Likelihood (or probability) of the risk occurring, or recurring, and then allocating a number from 1 to 5 to reflect this. The numbers represent the following values: Consequences: Likelihood: 1 = insignificant 1 = rare 2 = minor 2 = unlikely 3 = moderate 3 = possible 4 = major 4 = likely 5 = catastrophic 5 = almost certain (In the case of a ‘near miss’, by definition, no injury or damage has resulted. However, in slightly different circumstances, injury or damage could have resulted and it is the risk of this potential injury or damage which should be graded.) Instructions for use 1. Define the risk(s) explicitly in terms of the adverse impact that might arise from the risk; 2. Use Table 1 (see below) to determine the evidence based Impact score(s) for the potential adverse outcome(s) relevant to the risk being evaluated; 3. Use Table 2 (see below) to determine the evidence based Likelihood score(s) for those adverse outcomes. If possible score the likelihood by assigning a predicted frequency of the adverse outcome occurring. If this is not possible, assign a probability to the adverse outcome occurring within a given time frame, such as the lifetime of the project or the patient care episode. If it is not possible to determine a numerical probability, then use the probability descriptions to determine the most appropriate score. 4. Multiply the Impact Score for each of the descriptors with the Likelihood Score to obtain the risk rating which should be a score between 1 and 25; 5. Use the risk matrix, shown below to determine the colour banding for the risk in respect of each descriptor (the highest score will determine the overall risk level).





When assessing the risk of an adverse event occurring consideration should be given to using the likelihood and the consequence tables below.




1 2 3 4 5

Domains Negligible Minor Moderate Major Catastrophic

Impact on the safety of patients, staff or public (physical/ psychological harm)

Minimal injury requiring

no/minimal intervention or treatment No time off

work required

Minor injury or illness

requiring minor intervention Requiring time off work

for <3 days Increase in length of hospital stay by 1–3 days

Moderate injury requiring

professional intervention Requiring time off work for 4–14 days

Increase in length of hospital stay by 4–15 days RIDDOR/agency reportable incident An event which impacts on a small number of patients

Major injury leading to

long-term incapacity/ disability Requiring time off work for

>14 days Increase in length of hospital stay by >15 days Mismanagement of patient care with long-term effects

Incident leading to death

Multiple permanent injuries or irreversible health effects

An event which impacts on a large number of patients

Quality/ complaints/ audit

Peripheral element of treatment or service sub-optimal Informal complaint/inquiry

Overall treatment or service sub-optimal Formal complaint (stage 1) Local resolution Single failure to meet internal standards Minor implications for patient safety if unresolved Reduced performance rating if unresolved

Treatment or service has significantly reduced effectiveness Formal complaint (stage 2) Local resolution (with potential to go to independent review) Repeated failure to meet internal standards Major patient safety implications if findings are not acted on

Non-compliance with national standards with significant risk to patients if unresolved Multiple complaints/ independent review Low performance rating Critical report

Incident leading to totally unacceptable level or quality of treatment/service Gross failure of patient safety if findings not acted on Inquest/ ombudsman inquiry Gross failure to meet national standards

Human resources/ organisational development/ staffing/ competence

Short-term low staffing level that temporarily reduces

service quality (<1 day)

Low staffing level that

reduces service quality

Late delivery of key objective/

service due to lack of staff

Unsafe staffing level or competence (>1day) Low staff morale Poor staff attendance for mandatory/key training

Uncertain delivery of key objective/service due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff Very low staff morale No staff attendance for mandatory/key training

Non-delivery of key

objective/service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff No staff attending mandatory training/key training on an ongoing basis

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1 2 3 4 5

Domains Negligible Minor Moderate Major Catastrophic

Statutory duty/ inspections

No or minimal impact

or breech of guidance/ statutory duty

Breech of statutory

legislation Reduced performance

rating if unresolved

Single breech in

statutory duty Challenging external

recommendations/ improvement notice

Enforcement action

Multiple breeches in statutory duty

Improvement notices Low performance rating

Critical report

Multiple breeches in

statutory duty Prosecution

Complete systems change required

Zero performance rating

Severely critical report

Adverse publicity/ reputation

Rumours

Potential for public concern

Local media coverage

-short-term reduction in public confidence

Elements of public expectation not being met

Local media coverage – long-term reduction in public confidence

National media coverage with <3 days service well below reasonable public expectation

National media coverage with >3 days service well below reasonable public expectation.

MP concern(questions in the House)

Total loss of public confidence.

Business objectives/ projects

Insignificant cost increase/schedule slippage

<5 per cent over project budget

Schedule slippage

5–10 per cent over project budget

Schedule Slippage

Non-compliance with national 10-25 per cent over project budget

Schedule slippage

Key objective not met

Incident leading >25 per cent over project budget

Schedule slippage

Key objectives not met

Finance including claims

Small loss Risk of claim remote

Loss of 0.1–0.25 per cent of budget Claim less than £10,000

Loss of 0.25–0.5 per cent of budget Claim(s) between £10,000 and £100,000

Uncertain delivery of key objective/Loss of 0.5–1.0 per cent of budget Claim(s) between £100,000 and £1 million Purchasers failing to pay on time

Non-delivery of key objective/loss of >1 per cent of budget Failure to meet specification/ slippage Loss of contract/ payment by results Claim(s) >£1 million

Risk M

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Appendix D: Risk Assessment Template

Summary of task / hazard (Describe the hazard / activity giving cause to the hazard) Title • Bullet point summary

o

Risks associated with the task / hazard (Describe how harm may / will occur from the task / hazard. Include possible outcomes / consequences of the risks becoming realised) 1. Describe risk, bullet point potential harm

• Potential harm (e.g. patient harm, delay, reputation) 2. Describe risk, bullet point potential harm

• Potential harm

Risk groups/areas (those most likely or especially at risk) Operational emergency staff New/inexperienced staff EOC staff Visitors Non-emergency services (PTS) Service users/Public Critical Care/Air Ambulance Lone workers First or Co-Responders (e.g. CFR) Young or vulnerable persons Other emergency services New/expectant mothers Other ambulance services Contractors Other healthcare staff/organisations Administration staff Information governance/Caldicott impact link here

Existing controls (precautions in place) Gaps in control 1. Reference risks above, bullet point controls

• Controls

2. Reference risks above, bullet point controls • Controls



Risk rating (Risk rating with existing controls / precautions in place) – Refer to EEAST risk matrix Consequence score of incident (actual and potential)

(5) Catastrophic

(4) Major (3)

Moderate (2) Minor (1)

Insignificant

Likelihood score of incident (5)

Almost certain (4) Likely

(3) Possible (2)

Unlikely (1) Rare

Detail reasons for giving this score Enter rationale

Risk rating score Risk rating score (To attain risk rating multiply scores of consequence and likelihood)

Colour coded rating

Are the current controls adequate?

Yes or No with reason

If No, what controls can be established to mitigate the risk?

Risk rating score - following implementation of additional controls Risk rating score (To attain risk rating multiply scores of consequence and likelihood)

Colour coded rating



http://east24/what-is-information-governance.htm


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Appendix E: Quality Risk Assessment Template




Page 35 of 35



of 2

MEETING TITLE

PUBLIC BOARD

Date: 11.03.2020 Report Title: Annual Review of Standing Orders/Standing Financial Instructions/Scheme of

Delegation/Reservations Retained by Trust Board Agenda Item: 21 Author: E de Carteret, Head of Governance Lead Director: D Hosein, Chief Executive Officer Purpose: Assurance Decision


SUMMARY AND BACKGROUND: Good governance requires the organisation to undertake a review of the core compliance documents in place across the Trust annually. The review has been undertaken by the Head of Governance, in conjunction with the Director of Finance and Commissioning and the Deputy Head of Financial Services. The Audit Committee has reviewed all of the proposed amendments in the February 2020 meeting, and accepted the amended documents. The Committee therefore recommends to the Trust Board approval of these documents for the 2020/21 financial year. The documents are attached to this report as appendices. A summary of core changes is as follows: Matters Reserved for the Trust Board:

• Added approval of the Quality Accounts and Annual Governance Statement Scheme of Delegation:

• Removal of Senior Leadership Board • Removal of General Manager role due to move to Heads of Operations where applicable • Transfer of charitable funds elements from Audit Committee to the Charitable Funds Committee

(approved by Audit Committee in November 2019) • Removal of references to posts no longer in situ • Use of the term ‘Senior Information Risk Officer’ as a role of authority in its own right, rather than

the Director’s job title • Realignment of areas to reflect current responsibilities • Removal of authorisation from the Trust Chair on expenditures that do not meet the threshold for

Board review and approval. Review of historical approach demonstrates that this value has changed on a number of occasions in the past, to reflect the level of scrutiny deemed appropriate by the Audit Committee and Trust Board. Additionally, it was designed to enable Non-Executive oversight of contracts being committed to spanning more than one year. It is was recommended by the Audit Committee that this additional layer of assurance on values below the Board threshold be removed. Sections 2.2.3, 6.8.3c, 10.3.1e, 10.9.1d, 10.9.2d apply.

It should be noted that Section 7 – signing of contracts was discussed at the Committee. At present the minimum level for the signing of contracts is at Director level. The finance team have suggested that to align with other aspects of the SoD, the committee consider amending to give a lower level of delegation for smaller value contracts – for example, Head of Department in conjunction with Head of Finance for contracts up to £25K; Relevant Director with Head of Finance for up to £100k. The Committee also accepted this proposal. The Committee were broadly satisfied with this suggestion but asked for comparison with other services to be undertaken prior to utilisation. As such, it was agreed that a full review and refresh of the Scheme of Delegation be undertaken via a working group mid-year 2020/21, to ensure the document is consistent with other trusts and user-friendly.

Standing Orders:

• Reference to the Charitable Funds Committee included • Included clarity on voting and ex-officio Board members

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• Amended references from Trust Secretary to Head of Governance Standing Financial Instructions:

• No material changes recommended

RECOMMENDED ACTION: • Accept the Audit Committee’s recommendation and approve the amendments to the documents • Note the mid-year review of the scheme of delegation to be undertaken next year

KEY ISSUES IDENTIFIED N/A


PREVIOUSLY CONSIDERED BY: Reviewed between the Head of Governance, Director of Finance and Commissioning, and the Deputy Head of Financial Services Audit Committee reviewed and approved February 2020

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers] SR4


SR2: Failure to achieve continuous quality improvements in the quality of care delivered to our patients SR3: Failure to embed a patient-focussed culture that puts the patient at the heart of everything we do SR4: Failure to deliver an efficient, effective and economic service X Other: Please Specify

THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE Provide better care Value our people Value for money X Improve performance


LINK TO CQC: Caring Responsive Effective Well Led X Safe

RELEVANT LEGAL OR STATUTORY ISSUES Compliance with company legislation, and financial regulation

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RESERVATION OF

POWERS TO THE

TRUST BOARD

Reviewed at Audit Committee 6 February 2020

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POWERS RESERVED FOR THE TRUST BOARD

1. Code of Accountability 1.1 The Code of Conduct and Accountability which has been adopted by the Trust

requires the Board Members to determine those matters on which decisions are reserved to it and to ensure that management arrangements are in place to enable the clear delegation of its other responsibilities.

2. General Enabling Provision 2.1 The Trust Board may determine any matter it wishes at a full meeting within its

Standing Orders and statutory powers. 3. Regulation and Control 3.1 The Trust Board remains accountable for all of its functions, including those which

have been delegated, and would therefore expect to receive information about the exercise of delegated functions to enable it to maintain a monitoring role.

3.2 All powers of the Trust which have not been retained as reserved by the Trust Board

or delegated to a Board Committee shall be exercised on behalf of the Board by the Chief Executive. The Scheme of Delegation identifies any functions which the Chief Executive shall perform personally and those delegated to other directors or officers. All powers delegated by the Chief Executive can be re-assumed by their self should the need arise.

3.3 The Scheme of Delegation shows only the “top level” of delegation within the Trust.

The Scheme is to be used in conjunction with the system of budgetary control and other established procedures within the Trust.

3.4 Approval, suspension, variation or amendment of Standing Orders, Standing

Financial Instructions, Schedule of Matters Reserved to the Trust Board, and the Scheme of Delegation of Powers from the Board to officers.

3.5 Specification of financial and performance reporting arrangements. 3.6 Requiring and receiving the declaration of Directors’ interests which may conflict with

those of the Trust and determining the extent to which that Director may remain involved with the matter under consideration.

3.7 To receive reports from committees, including those which the Trust is required by

the Secretary of State or other regulation to establish, and to take appropriate action thereon.

3.8 Ratifications of any urgent decisions taken by the Chair. 3.9 Approval of arrangements relating to the discharge of the Trust’s responsibilities as a

corporate trustee for funds held on Trust. 4. Appointments 4.1. Appointment and agreement of the terms of reference of Board Committees. 4.2 Through the Remuneration Committee appoint, appraise, discipline and dismiss

individuals directly accountable to the Board. 4.3 Appoint vice chair of the Board.

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5. Policy Determination 5.1 Approval of all policies is delegated to the Trust’s management executive. 5.2 Approval of strategy, business plans and budgets. 5.3 Approval of the Trust’s Annual Plan prior to submission to NHSI. 6. Direct Operational Decisions 6.1 Approval of the acquisition, disposal or change of use of land and/or buildings as

specified in the table of financial limits as delegated within the Scheme of Delegation. 6.2 Approval of transactions with a value in excess of that currently specified in the table

of financial limits as delegated within the Scheme of Delegation. 6.3 Agreement of action on litigation against or on behalf of the Trust with the exception,

of clinical negligence payments, is delegated to the Director of Finance & Commissioning.

6.4 Approval of loans taken out with repayment periods in excess of one year. 7. Financial and Performance Reporting Arrangements 7.1 Continuous appraisal of the affairs of the Trust by means of the receipt of reports as it

sees fit from Directors, committees and officers of the Trust. 7.2 Approval of the Trust’s Annual Report, including the Annual Accounts and Annual

Governance Statement, prior to submission to Department of Health. 7.3 Approval of the Trust’s Quality Account, prior to submission to Department of Health. 7.4 Receipt and approval of the Annual Report(s) for funds held on trust. 8. Governance Arrangements 8.1 Assurance Framework: Provide evidence that the Trust is doing “its responsible

best” to manage itself to meet its objectives and protect patients, staff, and the public and other stakeholders against risks of all kinds.

9. Scheme of Delegation to Officers

9.1 Delegated matters in respect of decisions which may have a far reaching effect must

be reported to the Chief Executive. The delegation shown within the Scheme of Delegation is the lowest level to which authority is delegated. Delegation to lower levels is only permitted with written approval of the Chief Executive who will, before authorising such delegations, consult with other Senior Officers as appropriate. Each Director is responsible for the delegation within their Directorate. They should produce a scheme of delegation for matters within their Directorate. All items concerning finance must be carried out in accordance with Standing Financial Instructions and Standing Orders of the Trust Board.

APPROVED BY TRUST BOARD: 11 March 2020

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SCHEME OF

DELEGATION


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EAST OF ENGLAND AMBULANCE SERVICE NHS TRUST: SCHEME OF DELEGATION Delegated matters in respect of decisions which may have a far reaching effect must be reported to the Chief Executive. The delegation shown below is the lowest level to which authority is delegated by the Board of Directors. Delegation to lower levels is only permitted with written approval of the Chief Executive who will, before authorising such delegations, consult with other Senior Officers as appropriate. All items concerning Finance must be carried out in accordance with Standing Financial Instructions and Standing Orders of the Board of Directors.

DELEGATED MATTER AUTHORITY DELEGATED TO SFI PARA REF

1. FORWARD PLANS, BUDGETS, BUDGETARY CONTROL AND MONITORING

3

1.1 Preparation & Approval of Forward Plans & Budgets

3.1

1.1.1 Compilation and submission to Board of Directors a forward plan in respect of each financial year.

Chief Executive in conjunction with Director of Finance & Commissioning

3.1.1/3.1.3

1.1.2 Implementation and performance monitoring of the Forward Plan Executive Leadership Board 1.1.3 Preparation and submission of budgets for approval by the Board of Directors prior

to start of financial year Director of Finance & Commissioning 3.1.2

1.1.4 Monitor financial performance against budget and plan, and advise Board of Directors

Director of Finance & Commissioning 3.1.3

1.1.5 Provision of information to enable budgets to be compiled Budget Holders 3.1.4 1.1.6 Budget holders to sign up to their allocated budgets at commencement of each

financial year


1.1.7 Provision of adequate business planning and budget management training on an on-going basis to budget holders to help them manage successfully


2.2 Budgetary Delegation

2.2.1 Responsibility for delegation of the management of revenue budget to permit the

performance of a defined range of activities: Chief Executive 3.2.1 & 10.1.1

(a) Designation of budget holder Chief Executive 3.2.2 & 10.1.1 (b) Responsibility for management of revenue budget at individual budget level Budget Holder 3.2.2 & 10.1.1 (c) Responsibility for the totality of activities covered by each Corporate or

Operational Directorate Chief Executive or in their absence

relevant Executive Director

(d) Responsibility for all other revenue budgetary areas, e.g. reserves, non-recurring budgets


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2.2.2 Responsibility for delegation of the management of capital budget in line with the approved Capital Programme (See also Scheme of Delegation 10)

Chief Executive 3.4 & 12

(a) Designation of Budget Holder

Chief Executive 3.2.2 & 3.4 (b) Responsibility for management of the capital budget


(c) Responsibility for management of capital budget at individual level Capital Budget Holder 2.2.3 Authorised use of Virement

NB Virement is the transfer of resources between pay and non-pay or between Service Delivery and Support Services

Chief Executive

3.2.3

a) Value up to £500,000 Budget Holder with approval of Director of Finance &

Commissioning/Head of Finance

b) Value over £500,001

Board of Directors

3. ACCOUNTS AND REPORTS

4 3.1 Preparation and submission of financial reports in accordance with the accounting

policies, guidance and timetable prescribed and approved by the Department of Health

Director of Finance & Commissioning 4.1

3.2 Preparation and publication of annual report and audited accounts and presentation to Board of Directors and to the Annual Public Meeting of the Trust.

Chief Executive

4.2

4. BANK AND TREASURY MANAGEMENT POLICY

5 4.1 Compilation and submission of Treasury Management Policy to Board of Directors


4.2 Monitoring of Treasury Management Policy and provision of advice to Board of Directors


4.3 Monitoring compliance with Department of Health’s guidance on level of cleared funds


4.4 Responsibility for bank and Government Bank Accounts including preparation of detailed instructions for operation

Director of Finance & Commissioning 5.2 & 5.3

4.5 Review commercial banking arrangements of the Trust to reflect best practice and ensure through market testing (at least every 5-years) value for money.


4.6 Approval of banking arrangements Board of Directors 5.1.2 4.7 Opening of bank accounts Director of Finance & Commissioning 5.3.2

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4.8 Designation of authorised panel officers, by resolution of the Board of Directors for signing of cheques for cash, other cheques and authorisation of Government Banking Services and BACS payment schedules


4.8.1 Cheques or other orders drawn upon the main exchequer bank account with (a) Value below £5,000 One signature from the First Officer

Panel 5.3.4

(b) Value of £5,000 or more Two signatures, one from the First Officer Panel and the other from the

Second Officer Panel

5.3.5

4.8.2 Cheques or other orders drawn upon the main charitable fund bank account with: (See also Scheme of Delegation 16)

(a) Value below £5,000 One signature from the First Officer Panel

5.3.6

(b) Value over £5,001 Two signatures, one from the First Officer Panel and the other from the

Second Officer Panel

5.3.6

5. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS

6

5.1 Income 5.1.1 Design, maintain and ensure compliance with income and expenditure systems for

prompt banking of all monies Director of Finance & Commissioning 6.1.1 & 6.1.2

5.1.2 Approval and regular review of the level of all fees and charges, other than those determined by the Secretary of State or statute


5.1.3 Responsibility for debt recovery and associated procedures Director of Finance & Commissioning 6.3 5.1.4 Security of cash, cheques and other negotiable instruments Director of Finance & Commissioning 6.4 5.2 Money Laundering 5.2.1 Monitoring of money laundering regulations Director of Finance & Commissioning 6.5 5.2.2 Reporting of any cash payments in excess of €15,000 (approximately £10,000) in

respect of any single transaction to the Director of Finance & Commissioning All Employees 6.5

6. TENDERING AND CONTRACTING REGULATIONS

6.1 Legislation and Guidance Covering Public Procurement

6.1.1 Monitoring compliance with Public Contract Regulations 2015 and relevant EU Directives relating to public procurement


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6.2 E-Auctions

6.2.1 Monitoring of future expansion into e-auction activity


6.3 Capital Investment (See also Scheme of Delegation 10)

6.3.1 Monitor compliance with the requirements of guidance published on capital

investment and estate and property transactions Director of Finance & Commissioning 7.4

6.4 Quotations, Tendering, Leasing and Contract Procedures (Applicable to all goods and services including healthcare services)

7.5, 7.6 & 7.7

6.4.1 Quotation and Tendering Limits (all limits quoted include VAT): (a) Obtain one written or two verbal quotations for goods/services up to £4,999

at Procurement Department’s discretion Budget Holder in conjunction with

Procurement Department 7.7.2

(b) Competitive sourcing either through the Trust’s electronic tendering systems or by obtaining a minimum of two written quotations for goods/services between £5,000 and £19,999 at Procurement Department’s discretion

Budget Holder in conjunction with Procurement Department

7.7.2

(c) Competitive sourcing either through the Trust’s electronic market place system or by obtaining a minimum of three written quotations for goods/services from £20,000 to £50,000

Budget Holder in conjunction with Procurement Department

7.7.2

(d) Execute formal tender procedures and obtain minimum of three written competitive tenders (if feasible) for goods/services over £50,000 (EU Procurement Rules apply: Thresholds routinely change every two years and the Trust will apply these as published. Applicable thresholds from 1 January 2018 to 31 December 2020 are: Goods £118,133/ Services £181,302; and Works and Concessions £4,551,413 and Light Touch Regime £615,278)

Appropriate Head of Department or General Manager /Executive Director

and Director of Finance & Commissioning in conjunction with

Procurement Department

6.5 List of Approved Firms (See also Scheme of Delegation 8)

6.5.1 Compilation and maintenance of approved list of firms for tendering Director of Finance & Commissioning 7.5.5 & 7.6.8 6.5.2 Responsibility for ensuring all suppliers aware of the Trust’s Terms and Conditions

of Contract Director of Finance & Commissioning 7.6.8

6.5.3 Responsibility for ensuring financial standing and technical competence of approved contractors

Director of Finance & Commissioning 7.6.8 & 10.1.3

6.5.4 Responsibility for ensuring technical/medical competence of approved contractors for clinical governance purposes

Medical Director 7.6.8 & 10.1.3

6.5.5 Variation to use of approved firms/individuals or if a list does not exist for whatever reason, responsibility for ensuring appropriate checks are carried out for technical


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and financial capability of those first invited to tender 6.6 Invitation to Tender

6.6.1 Issue of all tenders for goods, materials, services, building, engineering works and disposals with appropriate Terms and Conditions regulating the conduct of the tender and appropriate Terms and Conditions on which Contract to be awarded

Director of Finance & Commissioning General Manager or Head of

department

7.6.1

6.7 Receipt and Safe Custody of Tenders

6.7.1 Receipt and safe custody of all tenders Director of Finance & Commissioning 7.6.2 6.8 Tender Opening/Evaluation/Acceptance/Recording

6.8.1 Opening Tenders: £50,000 and over or if conducted using the eProcurement system, view tender submissions via tender portal and grant access to the tender portal as appropriate

Director of Finance & Commissioning and/or Head of Procurement and /or

Tender Manager

7.6.3

6.8.2 Preparation and submission of formal written Tender Evaluation Report Designated Lead for tender process as defined by Head of Department or

General Manager or Executive Director together with Finance

Manager and other internal specialist advisor(s) (e.g. Procurement

Manager, estates, service users, as appropriate)

7.6.6

6.8.3 Review of formal written Tender Evaluation Report required for (in accordance with Scheme of Delegation 10.3)

7.8

(a) Formal Tenders up to £100,000 (Average annual contract term cost, including VAT) Maximum initial contract term of 3 years only

Head of Department or Head of Operations countersigned by

Executive Director

(b) Formal Tenders from £100,001 to £500,000 (Average annual contract term cost, including VAT) Maximum initial contract term of 3 years only

Head of Department /Executive Director/

Director (as appropriate/designated) with countersignature by Director of

Finance & Commissioning/Chief Executive (or designated deputy in

their absence)

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(c) Formal Tenders from £500,001 to £999,999 (Average annual contract term cost, including VAT) Maximum initial contract term of 3 years only

Chief Executive/Director of Finance & Commissioning

(d) Formal Tenders of £1M and over (Average annual contract term cost, including VAT)

(To be recorded in the Minutes of the Board of Directors) Maximum initial contract term of 3 years only

Board of Directors 7.6.7 & 7.8

(e) All formal tenders with a contract of greater than 3 years and a total contract value less than £3M.

Executive Leadership Board

(f) All formal tenders with a contract of greater than 3 years and a total contract value greater than £3M.

Board of Directors

(g) Tenders accepted that are not lowest expenditure or highest income to be reported to the Audit Committee


6.8.4 Approval of expenditure over agreed tender/quotation budget: Director of Finance & Commissioning 7 6.9 Register of Tenders

6.9.1 Maintenance of Tender Register Director of Finance & Commissioning 6.10 Quotation/Tender Waiver or Single Tender Action

7.5.3 & 7.9

Tender waiver requests for Orders under £25,000

Head of procurement, following Waiver Process

6.10.2 Orders over £25, 000 up to EU limits: the request will be forwarded to the CEO and DOFC for determining on the recommendation of the Head of Procurement.

Chief Executive Officer and Director of Finance and Commissioning

6.10.3 Approval of formal written report for the waiver of tenders or requests for single tender action over £50,000 (report to Audit Committee)

Chief Executive and Director of Finance & Commissioning upon

advice of procurement

6.10.4 EU Procurement Threshold Limits (see Scheme of Delegation 6.4.1 (d)) – No Waiver/Single Tender Action Permitted

No Delegated Authority

6.11 Private Finance for Capital Procurement

6.11.1 Approval of PFI capital procurement

Board of Directors 7.10

6.12 Compliance Requirements for All Contracts

6.12.1 All contracts, being legally binding, shall comply with best costing practice and

devised to manage contractual risk, whilst optimising the Trust’s opportunity to See 7.2 below

7.11 & 8.4

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generate income. Approval of all contracts entered into on behalf of the Trust. (See overlap with 7.2 below)

6.13 Procurement of In-House Services 6.13.1 Determination of in-house services to be subject to competitive tendering Board of Directors 7.14.2 6.13.2 Delegation of lead officer(s) to oversee and manage the process and contract on

behalf of the Trust Chief Executive 7.14.5

7. CONTRACTING FOR PROVISION OF SERVICES (INCOME)

7.1 Regular review of capacity and capability of the Trust to provide its mandatory goods and services

Board of Directors 8.1

7.2 All contracts, being potentially legally binding, shall comply with best costing practice and devised to manage contractual risk, whilst optimising the Trust’s opportunity to generate income. Approval of all contracts entered into on behalf of the Trust.

7.11 & 8.6

(a) Approval of Existing Business/Contract Rollover/New Business/ Diversification:

(i) Average Annual Contract Value up to £500,000. Initial contract term up to a maximum of 3 years.

Director of Finance & Commissioning following recommendation from

Executive Leadership Board approval

(ii) Average Annual Contract Value Between £500,001 to £999,999. Initial contract term up to a maximum of 3 years.

Chief Executive and/or Director of Finance & Commissioning following


(iii) Average Annual Contract Value over £1m. Initial contract term up to a maximum of 3 years. (To be recorded in the Minutes of the Board of Directors)

Board of Directors following recommendation from Executive

Leadership Board Contract signature by Chief Executive or nominated deputy in their absence

(iv) Contract term over 3 years with a contract value of less than £3M Executive Leadership Board (v) Contract term over 3 years with a contract value of greater than £3M Board of Directors (b) Contract Signing following approvals given at 7.2 (a) above: As per the delegated officers and

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values defined at 7.2 (a) (i), (ii),(iii) and (iv) above

7.3 Reporting on actual and forecast service activity income


8. TERMS OF SERVICE AND PAYMENT OF DIRECTORS AND EMPLOYEES

9 8.1 Funded Establishment 8.1.1 Agree workforce plans within annual budget Board of Directors 9.2.1 8.1.2 Authority to change establishment within Board of Director’s agreed financial

budget Director of People & Culture and


8.1.3 Authority to authorise temporary variations to pay rates within standard Agenda For Change Terms and Conditions

Chief Executive and Director of Finance & Commissioning with


8.1.4 Authority to fill funded post on the establishment within area of operational/corporate responsibility

Head of HR and Head of Finance (being vacancy panel) for approval, reported to Executive Leadership

Board

8.1.5 (a) Authority to permanently appoint staff to posts above the formal budgeted

establishment (i.e. increasing overall revenue cost to the Trust of £500,000 per annum)

Chief Executive and Director of Finance & Commissioning, following

recommendation from Executive Leadership Board

9.2.2

8.1.5 (b) Authority to permanently appoint staff to posts above the formal budgeted establishment (i.e. increasing overall revenue cost to the Trust above £500,001 per annum)

Chief Executive and Director of Finance & Commissioning, after approval with Board of Directors

8.1.6 The granting of additional increments to newly appointed staff within budget and regulations

Head of HR and Head of Finance (being vacancy panel) for approval,

reported to ELB

9.3.1

8.1.7 Authority to grant additional increments to existing or newly appointed staff above the formal budgeted position (i.e. increasing overall revenue cost to Trust)

Head of HR and Head of Finance (being vacancy panel) for

recommendation to ELB for approval

8.1.8 All requests for upgrading/re-grading shall be dealt with in accordance with Trust procedures

Director of People & Culture

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8.1.9 Additional staff to the agreed establishment with specifically allocated finance Appropriate Head of Department or Head of Operations or Director with

Director of Finance & Commissioning in accordance with Trust Policy

9.3.1

8.2 Engagement of Staff not on the Establishment 8.2.1 Authority to engage Non-medical consultancy staff – having regard to guidance an

approval requirements from NHS Improvement Executive Director in conjunction with Director of Finance & Commissioning

and Director of People & Culture

8.2.2 Booking of Bank, Locum or Agency Staff (Medical Locums, Nursing & Clerical) Excluding EOC within budget allocation – see 8.2.3 below

Head of Department or General Manager or nominated

deputy/Executive Director in conjunction with Medical Director,

Directors of Finance &Commissioning & Director of Clinical Quality and

Improvement (as appropriate)

8.2.3 Booking of Bank, Locum or Agency Staff for EOC and Primary Care within budget allocation

Senior EOC Manager (SEM) and Primary Care General Manager in

conjunction with Medical Director/Director of Clinical Quality

and Improvement for clinical personnel

8.3 Processing Payroll 8.3.1 Authority to design and implement standing data forms affecting pay, new starters,

variations and leavers Director of People & Culture or

nominated deputy 9.3.2

8.3.2 Authority to complete relevant starter, leaver and variation forms Line Manager in conjunction with Budget Holder where cost impact and

countersigned by Finance/HR Business Manager

8.3.3 Authority to complete and authorise negative/positive reporting forms Budget Holders/Managers/ Head of Department or Head of Operations/Directors/ Chair (as appropriate)

8.3.4 Authority to authorise overtime within Agenda for Change Terms and Conditions Head of Department or Head of

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Operations (or nominated deputy) /Executive Directors (as appropriate)

8.3.5 Authority to authorise travel and subsistence expenses Budget Holders/Head of Department or Head of Operations (or nominated

deputy)/Executive Directors/ Chair (as appropriate)

8.3.6 Approval of performance related pay assessment: (a) Performance Related Pay for Non-Board Members Chief Executive and Director of

Finance & Commissioning and Director of People & Culture with

approval of the Remuneration Committee

(b) Performance Related Pay for Board Executive Directors

Remuneration Committee

8.4 Contract of Employment (In accordance with Trust Policy) 9.5 8.4.1 Authority to issue contract of employment in a form approved by the Board of

Directors Director of People & Culture or

nominated Deputy

8.4.2 Authority to vary terms and conditions of employment within budget and regulations

Director of People & Culture or nominated Deputy in accordance with

Trust Policy

8.4.3 Authority to vary terms and conditions of employment not within budget and regulations (i.e. increasing overall revenue cost to Trust)

Chief Executive and Director of Finance & Commissioning, after

recommendation from the Executive Leadership Board

8.4.4 Renewal of fixed term Contract Head of HR and Head of Finance (being vacancy panel) for approval,

reported to ELB for approval

8.4.4a Redundancy – Authorisation for employees up to Band 7 or a small group of redundancies (under 20 employees)

Panel Comprising of: Chief Executive, Director of Finance & Commissioning

and Director of People & Culture

8.4.4b Redundancy – Authorisation for employees 8a and above or a large group of redundancies (over 20 employees)

Panel Comprising of: Chief Executive, Director of Finance & Commissioning and Director of People & Culture with

approval from Remuneration

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Committee 8.4.5 MARS – Authorisation Director of People & Culture with


8.4.6 Ill-Health Retirement – Decision to pursue retirement on grounds of ill health is an employee decision. Activation of Trust Procedures.

Head of Department or Deputy Director/Executive Director (as

appropriate) & Occupational Health

8.4.7 Dismissal – Authorisation Director of People & Culture & authorised Directors/Managers (band

8c and above) or Remuneration Committee

(as appropriate) in accordance with Trust Policy

8.5 Leave Authority (In accordance with Trust Policy) SFI 10.2.6 and SO 6

8.5.1 Study Leave – All study leave external to the UK and Ireland, including CME/professional leave

Chief Executive or nominated Deputy following recommendation from Head of Department or Head of Operations /

Director (as appropriate) and where appropriate in conjunction with the

Medical Director or Director of Clinical Quality and Improvement (as

appropriate) in accordance with Trust Policy

8.5.2 Study Leave – All study leave involving hospitality (Directorate required to obtain the necessary approval to study leave and maintain register and forward to the Head of Governance/Chief Executive for authorisation of any hospitality before acceptance).

Head of Department or Head of Operations /

Director (as appropriate) in conjunction with the Medical Director

or Director of Clinical Quality and Improvement (as appropriate)

Chief Executive/Head of Governance (for advance approval of hospitality)

8.6 Relocation Expenses

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8.6.1 Authorisation of payment of relocation expenses incurred by officers taking up new appointments (in accordance with local policy);

(a) Up to £8,000 Director of People & Culture or Remuneration Committee (as

appropriate)

(b) Over £8,001 Director of People & Culture and Chief Executive or Remuneration Committee (as appropriate)

8.7 Authorised Car and Mobile Phone Users

8.7.1 Requests for new posts to be authorised as car users or re-designation of existing

posts Director of Finance & Commissioning

8.7.2 Requests for authorised mobile phone status Budget Manager 9. FACILITIES FOR STAFF NOT EMPLOYED BY THE TRUST TO GAIN

PRACTICAL EXPERIENCE

9.1 Professional recognition, honorary contracts and insurance of medical staff Director of People & Culture or nominated deputy

9.2 Work experience students Director of People & Culture or nominated deputy

9.3 Management of Volunteers

9.3.1 Volunteer Car Drivers Chief Operating Officer

9.3.2 Community First Responders Chief Operating Officer

10. NON-PAY EXPENDITURE (See Scheme of Delegation 17 for Funds Held on Trust)

10

10.1 Approval of level of non-pay expenditure on an annual basis Board of Directors

10.1

10.2 Determination of the level of delegation to budget managers Chief Executive

3.2.2 & 10.1.1

10.3 Agree and maintain a list of managers authorised to place requisitions for the ordering and receipt of goods and services and authorisation of invoices (See overlap with Scheme of Delegation 16)


10.1.2 & 10.2.2

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10.3.1 Requisitioning and Ordering of Goods and Services and Authorisation of Invoices: 10.1.3 (a) All requisitions/invoices up to £10,000 Budget Managers as designated by

Budget Holders

(b) All requisitions/invoices up to £25,000 Head of Department or Head of Operations

(c) All requisitions/invoices between £25,001 and £100,000

This SFI will be waived to one signature in the event of a Declared Major Incident. The nominated staff member undertaking the role of Gold Commander shall be considered to have authorised delegated single signatory powers to the level of £100,000. This is specifically limited to costs incurred in relation to the management of the declared Major Incident, as where possible, Gold Commanders should, where circumstances allow, follow normal SFI process rather than default to this emergency delegation.

Head of Department countersigned by Executive Director as designated

(d) All requisitions/invoices between £100,001 and £500,000 Head of Department/Executive Director/Director (as appropriate and designated) with countersignature by

Director of Finance & Commissioning/Chief Executive (or Designated deputy in their absence)

(e) All requisitions/invoices over £500,001 Chief Executive/Director of Finance & Commissioning

10.3.2 On-Line Requisitioning or Ordering of Goods and Services: (a) Inclusion of Supplies within OLR catalogue Band 8c Manager or above in

conjunction with Head of Supplies

(b) All OLR catalogue requisitions up to £25,000 OLR Designated Officer within Directorate

(c) All OLR catalogue requisitions over £25,001 OLR Designated Officer with countersignature of Band 8c Manager

or above

10.3.3 Medicines Management (In Accordance with Medicines Management Policy) (a) Controlled Drugs Accountable Officer and Accountable Officer for Medicines

Management Medical Director

(b) Determination of the medicines management strategy and the standards to be used for the administration of all medicines used by the Trust, including

Medical Director with specialist advice from the Trust’s Pharmaceutical

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responsibility for the safe and secure handing of medicines Advisor and input from Medicines Management Group

(c) Medicine stocks must be obtained from a supplier approved by the Medical Director, and against formal orders signed by an authorised Paramedic. Only those medicines appearing in the Trust’s formulary are authorised to be purchased

Medical Director and authorised Paramedic in accordance with Medicines Management Policy

(d) Advisor to the Director of People & Culture on medicines management training requirements for all Trust clinicians.

Medical Director

10.4 Designation of authorised officers to issue of verbal orders in very exceptional circumstances (confirmation order required)


10.5 Development and maintenance of procedures on the seeking of professional advice regarding the supply of goods and services

10.1.2

10.5.1 Responsibility for ensuring financial standing and technical competence of approved contractors


10.5.2 Responsibility for ensuring technical/medical competence of approved contractors for clinical governance purposes

Medical Director 7.6.8 & 10.1.3

10.5.3 Variation to use of approved firms/individuals or if a list does not exist for whatever reason, responsibility for ensuring appropriate checks are carried out for technical and financial capability of those first invited to tender


10.6 System of Payment and Payment Verification

10.6.1 Responsibility for prompt payment of accounts, contract invoices and claims and

that payments are only made once the goods and services are received and been appropriately certified


10.6.2 Maintenance of register of employees (including specimens of their signatures) authorised to certify invoices


10.6.3 Pre-payments only permitted where exceptional circumstances apply. Authorisation of written report to permit pre-payment.


10.7 Petty Cash Disbursements

10.2.6

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10.7.1 Authority to define restrictions in value and by type of purchase for petty cash disbursements and maintenance of record system.


10.7.2 Petty Cash Disbursement limits: Expenditure up to £30 per transaction Budget Holder and Petty Cash Holder

10.8 Credit Cards

10.8.1 Development and monitoring of Credit Card Procedure Director of Finance & Commissioning 10.8.2 Authorisation to issue credit cards Director of Finance & Commissioning 10.8.3 Definition of credit limit Director of Finance & Commissioning 10.9 Leases, Tenancy Agreements and Licences

10.9.1 Approval of all new leases, tenancy agreements and licences, including any variation thereto: (N.B. Values relate to total length of lease/tenancy agreement/licence)

(a) Below £25,000 Head of Estates (b) Between £25,000 and £99,999 Head of Estates following

recommendation from Executive Leadership Board

(c) Between £100,000 – £500,000 Executive Leadership Board (d)Between £500,001 - £999,999 Director of Finance & Commissioning

following Executive Leadership Board recommendation

(e) Over £1M Board of Directors following recommendation from Executive

Leadership Board

10.9.2 Approval of all renewals of leases, tenancy agreements and licences, including any variation thereto: (N.B. Values relate to total length of lease/tenancy agreement/licence)

(a) Below £25,000 Head of Estates (b) Between £25,000 and £99,999 Head of Estates following

recommendation from Executive Leadership Board member

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(c) Between £100,000 and £500,000 Executive Leadership Board (d) Between £500,001 - £999,999 Director of Finance & Commissioning

following Executive Leadership Board recommendation

(e) Over £1M Board of Directors following recommendation from Executive

Leadership Board

10.9.2 Letting of premises to outside organisations Head of Estates and Director of Finance & Commissioning

10.9.3 Approval of rent based on professional assessment Head of Estates and Director of Finance & Commissioning

11. EXTERNAL BORROWING AND INVESTMENTS

11 11.1 External Borrowing (In accordance with Secretary of State Guidance)

11.1

11.1.1 Preparation of detailed procedural instructions concerning applications for loans and overdrafts


11.1.2 Approval of Borrowings from Department of Health Director of Finance & Commissioning/ following recommendation from Board

12. CAPITAL INVESTMENT, PRIVATE FINANCIAL, FIXED ASSET REGISTERS AND SECURITY OF ASSETS

12

12.1 Capital Investment & Private Finance

12.1 & 12.2 12.1.1 Approval of capital programme (including reserves list) as part of budget process

Board of Directors following recommendation from the

Performance & Finance Committee

12.1.2 Approval of business cases and PFI Schemes including approval of variations:

(a) Below £1m (Report to Executive Leadership Board)

Executive Leadership Board following recommendation by Director of

Finance & Commissioning & Capital Planning and Management Group

(b) Over £1m (Report to Executive Leadership Board) Board of Directors following recommendation by the Executive

Leadership Board

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12.1.3 Selection of architects, quantity surveyors, consultant engineers and other professional advisors within EU Regulations and CONCODE (in accordance with Tendering Procedures)

Director of Finance & Commissioning/Chief Executive

following professional advice

12.1.4 Budgetary delegation for management of capital budget in line with approved capital programme

Scheme of Delegation 2.2.2 refers 3.21

12.1.5 Financial monitoring and reporting on all capital scheme expenditure Director of Finance & Commissioning 12.1.6 Monitor compliance with the requirements of guidance published on capital

investment and estate and property transactions Director of Finance & Commissioning 7.4

12.2 Asset Registers

12.3 12.2.1 Maintenance of Asset Register and responsibility for re-valuation of assets in

accordance with the Capital Accounting Manual issued by the Department of Health


12.2.2 Approval of asset disposals (all disposals must be reported to Director of Finance & Commissioning to enable the Asset Register to be updated)

12.3.4 & 13.2

(a) “Protected Assets” as defined within the Trust’s Statutory Instrument and in accordance with the Capital Accounting Manual

Board of Directors

(b) Land and buildings Board of Directors (a) Other – where the asset has a residual value less than £9,999 Head of Finance (b) Other – where the asset has a residual value over £10,000 Director of Finance & Commissioning 12.3 Security of Assets

12.4

12.3.1 Overall control of fixed assets

Chief Executive 12.4.1 12.3.2 Asset control procedures


13. STORES AND RECEIPT OF GOODS (See Overlap with Scheme of Delegation 9.3)

13

13.1 Management and control of stores: 13.2.1 (a) General Head of Procurement and Band 8b

Manager or above

(b) Drugs Head of Procurement and Band 8b

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Manager or above following advice from the Medical Director (or Deputy)

(c) Fuel Deputy Director of Operational Support and Band 8b Manager or

above

13.2 Procedure and systems to regulate stores, including records for receipt of goods, issues, returns and losses

Head if Procurement and Band 8b Manager or above

13.3 Stocktaking Arrangements Director of Finance & Commissioning 14. DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS

14.1 Disposals and Condemnations of items included on the asset register (see Scheme of Delegation 12.2.2)

See Scheme of Delegation 12.2.2 14.1, 12.3.4 & 13.2

Disposals and condemnations of items not included on the asset register up to a value of £25,000

Head of Department with notification going to Head of Finance

Disposals and condemnations of items not included on the asset register up to a value from £25,001 to £100,000.

Head of Department countersigned by Executive Director as designated with notification going to Head of Finance

14.2 Losses and Special Payments Procedure 14.2 14.2.1 Special Payments – compensation payments made under legal obligation

(following written legal advice)

(a) Under £100,000 + costs Director of Finance & Commissioning or Chief Executive plus 1 other Board

Executive Director

(b) Over £100,001 + costs

Director of Finance & Commissioning or Chief Executive plus 1 other

Board Executive Director and 1 Audit Committee Member

14.2.2 Special Payments within limits set by the Department of Health governing: • Extra contractual payments to contractors • Ex-gratia payments • Extra statutory and extra regulatory payments

(a) Maximum limit of £50,000 Director of Finance & Commissioning and Chief Executive

(b) Over £50,001 Chief Executive with approval of the

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Executive Leadership Board 14.2.3 Losses within limits set by the Department of Health governing:

• Cash • Fruitless Payments (including abandoned capital schemes) • Bad debts and claims abandoned • Damage to buildings, fittings, furniture, equipment, loss of equipment,

property and stores

(a) Under £25,000 Director of Finance & Commissioning or Head of Finance

(b) £25,001 to £50,000 Director of Finance & Commissioning and Chief Executive or nominated

deputy in their absence

(c) £50,001 to £249,999 Director of Finance & Commissioning following recommendation by Executive Leadership Board

(d) Over £250,000 Chief Executive or Director of Finance & Commissioning and 1 other

Executive Board Director and 1 Audit Committee Member

14.2.4 Novel, contentious or repercussive losses or special payments Director of Finance & Commissioning to refer to Department of Health for

approval

14.2.5 All write-offs and special payments and losses to be reviewed by the Audit Committee


15. FINANCIAL SYSTEMS (IT)

15 15.1 Responsibility for accuracy and security of computerised financial data of the Trust Director of Finance & Commissioning 15.2 Risk assessment and approval of all requirements for general applications

impacting on corporate financial systems Director of Finance & Commissioning

16. PATIENTS’ PROPERTY

16 16.1 Provision of written instructions for the collection, safe custody, investment,

recording and disposal of money and other personal property handed in by patients, or found in the possession of patients dying in hospital or dead on arrival


16.3

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16.2 Operational management of patients’ property in accordance with patients’ property procedures

Head of Department or General Managers

17. FUNDS HELD ON TRUST

17 17.1 Corporate Trustee for the management of funds held in Trust Board of Directors monitored through

the Charitable Funds Committee

17.2 Nomination of Executive and Non-Executive Directors to discharge the Trust’s corporate trustee responsibilities

Board of Directors through appointment to the Charitable Funds

Committee

17.3 Management of trust funds: (a) Executive Fundraising Lead Director of Finance & Commissioning (b) Accounts Management Director of Finance & Commissioning 17.4 Reporting on income and expenditure on funds held in Trust to Charitable Funds

Committee (Audit Committee to sign off annual account) Director of Finance & Commissioning

17.5 Approval to Fundraising/Appeal Launch: (a) Projected Fundraising up to £5,000 Head of Department and Director of

Finance & Commissioning

(b) Projected Fundraising between £5,001 - £300,000 Charitable Funds Committee following Head of Department or Director of Finance & Commissioning support

(c) Over £300,000 Board of Directors following Charitable Funds Committee

recommendation

17.6 Funds held in Trust - Expenditure (a) Under £1,500 per request Head of Financial Services or Deputy

Head of Financial Services

(b) £1,501 to £5,000 per request Head of Finance (c) £5,001 to £25,000 per request Director of Finance & Commissioning

Requests over £25,001

Chief Executive, Director of Finance & Commissioning and Charitable Funds

Committee Chair/Member

18. ANTI-BRIBERY

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18.1 Nomination of Compliance Officer Board of Directors 18.2 Development and maintenance of policy Compliance Officer (Director of

Finance & Commissioning) in conjunction with Head of Governance

19. ACCEPTANCE OF GIFTS BY STAFF/STANDARDS OF BUSINESS CONDUCT (In Accordance with Standards of Business Conduct Policy in Respect of Interests, Gifts, Hospitality, Sponsorship, Advertising and Partnership Arrangements)

18

19.1 Development and maintenance of policy on standards of business conduct and acceptance of gifts and other benefits in kind by staff.

Head of Governance

19.2 Maintenance of Gifts and Hospitality Register

Head of Governance 19.3 Approval of Acceptance of Gifts/Hospitality which exceeds the limit of £25

Chief Executive/Director of Finance & Commissioning in support of Head of Department/Executive Director (as

appropriate)

19.4 Annual Audit of Hospitality Register Director of Finance & Commissioning/Audit Committee

19.5 Maintenance of Declaration of Interest Registers:

(a) Board of Directors

Head of Governance

(b) Trust Employees Head of Governance

20. AUTHORISATION OF COMMERCIAL SPONSORSHIP, ADVERTISING OR PARTNERSHIP ARRANGEMENTS

20.1 General Sponsorship, Advertising or Partnership Arrangements (including Charitable Fund Sponsorship)

Chief Executive with the Director of Communications and Engagement & Director of Finance & Commissioning

20.2 Research & Development Sponsorship, Advertising or Partnership Arrangements Director of Communications and Engagement, after approval by the Medical Director/Chief Executive

21. RETENTION OF DOCUMENTS/DATA PROTECTION

19 21.1 Compliance with Records Management – NHS Code of Practice Chief Executive in conjunction with

the Senior Information Risk Officer

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(SIRO) 21.2 Compliance with Access to Health Records Medical Director (as Caldicott

Guardian) in conjunction with the Senior Information Risk Officer

21.3 Compliance with the Data Protection and Freedom of Information Acts Head of Governance in conjunction with the Senior Information Risk

Officer

21.4 Caldicott Guardian Medical Director 22. RISK MANAGEMENT AND INSURANCE

20

22.1 Risk Management

22.1.1 Administers programme of risk management, approved and monitored by the

Board of Directors Chief Executive in conjunction with

the Head of Governance 20.1

22.1.2 Integration and evaluation of the programme of risk management to provide a basis to make a statement on the effectiveness of internal control (Annual Governance Statement) within the Annual Report and Accounts as required by current Department of Health guidance

Chief Executive in conjunction with

the Head of Governance

20.1

22.1.3 Review of Fire Precautions Director of Clinical Quality and Improvement

22.1.4 Review of all statutory compliance legislation pertaining to Health & Safety Director of Clinical Quality and Improvement

22.1.5 Review of compliance with environmental regulations, e.g. clean air and waste disposal

Infrastructure and Estates Programme Lead or Deputy Director of Operations

Support and Head of Estates and Band 8b Manager or above

22.1.6 Infection, Prevention & Control Responsibility Director of Clinical Quality and Improvement

22.1.7 Incident and Serious Incident Reporting Director of Clinical Quality and Improvement (in conjunction with the

appropriate external bodies and Trust’s Communications Team)

22.1.8 Infectious Diseases and Notifiable Outbreaks Medical Director 22.1.9 Safeguarding Director of Clinical Quality and

Improvement

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22.1.10 Senior Information Risk Officer/Senior Responsible Owner Chief Information Officer 22.1.11 Executive Responsibility for Maternity Services Director of Clinical Quality and

Improvement

22.1.12 Security Management Director Chief Executive in conjunction with Director of Clinical Quality and

Improvement

22.1.13 Sustainability Development Chief Executive 22.1.14 Health and Safety Lead Director of Clinical Quality and

Improvement

22.1.15 Emergency Planning (EPRR) Lead Chief Operating Officer 22.1.16 Child Protection and Vulnerable Persons Lead Director of Clinical Quality and

Improvement

22.1.17 Resuscitation Officer Medical Director 22.1.18 NHS Constitution Executive Lead Chief Executive 23.2 Insurance

23.2.1 Approval of insurance policies and engagement of additional insurance over and above the NHS Resolution Scheme.


24. CONSULTATION

24.1 Formal Consultation 24.1.1 Compliance with Section 242 of the NHS Act 2006 and Regulation 4A of the Local

Authority (Overview & Scrutiny Committee’s health scrutiny functions) Regulations 2002

Chief Executive in conjunction with the Director of Communications and

Engagement, and the Head of Department

24.2 Media Liaison 24.2.1 All enquiries: (a) within hours (Monday – Friday 9 am – 5 pm) Director of Communications and

Engagement and Communications Team in conjunction with Directors/

Managers (as appropriate)

(b) outside hours On-call Communications Team in conjunction with Designated Duty Manager or Executive Director (as

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appropriate)

24. ENGAGEMENT OF TRUST SOLICITORS 24.1 Award of Contract in accordance with tender procedures Board of Directors 24.2 Referral of Trust Issues for Legal Opinion: All requests for external legal advice will be routed through the Head of

Governance or an Executive Director. The leads for each are detailed below

(a) Corporate Law Head of Governance or Chief Executive

(b) Property, major transactions, commercial and associated contractual law

Director of Finance & Commissioning or Deputy Director for Operations

Support or Head of Estates

(c) Clinical and Risk Management Law

Director of Clinical Quality and Improvement and Head of

Governance (Risk)

(d) Contract or Commercial Law


(e) Employment Law

Director of People & Culture or Nominated Deputy

(f) R&D, Intellectual Property Law Medical Director/or nominated deputy in conjunction with Research Manager

25. PATIENT SERVICES 25.1 Patients’ and Relatives’ complaints management, including clinical negligence

complaints Director of Clinical Quality and

Improvement

25.2 Variation of operating and clinical sessions within existing resources Chief Operating Officer in conjunction with appropriate Head of Department (or nominated deputy) & Director of

Clinical Quality and Improvement and Medical Director

25.3 Variation to changes in operational fleet allocation: (a) Temporary Variation

Chief Operating Officer in conjunction with appropriate Head of Department

or their nominated deputy

(b) Permanent Change Chief Operating Officer in conjunction

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with Deputy Director of Operations Support

26. EXTENDED ROLE ACTIVITIES 26.1 Approval of staff to undertake extended professional clinical roles

Chief Executive in conjunction with Medical Director or

Director of Clinical Quality and Improvement (as appropriate)

27. POLICIES AND PROCEDURES 27.1 Approval of all non-clinical organisational/operational policies and procedures for

and on behalf of the Board of Directors

The Chief Executive will have discretion to declare matters for specific consideration directly to the Board of Directors for approval.

Executive Leadership Board ratification following approval from Compliance and Risk Group after recommendation and consultation

with relevant stakeholders

28. ATTESTATION OF SEALINGS AND REGISTER 28.1 Attestation of Sealings in accordance with Standing Orders of the Board of

Directors Chair and Chief Executive or

nominated deputies

28.2 Maintenance of Register of Sealings Head of Governance 29. RESEARCH & DEVELOPMENT (See also overlap with Scheme of Delegation 20

– Authorisation of Sponsorship Deals as well as Scheme of Delegation 6.12 - Compliance Requirements for All Contracts and 7 - Contracting for the Provision of Services)

29.1 Authorisation of Research and Development (subject to contract approvals) Delegation)

Chief Executive following recommendation from Clinical Best

Practice Group

29.2 Authorisation of Clinical Trials (subject to contract approvals) Chief Executive and Medical Director following recommendation from

Clinical Best Practice Group

30. CLINICAL PRODUCTS

30.1 Assessment and recommendation of clinical products Clinical Best Practice Group and Deputy Medical Director prior to

recommendation to Senior Leadership Board

31. MEDICINES INSPECTORATE (In Accordance with the Medicines

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Management Policy) 31.1 Review and implementation of Medicines and Healthcare products Regulatory

Agency (MHRA) Regulations Medical Director

32. REGULATION OF MEDICAL PRACTITIONERS

32.1 Responsible Officer

Medical Director

33. EXTERNAL AUDITOR SERVICES

tbc

33.1 Advise the organisation’s board on the selection and appointment of the external auditor

Director of Finance & Commissioning Auditor Panel

33.2 Advise the organisation’s board on the maintenance of an independent relationship with the appointed external auditor

Auditor Panel

33.3 Under the Audit Code, the External Auditor may provide the Trust with services which are outside the scope of the audit. Application of the Trust’s “Provision of Additional Services by the External Auditor” should be applied to ensure no conflict of interest and ethical standards are applied.

Auditor Panel approval required before engagement. If timing

precludes this, the Auditor Panel Chair and Director of Finance &

Commissioning may take action and report to next Auditor Panel meeting.

34 Emergency Preparedness, Resilience and Response compliance (In accordance with the Civil Contingencies Act 2004, the Health and Social Care Act 2012 particularly the subsection NHS England EPRR Framework):

34.1 Responsible Officer for discharging the duties and responsibilities of the Trust as a category 1 responder


34.2 Responsible Manager for attendance at Local Health Resilience Partnerships Head of Operations for each area Approved by Trust Board: 11 March 2020

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STANDING ORDERS


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C O N T E N T S 1. INTRODUCTION ..................................................................................................................... 1.1 Statutory Framework ............................................................................................................. 1.2 Terminology ........................................................................................................................... 1.3 NHS Framework ..................................................................................................................... 1.4 Delegation of Powers ............................................................................................................ 1.5 Integrated Governance .......................................................................................................... 2. THE TRUST BOARD: COMPOSITION OF MEMBERSHIP, TENURE AND ROLE OF

MEMBERS ......................................................................................................................... 2.1 Composition of the Membership of the Trust Board .......................................................... 2.2 Appointment of Chair and Members of the Trust ............................................................... 2.3 Terms of Office of the Chair and Members ......................................................................... 2.4 Appointment and Powers of Vice-Chair .............................................................................. 2.5 Joint Members ........................................................................................................................ 2.6 Role of Members .................................................................................................................... 2.7 Corporate role of the Board .................................................................................................. 2.8 Schedule of Matters Reserved to the Board and Scheme of Delegation .......................... 2.9 Lead Roles for Board Members ............................................................................................ 3. MEETINGS OF THE TRUST ..................................................................................................... 3.1 Calling meetings .................................................................................................................... 3.10 Chair's Ruling ....................................................................................................................... 3.11 Quorum ................................................................................................................................. 3.12 Voting .................................................................................................................................... 3.13 Suspension of Standing Orders ......................................................................................... 3.14 Variation and Amendment of Standing Orders ................................................................. 3.15 Record of Attendance .......................................................................................................... 3.16 Minutes ................................................................................................................................. 3.17 Admission of Public and the Press .................................................................................... 3.18 Observers at Trust Meetings .............................................................................................. 3.2 Notice of Meetings and the Business to be transacted...................................................... 3.3 Agenda and Supporting Papers ........................................................................................... 3.4 Petitions .................................................................................................................................. 3.5 Notice of Motion 3.6 Emergency Motions ............................................................................................................... 3.7 Motions: Procedure At and During a Meeting ..................................................................... 3.8 Motion to Rescind a Resolution ........................................................................................... 3.9 Chair of Meeting ..................................................................................................................... 4. APPOINTMENT OF COMMITTEES AND SUB-COMMITTEES ............................................... 4.1 Appointment of Committees ................................................................................................. 4.2 Joint Committees ................................................................................................................... 4.3 Applicability of Standing Orders and Standing Financial Instructions to Committees .. 4.4 Terms of Reference ............................................................................................................... 4.5 Delegation of powers by Committees to Sub-Committees ................................................ 4.6 Approval of Appointments to Committees .......................................................................... 4.7 Appointments for Statutory Functions ................................................................................ 4.8 Committees Established by the Trust Board ...................................................................... 4.9 Confidentiality ........................................................................................................................ 5. ARRANGEMENTS FOR THE EXERCISE OF TRUST FUNCTIONS BY DELEGATION ......... 5.1 Delegation of Functions to Committees, Officers or other Bodies ................................... 5.2 Emergency Powers and Urgent Decisions 5.3 Delegation to Committees ..................................................................................................... 5.4 Delegation to Officers ............................................................................................................ 5.5 Schedule of Matters Reserved to the Trust and Scheme of Delegation of Powers ......... 5.6 Duty to Report Non-Compliance with Standing Orders and Standing Financial

Instructions ....................................................................................................................... 6. OVERLAP WITH OTHER TRUST POLICY STATEMENTS/PROCEDURES, REGULATIONS

AND THE STANDING FINANCIAL INSTRUCTIONS ....................................................... 6.1 Policy Statements: General Principles ................................................................................

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6.2 Specific Policy Statements ................................................................................................... 6.3 Standing Financial Instructions ........................................................................................... 6.4 Specific Guidance .................................................................................................................. 7. DUTIES AND OBLIGATIONS OF BOARD MEMBERS/DIRECTORS AND SENIOR MANAGERS

UNDER THESE STANDING ORDERS ............................................................................. 7.1 Declaration of Interests ......................................................................................................... 7.2 Register of Interests .............................................................................................................. 7.3 Exclusion of Chair and Members in Proceedings on Account of Pecuniary Interest ..... 7.4 Standards of Business Conduct .......................................................................................... 8. CUSTODY OF SEAL, SEALING OF DOCUMENTS AND SIGNATURE OF DOCUMENTS .... 8.1 Custody of Seal ...................................................................................................................... 8.2 Sealing of Documents ........................................................................................................... 8.3 Register of Sealing ................................................................................................................ 8.4 Signature of documents ........................................................................................................ 9. MISCELLANEOUS .................................................................................................................... 9.1 Joint Finance Arrangements ................................................................................................ 9.2 Standing Orders to be given to Directors and Officers ...................................................... 9.3 Documents having the standing of Standing Orders ......................................................... 9.4 Review of Standing Orders ...................................................................................................

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1. INTRODUCTION 1.1 Statutory Framework 1.1.1 The East of England Ambulance Service NHS Trust is a statutory body which came into

existence on 1 July 2006 under The East of England Ambulance Service NHS Trust (Establishment) Order 2006 No 1619, (the Establishment Order).

1.1.1 The principal place of business of the Trust is: East of England Ambulance Service Headquarters Melbourn Station Whiting Way Off Back Lane Melbourn Cambridgeshire SG8 6EN 1.1.2 NHS Trusts are governed by Act of Parliament, mainly the National Health Service Act

1977 (NHS Act 1977), the National Health Service and Community Care Act 1990 (NHS & CC Act 1990) as amended by the Health Authorities Act 1995, the Health Act 1999, the Health and Social Care Act 2001, the NHS Act 2006 as amended by the Health Act 2009.

1.1.3 The functions of the Trust are conferred by this legislation. 1.1.4 As a statutory body, the Trust has specified powers to contract in its own name and to

act as a corporate trustee. In the latter role it is accountable to the Charity Commission for those funds deemed to be charitable as well as to the Secretary of State for Health and Social Care.

1.1.5 The Trust also has statutory powers under Section 28A of the NHS Act 1977, as

amended by the Health Act 1999, to fund projects jointly planned with local authorities, voluntary organisations and other bodies.

1.1.6 The Code of Accountability requires the Trust to adopt Standing Orders for the regulation

of its proceedings and business. The Trust must also adopt Standing Financial Instructions (SFIs) as an integral part of Standing Orders setting out the responsibilities of individuals.

1.1.7 The Trust will also be bound by such other statutes and legal provisions which govern

the conduct of its affairs. 1.1.8 Officers of the Trust should note that the Scheme of Delegation, SFIs and SOs do not

contain every legal obligation applicable to the Trust. The Trust and each officer of the Trust must comply with all requirements of legislation (which shall mean any statute, subordinate or secondary legislation, any enforceable community right within the meaning of Section 2(1) European Community Act 1972 and any applicable judgement of a relevant court of law which is a binding precedent in England) and all guidance and directions binding on the Trust. Legislation, guidance and directions will impose requirements additional to the Scheme of Delegation, SFIs and SOs. All such legislation and binding guidance and directions shall take precedence over the Scheme of Delegation, SFIs and SOs which shall be interpreted accordingly.

1.1.9 Should any difficulties arise regarding the interpretation or application of any of the SOs,

then the advice of the Head of Governance must be sought before acting. The user of these SOs should also be familiar with and comply with the provisions of the Trust’s

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SFIs. Note in particular procedures for Tendering, Quotations and Contracts and the

Schedule of Powers Reserved to the Board of Directors. 1.1.10 The failure to comply with the Standing Orders, Standing Financial Instructions or

Scheme of Delegation can, in certain circumstances, be regarded as a disciplinary matter that could result in dismissal.

1.1.11 Overriding SOs: If, for any reason, these SFIs are not complied with, full details of the

non-compliance and any justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the Audit Committee for referring action or ratification.

1.1.12 All members of the Trust Board and staff have a duty to disclose any non-compliance

with these SOs to the Head of Governance as soon as possible. 1.2 Terminology 1.2.1 Any expression to which a meaning is given in Health Service Acts, or in Financial

Directions made under the Acts, shall have the same meaning in these instructions; and “Accountable Officer” means the Officer responsible and accountable for funds entrusted

to the Trust. The Officer shall be responsible for ensuring the proper stewardship of public funds and assets. For this Trust it shall be the Chief Executive;

“Board” means the Chair, officer and non-officer members of the Trust collectively as a

body; “Budget” means a resource, expressed in financial terms, and proposed by the Board for

the purpose of carrying out, for a specific period, any or all of the functions of the Trust; “Budget Holder” means the Director or employee with delegated authority to manage

finances (income and expenditure) for a specific area of the organisation; “Chair of the Board (or Trust)” is the person appointed by the Secretary of State for

Health and Social Care to lead the Board and to ensure that it successfully discharges its overall responsibility for the Trust as a whole. The expression “the Chair of the Trust” shall be deemed to include the Vice-Chair of the Trust if the Chair is absent from the meeting or is otherwise unavailable;

“Chief Executive” means the Chief Officer/Accountable Officer of the Trust; “Commissioning” means the process for determining the need for and for obtaining the

supply of healthcare and related services by the Trust within available resources; “Committee” means a committee or sub-committee created and appointed by the Trust; “Committee members” means any persons formally appointed by the Board to sit on or to

chair specific committees;

“Contracting and Procuring” means the systems for obtaining the supply of goods, materials, manufactured items, services, building and engineering services, works of construction and maintenance and for disposal of surplus and obsolete assets;

“Director” means a person appointed as a director in accordance with the Membership

and Procedure Regulations and includes the Chair;

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“Director of Finance and Commissioning” means the Chief Financial Officer of the Trust; “Executive Director” means a person appointed as an Executive Director of the Trust

under Standing Order 2 and who is an officer of the Trust; “Funds held on trust” shall mean those funds, which the Trust holds at its date of

incorporation, receives on distribution by statutory instrument or chooses subsequently to accept under powers derived under Part 11, Chapter 2 of the NHS Act 2006. Such funds may or may not be charitable;

“Legal Adviser” means the properly qualified person appointed by the Trust to provide

legal advice; “Member” means officer or non-officer member of the Board as the context permits.

Member in relation to the Board does not include its Chair; “Associate Member” means a person appointed to perform specific statutory and non-

statutory duties which have been delegated by the Trust Board for them to perform and these duties have been recorded in an appropriate Trust Board minute or other suitable record;

“Membership, Procedure and Administration Arrangements Regulations” means NHS

Membership and Procedure Regulations (SI 1990/2024) and subsequent amendments. “Nominated Officer” means an officer charged with the responsibility for discharging

specific tasks within Standing Orders and Standing Financial Instructions; “Non-officer Member” means a member of the Trust who is not an officer of the Trust is

not to be treated as an officer by virtue of regulation 1(3) of the Membership, Procedure and Administration Arrangements Regulations;

“Officer” means employee of the Trust or any other person holding a paid appointment or

office within the Trust; “Officer Member” means a member of the Trust who is either an officer of the Trust or is

to be treated as an officer by virtue of regulation 1(3) (i.e. the Chair of the Trust or any person nominated by such a Committee for appointment as a Trust member);

“SFIs” means Standing Financial Instructions; “SOs” means Standing Orders “The 2006 Act” means the National Health Service Act 2006; “The 2009 Act” means the National Health Service Act 2009; “Trust” means the East of England Ambulance Service NHS Trust; “Head of Governance” means the person appointed to act independently of the Board to

provide advice on corporate governance issues to the Board and the Chair and to monitor the Trust’s compliance with the law, Standing Orders and Department of Health guidance;

“Vice-Chair” means the non-officer member appointed by the Board to take on the

Chair’s duties if the Chair is absent for any reason.

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1.2.2 Wherever the title Chief Executive, Director of Finance and Commissioning, or other nominated officer is used in these Standing Orders, it shall be deemed to include such other Directors or employees who have been duly authorised to represent them.

1.2.3 Wherever the term “employee” is used and where the context permits, it shall be deemed

to include employees of third parties contracted to the Trust when acting on behalf of the Trust.

1.3 NHS Framework 1.3.1 In addition to the statutory requirements the Secretary of State for Health and Social

Care through the Department of Health issues further directions and guidance. These are normally issued under cover of a circular or letter. The majority of these can be found on the department of health website. Members and employees should take particular note of the requirements of:

• Code of Conduct for NHS Managers • Standards of Business for NHS Staff • NHS Code of Conduct and Accountability • Code of Practice on Openness in the NHS • NHS Constitution

1.3.2 The Code of Accountability requires that, inter alia, Boards draw up a schedule of

decisions reserved to the Board, and ensure that management arrangements are in place to enable responsibility to be clearly delegated to senior executives (a scheme of delegation). The Code also requires the establishment of audit and remuneration committees with formally agreed terms of reference. The Codes of Conduct make various requirements concerning possible conflicts of interest of Board members.

1.3.3 The Code of Practice on Openness in the NHS sets out the requirements for public

access to information on the NHS. 1.4 Delegation of Powers The Trust has powers to delegate and make arrangements for delegation. The Standing

Orders set out the detail of these arrangements. Under the Standing Order relating to the Arrangements for the Exercise of Functions (SO 6) the Trust is given powers to "make arrangements for the exercise, on behalf of the Trust of any of their functions by a committee, sub-committee or joint committee appointed by virtue of Standing Order 5 or by an officer of the Trust, in each case subject to such restrictions and conditions as the Trust thinks fit or as the Secretary of State for Health and Social Care may direct". Delegated Powers are covered in the ‘Schedule of Matters reserved to the Board’ and the ‘Scheme of Delegation’ and have effect as if incorporated into the Standing Orders and Standing Financial Instructions.

1.5 Integrated Governance The Trust Board will monitor its integrated governance structure to ensure good

governance and decision-making is informed by intelligent information covering the full range of corporate, financial, clinical, operational, information and research governance. Integrated governance will better enable the Board to take a holistic view of the organisation and its capacity to meet its legal and statutory requirements and clinical, quality and financial objectives.

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2. THE TRUST BOARD: COMPOSITION OF MEMBERSHIP, TENURE AND ROLE OF MEMBERS

2.1 Composition of the Membership of the Trust Board In accordance with the Membership, Procedure and Administration Arrangements

regulations the composition of the Board shall be: 2.1.1 The Chair of the Trust; 2.1.2 Up to 5 non-officer members; 2.1.3 Up to 5 officer members (but not exceeding the number of non-officer members)

including:

• Chief Executive (Accountable Officer) • Director of Finance • A medical or dental practitioner

The Trust shall have not more than 11 and not less than 8 members (unless otherwise

determined by the Secretary of State for Health and Social Care and set out in the Trust’s Establishment Order or such other communication from the Secretary of State for Health and Social Care).

The Board may determine the appointment of ex-officio directors. These directors do not

have voting rights. The voting members of the Board are:

• Chair • Non-Executive Directors • Chief Executive • Medical Director • Director of Finance and Commissioning • Chief Operating Officer • Director of Clinical Quality and Improvement

The ex-officio and non-voting members of the Board are:

• Associate Non-Executive Directors • Director of People and Culture • Director of Communications and Engagement

2.2 Appointment of Chair and Members of the Trust Appointment of the Chair and Members of the Trust - Paragraph 4 of Schedule 5A to the

1977 Act, as inserted by the Health Act 1999, provides that the Chair is appointed by the Secretary of State for Health and Social Care, but otherwise the appointment and tenure of office of the Chair and members are set out in the Membership, Procedure and Administration Arrangements Regulations

2.3 Terms of Office of the Chair and Members The regulations setting out the period of tenure of office of the Chair and members and

for the termination or suspension of office of the Chair and members are contained in Sections 2 to 4 of the Membership and Procedure and Administration Arrangements Regulations.

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2.4 Appointment and Powers of Vice-Chair 2.4.1 Subject to Standing Order 2.4.2 below, the Chair and members of the Trust may appoint

one of their numbers, who is not also an officer member, to be Vice-Chair, for such period, not exceeding the remainder of his term as a member of the Trust, as they may specify on appointing him.

2.4.2 Any member so appointed may at any time resign from the office of Vice-Chair by giving

notice in writing to the Chair. The Chair and members may thereupon appoint another member as Vice-Chair in accordance with the provisions of Standing Order 2.4.1.

2.4.3 Where the Chair of the Trust has died or has ceased to hold office, or where they have

been unable to perform their duties as Chair owing to illness or any other cause, the Vice-Chair shall act as Chair until a new Chair is appointed or the existing Chair resumes their duties, as the case may be; and references to the Chair in these Standing Orders shall, so long as there is no Chair able to perform those duties, be taken to include references to the Vice-Chair.

2.5 Joint Members 2.5.1 Where more than one person is appointed jointly to a post mentioned in regulation

2(4)(a) of the Membership, Procedure and Administration Arrangements Regulations those persons shall count for the purpose of Standing Order 2.1 as one person.

2.5.2 Where the office of a member of the Board is shared jointly by more than one person:

(a) all of those persons may attend or take part in meetings of the Board; (b) if all are present at a meeting they should cast one vote if they agree; (c) in the case of disagreements, no vote should be cast; (d) the presence of one or more persons should count as the presence of one person

for the purposes of Standing Order 3.11 Quorum. 2.6 Role of Members The Board will function as a corporate decision-making body, Officer and Non-Officer

Members will be full and equal members. Their role as members of the Board of Directors will be to consider the key strategic and managerial issues facing the Trust in carrying out its statutory and other functions.

2.6.1 Executive Members Executive Members shall exercise their authority within the terms of these Standing

Orders and Standing Financial Instructions and the Scheme of Delegation. 2.6.2 Chief Executive The Chief Executive shall be responsible for the overall performance of the executive

functions of the Trust. They are the Accountable Officer for the Trust and shall be responsible for ensuring the discharge of obligations under Financial Directions and in line with the requirements of the Accountable Officer Memorandum for Trust Chief Executives.

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2.6.3 Director of Finance and Commissioning The Director of Finance and Commissioning shall be responsible for the provision of

financial advice to the Trust and to its members and for the supervision of financial control and accounting systems. They shall be responsible along with the Chief Executive for ensuring the discharge of obligations under relevant Financial Directions.

2.6.4 Non-Executive Members The Non-Executive Members shall not be granted nor shall they seek to exercise any

individual executive powers on behalf of the Trust. They may however, exercise collective authority when acting as members of or when chairing a committee of the Trust which has delegated powers.

2.6.5 Chair The Chair shall be responsible for the operation of the Board and chair all Board

meetings when present. The Chair has certain delegated executive powers. The Chair must comply with the terms of appointment and with these Standing Orders.

The Chair shall liaise with NHS Improvements over the appointment of Non-Executive

Directors and once appointed shall take responsibility either directly or indirectly for their induction, their portfolios of interests and assignments, and their performance.

The Chair shall work in close harmony with the Chief Executive and shall ensure that key

and appropriate issues are discussed by the Board in a timely manner with all the necessary information and advice being made available to the Board to inform the debate and ultimate resolutions.

2.7 Corporate role of the Board 2.7.1 All business shall be conducted in the name of the Trust. 2.7.2 All funds received in trust shall be held in the name of the Trust as corporate trustee. 2.7.3 The powers of the Trust established under statute shall be exercised by the Board

meeting in public session except as otherwise provided for in Standing Order No. 3. 2.7.4 The Board shall define and regularly review the functions it exercises on behalf of

Secretary of State for Health and Social Care. 2.8 Schedule of Matters Reserved to the Board and Scheme of Delegation The Board has resolved that certain powers and decisions may only be exercised by the

Board in formal session. These powers and decisions are set out in the ‘Schedule of Matters Reserved to the Board’ and shall have effect as if incorporated into the Standing Orders. Those powers which it has delegated to officers and other bodies are contained in the ‘Scheme of Delegation’.

2.9 Lead Roles for Board Members The Chair will ensure that the designation of Lead roles or appointments of Board

members as required by the Department of Health or as set out in any statutory or other guidance will be made in accordance with that guidance or statutory requirement (e.g. appointing a Lead Board Member with responsibilities for Infection Control or Child Protection Services etc.).

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3. MEETINGS OF THE TRUST 3.1 Calling meetings 3.1.1 Ordinary meetings of the Board shall be held at regular intervals at such times and

places as the Board may determine. 3.1.2 The Chair of the Trust may call a meeting of the Board at any time. 3.1.3 One third or more members of the Board may request a meeting in writing. If the Chair

refuses, or fails, to call a meeting within seven days of a requisition being presented, the members signing the requisition may forthwith call a meeting.

3.2 Notice of Meetings and the Business to be transacted 3.2.1 Before each meeting of the Board a written notice specifying the business proposed to

be transacted shall be delivered to every member, or sent by post to the usual place of residence of each member, so as to be available to members at least three clear days before the meeting. The notice shall be signed by the Chair or by an officer authorised by the Chair to sign on their behalf. Want of service of such a notice on any member shall not affect the validity of a meeting.

3.2.2 In the case of a meeting called by members in default of the Chair calling the meeting,

the notice shall be signed by those members. 3.2.3 No business shall be transacted at the meeting other than that specified on the agenda,

or emergency motions allowed under Standing Order 3.6. 3.2.4 A member desiring a matter to be included on an agenda shall make his/her request in

writing to the Chair at least 15 days before the meeting. The request should state whether the item of business is proposed to be transacted in the presence of the public and should include appropriate supporting information. Requests made less than 15 days before a meeting may be included on the agenda at the discretion of the Chair.

3.2.5 Before each meeting of the Board a public notice of the time and place of the meeting,

and the public part of the agenda, shall be displayed at the Trust’s website at least three clear days before the meeting, (required by the Public Bodies (Admission to Meetings) Act 1960 Section 1 (4) (a)).

3.3 Agenda and Supporting Papers The Agenda will be sent to members 6 days before the meeting and supporting papers,

whenever possible, shall accompany the agenda, but will certainly be dispatched no later than three clear days before the meeting, save in emergency.

3.4 Petitions Where a petition has been received by the Trust the Chair shall include the petition as an

item for the agenda of the next meeting. 3.5 Notice of Motion 3.5.1 Subject to the provision of Standing Orders 3.7 ‘Motions: Procedure At and During a

Meeting’ and 4.8 ‘Motions to Rescind a Resolution’, a member of the Board wishing to move a motion shall send a written notice to the Chief Executive who will ensure that it is brought to the immediate attention of the Chair.

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3.5.2 The notice shall be delivered at least 15 days before the meeting. The Chief Executive shall include in the agenda for the meeting all notices so received that are in order and permissible under governing regulations. This Standing Order shall not prevent any motion being withdrawn or moved without notice on any business mentioned on the agenda for the meeting.

3.6 Emergency Motions Subject to the agreement of the Chair, and subject also to the provision of Standing

Order 4.7 ‘Motions: Procedure At and During a Meeting’, a member of the Board may give written notice of an emergency motion after the issue of the notice of meeting and agenda, up to one hour before the time fixed for the meeting. The notice shall state the grounds of urgency. If in order, it shall be declared to the Trust Board at the commencement of the business of the meeting as an additional item included in the agenda. The Chair's decision to include the item shall be final.

3.7 Motions: Procedure At and During a Meeting 3.7.1 Who may Propose: A motion may be proposed by the Chair of the meeting or any

member present. It must also be seconded by another member. 3.7.2 Contents of Motion: The Chair may exclude from the debate at their discretion any

such motion of which notice was not given on the notice summoning the meeting other than a motion relating to:

• the reception of a report; • consideration of any item of business before the Trust Board; • the accuracy of minutes; • that the Board proceed to next business; • that the Board adjourn; • that the question be now put.

3.7.3 Amendments to Motions: A motion for amendment shall not be discussed unless it

has been proposed and seconded. Amendments to motions shall be moved relevant to the motion, and shall not have the effect of negating the motion before the Board. If there are a number of amendments, they shall be considered one at a time. When a motion has been amended, the amended motion shall become the substantive motion before the meeting, upon which any further amendment may be moved.

3.7.4 Rights of Reply to Motions

(a) Amendments: The mover of an amendment may reply to the debate on their amendment immediately prior to the mover of the original motion, who shall have the right of reply at the close of debate on the amendment, but may not otherwise speak on it.

(b) Substantive/Original Motion: The Director who proposed the substantive motion

shall have a right of reply at the close of any debate on the motion. 3.7.7 Withdrawing a Motion: A motion, or an amendment to a motion, may be withdrawn. 3.7.8 Motions Once Under Debate: When a motion is under debate, no motion may be

moved other than:

• an amendment to the motion; • the adjournment of the discussion, or the meeting; • that the meeting proceed to the next business; • that the question should be now put;

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• the appointment of an 'ad hoc' committee to deal with a specific item of business; • that a member/director be not further heard; • a motion under Section l (2) or Section l (8) of the Public Bodies (Admissions to

Meetings) Act l960 resolving to exclude the public, including the press (see Standing Order 3.17).

In those cases where the motion is either that the meeting proceeds to the ‘next

business’ or ‘that the question be now put’ in the interests of objectivity these should only be put forward by a member of the Board who has not taken part in the debate and who is eligible to vote.

If a motion to proceed to the next business or that the question be now put, is carried, the

Chair should give the mover of the substantive motion under debate a right of reply, if not already exercised. The matter should then be put to the vote.

3.8 Motion to Rescind a Resolution 3.8.1 Notice of motion to rescind any resolution (or the general substance of any resolution)

which has been passed within the preceding six calendar months shall bear the signature of the member who gives it and also the signature of three other members, and before considering any such motion of which notice shall have been given, the Trust Board may refer the matter to any appropriate Committee or the Chief Executive for recommendation.

3.8.2 When any such motion has been dealt with by the Trust Board it shall not be competent

for any director/member other than the Chair to propose a motion to the same effect within six months. This Standing Order shall not apply to motions moved in pursuance of a report or recommendations of a Committee or the Chief Executive.

3.9 Chair of Meeting 3.9.1 At any meeting of the Trust Board the Chair, if present, shall preside. If the Chair is

absent from the meeting, the Vice-Chair (if the Board has appointed one), if present, shall preside.

3.9.2 If the Chair and Vice-Chair are absent, such member (who is not also an Officer Member

of the Trust) as the members present shall choose shall preside. 3.10 Chair's Ruling The decision of the Chair of the meeting on questions of order, relevancy and regularity

(including procedure on handling motions) and their interpretation of the Standing Orders and Standing Financial Instructions, at the meeting, shall be final.

3.11 Quorum 3.11.1 No Board business shall be transacted at a meeting unless at least one-third of the

whole number of the Chair and members (including at least one member who is also an Officer Member of the Trust and one member who is not) is present.

3.11.2 An Officer in attendance for an Executive Director (Officer Member) but without formal

acting up status may not count towards the quorum. 3.11.3 If the Chair or member has been disqualified from participating in the discussion on any

matter and/or from voting on any resolution by reason of a declaration of a conflict of interest (see SO No.7) that person shall no longer count towards the quorum. If a quorum is then not available for the discussion and/or the passing of a resolution on any

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matter, that matter may not be discussed further or voted upon at that meeting. Such a position shall be recorded in the minutes of the meeting. The meeting must then proceed to the next business.

3.12 Voting 3.12.1 Save as provided in Standing Orders 3.13 - Suspension of Standing Orders and 3.14 -

Variation and Amendment of Standing Orders, every question put to a vote at a meeting shall be determined by a majority of the votes of members present and voting on the question. In the case of an equal vote, the person presiding (i.e.: the Chair of the meeting shall have a second or casting vote).

3.12.2 At the discretion of the Chair all questions put to the vote shall be determined by oral

expression or by a show of hands, unless the Chair directs otherwise, or it is proposed, seconded and carried that a vote be taken by paper ballot.

3.12.3 If at least one third of the members present so request, the voting on any question may

be recorded so as to show how each member present voted or did not vote (except when conducted by paper ballot).

3.12.4 If a member so requests, their vote shall be recorded by name. 3.12.5 In no circumstances may an absent member vote by proxy. Absence is defined as being

absent at the time of the vote. 3.12.6 A manager who has been formally appointed to act up for an Officer Member during a

period of incapacity or temporarily to fill an Executive Director vacancy shall be entitled to exercise the voting rights of the Officer Member.

3.12.7 A manager attending the Trust Board meeting to represent an Officer Member during a

period of incapacity or temporary absence without formal acting up status may not exercise the voting rights of the Officer Member. An Officer’s status when attending a meeting shall be recorded in the minutes.

3.12.8 For the voting rules relating to joint members see Standing Order 2.5. 3.13 Suspension of Standing Orders 3.13.1 Except where this would contravene any statutory provision or any direction made by the

Secretary of State for Health and Social Care or the rules relating to the Quorum (SO 3.11), any one or more of the Standing Orders may be suspended at any meeting, provided that at least two-thirds of the whole number of the members of the Board are present (including at least one member who is an Officer Member of the Trust and one member who is not) and that at least two-thirds of those members present signify their agreement to such suspension. The reason for the suspension shall be recorded in the Trust Board's minutes.

3.13.2 A separate record of matters discussed during the suspension of Standing Orders shall

be made and shall be available to the Chair and members of the Trust. 3.13.3 No formal business may be transacted while Standing Orders are suspended. 3.13.4 The Audit Committee shall review every decision to suspend Standing Orders. 3.14 Variation and Amendment of Standing Orders These Standing Orders shall not be varied except in the following circumstances:

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• upon a notice of motion under Standing Order 3.5; • upon a recommendation of the Chair or Chief Executive included on the agenda for

the meeting; • that two thirds of the Board members are present at the meeting where the variation

or amendment is being discussed, and that at least half of the Trust’s Non-Officer members vote in favour of the amendment;

• providing that any variation or amendment does not contravene a statutory provision or direction made by the Secretary of State for Health and Social Care.

3.15 Record of Attendance The names of the Chair and Directors/members present at the meeting shall be

recorded. 3.16 Minutes 3.16.1 The minutes of the proceedings of a meeting shall be drawn up and submitted for

agreement at the next ensuing meeting where they shall be signed by the person presiding at it.

3.16.2 No discussion shall take place upon the minutes except upon their accuracy or where the

Chair considers discussion appropriate. 3.16.3 Minutes shall be circulated in accordance with directors’ wishes. Where providing a

record of a public meeting the minutes shall be made available to the public (required by Code of Practice on Openness in NHS)

3.17 Admission of Public and the Press 3.17.1 Where meetings are to be held in public, the following will apply:

(a) Admission and exclusion on grounds of confidentiality of business to be transacted

The public and representatives of the press may attend meetings of the Board of

Directors by invitation of the Chair only and shall be required to withdraw upon the Board of Directors as follows:

“that representatives of the press and other members of the public be excluded

from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”, Section 1(2) Public Bodies (Admission to Meetings) Act 1960.

(b) General Disturbances The Chair (or Vice Chair if one has been appointed) or the person presiding over

the meeting shall give such directions as they consider fit with regard to the arrangements for meetings and accommodation of the public and representatives of the press such as to ensure that the Trust’s business shall be conducted without interruption and disruption and, without prejudice to the power to exclude on grounds of the confidential nature of the business to be transacted, the public will be required to withdraw upon the Trust Board resolving as follows:

“That in the interests of public order the meeting adjourn for (the period to be

specified) to enable the Trust Board to complete its business without the presence of the public.” Section 1(8) Public Bodies (Admission to Meetings) Act 1960.

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(c) Business proposed to be transacted when the press and public have been

excluded from a meeting – Confidentiality

Matters to be dealt with by the Trust Board following the exclusion of representatives of the press, and other members of the public, as provided in 3.17.1 (a) and (b) above, shall be confidential to the members of the Board.

Members and Officers or any employee of the Trust in attendance shall not reveal

or disclose the contents of papers marked 'In Confidence' or ‘Non-Disclosable’ or minutes headed 'Items Taken in Private' or ‘Non-Disclosable’ outside of the Trust, without the express permission of the Trust. This prohibition shall apply equally to the content of any discussion during the Board meeting which may take place on such reports or papers.

(d) Use of Mechanical or Electrical Equipment for Recording or Transmission of

Meetings

Nothing in these Standing Orders shall be construed as permitting the introduction by the public, or press representatives, of recording, transmitting, video or similar apparatus into meetings of the Trust or Committee thereof. Such permission shall be granted only upon resolution of the Trust.

3.18 Observers at Trust Meetings The Trust Board will decide what arrangements and terms and conditions it feels are

appropriate to offer in extending an invitation to observers to attend and address any of the Trust Board's meetings and may change, alter or vary these terms and conditions as it deems fit.

4. APPOINTMENT OF COMMITTEES AND SUB-COMMITTEES 4.1 Appointment of Committees 4.1.2 Subject to such directions as may be given by the Secretary of State for Health and

Social Care, the Trust Board may appoint committees of the Trust. 4.1.3 The Trust Board shall determine the membership and terms of reference of committees

and sub-committees and shall if it requires to, receive and consider reports of such committees.

4.2 Joint Committees 4.2.1 Joint committees may be appointed by the Trust by joining together with one or more

other health service bodies consisting of, wholly or partly of the Chair and members of the Trust or other health service bodies, or wholly of persons who are not members of the Trust or other health bodies in question.

4.2.2 Any committee or joint committee appointed under this Standing Order may, subject to

such directions as may be given by the Secretary of State for Health and Social Care or the Trust or other health bodies in question, appoint sub-committees consisting wholly or partly of members of the committees or joint committee (whether or not they are members of the Trust or health bodies in question) or wholly of persons who are not members of the Trust or health bodies in question or the committee of the Trust or health bodies in question.

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4.3 Applicability of Standing Orders and Standing Financial Instructions to

Committees The Standing Orders and Standing Financial Instructions of the Trust, as far as they are

applicable, shall as appropriate apply to meetings and any committees established by the Trust. In which case the term “Chair” is to be read as a reference to the Chair of other committee as the context permits, and the term “member” is to be read as a reference to a member of other committee also as the context permits. (There is no requirement to hold meetings of committees established by the Trust in public).

4.4 Terms of Reference Each such committee shall have such terms of reference and powers and be subject to

such conditions (as to reporting back to the Board), as the Board shall decide and shall be in accordance with any legislation and regulation or direction issued by the Secretary of State for Health and Social Care. Such terms of reference shall have effect as if incorporated into the Standing Orders.

4.5 Delegation of powers by Committees to Sub-Committees Where committees are authorised to establish sub-committees they may not delegate

executive powers to the sub-committee unless expressly authorised by the Trust Board. 4.6 Approval of Appointments to Committees The Board shall approve the appointments to each of the committees which it has

formally constituted. Where the Board determines, and regulations permit, that persons, who are neither members nor officers, shall be appointed to a committee the terms of such appointment shall be within the powers of the Board as defined by the Secretary of State for Health and Social Care. The Board shall define the powers of such appointees and shall agree allowances, including reimbursement for loss of earnings, and/or expenses in accordance where appropriate with national guidance.

4.7 Appointments for Statutory Functions Where the Board is required to appoint persons to a committee and/or to undertake

statutory functions as required by the Secretary of State for Health and Social Care and where such appointments are to operate independently of the Board such appointment shall be made in accordance with the regulations and directions made by the Secretary of State for Health and Social Care.

4.8 Committees Established by the Trust Board The mandatory committees, sub-committees, and joint-committees established by the

Board are: 4.8.1 Audit Committee In line with the requirements of the NHS Audit Committee Handbook, NHS Codes of

Conduct and Accountability, and the Higgs report, an Audit Committee will be established and constituted to provide the Trust Board with an independent and objective review on its financial systems, financial information and compliance with laws, guidance, and regulations governing the NHS. The Terms of Reference will be approved by the Trust Board and reviewed on a periodic basis.

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The Higgs report recommends a minimum of three non-executive directors be appointed,

unless the Board decides otherwise, of which one must have significant, recent and relevant financial experience.

4.8.2 Remuneration and Terms of Service Committee In line with the requirements of the NHS Codes of Conduct and Accountability, and the

Higgs report, a Terms of Service and Remuneration Committee will be established and constituted.

The Higgs report recommends the committee be comprised exclusively of Non-Executive

Directors, a minimum of three, who are independent of management. The purpose of the Committee will be to advise the Trust Board about appropriate

remuneration and terms of service for the Chief Executive and other Executive Directors including:

(a) all aspects of salary (including any performance-related elements/bonuses); (b) provisions for other benefits, including pensions and cars; (c) arrangements for termination of employment and other contractual terms. The following are discretionary committees, which the Board may amend at any time: 4.8.3 Quality Governance Committee The purpose of the Committee is to contribute and to be accountable to the Trust Board

for the risk and governance frameworks, internal controls and related assurances which underpin the Trust achieving its strategic objectives. The Committee will assure the Trust Board on the development and monitoring of quality and risk systems within the Trust to ensure that quality, patient safety and risk management are key component of all activities of the Trust.

4.8.4 Performance and Finance Committee The purpose of this Committee is to review the financial statements, activity and

performance information of the organisation, including capital development, and provide assurance to the Board on appropriate action. It will specifically give detailed scrutiny to financial and operational performance against plans and forecasts, highlighting and seeking assurance on deviation or recovery.

4.8.5 Workforce Committee

The purpose of the Committee is to provide oversight and challenge to strategies, ensuring they are developed to foster the attraction, development, engagement, wellbeing, retention and deployment of a high quality workforce and ensure essential standards of quality and safety are maintained. It will also be responsible for providing oversight and challenge to workforce change, ensuring that this will drive through legislative and best practice human resource management to support achievement of Trust objectives within a robust governance framework, monitoring implementation of the people and culture strategies and workforce plans, monitoring performance against key workforce metrics and scrutinising the achievement of workforce resourcing and performance management framework.

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4.8.6 Charitable Funds Committee

The purpose of the Committee is to provide oversight, assurance monitoring of the charitable funds strategy, approach and utilisation on behalf of the Corporate Trustee, ensuring that charitable funds are utilised and managed in line with charitable legislation and requirements. It will specifically give detailed scrutiny to proposed expenditure and the annual charitable accounts and report.

4.8.7 Other Committees The Board may also establish such other committees as required to discharge the

Trust's responsibilities. 4.9 Confidentiality 4.9.1 A member of a committee shall not disclose a matter dealt with by, or brought before, the

committee without its permission until the committee shall have reported to the Board or shall otherwise have concluded on that matter.

4.9.2 A Director of the Trust or a member of a committee shall not disclose any matter

reported to the Board or otherwise dealt with by the committee, notwithstanding that the matter has been reported or action has been concluded, if the Board or committee shall resolve that it is confidential.

5. ARRANGEMENTS FOR THE EXERCISE OF TRUST FUNCTIONS BY DELEGATION 5.1 Delegation of Functions to Committees, Officers or other Bodies 5.1.1 Subject to such directions as may be given by the Secretary of State for Health and

Social Care, the Board may make arrangements for the exercise, on behalf of the Board, of any of its functions by a committee, sub-committee appointed by virtue of Standing Order 4, or by an officer of the Trust, or by another body as defined in Standing Order 5.1.2 below, in each case subject to such restrictions and conditions as the Trust thinks fit.

5.1.2 Section 16B of the NHS Act 1977 allows for regulations to provide for the functions of

Trusts to be carried out by third parties. In accordance with The Trusts (Membership and Procedure and Administration Arrangements) Regulations the functions of the Trust may also be carried out in the following ways:

(a) by another Trust; (b) jointly with any one or more of the following: NHS trusts, NHS Improvement and

Clinical Commissioning Group (c) by arrangement with the appropriate Trust or Clinical Commissioning Group, by a

joint committee or joint sub-committee of the Trust and one or more other health service bodies;

(d) NHS Improvement and the Clinical Commissioning Groups

5.1.3 Where a function is delegated by these Regulations to another Trust, then that Trust or health service body exercises the function in its own right; the receiving Trust has responsibility to ensure that the proper delegation of the function is in place. In other situations, i.e. delegation to committees, sub-committees or officers, the Trust delegating the function retains full responsibility.

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5.2 Emergency Powers and Urgent Decisions The powers which the Board has reserved to itself within these Standing Orders (see

Standing Order 3.6) may in emergency or for an urgent decision be exercised by the Chief Executive and the Chair after having consulted at least two non-officer members. The exercise of such powers by the Chief Executive and Chair shall be reported to the next formal meeting of the Trust Board in public session for formal ratification.

5.3 Delegation to Committees 5.3.1 The Board shall agree from time to time the delegation of executive powers to be

exercised by other committees, or sub-committees, or joint-committees, which it has formally constituted in accordance with directions issued by the Secretary of State for Health and Social Care. The constitution and terms of reference of these committees, or sub-committees, or joint committees, and their specific executive powers shall be approved by the Board in respect of its sub-committees.

5.3.2 When the Board is not meeting as the Trust in public session it shall operate as a

committee and may only exercise such powers as may have been delegated to it by the Trust in public session.

5.4 Delegation to Officers 5.4.1 Those functions of the Trust which have not been retained as reserved by the Board or

delegated to other committee or sub-committee or joint-committee shall be exercised on behalf of the Trust by the Chief Executive. The Chief Executive shall determine which functions they will perform personally and shall nominate officers to undertake the remaining functions for which he/she will still retain accountability to the Trust.

5.4.2 The Chief Executive shall prepare a Scheme of Delegation identifying their proposals

which shall be considered and approved by the Board. The Chief Executive may periodically propose amendment to the Scheme of Delegation which shall be considered and approved by the Board.

5.4.3 Nothing in the Scheme of Delegation shall impair the discharge of the direct

accountability to the Board of the Director of Finance and Commissioning to provide information and advise the Board in accordance with statutory or Department of Health requirements. Outside these statutory requirements the roles of the Director of Finance and Commissioning shall be accountable to the Chief Executive for operational matters.

5.5 Schedule of Matters Reserved to the Trust and Scheme of Delegation of Powers The arrangements made by the Board as set out in the "Schedule of Matters Reserved

to the Board” and “Scheme of Delegation” of powers shall have effect as if incorporated in these Standing Orders.

5.6 Duty to Report Non-Compliance with Standing Orders and Standing Financial

Instructions If for any reason these Standing Orders are not complied with, full details of the non-

compliance and any justification for non-compliance and the circumstances around the non-compliance, shall be reported to the next formal meeting of the Board for action or ratification. All members of the Trust Board and staff have a duty to disclose any non-compliance with these Standing Orders to the Chief Executive or the Head of Governance as soon as possible.

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6. OVERLAP WITH OTHER TRUST POLICY STATEMENTS/PROCEDURES,

REGULATIONS AND THE STANDING FINANCIAL INSTRUCTIONS 6.1 Policy Statements: General The Trust Board will from time to time agree and approve Policy statements/ procedures

which will apply to all or specific groups of staff employed by the East of England Ambulance Service NHS Trust. The decisions to approve such policies and procedures will be recorded in an appropriate Trust Board minute and will be deemed where appropriate to be an integral part of the Trust's Standing Orders and Standing Financial Instructions.

6.2 Specific Policy Statements Notwithstanding the application of SO 6.1 above, these Standing Orders and Standing

Financial Instructions must be read in conjunction with the following Policy statements:

• the Standards of Business Conduct and Conflicts of Interest Policy for the East of England Ambulance Service NHS Trust staff;

• the staff Disciplinary and Appeals Procedures adopted by the Trust both of which shall have effect as if incorporated in these Standing Orders.

6.3 Standing Financial Instructions Standing Financial Instructions adopted by the Trust Board in accordance with the

Financial Regulations shall have effect as if incorporated in these Standing Orders. 6.4 Specific Guidance Notwithstanding the application of SO 6.1 above, these Standing Orders and Standing

Financial Instructions must be read in conjunction with the following guidance and any other issued by the Secretary of State for Health and Social Care:

• Standards of Business Conduct (HSG(93)5) and Conflicts of Interest; • Caldicott Guardian 1997 and Caldicott Guardian 2 2013; • Human Rights Act 1998; • Freedom of Information Act 2000.

7. DUTIES AND OBLIGATIONS OF BOARD MEMBERS/DIRECTORS AND SENIOR

MANAGERS UNDER THESE STANDING ORDERS 7.1 Declaration of Interests 7.1.1 Requirements for Declaring Interests and Applicability to Board Members The NHS Code of Accountability and Standing Order 6, which is based on the

regulations, requires Trust Board Members to declare any material or pecuniary interests (which includes monetary) for personal or family interests that he/she has and which are relevant and material to the NHS Board of which they are a member. All existing Board members should declare such interests. Any Board members appointed subsequently should do so on appointment.

7.1.2 Interests which should be declared pursuance to 7.1.1 above include:

(a) Interests which should be regarded as “relevant and material” are:

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(i) Directorships, including Non-Executive Directorships held in private

companies or PLCs (with the exception of those of dormant companies); (ii) Ownership or part-ownership of private companies, businesses or

consultancies likely or possibly seeking to do business with the NHS; (iii) Majority or controlling share-holdings in organisations likely or possibly

seeking to do business with the NHS; (iv) A position of authority in a charity or voluntary organisation in the field of

health and social care; (v) Any connection with a voluntary or other organisation contracting for NHS

services. (vi) Research funding/grants that may be received by an individual or their

department; (vii) Interests in pooled funds that are under separate management; (viii) Any other commercial interest in the decision before the meeting. (b) For the avoidance of doubt, any member of the Trust Board who comes to know

that the Trust has entered into or proposes to enter into a contract in which they or any person connected with them (as defined in Standing Order 7.3 below and elsewhere) has any pecuniary interest, direct or indirect, the Director shall declare their interest by giving notice in writing of such fact to the Trust via the Head of Governance as soon as practicable.

7.1.3 Advice on Interests If Board members have any doubt about the relevance of an interest, this should

be discussed with the Chair of the Trust or with the Head of Governance. Financial Reporting Standard No 8 (issued by the Accounting Standards Board) specifies

that influence rather than the immediacy of the relationship is more important in assessing the relevance of an interest. The interests of partners in professional partnerships including general practitioners should also be considered.

7.1.4 Recording of Interests in Trust Board Minutes At the time Board members' interests are declared, they should be recorded in the Trust

Board minutes. Any changes in interests should be declared at the next Trust Board meeting following

the change occurring and recorded in the minutes of that meeting. 7.1.5 Publication of Declared Interests in Annual Report Board members' directorships of companies likely or possibly seeking to do business

with the NHS should be published in the Trust's annual report. The information should be kept up to date for inclusion in succeeding annual reports.

7.1.6 Conflicts of Interest which Arise during the Course of a Meeting

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During the course of a Trust Board meeting, if a conflict of interest is established, the

Board member concerned should withdraw from the meeting and play no part in the relevant discussion or decision. (See overlap with SO 7.3).

7.2 Register of Interests 7.2.1 The Chair will ensure that a Register of Interests is established to record formally

declarations of interests of Board or Committee members. In particular the Register will include details of all directorships and other relevant and material interests (as defined in SO 7.1.2) which have been declared by both executive and non-executive Trust Board members.

7.2.2. These details will be kept up to date by means of an annual review of the Register in

which any changes to interests declared during the preceding twelve months will be incorporated.

7.2.3 The Register will be available to the public and the Chair and Chief Executive will take

reasonable steps to bring the existence of the Register to the attention of local residents and to publicise arrangements for viewing it.

7.3 Exclusion of Chair and Members in Proceedings on Account of Pecuniary Interest 7.3.1 Definition of Terms used in interpreting “Pecuniary” Interest For the sake of clarity, the following definition of terms is to be used in interpreting this

Standing Order:

(a) “Spouse” shall include any person who lives with another person in the same household (and any pecuniary interest of one spouse shall, if known to the other spouse, be deemed to be an interest of that other spouse);

(b) “Contract” shall include any proposed contract or other course of dealing;

(c) “Pecuniary Interest” Subject to the exceptions set out in this Standing Order, a person shall be treated

as having an indirect pecuniary interest in a contract if:

(i) he/she, or a nominee of his, is a member of a company or other body (not being a public body), with which the contract is made, or to be made or which has a direct pecuniary interest in the same, or

(ii) he/she is a partner, associate or employee of any person with whom the

contract is made or to be made or who has a direct pecuniary interest in the same.

(d) Exception to Pecuniary Interests

A person shall not be regarded as having a pecuniary interest in any contract if:

(i) neither he/she or any person connected with him/her has any beneficial

interest in the securities of a company of which he or such person appears as a member, or

(ii) any interest that he/she or any person connected with him/her may have in

the contract is so remote or insignificant that it cannot reasonably be regarded

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as likely to influence him in relation to considering or voting on that contract, or

(c) those securities of any company in which he/she (or any person connected

with him/her) has a beneficial interest do not exceed £5,000 in nominal value or one percent of the total issued share capital of the company or of the relevant class of such capital, whichever is the less.

Provided, however, that where Paragraph (c) above applies, the person shall

nevertheless be obliged to disclose/declare their interest in accordance with Standing Order 7.1.2(b).

7.3.2 Exclusion in Proceedings of the Trust Board (a) Subject to the following provisions of this Standing Order, if the Chair or a Director of

the Board of Directors has any pecuniary interest, direct or indirect, in any contract, proposed contract or other matter and is present at a meeting of the Board of Directors at which the contract or other matter is the subject of consideration, they shall at the meeting and as soon as is practicable after its commencement disclose the fact and shall not take part in the consideration or discussion of the contract or other matter or vote on any question with respect to it.

(b) The State for Health and Social Care may, subject to such conditions as they may

think fit to impose, remove any disability imposed by this Standing Order in any case in which it appears to them in the interests of the National Health Service that the disability should be removed. (See SO 7.3.3 on the ‘Waiver’ which has been approved by the Secretary of State for Health and Social Care).

(c) The Trust Board may exclude the Chair or a Director of the Board from a meeting of

the Board of Directors while any contract, proposed contract or other matter in which they have a pecuniary interest is under consideration.

(d) Any remuneration, compensation or allowance payable to the Chair or a Member by

virtue of paragraph 11 of Schedule 5A to the National Health Service Act 1977 (pay and allowances) shall not be treated as a pecuniary interest for the purpose of this Standing Order.

(e) This Standing Order applies to a committee or subcommittee and to a joint committee

or subcommittee as it applies to the Trust and applies to a member of any such committee or subcommittee (whether or not they are also a member of the Trust) as it applies to a Director of the Trust.

7.3.3 Waiver of Standing Orders made by the Secretary of State for Health and Social Care

(a) Power of the Secretary of State for Health and Social Care to make waivers Under regulation 11(2) of the NHS (Membership and Procedure Regulations SI

1999/2024 (“the Regulations”), there is a power for the Secretary of State for Health and Social Care to issue waivers if it appears to the Secretary of State for Health and Social Care in the interests of the health service that the disability in regulation 11 (which prevents a Chair or a member from taking part in the consideration or discussion of, or voting on any question with respect to, a matter in which they have a pecuniary interest) is removed. A waiver has been agreed in line with sub-sections 7.3.3(b) to 7.3.3(d) below.

(b) Definition of ‘Chair’ for the purpose of interpreting this waiver

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For the purposes of paragraph 7.3.3(c) (below), the “relevant Chair” is – (i) at a meeting of the Trust, the Chair of that Trust; (ii) at a meeting of a Committee:

• in a case where the member in question is the Chair of that Committee, the Chair of the Trust; and

• in the case of any other member, the Chair of that Committee.

(c) Application of Waiver

A waiver will apply in relation to the disability to participate in the proceedings of the Trust on account of a pecuniary interest. It will apply to:

(i) A member of the East of England Ambulance Service NHS Trust (“the Trust”), who

is a healthcare professional, within the meaning of regulation 5(5) of the Regulations, and who is providing or performing, or assisting in the provision or performance, of:

• services under the National Health Service Act 1977; or • services in connection with a pilot scheme under the National Health Service

Act 1997; for the benefit of persons for whom the Trust is responsible.

(ii) Where the ‘pecuniary interest’ of the member in the matter which is the subject of consideration at a meeting at which they are present:

• arises by reason only of the member’s role as such a professional providing or

performing, or assisting in the provision or performance of, those services to those persons;

• has been declared by the relevant Chair as an interest which cannot

reasonably be regarded as an interest more substantial than that of the majority of other persons who:

- are members of the same profession as the member in question, - are providing or performing, or assisting in the provision or performance of,

such of those services as he provides or performs, or assists in the provision or performance of, for the benefit of persons for whom the Trust is responsible.

(d) Conditions which apply to the waiver and the removal of having a pecuniary

interest

The removal is subject to the following conditions:

• the member must disclose their interest as soon as practicable after the commencement of the meeting and this must be recorded in the minutes;

• the relevant Chair must consult the Chief Executive before making a declaration in

relation to the member in question pursuant to paragraph 8.3.3(b) above, except where that member is the Chief Executive;

• in the case of a meeting of the Trust:

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- the member may take part in the consideration or discussion of the matter which must be subjected to a vote and the outcome recorded;

- may not vote on any question with respect to it.

• in the case of a meeting of the Committee:

- the member may take part in the consideration or discussion of the matter which must be subjected to a vote and the outcome recorded;

- may vote on any question with respect to it; but - the resolution which is subject to the vote must comprise a recommendation to,

and be referred for approval by, the Trust Board.

7.4 Standards of Business Conduct 7.4.1 Trust Policy and National Guidance All Trust staff and members of must comply with the Trust’s Standards of Business

Conduct and Conflicts of Interest Policy and the national guidance contained in HSG(93)5 on ‘Standards of Business Conduct for NHS staff’ (see SO 6.2).

7.4.2 Interest of Members and Officers in Contracts

(a) Any Member or Officer of the Trust who comes to know that the Trust has

entered into or proposes to enter into a contract in which they or any person connected with them (as defined in SO 7.3) has any pecuniary interest, direct or indirect, the Officer shall declare their interest by giving notice in writing of such fact to the Chief Executive or Trust’s Head of Governance as soon as practicable.

(b) A Member or Officer should also declare to the Chief Executive any other

employment or business or other relationship of theirs, or of a cohabiting spouse, that conflicts, or might reasonably be predicted could conflict with the interests of the Trust.

(c) The Trust will require interests, employment or relationships so declared to be

entered in a register of interests of staff. 7.4.3 Canvassing of and Recommendations by Members in Relation to Appointments

(a) Canvassing of members of the Trust or of any Committee of the Trust directly or indirectly for any appointment under the Trust shall disqualify the candidate for such appointment. The contents of this paragraph of the Standing Order shall be included in application forms or otherwise brought to the attention of candidates.

(b) Members of the Trust shall not solicit for any person any appointment under the

Trust or recommend any person for such appointment; but this paragraph of this Standing Order shall not preclude a member from giving written testimonial of a candidate’s ability, experience or character for submission to the Trust

(c) Informal discussions outside appointments panels or committees, whether

solicited or unsolicited, should be declared to the panel or committee. 7.4.4 Relatives of Members or Officers

(a) Candidates for any staff appointment under the Trust shall, when making an

application, disclose in writing to the Trust whether they are related to any member or the holder of any office under the Trust. Failure to disclose such a

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relationship shall disqualify a candidate and, if appointed, render them liable to instant dismissal.

(b) The Chair and every member and officer of the Trust shall disclose to the Trust

Board any relationship between themselves and a candidate of whose candidature that member or officer is aware. It shall be the duty of the Chief Executive to report to the Trust Board any such disclosure made.

(c) On appointment, members (and prior to acceptance of an appointment in the

case of Executive Directors) should disclose to the Trust whether they are related to any other member or holder of any office under the Trust.

(d) Where the relationship to a member of the Trust is disclosed, the Standing Order

headed ‘Disability of Chair and members in proceedings on account of pecuniary interest’ (SO 8) shall apply.

8. CUSTODY OF SEAL, SEALING OF DOCUMENTS AND SIGNATURE OF

DOCUMENTS 8.1 Custody of Seal The common seal of the Trust shall be kept by the Chief Executive or a nominated

Manager by them in a secure place. 8.2 Sealing of Documents 8.2.1 The Seal of the Trust shall not be fixed to any documents unless the sealing has been

authorised by a resolution of the Board or of a committee, thereof or where the Board has delegated its powers.

8.2.2 The seal is a Corporate signature. It may be interchangeable for the words for and on

behalf of the Trust for documents of minor importance and/or minor value. 8.2.3 The use of the seal indicates that the document is important and /or valuable. 8.2.4 No Common Law exists regarding any financial limits which require a seal. 8.2.5 The Trust or its Officers may decide that a document shall be sealed within the

provisions of the NHS Act. 8.2.6 The following documents will be sealed

• Land conveyances • Shares or bond transfers and sales • Building or Construction Contracts valued in excess of £500,000 • When a seal is requested by the other party

8.2.7 Before any building, engineering, property or capital document is sealed it must be

approved and signed by the Director of Finance and Commissioning (or an officer nominated by them) and authorised and countersigned by the Chief Executive (or an officer nominated by them, who shall not be within the originating directorate).

8.3 Register of Sealing The Chief Executive shall keep a register in which they, or another manager of the

Authority authorised by them, shall enter a record of the sealing of every document. 8.4 Signature of documents

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Where any document will be a necessary step in legal proceedings on behalf of the

Trust, it shall, unless any enactment otherwise requires or authorises, be signed by the Chief Executive or any Executive Director.

In land transactions, the signing of certain supporting documents will be delegated to

Managers and set out clearly in the Scheme of Delegation but will not include the main or principal documents effecting the transfer (e.g. sale/purchase agreement, lease, contracts for construction works and main warranty agreements or any document which is required to be executed as a deed).

9. MISCELLANEOUS 9.1 Joint Finance Arrangements The Board may confirm contracts to purchase from a voluntary organisation or a local

authority using its powers under Section 28A of the NHS Act 1977. The Board may confirm contracts to transfer money from the NHS to the voluntary sector or the health related functions of local authorities where such a transfer is to fund services to improve the health of the local population more effectively than equivalent expenditure on NHS services, using its powers under Section 28A of the NHS Act 1977, as amended by section 29 of the Health Act 1999.

9.2 Standing Orders to be given to Directors and Officers It is the duty of the Chief Executive to ensure that existing directors and officers and all

new appointees are notified of and understand their responsibilities within Standing Orders and SFIs. Updated copies shall be issued to staff designated by the Chief Executive. New designated officers shall be informed in writing and shall receive copies where appropriate.

9.3 Documents having the standing of Standing Orders Standing Financial Instructions and Reservation of Powers to the Board and Delegation

of Powers shall have the effect as if incorporated into SOs. 9.4 Review of Standing Orders Standing Orders shall be reviewed annually by the Trust. The requirement for review

extends to all documents having the effect as if incorporated in SOs. APPROVED BY TRUST BOARD: 11 March 2020

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STANDING FINANCIAL

INSTRUCTIONS


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C O N T E N T S

1. INTRODUCTION ........................................................................................................ 1 2. AUDIT ........................................................................................................................ 5 3. FORWARD PLANS, BUDGETS, BUDGETARY CONTROL & MONITORING ......... 9 4. ACCOUNTS AND REPORTS .................................................................................. 11 5. BANK AND TREASURY MANAGEMENT POLICY ................................................. 12 6. INCOME, FEES AND CHARGES AND SECURITY OF CASH,

CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS ...................................... 13 7. TENDERING AND CONTRACTING REGULATIONS ............................................ 15 8. CONTRACTING FOR PROVISION OF SERVICES ................................................ 26 9. TERMS OF SERVICE AND PAYMENT OF DIRECTORS AND EMPLOYEES INCLUDING GOVERNOR EXPENSES ................................... 27 10. NON-PAY EXPENDITURE ...................................................................................... 30 11. EXTERNAL BORROWING AND INVESTMENTS ................................................... 33 12. CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET REGISTERS AND SECURITY OF ASSETS ............................................................ 34 13. STORES AND RECEIPT OF GOODS ..................................................................... 37 14. DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL PAYMENTS ..... 38 15. FINANCIAL SYSTEMS INFORMATION TECHNOLOGY (IT) ................................. 40 16. PATIENTS' PROPERTY .......................................................................................... 41 17. FUNDS HELD ON TRUST ....................................................................................... 41 18 ACCEPTANCE OF GIFTS BY STAFF AND LINK TO STANDARDS OF BUSINESS CONDUCT ............................................................................................ 42 19. RETENTION OF DOCUMENTS .............................................................................. 42 20. RISK MANAGEMENT AND INSURANCE ............................................................... 43 21. CONSULTATION ..................................................................................................... 44

Page

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STANDING FINANCIAL INSTRUCTIONS 1. INTRODUCTION 1.1 General 1.1.1 These Standing Financial Instructions (SFIs) shall have effect as if incorporated

in the Standing Orders (SOs) of the Trust. 1.1.2 These SFIs detail the financial responsibilities, policies and procedures adopted

by the Trust. They are designed to ensure that the Trust’s financial transactions are carried out in accordance with the law and with Government policy in order to achieve probity, accuracy, economy, efficiency and effectiveness. They should be used in conjunction with the Schedule of Decisions Reserved to the Board and the Scheme of Delegation adopted by the Trust.

1.1.3 These SFIs identify the financial responsibilities which apply to everyone working

for the Trust and its constituent organisations, including Trading Units. They do not provide detailed procedural advice and should be read in conjunction with the detailed departmental and financial procedure notes. All financial procedures must be approved by the Director of Finance & Commissioning.

1.1.4 Officers of the Trust should note that the Scheme of Delegation, SFIs and SOs,

do not contain every legal obligation applicable to the Trust. The Trust and each officer of the Trust must comply with all requirements of legislation (which shall mean any statute subordinate or secondary legislation (which shall mean any statute, subordinate or secondary legislation, any enforceable community right within the meaning of Section 2(1) European Community Act 1972 and any applicable judgement of a relevant court of law which is a binding precedent in England) and all guidance and directions binding on the Trust. Legislation, guidance and directions will impose requirements additional to the Scheme of Delegation, SFIs and SOs. All such legislation and binding guidance and directions shall take precedence over the Scheme of Delegation, SFIs and SOs which shall be interpreted accordingly.

1.1.5 Should any difficulties arise regarding the interpretation or application of any of

the SFIs, then the advice of the Director of Finance & Commissioning must be sought before acting. The user of these SFIs should also be familiar with and comply with the provisions of the Trust’s SOs. Note in particular procedures for Tendering, Quotations and Contracts and the Schedule of Powers Reserved to the Board.

1.1.6 The failure to comply with the Scheme of Delegation, SFIs and SOs can, in

certain circumstances, be regarded as a disciplinary matter that could result in dismissal.

1.1.7 Overriding SFIs: If, for any reason, these SFIs are not complied with, full details

of the non-compliance and any justification for non-compliance and the circumstances around the non-compliance shall be reported to the next formal meeting of the Audit Committee for referring action or ratification.

1.1.8 All members of the Board and staff have a duty to disclose any non-compliance

with these SFIs to the Director of Finance & Commissioning as soon as possible.

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1.2 Terminology 1.2.1 Any expression to which a meaning is given in Health Service Acts, or in

Financial Directions made under the Acts, shall have the same meaning in these instructions; and

“Accountable Officer” means the Officer responsible and accountable for funds

entrusted to the Trust. The Officer shall be responsible for ensuring the proper stewardship of public funds and assets. For this Trust it shall be the Chief Executive;

“Board” means the Board of Directors comprising of a Chair, officer and non-

officer members of the Trust collectively as a body; “Budget” means a resource, expressed in financial terms, and proposed by the

Board for the purpose of carrying out, for a specific period, any or all of the functions of the Trust;

“Budget Holder” means the Director or employee with delegated authority to

manage finances (income and expenditure) for a specific area of the organisation;

“Chair of the Board (or Trust)” is the person appointed by the Secretary of State

for Health and Social Care to lead the Board and to ensure that it successfully discharges its overall responsibility for the Trust as a whole. The expression “the Chair of the Trust” shall be deemed to include the Vice-Chair of the Trust if the Chair is absent from the meeting or is otherwise unavailable;

“Chief Executive” means the Chief Officer/Accountable Officer of the Trust; “Commissioning” means the process for determining the need for and for

obtaining the supply of healthcare and related services by the Trust within available resources;

“Committee” means a committee or sub-committee created and appointed by the

Trust; “Committee members” means any persons formally appointed by the Board to sit

on or to chair specific committees; “Constitution” means the Constitution of the Trust and all annexes to it

established in accordance with the NHS Act 2006 and the Health and Social Care Act 2012,

“Contracting and Procuring” means the systems for obtaining the supply of

goods, materials, manufactured items, services, building and engineering services, works of construction and maintenance and for disposal of surplus and obsolete assets;

“Department of Heath” means the Government department with overall

responsibility for the NHS “Director” means a person appointed as a director in accordance with the

Membership and Procedure Regulations and includes the Chair; “Director of Finance & Commissioning” means the Chief Financial Officer of the

Trust;

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“Funds held on trust” shall mean those funds, which the Trust holds at its date of

incorporation, receives on distribution by statutory instrument or chooses subsequently to accept under powers derived under Part 11, Chapter 2 of the NHS Act 2006. Such funds may or may not be charitable;

“Legal Adviser” means the properly qualified person appointed by the Trust to

provide legal advice; “Member” means officer or non-officer member of the Board as the context

permits. Member in relation to the Board does not include its Chair; “Associate Member” means a person appointed to perform specific statutory and

non-statutory duties which have been delegated by the Trust Board for them to perform and these duties have been recorded in an appropriate Trust Board minute or other suitable record.

“Membership, Procedure and Administration Arrangements Regulations” means

NHS Membership and Procedure Regulations (SI 1990/2024) and subsequent amendments.

“Nominated Officer” means an officer charged with the responsibility for

discharging specific tasks within Standing Orders and Standing Financial Instructions;

“Non-officer Member” means a member of the Trust who is not an officer of the

Trust is not to be treated as an officer by virtue of regulation 1(3) of the Membership, Procedure and Administration Arrangements Regulations (i.e Non-Executive Director);

“Officer” means employee of the Trust or any other person holding a paid

appointment or office within the Trust; “Officer Member” means a member of the Trust who is either an officer of the

Trust or is to be treated as an officer by virtue of regulation 1(3) (i.e. the Chair of the Trust, Non-Executive Director or any person nominated by such a Committee for appointment as a Trust member);

“Senior Independent Director” means the senior independent director from time to time appointed in accordance with paragraph 24 of the Trust’s draft NHS Constitution.

“SFIs” means Standing Financial Instructions; “SOs” means Standing Orders; “The 2006 Act” means the National Health Service Act 2006; ““The 2012 Act” means the Health and Social Care Act 2012; “Trust” means the East of England Ambulance Service NHS Trust; “Trust Secretary” means a person appointed to act independently of the Board to

provide advice on corporate governance issues to the Board and the Chair and the Members’ Council and to monitor the Trust’s compliance with the law, Standing Orders and Department of Health guidance;

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“Vice-Chair” means the non-officer member appointed by the Board to take on the Chair’s duties if the Chair is absent for any reason.

1.2.2 Wherever the title Chief Executive, Director of Finance & Commissioning, or

other nominated officer is used in these instructions, it shall be deemed to include such other Directors or employees who have been duly authorised to represent them.

1.2.3 Wherever the term “employee” is used and where the context permits, it shall be

deemed to include employees of third parties contracted to the Trust when acting on behalf of the Trust.

1.3 Responsibilities and Delegation 1.3.1 The Board of Directors The Board exercises financial supervision and control by: (a) Formulating the financial strategy;

(b) Requiring the submission and approval of budgets within approved income;

(c) Defining and approving essential features in respect of important procedures and financial systems (including the need to obtain value for money);

(d) Defining specific responsibilities placed on members of the Board and employees as directed in the Scheme of Delegation document.

1.3.2 The Board has resolved that certain powers and decisions may only be exercised

by the Board in formal session. These are set out in the “Reservation of Matters Reserved to the Board” document. All other powers have been delegated to such other committees as the Trust has established.

1.3.3 The Chief Executive and Director of Finance & Commissioning The Chief Executive and Director of Finance & Commissioning will, as far as

possible, delegate their detailed responsibilities, but they remain accountable for financial control.

Within the SFIs, it is acknowledged that the Chief Executive is ultimately

accountable to the Board, and, as Accountable Officer, to the Secretary of State, for ensuring that the Board meets its obligation to perform its functions within the available financial resources. The Chief Executive has overall executive responsibility for the Trust’s activities; is responsible to the Chair and the Board for ensuring that its financial obligations and targets are met and has overall responsibility for the Trust’s system of internal control.

1.3.4 It is a duty of the Chief Executive to ensure that Members of the Board, and

employees and all new appointees, are notified of and put in a position to understand their responsibilities within these Instructions.

1.3.5 The Director of Finance & Commissioning The Director of Finance & Commissioning is responsible for:

(a) Implementing the Trust’s financial policies and for coordinating any corrective action necessary to further these policies;

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(b) Maintaining an effective system of internal financial control, including ensuring that detailed financial procedures and systems incorporating the principles of separation of duties and internal checks are prepared, documented and maintained to supplement these instructions;

(c) Ensuring that sufficient records are maintained to show and explain the

Trust’s transactions, in order to disclose, with reasonable accuracy, the financial position of the Trust at any time;

and, without prejudice to any other functions of the Trust, and employees of the

Trust, the duties of the Director of Finance & Commissioning include: (d) The provision of financial advice to other members of the Board, and

employees (e) The design, implementation and supervision of systems of internal

financial control; (f) The preparation and maintenance of such accounts, certificates,

estimates, records and reports as the Trust may require for the purpose of carrying out its statutory duties.

1.3.6 Board of Directors and Employees

All members of the Board and employees, severally and collectively, are responsible for: (a) The security of the property of the Trust; (b) Avoiding loss; (c) Exercising economy and efficiency in the use of resources; (d) Conforming to the requirements of Standing Orders, Standing Financial

Instructions, Financial Procedures and the Scheme of Delegation.

1.3.7 Contractors and their Employees

Any contractor or employee of a contractor who is empowered by the Trust to commit the Trust to expenditure or who is authorised to obtain income shall be covered by these instructions. It is the responsibility of the Chief Executive to ensure that such persons are made aware of this.

1.3.8 For all members of the Board and any employees who carry out a financial

function, the form in which financial records are kept and the manner in which members of the Board and employees discharge their duties must be to the satisfaction of the Director of Finance & Commissioning.

2. AUDIT 2.1 Audit Committee 2.1.1 In accordance with Standing Orders, the Board shall formally establish an Audit

Committee, comprising of Non-Executive Directors to perform such monitoring, reviewing and other functions that are appropriate. These will be clearly defined in the terms of reference and following the good practice guidance set out in the NHS Audit Committee Handbook. The Committee will provide an independent and objective view of internal control by:

(a) Overseeing Internal and External Audit services;

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(b) Reviewing financial and information systems, monitoring the integrity of the financial statements and reviewing any significant financial reporting judgements;

(c) Review the establishment and maintenance of an effective system of

integrated governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical), that supports the achievement of the organisation’s objectives;

(d) Monitoring compliance with Standing Orders and Standing Financial

Instructions; (e) Reviewing schedules of losses and compensations and making

recommendations to the Board; (f) Reviewing the arrangements in place to support the Assurance

Framework process prepared on behalf of the Board and advising the Board accordingly.

2.1.2 Where the Audit Committee considers there is evidence of ultra vires

transactions, evidence of improper acts, or if there are other important matters that the Committee wishes to raise, the Chair of the Audit Committee should raise the matter at a full meeting of the Board. Exceptionally, the matter may need to be referred to the Department of Health. (To the Director of Finance & Commissioning in the first instance).

2.1.3 It is the responsibility of the Director of Finance & Commissioning to ensure an

adequate Internal Audit service is provided and the Audit Committee shall be involved in the selection process when/if an Internal Audit service provider is changed.

2.2 Director of Finance & Commissioning 2.2.1 The Director of Finance & Commissioning is responsible for: (a) Ensuring there are arrangements to review, evaluate and report on the

effectiveness of internal financial control, including the establishment of an effective internal audit function;

(b) Ensuring that the internal audit function is adequate and meets the NHS

mandatory audit standards; (c) Deciding at what stage to involve the Police in cases of misappropriation

and other irregularities not involving fraud or corruption in accordance with the Trust’s Counter Fraud and Security Policy and Procedure.

(d) Ensuring that an annual internal audit report is prepared for consideration

of the Audit Committee (and the Board). The report must cover:

(i) a clear opinion on the effectiveness of internal control in accordance with current assurance framework guidance issued by the Department of Health including for example compliance with control criteria and standards;

(ii) major internal financial control weaknesses discovered; (iii) progress on the implementation of internal audit recommendations; (iv) progress against plan over the previous year; (v) strategic audit plan covering the coming three years; (vi) a detailed plan for the coming year.

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2.2.2 The Director of Finance & Commissioning or designated auditors are entitled without necessarily giving prior notice to require and receive:

(a) Access to all records, documents and correspondence relating to any

financial or other relevant transactions, including documents of a confidential nature;

(b) Access at all reasonable times to any Trust land and premises or to

members of the Board or employee of the Trust; (c) The production of any cash, stores or other property of the Trust under a

member of the Board and an employee’s control; and (d) Explanations concerning any matter under investigation. 2.3 Role of Internal Audit 2.3.1 Internal Audit will review, appraise and report upon: (a) The extent of compliance with and the financial effect of relevant

established policies, plans and procedures; (b) The adequacy and application of financial and other related management

controls; (c) The suitability of financial and other related management data. (d) The extent to which the Trust’s assets and interests are accounted for and

safeguarded from loss of any kind arising from:

(i) fraud and other offences; (ii) waste, extravagance, inefficient administration; (iii) poor value for money or other causes. (e) Internal Audit shall also independently verify the Assurance Statements in

accordance with guidance from the Department of Health. 2.3.2 Whenever any matter arises which involves, or is thought to involve, irregularities

concerning cash, stores or other property or any suspected irregularity in the exercise of any function of a pecuniary nature, the Director of Finance & Commissioning must be notified immediately.

2.3.3 The Head of Internal Audit will normally attend Audit Committee meetings and

has a right of access to all Audit Committee members, the Chair and Chief Executive of the Trust.

2.3.4 Internal audit primarily provides an independent and objective opinion to the

Accountable Officer, the Board and the Audit Committee on risk management, control and governance, by measuring and evaluating their effectiveness in achieving the organisation’s agreed objectives. In addition, internal audit’s findings and recommendations are beneficial to line management in the audited areas. Risk management, control and governance comprise the policies, procedures and operations established to ensure the achievement of objectives, the appropriate assessment of risk, the reliability of internal and external reporting and accountability processes, compliance with applicable laws and regulations, and compliance with the behavioural and ethical standards set for the organisation.

2.3.5 Internal audit also provides an independent and objective consultancy service

specifically to help line management improve the organisation’s risk management, control and governance. The service applies the professional skills

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of internal audit through a systematic and disciplined evaluation of the policies, procedures and operations that management put in place to ensure the achievement of the organisation’s objectives, and through recommendations for improvement. Such consultancy work contributes to the opinion which internal audit provides on risk management, control and governance.

2.3.6 The Head of Internal Audit shall be accountable to the Director of Finance &

Commissioning. The reporting system for internal audit shall be agreed between the Director of Finance & Commissioning, the Audit Committee and the Head of Internal Audit. The agreement shall be in writing and shall comply with the guidance on reporting contained in the NHS Internal Audit Standards. The reporting system shall be reviewed at least every three years.

2.3.7 Internal auditors must have an impartial, unbiased attitude and avoid any conflict

of interest. Steps must be taken to avoid or manage transparently and openly such conflicts of interest so that there is no real or perceived threat or impairment to independence in performing the audit role. All internal auditors working within the NHS must complete an annual declaration of interest identifying possible conflicts of interest and the actions taken to mitigate them. This process, and its outcomes, should be communicated to the Audit Committee annually.

2.3.8 An assessment of the performance of the internal audit provider against Public

Sector Internal Audit Standards must be conducted at least once every five years by a qualified, independent reviewer and reported to the Audit Committee

2.3.9 The Head of Internal Audit should make provision for the results of external quality reviews to be reported to the Accountable Officer and Audit Committee. Any consequent improvement plans should be agreed with, and reported to, the Accountable Officer.

2.4 External Audit 2.4.1 The External Auditor is appointed by the Trust Board, following a

recommendation by the Trust’s Audit Panel and is paid for by the Trust. The Audit Committee must ensure a cost-efficient service. If there are any problems relating to the service provided by the External Auditor, then this should be raised with the External Auditor and referred on to the Audit Panel if the issue cannot be resolved.

2.4.2 Before engaging the auditor for additional services, the Trust’s Provision of

Additional Services by the Auditor procedure should be followed. Before engaging the auditor for additional services, outside the scope of the audit this will be reported to the Audit Committee for approval, or if timing precludes this, then it will be agreed jointly by the Chair of the Audit Committee and the Director of Finance & Commissioning and reported to the next Audit committee meeting.

2.5 Anti-Bribery, Fraud and Corruption 2.5.1 In line with their responsibilities, the Trust Chief Executive and Director of

Finance and Commissioning shall monitor and ensure compliance with the anti-fraud and bribery clauses in the NHS Standard Contract. The anti-fraud and bribery clauses are set out in Service Conditions 24 of the contract and place obligations on providers of NHS services.

2.5.2 The Trust shall nominate a suitable person to carry out the duties of the Counter Fraud Specialist as specified by the NHS Anti-Fraud Manual.

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2.5.3 The Counter Fraud Specialist shall report to the Trust Director of Finance and Commissioning and shall work with staff in the NHS Counter Fraud Authority in accordance with the NHS Anti-Fraud Manual.

2.5.4 The Counter Fraud Specialist will provide a written report, at least annually, on anti-fraud and bribery work within the Trust.

2.6 Security Management 2.6.1 In line with their responsibilities, the Trust’s Chief Executive will monitor and

ensure compliance with Directions issued in the Standard National Contract regarding the Standards for Providers relating to security management.

2.6.2 The Trust shall nominate a suitable person to carry out the duties of the Local

Security Management Specialist (LSMS) as specified in the Standard National Contract on NHS security management.

2.6.3 The Chief Executive has overall responsibility for controlling and coordinating

security. However, key tasks are delegated to the Security Management Director (SMD) and the appointed Local Security Management Specialist (LSMS).

3. FORWARD PLANS, BUDGETS, BUDGETARY CONTROL AND

MONITORING 3.1 Preparation and Approval of Forward Plans and Budgets 3.1.1 The Chief Executive will compile and submit to the Board a forward plan which

takes into account financial targets and forecast limits of available resources. Each forward plan will include information about:

(a) The activities other than the provision of goods and services for the

purposes of the health service in England that the Trust proposes to carry on and the income it expects to receive doing so.

(b) A statement of the significant assumptions on which the plan is based;

(c) Details of major changes in workload, delivery of services or resources

required to achieve the plan; and

(d) All requirements defined within Department of Health guidance. 3.1.2 Prior to the start of the financial year the Director of Finance & Commissioning

will, on behalf of the Chief Executive, prepare and submit budgets for approval by the Board. Such budgets will:

(a) Be in accordance with the aims and objectives set out in the Forward

Plan; (b) Accord with workload and workforce plans; (c) Be produced following discussion with appropriate budget holders; (d) Be prepared within the limits of available funds; (e) Identify potential risks.

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3.1.3 The Director of Finance & Commissioning shall monitor financial performance against budget and plan, periodically review them, and report to the Board.

3.1.4 All budget holders must provide information as required by the Director of

Finance & Commissioning to enable budgets to be compiled. 3.1.5 All budget holders will sign up to their allocated budgets at the commencement of

each financial year. 3.1.6 The Director of Finance & Commissioning has a responsibility to ensure that

adequate training is delivered on an on-going basis to budget holders to help them manage their budgets successfully.

3.2 Budgetary Delegation 3.2.1 The Chief Executive may delegate the management of a budget to permit the

performance of a defined range of activities. This delegation must be in writing and be accompanied by a clear definition of:

(a) the amount of the budget; (b) the purpose(s) of each budget heading; (c) individual and group responsibilities; (d) authority to exercise virement; (e) achievement of planned levels of service; (f) the financial monitoring timetable. 3.2.2 The Chief Executive and delegated budget holders must not exceed the

budgetary total or virement limits set by the Board. 3.2.3 Any budgeted funds not required for their designated purpose(s) revert to the

immediate control of the Chief Executive, subject to any authorised use of virement.

3.2.4 Non-recurring budgets should not be used to finance recurring expenditure

without the authority in writing of the Chief Executive, as advised by the Director of Finance & Commissioning.

3.3 Budgetary Control and Reporting 3.3.1 The Director of Finance & Commissioning will devise and maintain systems of

budgetary control. These will include: (a) Financial reports to the Board in a form approved by the Board containing: (i) income and expenditure to date showing trends and forecast year-

end position; (ii) movements in working capital; (iii) movements in cash and capital; (iv) capital project spend and projected outturn against plan; (v) explanations of any material variances from plan; and (vi) details of any corrective action where necessary and the Chief

Executive’s and/or Director of Finance & Commissioning’s view of whether such actions are sufficient to correct the situation.

(b) The issue of timely, accurate and comprehensible advice and financial

reports to each budget holder, covering the areas for which they are responsible;

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(c) Investigation and reporting of variances from financial, workload and workforce budgets;

(d) Monitoring of management action to correct variances; and (e) Arrangements for the authorisation of budget transfers. 3.3.2 Each budget holder is responsible for ensuring that: (a) Any likely overspending or reduction of income which cannot be met by

virement is not incurred without the prior consent of the Board; (b) The amount provided in the approved budget is not used in whole or in

part for any purpose other than that specifically authorised subject to the rules of virement;

(c) No permanent employees are appointed without the approval of the Chief

Executive other than those provided for within the available resources and workforce establishment as approved by the Board.

3.3.3 The Chief Executive is responsible for identifying and implementing cost

improvements and income generation initiatives in accordance with the requirements of the Annual Business Plan and a balanced budget.

3.4 Capital Expenditure The general rules applying to delegation and reporting shall also apply to capital

expenditure. (The particular applications relating to capital are contained in SFI 12.)

3.5 Financial Reporting Returns The Chief Executive is responsible for ensuring that the appropriate monitoring

forms are submitted to the requisite monitoring organisation. 4. ACCOUNTS AND REPORTS 4.1 The Director of Finance & Commissioning, on behalf of the Trust, will: (a) Prepare financial returns in accordance with the accounting policies and

guidance given by the Department of Health and the Treasury, the Trust’s accounting policies, and generally accepted accounting practice;

(b) Prepare and submit annual financial reports to the Department of Health

certified in accordance with current guidelines; (c) Submit financial returns to the Department of Health for each financial

year in accordance with the timetable prescribed by the Department of Health.

4.2 The Trust’s annual accounts must be audited by an auditor appointed by the

Trust’s Board. The Trust’s audited annual accounts must be presented to a public meeting and made available to the public.

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4.3 The Trust will publish an annual report, in accordance with guidelines on local accountability, and present it at a public meeting. The document will comply with the Department of Health’s Manual for Accounts.

5. BANK AND TREASURY MANAGEMENT POLICY 5.1 General 5.1.1 The Director of Finance & Commissioning is responsible for managing the Trust’s

banking arrangements and for advising the Trust on the provision of banking services and operation of accounts. This advice will take into account guidance/directions issued from time to time by the Department of Health. The Trust will operate in line with its Treasury Management Policy.

5.1.2 The Board shall approve the banking arrangements. 5.2 Bank and Government Bank Accounts 5.2.1 The Director of Finance & Commissioning is responsible for:

(a) Bank accounts and Government Bank accounts;

(b) Establishing separate bank accounts for the Trust’s non-exchequer funds;

(c) Ensuring payments made from bank or Government Bank accounts do not exceed the amount credited to the account except where arrangements have been made;

(d) Reporting to the Board all arrangements made with the Trust’s bankers for accounts to be overdrawn;

(e) Monitoring compliance with DH guidance on the level of cleared funds. 5.3 Banking Procedures 5.3.1 The Director of Finance & Commissioning will prepare detailed instructions on the

operation of bank and Government Bank accounts which must include:

(a) The conditions under which each bank and Government Bank account is to be operated;

(b) Those authorised to sign cheques or other orders drawn on the Trust’s accounts in accordance with the limits set out in the Scheme of Delegation;

(c) The limit to be applied to any overdraft. 5.3.2 The Director of Finance & Commissioning must advise the Trust's bankers in

writing of the conditions under which each account will be operated. All funds shall be held in accounts in the name of the Trust. No officer other than the Director of Finance & Commissioning shall open any bank account in the name of the Trust.

5.3.3 The Director of Finance & Commissioning shall advise the bankers of any alterations in the conditions of operation of accounts that may be required by financial regulations of the Health Service or by resolution of the Board as may be necessary from time to time.

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5.3.4 Cheques or other orders drawn upon the main exchequer bank account with a value of less than £5,000 shall be signed by a panel of first officers, nominated by the Board by specific resolution in accordance with the Scheme of Delegation;

5.3.5 Cheques or other orders drawn upon the main exchequer bank account with a

value of £5,000 or more shall be signed by two people: one from the first officer panel and the second from the second officer panel, also nominated by the Board by specific resolution in accordance with the Scheme of Delegation.

5.3.6 Cheques or other orders drawn upon the main charitable fund bank account with

a value of less than £5,000 shall be signed by two persons from a panel of first officers, and over £5,000 by two signatures, one from the first officer panel and the other from the second officer panel nominated by the Board.

5.3.7 The Director of Finance & Commissioning shall notify the bankers in writing of

any officer or officers nominated to authorise the payment of money from any subsidiary bank account. The bankers shall be notified promptly of the cancellation of any such authorisation. Payments drawn on subsidiary bank accounts shall be authorised as follows:

(a) by the use of cheques with a handwritten signature where the security procedures have been approved by the Audit Committee;

(b) all cheques shall bear a second manual signature if over the value of £5,000.

(c) in the preparation of manual cheques, the Director of Finance & Commissioning may use a mechanical means of printing in figures the amount to be paid in place of the amount in words;

(d) the Director of Finance & Commissioning may, in place of his/her handwritten signature, use a facsimile signature applied to cheques by mechanical means.

5.3.8 All cheques will be treated as controlled stationery and securely stored in the

charge of a duly designated officer controlling their issue. 5.3.9 The Director of Finance & Commissioning may enter into a formal agreement

with other bodies for payments to be made on behalf of the Trust from bank accounts maintained in the name of such other bodies or by electronic funds transfer, i.e. BACS. Where such an agreement is entered into, the Director of Finance & Commissioning shall ensure that the security arrangements of such other bodies relating to the bank accounts in question are adequate.

5.4 Tendering and Review 5.4.1 The Director of Finance & Commissioning will review the commercial banking

arrangements of the Trust at regular intervals to ensure they reflect best practice and represent best value for money by periodically seeking competitive tenders for the Trust’s commercial banking business.

5.4.2 Competitive tenders should be sought at least every five years. The results of

the tendering exercise should be reported to the Board. 6. INCOME, FEES AND CHARGES AND SECURITY OF CASH, CHEQUES AND

OTHER NEGOTIABLE INSTRUMENTS 6.1 Income Systems

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6.1.1 The Director of Finance & Commissioning is responsible for designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, and collection and coding of all monies due.

6.1.2 The Director of Finance & Commissioning is also responsible for the prompt

banking of all monies received. 6.2 Fees and Charges 6.2.1 The Trust shall follow the Department of Health’s guide and advice in regard to

the application of Payment by Results (PbR) and the National Tariff 6.2.2 The Director of Finance & Commissioning is responsible for approving and

regularly reviewing the level of all fees and charges other than those determined by the Department of Health or by Statute. Independent professional advice on matters of valuation shall be taken as necessary. Where sponsorship income (including items in kind such as subsidised goods or loans of equipment) is considered the guidance in the Department of Health’s Commercial Sponsorship – Ethical standards in the NHS shall be followed.

6.2.3 All employees must inform the Director of Finance & Commissioning promptly of

money due arising from transactions which they initiate/deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.

6.3 Debt Recovery 6.3.1 The Director of Finance & Commissioning is responsible for the appropriate

recovery action on all outstanding debts. 6.3.2 Income not received should be dealt with in accordance with losses procedures. 6.3.3 Overpayments should be detected (or preferably prevented) and recovery

initiated. 6.4 Security of Cash, Cheques and Other Negotiable Instruments 6.4.1 The Director of Finance & Commissioning is responsible for: (a) Approving the form of all receipt books, agreement forms, or other means

of officially acknowledging or recording monies received or receivable; (b) Ordering and securely controlling any such stationery; (c) The provision of adequate facilities and systems for employees whose

duties include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys and for coin operated machines;

(d) Prescribing systems and procedures for handling cash and negotiable

securities on behalf of the Trust. 6.4.2 Official money shall not under any circumstances be used for the encashment of

private cheques or IOUs. 6.4.3 All cheques, postal orders, cash etc. shall be banked intact. Disbursements shall

not be made from cash received, except under arrangements approved by the Director of Finance & Commissioning.

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6.4.4 The holders of safe keys shall not accept unofficial funds for depositing in their

safes unless such deposits are in special sealed envelopes or locked containers. It shall be made clear to the depositors that the Trust is not to be held liable for any loss and written indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss.

6.5 The Money Laundering, Terrorist Financing and Transfer of Funds

(Information on the Payer) Regulations 2017 Under no circumstances will the Trust accept cash payments in excess of

€15,000 (approximately £10,000) in respect of any single transaction. Any attempts by an individual to effect payment above this amount should be notified immediately to the Director of Finance & Commissioning.

7. TENDERING AND CONTRACTING REGULATIONS 7.1 Duty to Comply with Standing Orders and Standing Financial Instructions The procedure for making all contracts by or on behalf of the Trust shall comply

with Standing Orders and Standing Financial Instructions (except where Standing Order No.4.13 Suspension of Standing Orders, is applied).

7.2 Legislation and Guidance Covering Public Procurement The Trust shall comply with the Public Contracts Regulations 2015 and any

relevant EU Directives and all requirements binding on the Trust derived from the EU Treaty relating to procurement by the Trust relating to the processes to be applied when awarding all forms of contract. Such legislation shall be incorporated into the Board’s Standing Orders and SFIs.

7.3 E-Auctions The Trust does not presently conduct E-auction activity. 7.4 Capital Investment (See overlap with SFI No. 12)

The Trust shall comply as far as is practicable with the requirements of the Department of Health “Capital Investment Manual” and “Estate code in respect of capital investment and estate and property transactions. In the case of management consultancy contracts the Trust shall comply as far as is practicable with Department of Health guidance “The Procurement and Management of Consultants within the NHS”.

7.5 Formal Competitive Tendering 7.5.1 General Applicability

Subject to SFI 7.5.3 the Trust shall ensure that competitive tenders are invited for:

• the supply of goods, materials and manufactured articles; • the provision of services including all forms of management consultancy

services (other than specialised services sought from or provided by the Department of Health);

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• the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens); and

• disposal of any tangible or intangible property (including equipment and

intellectual property).

7.5.2 Light Touch Regime for the Purposes of Public Contracts Regulations 2015

Where the Trust has a requirement to procure health, education or transport services, etc (classed as Part B services for the purposes of the Public Contracts Regulations 2006) (whether by way of sub-contract or otherwise) the Trust shall consider its duties under the EU Treaty and whether such service requirement should be advertised.

Where the Trust considers that the circumstances require it to advertise for the supply of healthcare services (and/or other services classed as Part B services for the purposes of the Public Contracts Regulations 2006) the Standing Orders and SFIs shall apply as far as they are applicable to the tendering procedure although at all times the Trust should consider its duties under SFI paragraph 7.2 above.

7.5.3 Exceptions and Instances where Formal Tendering need not be applied Formal tendering procedures need not be applied where: (a) The estimated expenditure or income does not, or is not reasonably

expected to, exceed the financial limits defined with the Scheme of Delegation.

(b) The supply can be obtained under a framework agreement that has itself

been procured in compliance with the duties set out at SFI 7.2 above, and where the Trust is entitled to access such a framework agreement.

(c) Regarding disposals as set out in SFI No. 15.

Subject to the duties at SFI paragraph 7.2 above (and to obtaining appropriate advice from the Trust’s Procurement Department and where it considers necessary external professional advice); formal tendering procedures may be waived in the following circumstances:

(d) In very exceptional circumstances where the Chief Executive decides that

formal tendering procedures would not be practicable or the estimated expenditure or income would not warrant formal tendering procedures and the circumstances are detailed in an appropriate formal tender waiver report in accordance with the Scheme of Delegation;

(e) Where the requirement is covered by an existing contract (e.g. NHS Supply Chain and Crown Commercial Services);

(f) Where a consortium arrangement is in place and a lead organisation has been appointed to carry out tendering activity on behalf of the consortium members, including the Trust;

(g) Where the timescale genuinely precludes competitive tendering but failure to plan the work properly would not be regarded as a justification for a tender waiver/single tender;

(h) Where specialist expertise is required and can be demonstrated to be available from only one source then single tender action approval should be requested;

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(i) When the requirement is essential to complete a project, and arises as a consequence of a recently completed assignment and engaging different consultants for the new task would be inappropriate;

(j) Where there is a clear benefit to be gained from maintaining continuity with an earlier project. However, in such cases the benefits of such continuity must outweigh any potential financial advantage to be gained by competitive tendering;

(k) For the provision of legal advice and services providing that any legal firm

or partnership commissioned by the Trust is regulated by the Law Society for England and Wales for the conduct of their business (or by the Bar Council for England and Wales in relation to the obtaining of Counsel’s opinion) and are generally recognised as having sufficient expertise in the area of work for which they are commissioned.

The Director of Finance & Commissioning will ensure that any fees paid are reasonable and within commonly accepted rates for the costing of such work;

(l) Where allowed and provided for in the Capital Investment Manual.

The waiving of competitive tendering procedures should not be used to avoid competition or for administrative convenience or to award further work to a consultant originally appointed through a competitive procedure. Where it is decided that competitive tendering is not applicable and should be waived, the fact of the waiver and the reasons should be documented and recorded in an appropriate Trust record and reported to the Audit Committee at each meeting.

7.5.4 Fair, Transparent and Adequate Competition

Where the exceptions set out in SFIs 7.1 and 7.5.3 apply, the Trust shall ensure that invitations to tender, whether regulated by the Public Contracts Regulations 2015 or not that the tender process adopted is fair and transparent and is considered in a fair and transparent manner. Where a tender process is conducted, the Trust shall, in order to ensure best value is obtained, invite tenders from a sufficient number of firms/individuals to provide fair and adequate competition, and in no case less than two firms/individuals, having regard to their capacity to supply the goods or materials or to undertake the service or works required.

7.5.5 List of Approved Firms (Estates Contractors and Other Areas Deemed Appropriate)

Where the Trust is satisfied under its duties at SFI 7.2 above that an open tender process is not necessary, the Trust shall ensure that the firms/individuals invited to tender (and, where appropriate, quote) are among those on approved lists for estates contractors and other areas deemed appropriate). Where, in the opinion of the Director of Finance & Commissioning, it is desirable to seek tenders from firms not on the approved lists, the reason shall be recorded in writing to the Chief Executive (see SFI 7.6.8 List of Approved Firms).

7.5.6 Building and Engineering Construction Works

Competitive tendering cannot be waived for building and engineering construction works and maintenance (other than in accordance with Concode) without Departmental of Health approval.

7.5.7 Items Which Subsequently Breach Thresholds after Original Approval

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Items estimated to be below the limits set in this SFI for which formal tendering procedures are not used which subsequently prove to have a value above such limits shall be reported to the Chief Executive, and be recorded in the Trust’s Tender Register. No award shall be made for breach of the OJEU limit; any such breach will require an OJEU exercise to be conducted.

7.6 Contracting/Tendering Procedure 7.6.1 Invitation to Tender (a) Where tenders are not conducted using the eProcurement system, all invitations to tender shall state that no tender will be accepted unless: (i) Submitted in a plain sealed package or envelope bearing a pre-

printed label supplied by the Trust (or the word “tender” followed by the subject to which it relates and its unique tender reference number) and the latest date and time for the receipt of such tender addressed to the Procurement Department;

(ii) Tender envelopes/packages shall not bear any names or marks

indicating the sender. The use of courier/postal services must not identify the sender on the envelope or on any receipt so required by the deliverer.

(b) Every tender for goods, materials, services or disposals shall contain and

comprise appropriate terms and conditions regulating the conduct of the tender and shall contain appropriate terms and conditions on which the contract is to be awarded and shall be substantively based to regulate the provision of the goods, materials, services to be provided or in relation to the disposal.

(c) Every tender for building or engineering works (except for maintenance

work, when Concode guidance shall be followed) shall contain terms and conditions on which the contract to be awarded shall be substantively based and shall embody or be in the terms of the current edition of a suitable and recognised industry form of contract including but not limited to one of the Joint Contracts Tribunal Standard Forms of Building Contract or the NEC Standard Forms of Contract or Department of the Environment (GC/Wks) Standard Forms of Contract; or, when the content of the work is primarily engineering, the General Conditions of Contract recommended by the Institution of Mechanical and Electrical Engineers and the Association of Consulting Engineers (Form A), or (in the case of civil engineering work) the General Conditions of Contract recommended by the Institute of Civil Engineers, the Association of Consulting Engineers and the Federation of Civil Engineering Contractors. These documents shall be modified and/or amplified to accord with Department of Health guidance and (in minor respects only), to cover special features of individual projects.

7.6.2 Receipt and Safe Custody of Tenders Where tenders are not conducted electronically, the Chief Executive or his

nominated officer will be responsible for the receipt, endorsement and safe custody of tenders received until the time appointed for their opening.

The date and time of receipt of each tender shall be endorsed on the tender

envelope/package. 7.6.3 Opening Tenders and Register of Tenders

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(a) As soon as practicable after the date and time stated as being the last

time for the receipt of tenders where the eProcurement system has not been used, they shall be opened as determined by the Director of Finance & Commissioning. For tenders that have been undertaken on the eProcurement system, the Director of Finance & Commissioning is responsible for granting access to the system in order that tender submissions can be reviewed.

(b) The “originating” department will be taken to mean the department

sponsoring or commissioning the tender. (c) The involvement of Finance Directorate staff in the preparation of a tender

proposal will not preclude the Director of Finance & Commissioning or any approved senior manager from the Finance Directorate from serving as one of the two Officers to open tenders.

(d) Every tender received shall be marked with the date of opening and

initialled by those present at the opening. (e) A record shall be maintained by the Chief Executive, or a person

authorised by him, to show for each set of competitive tender invitations despatched:

• the name of all individual firms invited; • the names of individual firms from which tenders have been received; • the date the tenders were opened; • the persons present at the opening; • the price shown on each tender; • a note where price alterations have been made on the tender.

This register shall be signed by those present.

A note shall be made in the record if any one tender price has had so many alterations that it cannot be easily read or understood.

(f) Incomplete tenders, i.e., those from which information necessary for the

adjudication of the tender is missing, and amended tenders, i.e., those amended by the tenderer upon his own initiative either orally or in writing after the due time for receipt, but prior to the opening of other tenders, should be dealt with in the same way as late tenders. (SFI paragraph 7.6.5 below)

7.6.4 Admissibility of Tenders (a) If, for any reason, the designated officers are of the opinion that the

tenders received are not strictly competitive (for example, because their numbers are insufficient or any are amended, incomplete or qualified), no contract shall be awarded without the approval of the Chief Executive.

(b) Where only one tender is sought and/or received, the Chief Executive and

Director of Finance & Commissioning shall, as far as practicable, ensure that the price to be paid is fair and reasonable and will ensure value for money for the Trust.

7.6.5 Late Tenders (a) Tenders received after the due time and date, but prior to the opening of

the other tenders, may be considered only if the Chief Executive or his

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nominated officer decides that there are exceptional circumstances, i.e., despatched in good time but delayed through no fault of the tenderer.

(b) Only in the most exceptional circumstances will a tender be considered

which is received after the opening of the other tenders and only then if the tenders that have been duly opened have not left the custody of the Chief Executive or his nominated officer or if the process of evaluation and adjudication has not started.

(c) While decisions as to the admissibility of late, incomplete or amended

tenders are under consideration, the tender documents shall be kept strictly confidential, recorded, and held in safe custody by the Chief Executive or his nominated officer.

7.6.6 Acceptance of Formal Tenders (a) Any discussions with a tenderer which are deemed necessary to clarify

technical aspects of his tender before the award of a contract will not disqualify the tender.

(b) The lowest tender, if payment is to be made by the Trust, or the highest, if

payment is to be received by the Trust, shall be accepted unless there are good and sufficient reasons to the contrary. Such reasons shall be set out in either the contract file or other appropriate record.

It is accepted that for professional services such as management

consultancy, the lowest price does not always represent the best value for money. Other factors affecting the success of a project include:

(i) experience and qualifications of team members; (ii) understanding of client’s needs; (iii) feasibility and credibility of proposed approach; (iv) ability to complete the project on time. Where other factors are taken into account in selecting a tenderer, these

must be clearly recorded and documented in the contract file, and the reason(s) for not accepting the lowest tender clearly stated.

(c) No tender shall be accepted which will commit expenditure in excess of

that which has been allocated by the Trust and which is not in accordance with these instructions, except with the authorisation of the Chief Executive.

(d) The use of these procedures must demonstrate that the award of the

contract was: (i) not in excess of the going market rate/price current at the time the

contract was awarded; (ii) that best value for money was achieved. (e) All tenders should be treated as confidential and should be retained for

inspection. (f) Where examination of tenders reveals errors which would affect the

tender figure, the tenderer is to be given details of such errors and afforded the opportunity of confirming or withdrawing his offer.

(g) Where the form of contract included a fluctuation clause all applications

for price variations must be submitted in writing by the tenderer and shall be approved by the Chief Executive or nominated officer.

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(h) The Director of Finance & Commissioning shall ensure that any post-tender negotiations are conducted before a witness, with the newly negotiated prices being properly recorded.

7.6.7 Tender Reports to the Trust Board Approval of contracts to be awarded, with a maximum 3 year initial contract term

with an average annual contract term cost of £1m will be reserved by the Trust Board.

Approval of contracts to be awarded, that have a contract term greater than 3

years and a total contract value in excess of £3m will be reserved by the Trust Board.

7.6.8 Lists of Approved Firms (Estates Contractors and Other Areas Deemed

Appropriate) (a) Responsibility for Maintaining List (i) A manager or external contractor nominated by the Chief Executive

shall on behalf of the Trust maintain lists of approved firms from which tenders and quotations may be invited. Where such an approved list is used it must be kept under frequent review. The lists shall include all firms who have applied for permission to tender and as to whose technical competence and financial stability the Trust is satisfied.

(ii) All suppliers must be made aware of the Trust’s Terms and

Conditions of Contract.

(iii) Where a firm is included on an approved list of tenderers, the Trust shall, as a condition for inclusion, ensure that it is satisfied that when engaging, training, promoting or dismissing employees or in any conditions of employment, that such firm shall not unlawfully discriminate on the grounds of the protected characteristics of: age, disability, gender reassignment, race, religion/belief, gender, sexual orientation, marriage/civil partnership, pregnancy/maternity. The Trust will not tolerate unfair discrimination on the basis of spent criminal convictions, Trade Union membership or non-membership. In addition, the Trust will have due regard to advancing equality of opportunity between people from different groups and foster good relations between people from different groups and will comply with all relevant legislation including but not limited to, the Equality Act 2010 and any amending and/or related legislation or binding guidance.

(iv) Where a firm is included on an approved list of tenderers the Trust shall ensure that it is satisfied that such firm conforms with the requirements of the Health and Safety at Work Act 1974, the Regulatory Reform (Fire Safety) Order and any amending and/or other related legislation concerned with fire, the health, safety and welfare of workers and other persons, and to any relevant British Standard Code of Practice issued by the British Standard Institution. As part of any process to identify or review firms for an approved list, firms must provide to the appropriate manager a copy of its health and safety policy, risk assessments, safe systems at work, together with any licences for other statutory authorities or

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approvals and evidence of the safety of plant and equipment, when requested.

(b) Building and Engineering Construction Works Where permitted under SFI paragraph 7.5.5 above, invitations to tender

shall be made only to firms included on the approved list of tenderers compiled in accordance with this paragraph 7.6.8, or on the separate maintenance list compiled by an accredited body certified as such by the Director of Finance & Commissioning or a list compiled in accordance with Concode guidance.

(c) Financial Standing and Technical Competence of Contractors The Director of Finance & Commissioning may make or institute any

enquiries deemed appropriate concerning the financial standing and financial suitability of approved contractors. The Director with lead responsibility for clinical governance will similarly make such enquiries as is felt appropriate to be satisfied as to their technical/medical competence.

7.6.9 Exceptions to using Approved Contractors

If, in the opinion of the Chief Executive and the Director of Finance & Commissioning (or the Director with lead responsibility for clinical governance) it is impractical to use a potential contractor from the list of approved firms/individuals (for example, where specialist services or skills are required and there are insufficient suitable potential contractors on the list), or where a list for whatever reason has not been prepared, the Chief Executive should ensure that appropriate checks are carried out as to the technical and financial capability of those firms that are invited to tender or quote. An appropriate record in the contract file should be made of the reasons for inviting a tender or quote other than that from an approved list.

7.7 Quotations 7.7.1 General Position on Quotations

Quotations are required where formal tendering procedures are not adopted and where the intended expenditure or income exceeds, or is reasonably expected to exceed £5,000 but not exceed £50,000 (inclusive of VAT).

7.7.2 Competitive Quotations (where the eProcurement system has not been used to obtain quotes) (a) Written quotations should be obtained from at least three [3]

firms/individuals if contract value is between £20,000- £50,000 (inclusive of VAT) based on specifications or terms of reference prepared by, or on behalf of, the Trust. Below the value of £20,000 at least two [2] verbal/written quotations should be obtained following liaison with the Procurement Department, as set out in the Scheme of Delegation.

(b) Quotations should be in writing, or be submitted using the eProcurement

system unless the Chief Executive or his nominated officer determines that it is impractical to do so, in which case quotations may be obtained by

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telephone. Confirmation of telephone quotations should be obtained as soon as possible and the reasons why the telephone quotation was obtained should be set out in a permanent record.

(c) All quotations should be treated as confidential and should be retained for

inspection. (d) The Chief Executive or his nominated officer should evaluate the

quotation and select the quote which gives the best value for money. If this is not the lowest quotation if payment is to be made by the Trust, or the highest if payment is to be received by the Trust, then the choice made and the reasons why should be recorded in a permanent record.

7.7.3 Quotations to be within Financial Limits

No quotation shall be accepted which will commit expenditure in excess of that which has been allocated by the Trust and which is not in accordance with Standing Financial Instructions except with the authorisation of either the Chief Executive or Director of Finance & Commissioning.

7.8 Authorisation of Tenders and Competitive Quotations

Providing all the conditions and circumstances set out in these Standing Financial Instructions have been fully complied with, awarding of a contract may be decided in accordance with the Trust’s Scheme of Delegation. These levels of authorisation may be varied or changed and need to be read in conjunction with the Trust Board’s Scheme of Delegation. Formal authorisation must be put in writing. In the case of authorisation by the Trust Board, this shall be recorded in its Minutes.

7.9 Instances where Formal Competitive Tendering or Competitive Quotation is

not required Where competitive tendering or a competitive quotation is not required, the Trust should adopt one of the following alternatives: (a) The Trust shall use the NHS Supply Chain for procurement of all goods

and services unless the Chief Executive or nominated officers deem it inappropriate. The decision to use alternative sources must be documented.

(b) If the Trust does not use the NHS Supply Chain – where tenders or

quotations are not required, because expenditure is below £5,000 (inclusive of VAT) the Trust shall procure goods and services in accordance with procurement procedures approved by the Director of Finance & Commissioning.

7.10 Private Finance for Capital Procurement (see overlap with SFI No. 12)

The Trust should consider market-test for PFI (Private Finance Initiative funding) when considering a capital procurement. When the Board proposes, or is required, to use finance provided by the private sector, the following should apply:

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(a) The Chief Executive shall demonstrate that the use of private finance represents value for money and genuinely transfers risk to the private sector.

(b) Where the sum exceeds Department of Health delegation limits, a

business case must be referred to the appropriate Department of Health for approval or treated as per current guidelines.

(c) The proposal must be specifically agreed by the Board of the Trust. (d) The selection of a contractor/finance company must be on the basis of

competitive tendering or quotations. 7.11 Compliance Requirements for All Contracts

The Board may only enter into contracts on behalf of the Trust within the statutory powers of the Trust delegated to it by the Secretary of State and shall comply with: (a) The Trust’s Standing Orders and Standing Financial Instructions; (b) EU Directives and other statutory provisions; (c) Any relevant directions including Concode and guidance on the

Procurement and Management of Consultants. (d) Such of the NHS Standard Contract Conditions as are applicable. (e) Contracts with NHS Foundation Trusts must be in a form compliant with

appropriate NHS guidance. (f) Where appropriate contracts shall be in or embody the same terms and

conditions of contract as was the basis on which tenders or quotations were invited.

(g) In all contracts made by the Trust, the Board shall endeavour to obtain

best value for money by use of all systems in place. The Chief Executive shall nominate an officer who shall oversee and manage each contract on behalf of the Trust.

(h) In all contracts made by the Trust, the Trust must comply with all

applicable laws, regulations, codes and sanctions relating to anti-bribery and anti-corruption including but not limited to the Bribery Act 2010.

(i) Cancellation of Contracts Except where specific provision is made in

model Forms of Contracts or standard schedules of Conditions approved for use within the NHS and in accordance with Standing Orders 7.2 and 7.4, there shall be inserted in every written contract a clause empowering the Trust to cancel the Contract and to recover from the contractor the amount of any loss resulting from such cancellation, if the contractor shall have offered, or given or agreed to give, any person any gift or consideration of any kind as an inducement or reward for doing or forbearing to do or for having done or fordone to do any action in relation to the obtaining or execution of the contract or any other contract with the Trust, or for showing or forbearing to show favour or disfavour to any person in relation to the contracts or any other contract with the Trust, or is the like acts shall have been done by any person employed by him or acting on his behalf (whether with or without the knowledge of the contractor) or if in relation to any contract with the Trust the contractor or any person employed by him/her or acting on his/her behalf shall have

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committed any offence under the Anti-Bribery Act 2010 or any other appropriate legislation.

(j) Determination of Contracts for Failure to Deliver Goods or Material –

There shall be inserted in every written contract for the supply of goods or materials a clause to secure that, should the contractor fail to deliver the goods or materials or any portion thereof within the time or times specified in the contract, the Trust may without prejudice determine the contract either wholly or to the extent of such default and purchase other goods, or material of similar description to make good (a) such default, or (b) in the event of the contract being wholly determined the goods or materials remaining to be delivered. The clause shall further secure that the amount by which the costs of so purchasing other goods and materials exceeds the amount which would have been payable to the contractor in respect of the goods or materials shall be recoverable from the contractor.

7.12 Personnel and Agency or Temporary Staff Contracts

The Chief Executive shall nominate officers with delegated authority to enter into contracts of employment regarding staff, agency staff or temporary staff service contracts.

7.13 Disposals Competitive tendering or quotation procedures shall not apply to the disposal of: (a) Any matter in respect of which a fair price can be obtained only by

negotiation or sale by auction as determined (or predetermined in a reserve) by the Chief Executive or his nominated officer.

(b) Obsolete or condemned articles and stores, which may be disposed of in

accordance with the procurement supplies policy of the Trust. (c) Items to be disposed of with an estimated sale value of less than £2,500,

this figure to be reviewed on a periodic basis. (d) Items arising from works of construction, demolition or site clearance,

which should be dealt with in accordance with the relevant contract. (e) Land or buildings concerning which Department of Health Guidance has

been issued but subject to compliance with such guidance. 7.14 In-house Services 7.14.1 The Chief Executive shall be responsible for ensuring that best value for money

can be demonstrated for all services provided on an in-house basis. The Trust may also determine from time to time that in-house services should be market tested by competitive tendering.

7.14.2 In all cases where the Board determines that in-house services should be subject

to competitive tendering, the following groups shall be set up: (a) Specification group, comprising the Chief Executive or nominated officer/s

and specialist; (b) In-house Tender Group, comprising a nominee of the Chief Executive and

technical support.

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(c) Evaluation Team, comprising normally a specialist officer, a procurement officer and a Finance representative. For services having a likely annual expenditure exceeding £1m a Non-Executive director should be a member of the Evaluation Team.

7.14.3 All groups should work independently of each other and individual officers may

be a member of more than one group but no member of the In-house Tender Group may participate in the evaluation of tenders.

7.14.4 The Evaluation Team shall make recommendations to the Board following any

benchmarking process or a market testing exercise carried out pursuant to SFI paragraph 7.2 above.

7.14.5 The Chief Executive shall nominate an officer to oversee and manage the

contract on behalf of the Trust. 7.15 Applicability of SFIs on Tendering and Contracting to Funds held in Trust

(see overlaps with SFI No. 17) These instructions shall not only apply to expenditure from Exchequer funds but

also to works, services and goods purchased from the Trust’s trust funds and private resources.

8. CONTRACTING FOR PROVISION OF SERVICES 8.1. The Board shall regularly review and shall at all times maintain and ensure the

capacity and capability of the Trust to provide its mandatory goods and services referred to in its Statutory Instrument and related guidance.

8.2 The Chief Executive, as the Accountable Officer, is responsible for ensuring the

Trust enters into suitable Contracts/Service Level Agreements (SLAs) with all commissioners for the provision of NHS services

8.3 The Trust Board will ensure that all Contracts/SLAs for the provision of its

mandatory goods and services will comply with national guidance, particularly the principles detailed within the NHS Constitution, a ‘Patient Led NHS and Practice Based Commissioning’.

8.4 All Contracts/SLAs should aim to implement the agreed priorities contained within

the Annual Plan and wherever possible, be based upon integrated care pathways to reflect expected patient experience. In discharging this responsibility, the Chief Executive should take into account:

• the standards of service quality expected;

• the relevant national service framework (if any);

• the provision of reliable information on cost and volume of services;

• the NHS National Performance Assessment Framework;

• that Contracts/SLAs build where appropriate on existing Joint Investment Plans;

• those Contracts/SLAs are based on integrated care pathways.

8.5 Where the Trust enters into a relationship with another organisation for the supply or receipt of other services, clinical or non-clinical, the responsible officer should ensure that an appropriate contract is present and signed by both parties in accordance with the Scheme of Delegation.

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8.6 All contracts shall comply with best practice and shall be so devised as to

manage contractual risk, insofar as it is reasonably achievable in the circumstances of each contract, whilst optimising the Trust’s opportunity to generate income.

8.7 All contracts with NHS Foundation Trusts shall be legally binding. 8.8 In carrying out these functions, the Chief Executive should take into account the

advice of Directors regarding: (a) costing and pricing of services and/or goods; (b) payment terms and conditions; (c) billing systems and cash flow management; (d) the contract negotiating process and timetable; (e) the provision of contract data; (f) contract monitoring arrangements; (g) amendments to contracts; and (h) any other matters relating to contracts of a legal or non-financial nature. 8.9 The Director of Finance & Commissioning shall produce regular reports detailing

actual and forecast service activity income with a detailed assessment of the impact of the variable elements of income.

9. TERMS OF SERVICE AND PAYMENT OF DIRECTORS AND

EMPLOYEES (INCLUDING GOVERNOR EXPENSES)

9.1 Remuneration and Terms of Service (see overlap with SO No.4) 9.1.1 In accordance with Standing Orders, the Board shall establish a Remuneration

Committee, with clearly defined terms of reference, specifying which posts fall within its area of responsibility, its composition, and the arrangements for reporting.

9.1.2 The Committee of Non-Executive Directors will:

(a) advise the Board about appropriate remuneration and terms of service for the Chief Executive, other officer members employed by the Trust and other senior employees including: (i) all aspects of salary (including any performance-related

elements/bonuses);

(ii) provisions for other benefits, including pensions and cars;

(iii) arrangements for termination of employment and other contractual terms;

(b) make such recommendations to the Board on the remuneration and terms of service of officer members of the Board (and other senior employees) to ensure they are fairly rewarded for their individual contribution to the Trust – having proper regard to the Trust’s circumstances and performance and to the provisions of any national arrangements for such members and staff where appropriate;

(c) monitor and evaluate the performance of individual officer members (and other senior employees);

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(d) advise on and oversee appropriate contractual arrangements for such

staff including the proper calculation and scrutiny of termination payments taking account of such national guidance as is appropriate.

9.1.3 The Committee shall report in writing to the Board the basis for its

recommendations. The Board shall use the report as the basis for their decisions, but remain accountable for taking decisions on the remuneration and terms of service of officer members. Minutes of the Board’s meetings should record such decisions.

9.1.4 The Board will approve proposals presented by the Chief Executive for any

changes in the remuneration and conditions of service for those employees not covered by the Committee.

9.1.5 The Trust will pay allowances to the Chair and non-officer members of the Board

in accordance with instructions issued by the Secretary of State for Health and Social Care.

9.2 Funded Establishment 9.2.1 The workforce plans agreed and incorporated within the annual budget will form

the funded establishment of the Trust. 9.2.2 The funded establishment of any department may only be varied in accordance

with the Scheme of Delegation. 9.3 Staff Appointments 9.3.1 No Director or employee may engage, re-engage or re-grade employees, either

on a permanent or temporary nature, or hire agency staff, or agree to changes in any aspect of remuneration unless:

(a) authorised to do so by the Chief Executive; and (b) within the limit of his approved budget and funded establishment. 9.3.2 The Board will approve procedures presented by the Chief Executive for the

determination of commencing pay rates, conditions of service, etc. for employees.

9.4 Processing Payroll 9.4.1 The Director of Finance & Commissioning is responsible for arranging the

provision of an appropriate payroll service. Together with the service provider, the Director of Finance & Commissioning is responsible for:

(a) Specifying timetables for submission of properly authorised time records

and other notifications; (b) The final determination of pay and allowances; (c) Making payment on agreed dates; (d) Agreeing method of payment. 9.4.2 Together with the service provider, the Director of Finance & Commissioning will

issue instructions regarding: (a) Verification and documentation of data;

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(b) The timetable for receipt and preparation of payroll data and the payment

of employees and allowances; (c) Maintenance of subsidiary records for superannuation, income tax, social

security and other authorised deductions from pay; (d) Security and confidentiality of payroll information; (e) Checks to be applied to completed payroll before and after payment; (f) Authority to release payroll data under the provisions of the Data

Protection Act; (g) Methods of payment available to various categories of employee and

officers; (h) Procedures for payment by cheque, bank credit, or cash to employees

and officers; (i) Procedures for the recall of cheques and bank credits; (j) Pay advances and their recovery; (k) Maintenance of regular and independent reconciliation of pay control

accounts; (l) Separation of duties of preparing records and handling cash; (m) A system to ensure the recovery from those leaving the employment of

the Trust of sums of money and property due by them to the Trust. 9.4.3 Managers authorised under the Scheme of Delegation have delegated

responsibility for: (a) Submitting time records and other notifications in accordance with agreed

timetables; (b) Completing time records and other notifications in accordance with the

Director of Finance & Commissioning’s instructions and in the form prescribed by the Director of Finance & Commissioning;

(c) Submitting termination forms in the prescribed form immediately upon

knowing the effective date of an employee’s or officer’s resignation, termination or retirement. Where an employee fails to report for duty or to fulfil obligations in circumstances that suggest they have left without notice, the Human Resources Department must be informed immediately.

9.4.4 Regardless of the arrangements for providing the payroll service, the Director of

Finance & Commissioning shall ensure that the chosen method is supported by appropriate (contracted) terms and conditions, adequate internal controls and audit review procedures and that suitable arrangements are made for the collection of payroll deductions and payment of these to appropriate bodies.

9.4.5 All employees have delegated responsibility for reviewing their own expenses

and pay receipts, and must notify the payroll service provider of any over-payment.

9.5 Contracts of Employment 9.5.1 The Board shall delegate responsibility to an officer for:

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(a) Ensuring that all employees are issued with a Contract of Employment in a form approved by the Board and which complies with employment legislation;

(b) Dealing with variations to, or termination of, contracts of employment. 10. NON-PAY EXPENDITURE 10.1 Delegation of Authority 10.1.1 The Board will approve the level of non-pay expenditure on an annual basis and

the Chief Executive will determine the level of delegation to budget managers. 10.1.2 The Chief Executive and Director of Finance & Commissioning will set out: (a) The list of managers who are authorised to place requisitions for the

supply of goods and services; (b) The maximum level of each requisition and the system for authorisation

above that level. 10.1.3 The Chief Executive shall set out procedures on the seeking of professional

advice regarding the supply of goods and services. 10.2 Choice, Requisitioning, Ordering, Receipt and Payment for Goods and

Services (See overlap with SFI 7) 10.2.1 Requisitioning The requisitioner, in choosing the item to be supplied (or the service to be

performed) shall always obtain the best value for money for the Trust. In so doing, the advice of the Trust’s adviser on supply shall be sought. Where this advice is not acceptable to the requisitioner, the Director of Finance & Commissioning (and/or the Chief Executive) shall be consulted.

10.2.2 System of Payment and Payment Verification The Director of Finance & Commissioning shall be responsible for the prompt

payment of accounts and claims. Payment of contract invoices shall be in accordance with contract terms, or otherwise, in accordance with national guidance.

10.2.3 The Director of Finance & Commissioning will: (a) Advise the Board regarding the setting of thresholds above which

quotations (competitive or otherwise) or formal tenders must be obtained; and, once approved, the thresholds should be incorporated in Standing Orders and Standing Financial Instructions and regularly reviewed;

(b) Prepare procedural instructions or guidance within the Scheme of

Delegation on the obtaining of goods, works and services incorporating the thresholds;

(c) Be responsible for the prompt payment of all properly authorised accounts

and claims;

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(d) Be responsible for designing and maintaining a system of verification, recording and payment of all amounts payable. The system shall provide for:

(i) a list of Board Directors and employees (including specimens of

their signatures) authorised to certify invoices; (ii) certification that:

• goods have been duly received, examined and are in accordance with specification and the prices are correct;

• work done or services provided have been satisfactorily carried out in accordance with the order and, where applicable, the materials used are of the requisite standard and the charges are correct;

• in the case of contracts based on the measurement of time, materials or expenses, the time charged is in accordance with the time sheets, the rates of labour are in accordance with the appropriate rates, the materials have been checked as regards quantity, quality and price and the charges for the use of vehicles, plant and machinery have been examined;

• where appropriate, the expenditure is in accordance with regulations and all necessary authorisations have been obtained;

• the account is arithmetically correct;

• the account is in order for payment. (iii) a timetable and system for submission to the Director of Finance &

Commissioning of accounts for payment; provision shall be made for the early submission of accounts subject to cash discounts or otherwise requiring early payment.

(iv) instructions to employees regarding the handling and payment of

accounts within the Finance Department. (e) Be responsible for ensuring that payment for goods and services is only

made once the goods and services are received. The only exceptions are set out in SFI No. 10.2.4 below.

10.2.4 Prepayments

Prepayments are only permitted where exceptional circumstances apply (e.g., payments made under normal trading arrangements for booking and pre-payment of course/conference fees, leasing and maintenance contracts and where Department of Health Guidance under Form 25 of Procure 21 for capital schemes applies). In such instances: (a) Prepayments are only permitted where the financial advantages outweigh

the disadvantages (b) The appropriate officer must provide, in the form of a written report to the

Director of Finance & Commissioning, a case setting out all relevant circumstances of the purchase. The report must set out the effects on the Trust if the supplier is at some time during the course of the prepayment agreement unable to meet his commitments;

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(c) The Director of Finance & Commissioning will need to be satisfied with the proposed arrangements before contractual arrangements proceed (taking into account the EU public procurement rules where the contract is above a stipulated financial threshold);

(d) The budget holder is responsible for ensuring that all items due under a

prepayment contract are received and they must immediately inform the appropriate Director or Chief Executive if problems are encountered.

10.2.5 Official Orders Official orders must: (a) Be consecutively numbered; (b) Be in a form approved by the Director of Finance & Commissioning; (c) State the Trust’s terms and conditions of trade; (d) Only be issued to, and used by, those duly authorised by the Chief

Executive. 10.2.6 Duties of Managers and Officers Managers and officers must ensure that they comply fully with the guidance and

limits specified by the Director of Finance & Commissioning and that: (a) All contracts, leases, tenancy agreements and other commitments which

may result in a liability are reported formally to the Director of Finance & Commissioning in advance of any commitment being made;

(b) Contracts above specified thresholds are advertised and awarded in

accordance with European Union (EU) and General Agreements on Tariff and Trade (GATT) rules on public procurement and comply with legislation and government guidance on competitive procurement;

(c) Where consultancy advice is being obtained, the procurement of such

advice must be in accordance with guidance issued by the Department of Health;

(d) No order shall be issued for any item or items to any firm which has made

an offer of gifts, reward or benefit to Directors or employees, other than: (i) isolated gifts of a trivial character or inexpensive seasonal gifts, such

as calendars; (ii) conventional hospitality, such as lunches in the course of working

visits. (iii) Any gifts or hospitality, the value of which exceeds the limits set out

in the Trust’s Scheme of Delegation, must be entered into the hospitality register.

(This provision needs to be read in conjunction with Standing Order No. 6

and the Trust’s Standards of Business Conduct Policy in Respect of Interests, Gifts, Hospitality, Sponsorship, Advertising and Partnership Arrangements and the Anti-Bribery Policy).;

(e) No requisition/order is placed for any item or items for which there is no

budget provision unless authorised by the Director of Finance & Commissioning on behalf of the Chief Executive;

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(f) All goods, services or works are ordered on an official order except works and services executed in accordance with a contract and purchases from petty cash/purchase cards;

(g) Verbal orders must only be issued very exceptionally – by an employee

designated by the Chief Executive and only in cases of emergency or urgent necessity. These must be confirmed by an official order and clearly marked “Confirmation Order”;

(h) Orders are not split or otherwise placed in a manner devised so as to

avoid the financial thresholds; (i) Goods are not taken on trial or loan in circumstances that could commit

the Trust to a future uncompetitive purchase; (j) Changes to the list of employees and officers authorised to certify

invoices are notified to the Director of Finance & Commissioning; (k) Purchases from petty cash are restricted in value and by type of purchase

in accordance with instructions issued by the Director of Finance & Commissioning;

(l) Petty cash records are maintained in a form as determined by the Director

of Finance & Commissioning. 10.2.7 The Chief Executive and Director of Finance & Commissioning shall ensure that

the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with the guidance contained within Concode. The technical audit of these contracts shall be the responsibility of the relevant Director.

10.3 Joint Finance Arrangements with Local Authorities and Voluntary Bodies

(see overlap with Standing Order No. 9.1) Payments to local authorities and voluntary organisations made under the powers

of section 78 of the NHS Act 2006 shall comply with procedures laid down by the Director of Finance & Commissioning which shall be in accordance with these Acts. (See overlap with Standing Order No. 9.1)

11. EXTERNAL BORROWING AND INVESTMENTS 11.1 External Borrowing 11.1.1 The Director of Finance & Commissioning will advise the Board concerning the

Trust’s ability to pay interest on, and repay the Public Dividend Capital (PDC) and any loans or overdrafts within the limits set by the Department of Health. The Director of Finance & Commissioning is also responsible for reporting periodically to the Board concerning the PDC and all loans and overdrafts.

11.1.2 Any application for a loan or overdraft, or for additional PDC, will only be made by

the Director of Finance & Commissioning or by an employee so delegated. 11.1.3 The Director of Finance & Commissioning must prepare procedural instructions

concerning applications for loans, overdrafts or PDC. 11.1.4 All short-term borrowings should be kept to the minimum period possible,

consistent with the overall cash flow position, represent good value for money, and comply with the latest guidance from the Department of Health. Any short

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term borrowing requirement must be authorised by the Director of Finance & Commissioning. Short term borrowing has a maximum term of 6 months.

11.1.5 Any short-term borrowing must be with the authority of two members of an

authorised panel, one of which must be the Chief Executive or the Director of Finance & Commissioning. The Board must be made aware of all short-term borrowings at the next Board meeting.

11.1.6 All long-term borrowing must be consistent with the plans outlined in the current

Annual Plan and be approved by the Trust Board. 11.2 Investments 11.2.1 Temporary cash surpluses must be held only in such public or private sector

investments as specified in the Trust’s Treasury Management Policy and as notified by the Secretary of State and authorised by the Board.

11.2.2 The Director of Finance & Commissioning is responsible for advising the Board

on investments and shall report periodically to the Board concerning the performance of investments held.

11.2.3 The Director of Finance & Commissioning will prepare detailed procedural

instructions on the operation of investment accounts and on the records to be maintained.

11.2.4 The Trust must comply with all relevant guidance published on investment in

force. 12. CAPITAL INVESTMENT, PRIVATE FINANCING, FIXED ASSET

REGISTERS AND SECURITY OF ASSETS 12.1 Capital Investment 12.1.1 The Board shall approve a programme of building, engineering and design

schemes known as the capital programme, as part of the budgetary process. In addition, further list of such schemes known as the reserves list shall be provided for situations where additional monies or slippage on existing schemes etc., enable resources to become available to provide additional works. The Chief Executive shall approve the commencement of such reserve schemes as required.

12.1.2 Where a requirement for a capital scheme not already in the approved

programme arises during the course of the year, approval for its commencement shall be in accordance with the Scheme of Delegation and a report shall be made to the next meeting of the Board, showing the impact of the new scheme on the capital programme and the revenue consequences.

12.1.3 The Chief Executive: (a) Shall ensure that there is an adequate appraisal and approval process in

place for determining capital expenditure priorities and the effect of each proposal upon business plans;

(b) Is responsible for the management of all stages of capital schemes and

for ensuring that schemes are delivered on time and to cost;

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(c) Is responsible for reporting to the Board any significant variation to planned capital schemes.

12.1.4 For every capital expenditure proposal the Chief Executive shall ensure: (a) That a business case (in line with the guidance contained within Capital

Investment Manual – http://www.info.doh.gov.uk/doh/finman.hsf) is produced setting out:

(i) An option appraisal of potential benefits compared with known

costs to determine the option with the highest ratio of benefits to costs;

(ii) The involvement of appropriate Trust personnel and external agencies;

(iii) Appropriate project management and control arrangements. (b) That the Director of Finance & Commissioning has certified professionally

to the costs and revenue consequences detailed in the business case. 12.1.5 For capital schemes where the contracts stipulate staged payments, the Chief

Executive will issue procedures for their management, incorporating the recommendations of Concode” and the Capital Investment Manual.

12.1.6 The Director of Finance & Commissioning shall assess on an annual basis the

requirement for the operation of the construction industry tax deduction scheme in accordance with Her Majesty’s Revenue and Customs guidance.

12.1.7 The Director of Finance & Commissioning shall issue procedures governing the

financial management, including variations to contract of capital investment projects and valuation for accounting purposes; and shall issue procedures for the regular reporting of expenditure and commitment against authorised expenditure.

12.1.8 The approval of a capital programme shall not constitute approval for expenditure

on any scheme. The Chief Executive shall issue to the manager responsible for the scheme: (a) Specific authority to commit expenditure; (b) Authority to proceed to tender; (c) Approval to accept a successful tender in accordance with the Trust’s

Tendering and Contracting Procedures. (Officers must comply with SFI No. 7 – Tendering and Contracting Regulations) The Chief Executive will issue a scheme of delegation for capital investment management in accordance with “Concode” guidance and the Trust’s Standing Orders.

12.2 Private Finance 12.2.1 The Trust should normally test for PFI when considering capital procurement.

When the Trust proposes to use finance which is to be provided other than through its Allocations, the following procedures shall apply:

(a) The Director of Finance & Commissioning shall demonstrate that the use

of private finance represents value for money and genuinely transfers significant risk to the private sector;

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(b) Where the sum involved exceeds delegated limits, the business case must be referred to the Department of Health or in line with any current guidelines;

(c) The proposal must be specifically agreed by the Board. 12.3 Asset Registers 12.3.1 The Chief Executive is responsible for the maintenance of registers of assets,

taking account of the advice of the Director of Finance & Commissioning concerning the form of any register and the method of updating, and arranging for a physical check of assets against the asset register to be conducted once a year.

12.3.2 The Trust shall maintain an asset register recording fixed assets. The minimum

data set to be held within these registers shall be as specified in the Capital Accounting Manual as issued by the Department of Health.

12.3.3 Additions to the fixed asset register must be clearly identified to an appropriate

budget holder and be validated by reference to: (a) Properly authorised and approved agreements, architect’s certificates,

supplier’s invoices and other documentary evidence in respect of purchases from third parties;

(b) Stores, requisitions and wages records for own materials and labour

including appropriate overheads; (c) Lease agreements in respect of assets held under a finance lease and

capitalised. 12.3.4 Where capital assets are sold, scrapped, lost or otherwise disposed of, their

value must be removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where appropriate).

12.3.5 The Director of Finance & Commissioning shall approve procedures for

reconciling balances on fixed assets accounts in ledgers against balances on fixed asset registers.

12.3.6 The process for revoking assets periodically must be approved by the Audit

Committee and by the Board 12.3.7 The value of each asset shall be re-valued at appropriate periodic intervals and in

accordance with the requirements specified in the Capital Accounting Manual issued by the Department of Health.

12.3.7 The value of each asset shall be depreciated using methods and rates as

specified in the Capital Accounting Manual issued by the Department of Health. 12.3.8 The Director of Finance & Commissioning of the Trust shall calculate and pay

capital charges as specified in the Capital Accounting Manual issued by the Department of Health.

12.4 Security of Assets 12.4.1 The overall control of fixed assets is the responsibility of the Chief Executive.

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12.4.2 Asset control procedures (including fixed assets, cash, cheques and negotiable instruments, and also including donated assets) must be approved by the Director of Finance & Commissioning. This procedure shall make provision for:

(a) recording managerial responsibility for each asset;

(b) identification of additions and disposals;

(c) identification of all repairs and maintenance expenses;

(d) physical security of assets;

(e) periodic verification of the existence of, condition of and title to assets recorded;

(f) identification and reporting of all costs associated with the retention of an asset; and

(g) reporting, recording and safekeeping of cash, cheques and negotiable instruments.

12.4.3 All discrepancies revealed by verification of physical assets to fixed asset register

shall be notified to the Director of Finance & Commissioning. 12.4.4 Whilst each employee and officer has a responsibility for the security of property

of the Trust, it is the responsibility of Board members and senior employees in all disciplines to apply such appropriate routine security practices in relation to NHS property as may be determined by the Board. Any breach of agreed security practices must be reported in accordance with agreed procedures.

12.4.5 Any damage to the Trust’s premises, vehicles and equipment, or any loss of

equipment, stores or supplies must be reported by Board members and employees in accordance with the procedure for reporting losses.

12.4.6 Where practical, assets should be marked as Trust property. 12.4.7 Trust assets must not be used for private purposes other than that associated

with private healthcare. Agreement for such use must be given by the Chief Executive.

13. STORES AND RECEIPT OF GOODS 13.1 General Position 13.1.1 Stores, defined in terms of controlled stores and departmental stores (for

immediate use) should be: (a) kept to a minimum; (b) subjected to annual stock take; (c) valued at the lower of cost and net realisable value; (d) obsolete or excess stock shall be valued at net realisable value. 13.2 Control of Stores, Stocktaking, Condemnations and Disposal 13.2.1 Subject to the responsibility of the Director of Finance & Commissioning for the

systems of control, overall responsibility for the control of stores shall be delegated to an employee by the Chief Executive. The day-to-day responsibility may be delegated by him to departmental employees and stores managers/keepers, subject to such delegation being entered in a record available to the Director of Finance & Commissioning. The control of any pharmaceutical

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stocks shall be the responsibility of a designated Pharmaceutical Officer; the control of any fuel, oil and coal of a designated estates manager.

13.2.2 The responsibility for security arrangements and the custody of keys for any

stores and locations shall be clearly defined in writing by the designated manager/Pharmaceutical Officer. Wherever practicable, stocks should be marked as health service property.

13.2.3 The Director of Finance & Commissioning shall set out procedures and systems

to regulate the stores including records for receipt of goods, issues, and returns to stores, and losses.

13.2.4 Stocktaking arrangements shall be agreed with the Director of Finance &

Commissioning and there shall be a physical check covering all items in store at least once a year.

13.2.5 Where a complete system of stores control is not justified, alternative

arrangements shall require the approval of the Director of Finance & Commissioning.

13.2.6 Designated Managers shall be responsible for a system approved by the Director

of Finance & Commissioning for a review of slow moving and obsolete items and for condemnation, disposal and replacement of all unserviceable articles. The designated Officer shall report to the Director of Finance & Commissioning any evidence of significant overstocking and of any negligence or malpractice (see also overlap with SFI No. 15, Disposals and Condemnations, Losses and Special Payments). Procedures for the disposal of obsolete stock shall follow the procedures set out for disposal of all surplus and obsolete goods.

13.3 Goods Supplied by NHS Supply Chain 13.3.1 For goods supplied via the NHS Supply Chain central warehouses, the Chief

Executive shall identify those authorised to requisition and accept goods from the store. The authorised person shall check receipt against the delivery note before forwarding this to the Director of Finance & Commissioning who shall be satisfied that the goods have been received before accepting the recharge.

14. DISPOSALS AND CONDEMNATIONS, LOSSES AND SPECIAL

PAYMENTS 14.1 Disposals and Condemnations 14.1.1 Procedures The Director of Finance & Commissioning must prepare detailed procedures for

the disposal of assets including condemnations, and ensure that these are notified to managers.

14.1.2 When it is decided to dispose of a Trust asset, the Head of Department or

authorised deputy will determine and advise the Director of Finance & Commissioning of the estimated market value of the item, taking account of professional advice where appropriate.

14.1.3 All unserviceable articles shall be: (a) condemned or otherwise disposed of by an employee authorised for that

purpose by the Director of Finance & Commissioning;

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(b) recorded by the Condemning Officer in a form approved by the Director of

Finance & Commissioning which will indicate whether the articles are to be converted, destroyed or otherwise disposed of. All entries shall be confirmed by the countersignature of a second employee authorised for the purpose by the Director of Finance & Commissioning.

14.1.4 The Condemning Officer shall satisfy himself as to whether or not there is

evidence of negligence in use and shall report any such evidence to the Director of Finance & Commissioning who will take the appropriate action.

14.2 Losses and Special Payments 14.2.1 The Director of Finance & Commissioning must prepare procedural instructions

on the recording of and accounting for condemnations, losses and special payments. These procedures shall follow Department of Health guidance which also lays down the limits of authority delegated to the Trust. The Director of Finance & Commissioning must also prepare a “Counter Fraud and Security Policy and Procedure” to be approved by the Trust Board, which sets out the action to be taken both by persons detecting a suspected fraud and by those persons responsible for investigating it.

14.2.2 Any employee or officer discovering or suspecting a loss of any kind must either immediately inform their head of department, who must immediately inform the Chief Executive and Director of Finance & Commissioning or inform an officer charged with responsibility for responding to concerns involving loss. This officer will then appropriately inform the Director of Finance & Commissioning and/or Chief Executive. Alternatively an employee may contact the NHS Fraud and Corruption Reporting Line. Under no circumstances should an employee challenge the suspected offender, nor tamper with any evidence nor seek to entrap, as this may undermine options available to the Trust, counter-fraud service and/or police. Where a criminal offence is suspected, the Director of Finance & Commissioning must immediately inform the police if theft or arson is involved. In cases of fraud or corruption or of anomalies which may indicate fraud or corruption, the Director of Finance & Commissioning must inform the relevant LCFS and NHS Protect in accordance with Secretary of State for Health and Social Care’s Directions.

The Director of Finance & Commissioning must notify NHS Protect and the

External Auditor of all frauds. 14.2.3 For losses apparently caused by theft, arson, neglect of duty or gross

carelessness, except if trivial, the Director of Finance & Commissioning must immediately notify:

(a) the Board; (b) the External Auditor. 14.2.4 Within limits delegated to it by the Department of Health, the Board, and such

officers as subsequently delegated by them (see Scheme of Delegation) shall approve the writing-off of losses.

14.2.5 The Director of Finance & Commissioning shall be authorised to take any

necessary steps to safeguard the Trust’s interests in bankruptcies and company liquidations.

14.2.6 For any loss, the Director of Finance & Commissioning should consider whether

any insurance claim can be made.

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14.2.7 The Director of Finance & Commissioning shall maintain a Losses and Special Payments Register in which write-off action is recorded.

14.2.8 No special payments exceeding delegated limits shall be made without the prior

approval of the Department of Health. 14.2.9 All losses and special payments must be reported to the Audit Committee at

every meeting. 15. FINANCIAL SYSTEMS - INFORMATION TECHNOLOGY (IT) 15.1 Responsibilities and Duties of the Director of Finance & Commissioning 15.1.1 The Director of Finance & Commissioning, who is responsible for the accuracy

and security of the computerised financial data of the Trust, shall: (a) Devise and implement any necessary procedures to ensure adequate

(reasonable) protection of the Trust’s data, programs and computer hardware for which the Director is responsible from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Act 1998;

(b) Ensure that adequate (reasonable) controls exist over data entry,

processing, storage, transmission and output to ensure security, privacy, accuracy, completeness and timeliness of the data, as well as the efficient and effective operation of the system;

(c) Ensure that adequate controls exist such that the computer operation is

separated from development, maintenance and amendment; (d) Ensure that an adequate management (audit) trail exists through the

computerised system and that such computer audit reviews as the Director may consider necessary are being carried out.

15.1.2 The Director of Finance & Commissioning shall need to ensure that new financial

systems and amendments to current financial systems are developed in a controlled manner and thoroughly tested prior to implementation. Where this is undertaken by another organisation, assurances of adequacy must be obtained from them prior to implementation.

15.1.3 The Director of Finance & Commissioning shall publish and maintain a Freedom

of Information (FOI) Publication Scheme, or adopt a model Publication Scheme approved by the Information Commissioner. A Publication Scheme is a complete guide to the information routinely published by a public authority. It describes the classes or types of information about the Trust that is made publicly available.

15.2 Responsibilities and Duties of other Directors and Officers in relation to

Computer Systems of a General Application In the case of computer systems which are proposed General Applications (i.e.,

normally those applications which the majority of Trusts in the Region wish to sponsor jointly) all responsible directors and employees will send to the Director of Finance & Commissioning:

(a) details of the outline design of the system;

(b) in the case of packages acquired either from a commercial organisation, from the NHS, or from another public sector organisation, the operational requirement.

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15.3 Contracts for Computer Services with other Health Bodies or Outside

Agencies The Director of Finance & Commissioning shall ensure that contracts for

computer services for financial applications with another health organisation or any other agency shall clearly define the responsibility of all parties for the security, privacy, accuracy, completeness and timeliness of data during processing, transmission and storage. The contract should also ensure rights of access for audit purposes.

Where another health organisation or any other agency provides a computer

service for financial applications, the Director of Finance & Commissioning shall periodically seek assurances that adequate controls are in operation.

15.4 Risk Assessment The Director of Finance & Commissioning shall ensure that risks to the Trust

arising from the use of IT are effectively identified and considered and appropriate action taken to mitigate or control risk. This shall include the preparation and testing of appropriate disaster recovery plans.

15.5 Requirements for Computer Systems which have an impact on Corporate

Financial Systems Where computer systems have an impact on corporate financial systems the

Director of Finance & Commissioning shall need to be satisfied that: (a) Systems acquisition, development and maintenance are in line with

corporate policies such as an Information Technology Strategy; (b) Data produced for use with financial systems is adequate, accurate,

complete and timely and that a management (audit) trail exists; (c) Director of Finance & Commissioning staff have access to such data; (d) Such computer audit reviews as are considered necessary are being

carried out. 16. PATIENTS’ PROPERTY 16.1 The Trust has a responsibility to provide safe custody for money and other

personal property handed in by patients, in the possession of unconscious or confused patients, or found in the possession of deceased or dead on arrival patients and shall determine procedures to ensure safe custody.

16.2 The Chief Executive is responsible for ensuring that patients or their guardians,

as appropriate, are informed, either through notices or oral advice that the Trust will not accept responsibility or liability for patients’ property brought into Health Service premises/vehicles, unless it is handed in for safe custody and a copy of an official patients’ property record is obtained as a receipt.

16.3 The Director of Finance & Commissioning must provide detailed written

instructions on the handling of patients’ property. 16.4 Staff should be informed, on appointment, by the appropriate departmental or

senior manager, of their responsibilities and duties for the administration of the property of patients.

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17. FUNDS HELD ON TRUST 17.1 Corporate Trustee 17.1.1 Standing Order No. 2.8 outlines the Trust’s responsibilities as a corporate trustee

for the management of funds it holds on trust, along with Standing Order 1.14 that defines the need for compliance with Charities Commission latest guidance and good practice.

17.1.2 The discharge of the Trust’s corporate trustee responsibilities is distinct from its

responsibilities for exchequer funds and may not necessarily be discharged in the same manner, but there must still be adherence to the overriding general principles of financial regularity, prudence and propriety. Trustee responsibilities cover both charitable and non-charitable purposes.

17.1.3 The Director of Finance & Commissioning shall ensure that each trust fund which

the Trust is responsible for managing is managed appropriately with regard to its purpose and to its requirements.

17.2 Accountability to Charity Commission and Secretary of State for Health

and Social Care 17.2.1 The trustee responsibilities must be discharged separately and full recognition

given to the Trust’s dual accountabilities to the Charity Commission for charitable funds held on trust and to the Secretary of State for all funds held on trust.

17.2.2 The Schedule of Matters Reserved to the Board and the Scheme of Delegation

make clear where decisions regarding the exercise of discretion regarding the disposal and use of the funds are to be taken and by whom. All Trust Board members and Trust officers must take account of that guidance before taking action.

17.3 Applicability of Standing Financial Instructions to Funds held on Trust 17.3.1 Insofar as it is possible to do so, most of the sections of these Standing Financial

Instructions will apply to the management of funds held on trust. (See overlap with SFI No: 7.15.)

17.3.2 The overriding principle is that the integrity of each Trust must be maintained and

statutory and Trust obligations met. Materiality must be assessed separately from Exchequer activities and funds.

18. ACCEPTANCE OF GIFTS BY STAFF AND LINK TO STANDARDS OF

BUSINESS CONDUCT (see overlap with SO 10.2.6(d)) The Director of Finance & Commissioning shall ensure that all staff and

governors are made aware of the Trust’s policy on acceptance of gifts and other benefits in kind by staff. The Trust’s Standards of Business Conduct Policy in Respect of Interests, Gifts, Hospitality, Sponsorship, Advertising and Partnership Arrangements and the Anti-Bribery Policy follows guidance contained in the Department of Health circular HSG(93)5 ‘Standards of Business Conduct for NHS Staff’ and is also deemed to be an integral part of the Standing Orders and Standing Financial Instructions.

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19. RETENTION OF DOCUMENTS 19.1 The Chief Executive shall be responsible for maintaining archives for all records

required to be retained in accordance with Department of Health guidelines. 19.2 The records held in archives shall be capable of retrieval by authorised persons. 19.3 Records held in accordance with latest Department of Health guidance shall only

be destroyed at the express instigation of the Chief Executive. Detail shall be maintained of records so destroyed.

20. RISK MANAGEMENT AND INSURANCE 20.1 Programme of Risk Management The Chief Executive shall ensure that the Trust has a programme of risk

management, in accordance with current Department of Health assurance framework requirements, which will be approved and monitored by the Board.

The programme of risk management shall include: (a) A process for identifying and quantifying risks and potential liabilities; (b) Engendering among all levels of staff a positive attitude towards the

control of risk; (c) Management processes to ensure all significant risks and potential

liabilities are addressed including effective systems of internal control, cost effective insurance cover and decisions on the acceptable level of retained risk;

(d) Contingency plans to offset the impact of adverse events; (e) Audit arrangements including: internal audit, clinical audit, health and

safety review; (f) A clear indication of which risks shall be insured;

(g) Arrangements to review the Risk Management programme.

The existence, integration and evaluation of the above elements will assist in providing a basis to make a statement on the effectiveness of internal control (Annual Governance Statement) within the Annual Report and Accounts as required by the Department of Health guidance.

20.2 Insurance: Risk Pooling Schemes Administered by NHS Resolution The Board shall decide if the Trust will insure through the risk pooling schemes

administered by the NHS Resolution or self-insure for some or all of the risks covered by the risk pooling schemes. If the Board decides not to use the risk pooling schemes for any of the risk areas (clinical, property and employers/third party liability) covered by the scheme, this decision shall be reviewed annually.

20.3 Insurance Arrangements with Commercial Insurers

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20.3.1 There is a general prohibition, on entering into insurance arrangements with commercial insurers. There are, however, three exceptions when Trust’s may enter into insurance arrangements with commercial insurers. The exceptions are:

(a) Trust’s may enter commercial arrangements for insuring motor vehicles

owned by the Trust including insuring third party liability arising from their use;

(b) where the Trust is involved with a consortium in a Private Finance Initiative contract and the other consortium members required that commercial insurance arrangements are entered into; and

(c) where income generation activities take place. Income generation activities should normally be insured against all risks using commercial insurance. If the income generation activity is also an activity normally carried out by the Trust for a NHS purpose the activity may be covered in the risk pool. Confirmation of coverage in the risk pool must be obtained from the Litigation Authority. In any case of doubt concerning a Trust’s powers to enter into commercial insurance arrangements the Finance Director should consult with the Department of Health.

20.4 Arrangements to be followed by the Board in Agreeing Insurance Cover 20.4.1 Where the Board decides to use the risk pooling schemes administered by the

NHS Resolution the Director of Finance & Commissioning shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme. The Director of Finance & Commissioning shall ensure that documented procedures cover these arrangements.

20.4.2 Where the Board decides not to use the risk pooling schemes administered by

the NHS Resolution for one or other of the risks covered by the schemes, the Director of Finance & Commissioning shall ensure that the Board is informed of the nature and extent of the risks that are self insured as a result of this decision. The Director of Finance & Commissioning will draw up formal documented procedures for the management of any claims arising from third parties and payments in respect of losses which will not be reimbursed.

20.4.3 All the risk pooling schemes require Scheme members to make some

contribution to the settlement of claims (the ‘deductible’). The Director of Finance & Commissioning should ensure documented procedures also cover the management of claims and payments below the deductible in each case.

21. CONSULTATION IN RELATION TO CHANGES TO SERVICES 21.1 The Trust should take into account the legal duties of consultation that are

applicable to the Trust when considering any changes to service provision at an early stage and seek advice where necessary.

21.2 Section 242 of the National Health Service Act 2006 sets out the Trust’s duty as

respects health services for which it is responsible, that persons to whom those services are being or may be provided or, directly or through representatives, included in and consulted on:

(a) The planning of the provision of those services;

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(b) The development and consideration of proposals for changes in the way those services are provided; and

(c) Decisions to be made by that body affecting the operation of those

services. 21.3 Regulation 4A of the Local Authority (Overview and Scrutiny Committee’s Health

Scrutiny functions) Regulations 2002 sets out that the Trust needs to consult with the Overview and Scrutiny Committee of a Local Authority where:

(a) The Trust proposes to make an application to the Regulator to vary the

terms of its authorisation; and

(b) That application, if successful, would result in a substantial variation of the provision by the Trust of protected goods or services in the area of that local authority.

References: Counter Fraud and Security Policy and Procedure Annual Plan, Manual of Accounts, Department of Health Concode, Department of Health Capital Investment Manual, Department of Health APPROVED BY TRUST BOARD: 11 March 2020

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MEETING TITLE

PUBLIC BOARD

Date: 11.03.2020 Report Title: Annual Corporate Governance Review, including Evaluation of

Board and Sub-Committees, Committee Terms of Reference and agenda plans, declarations of interest and register of seals

Agenda Item: 22 Author: E. De Carteret, Head of Governance Lead Director: N. Scrivings, Chair Purpose: Assurance Decision


SUMMARY AND BACKGROUND: Annual Evaluation of Board Committees: Good governance practice requires an annual review of the Trust Board and Committee’s effectiveness; this report provides detail on findings and actions recommended to be taken. The approach taken was as follows:

1. A survey has been undertaken for the Board and its Sub-Committees to canvas both members and information providers for their views on effectiveness

2. A review of quoracy for each of the meetings 3. Provision of late papers 4. Analysis by the new Trust Chair and Head of Governance on wider matters of best practice,

including incorporation of findings from the governance analysis and proposal discussed at Private Board in February 2020

The main body of this report seeks to thematically outline the findings and provide a suite of recommendations to progress continuous improvement in the Board’s approach. Themes for improvement include:

• Quality of information • Frequency of meetings • Balance between strategic and operational focus • Skills, knowledge and experience

All actions identified seek to continue the improvement journey implemented in January 2019. Board should also note that best practice recommends an externally-led assessment every three years, with the Trust’s last review undertaken in March 2018 – as such, it is recommended that an external review be scheduled for the end of the 2020/21 financial year. Terms of Reference and Agenda Plans The terms of reference for all existing board sub-committees have been reviewed (Performance & Finance, Audit, Quality Governance, Workforce and Remuneration) and are tabled for approval. Additionally, the two new committees proposed and accepted at the February meeting (Transformation and Change and the People Engagement committee) have been drafted for approval. Key changes across all terms of reference are as follows:

• General realignment of remit to support implementation of the two new committees • Reduction of Non-Executive Director membership to two (instead of three) in the existing, non-

statutory committees • Expansion of membership to include Executive leadership in the non-statutory committees • Incorporation of key metrics and escalation triggers to enable improved assurance and reporting to

Board.

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The terms of reference and associated agenda plans are therefore attached for approval as follows: 22i – Trust Board 22ii – Audit Committee 22iii – Remuneration and Nomination Committee 22iiv – Quality Governance Committee 22v – Workforce Committee 22vi – Performance and Finance Committee 22vii – Transformation and Change Committee 22viii – People Engagement Committee Declarations of Interest The NHS Code of Accountability and Standing Order 6, which is based on the regulations, requires Trust Board Members to declare any material or pecuniary interests (which includes monetary) for personal or family interests that he/she has and which are relevant and material to the NHS Board of which they are a member. All existing Board members should declare such interests. Any Board members appointed subsequently should do so on appointment. Section 7.1.2 of the Trust’s Standing Orders details examples of such interests that should be declared. Trust Board members are required to advise of relevant interests on appointment. Any changes in interests are required to be declared at the next Trust Board meeting following the change occurring and recorded in the minutes of that meeting. Details of the Trust Board members’ declarations are published in the Trust’s annual report, and the Register of Directors’ Interests is made available to the public via the Trust’s website.

The Register for the financial year 2019/2020 is attached and sets out the interests of all Executive, Associate and Non-Executive Directors of the Trust who have served during this period. Annual Review of Register of Seals In the 2019/2020 financial year to date (2 March 2020) the Executive Directors have applied the Corporate Seal of the Trust to 15 documents as detailed here: 11th February 2019 Deed of Surrender, Witham Essex 11th February 2019 Lease, Witham Essex 19th February 2019 License to carry out works, Babbage Road, Stevenage 2nd May 2019 Deed of variation of lease (Telecoms), Hinchingbrooke Ambulance station 14th March 2019 Lease, counterpart and surrender, Southend on Sea 14th March 2019 Contract, Suffolk Park 10th July 2019 Lease of unit contract, Kings Langley 1st August 2019 Lease of unit 5 contract, James Carter Road Mildenhall 12th November 2019 Deed of rectification of lease, 12 Aviation Way Southend 22nd August 2019 Warranties, purchase of land at Suffolk Park 21st October 2019 Lease of unit 7, Kings Lynn 24th October 2019 Reversionary lease, Witham 5th February 2020 Reversionary lease, Atlantic Square Witham Essex 13th February 2020 Deed of surrender, lease & licence for alterations, 12 Aviation Way, Southend 13th February 2020 Lease of plot 9b, Longwater Car Park

All actions have been taken in accordance with the Trust Board’s Scheme of Delegation and no inherent risks are to be reported to the Trust Board in the application of the Corporate Seal.

RECOMMENDED ACTION:



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• Note the findings of the annual effectiveness review and accept the recommendations, agreeing for these to be encompassed within the Governance and Well led section of the Integrated Improvement Plan

• Approve the terms of reference for the board sub-committees • Consider undertaking an externally facilitated governance and well led review at the end of the 2020/21

financial year • Review the declarations of interest and approve publication, and inclusion within the annual report • Note the utilisation of the Trust Seal within the 2019/2020 financial year for assurance purposes

KEY ISSUES IDENTIFIED None noted

DECISION OR RESOURCE REQUIRED: N/A other than actions noted above

PREVIOUSLY CONSIDERED BY: Private Board in February reviewed the governance proposal to provide feedback

LINKS TO THE BAF AND KEY RISK AREAS: [please provide associated risk reference numbers] Annual review of effectiveness is best practice for Trust Board’s and drives continuous improvement within the Well Led domain of the regulatory framework. As such, completion of the review and implementation of findings relates to risk ID1187: Failure to ensure a well governed and accountable trust that meets the inspection standards, currently scoring 16. It is anticipated that this score can and will reduce following the Board’s well led self assessment in April – providing assurance on the controls in place.




X

SR4: Failure to deliver an efficient, effective and economic service Other: Please Specify

THIS REPORT SUPPORTS THE DELIVERY OF WHICH STRATEGIC OBJECTIVE Provide better care X Value our people X Value for money X Improve performance X


LINK TO CQC: Caring Responsive Effective Well Led X Safe




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Standing Orders NHS Foundation Trust Code of Governance CQC Key Line of Enquiry ‘Well-led’

Annual Corporate Governance Review, including Evaluation of Board and Sub-Committees, Committee Terms of Reference and agenda plans Each year the Trust undergoes a review of Board and sub-committee effectiveness, in order to review progress made in the financial year and identify areas for improvement in the coming 12 months. In the review undertaken at the end of the 2018/19 financial year, the findings were broadly positive with two themes relating to induction of Board members and ongoing development. Steps were taken as a result including development of the Induction pack and completion of NED training supplied by NHS Providers, and steps have been taken with the new Chair to complete a skills matrix for ongoing development. Board development sessions are undertaken every other month with a schedule in place. Since the last effectiveness review there has been significant change of personnel at Board level, which has afforded the opportunity for a greater level of ‘independent scrutiny’ to the level of effectiveness achieved. Furthermore, the new Chair commencing in post in November 2019 has enabled an in depth review of governance functions, which have been incorporated into this annual review, as well as the governance proposal discussed at the February Private Board; this has resulted in a number of the changes evidenced in the Board Sub-Committees’ terms of reference referred to later in this report. The report encompasses the following core areas:

• Annual Effectiveness overview for 2019/2020 • Annual Effectiveness – thematic results • Proposed actions to make further improvements • Sub-Committee terms of reference and schedules for 2020/21

1. Annual Effectiveness overview for 2019/2020 The annual effectiveness review consisted of three core areas of feedback – a survey of members and relevant parties; analysis of committee functionality; and the review undertaken by the Trust Chair and Head of Governance over the course of three months commencing in December 2019. The review comprised of three overarching areas of effectiveness, namely:

• Structure – including frequency of meetings, the agenda and schedule, and time afforded • Leadership – including quoracy, skills and experience and constructive challenge • Infrastructure and Support – including information provision and flow to the committee and

board to enable robust decision making The table below provides an overview of the approach and input. The key ‘S’ denotes a survey question, and greyed out boxes denote where questions were specific to only one committee (Board):



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Domain Area Board Audit Remcom Quality P&F Workforce Structure Percentage of

meetings cancelled 0 0 33% (1) 0 0 10% (1)

Frequency of meetings (S) (just right)

100% 90% 20% 13%

Agenda prioritises correct issues (S) (positive or neutral)

88% 100% 100% 90% 100% 66%

Sufficient time on each item (S) (usually or always)

75% 90% 100% 70% 50% 89%

Leadership Percentage of meetings quorate

100% 100% 100% 100% 100% 100%

Skills, knowledge and experience (S) (positive or neutral)

94% 100% * 100% 90% 100% 100%

Models the values and culture (S)(usually or always)

56% 100% 100% 80% 70% 78%

Sufficient challenge (S) (positive or neutral)

94% 100% 100% 100% 100% 100%

Infrastructure and Support

Percentage of papers late to the governance team

48% 44% 50% 56% 70% 67%

Receipt of timely information (S) (positive or neutral)

88% 100% 66% 78% 100% 88%

Information is the right quality (S) (positive or neutral)

62% 90% 100% 60% 80% 44%

Information in the right format (S) (positive or neutral)

62% 100% 100% 50% 70% 66%

Sufficient flow from committees to Board (positive or neutral) (S)

78%

All surveys also gave the opportunity for narrative comments, which are outlined in the appendices to this report. However, the most common areas of feedback have been included within the thematic detail, as follows. 2. Annual Effectiveness – thematic results It can be seen from the table in section one and the detailed appendices that the findings from the survey and analysis were broadly positive. Areas where no focussed improvement work is required are:



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• Quoracy – all meetings have been quorate • Skills, knowledge and experience on the Board and Committees have been deemed

sufficient to meet the perceived needs. Note, it must be recognised that there is a gap as Audit Committee Chair, which is already being recruited to.

• The level of constructive challenge is considered to be sufficient and effective to enable good decision making

Areas requiring focus are as follows. Each will be summarised in more detail below:

• Information quality, timeliness and format • Frequency of meetings • Time spent on each agenda item, prioritisation of issues and flow to the Board • Values and culture

Information quality, timeliness and format The findings demonstrate the greatest proportion of work to do relates to information quality and flow. Across the Board and all committees, there is a recognition that how the Trust analyses, reports and utilises data needs to be improved – it is important to note that this was a core factor in recognition of the need to recruit a Chief Information Officer, who commenced in post in quarter three. A further aspect in this area includes the timeliness of papers. Whilst all meetings and committees were furnished with papers a minimum of 5 days prior to the meeting, a significant proportion of papers were received centrally after the submission deadline, which prevents quality assurance checks being undertaken – this will have contributed to the poor scores for information quality. Specific qualitative feedback on information quality and format included:

Greater focus on KPIs needed Volume of data too high with key points not easily found Improved informatics needed to make reports more succinct and meaningful Papers should be shorter to focus on key issues Performance report is hard to navigate Sort out data flows so we have one data source for assurance across the Trust

Actions are identified in section three below, although Board are encouraged to recall that work has already been agreed (January 2020) led by the Chief Information Officer on informatics. Frequency of meetings Feedback on the frequency of the two monthly committees (Performance & Finance and Workforce) made clear that the increased frequency adversely impacted upon the ability to progress delivery of actions and workload. Frequency was increased following the last effectiveness review due to a lack of assurance on key areas of the committee portfolios – an area greatly improved for performance and finance committee. There remains challenge to the Workforce Committee remit, but qualitative feedback supports the governance proposal in February and suggests the scope of the committee’s remit as being too wide to enable sufficient focus on the key risk areas, due to inclusion of aspects such as engagement, involvement, communication.



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Specific feedback to frequency included: Move to monthly P&F has brought improvement to grip, focus and assurance, and so can reduce to bi-monthly again Monthly has been onerous for the exec team Need concise agendas with a small number of items Agenda is too full Bi-monthly meeting is recommended Monthly meetings have made it v challenging to provide timely data with clear progression of actions

Time spent on agenda items, prioritisation of issues and flow to the Board Results in relation to the sufficiency of time spent on agenda items varies across the Board and committees and reflects in part the ability to balance between operational and strategic requirements. Most impacted are the Trust Board, Performance & Finance and Workforce Committees. Issues can be taken as follows:

• Lack of clear and consistent metrics and escalation triggers • Wide scope of committees resulting in large schedules of business • Overlap across some committees resulting in replication • Lack of corporate strategy and clearly defined sub-strategies to focus Board and Committee

oversight Specific feedback includes:

Struggles to address a lengthy agenda Some topics not fully addressed due to being down the large agenda Schedules need realigning so things don’t come to every meeting I’m pleased we are starting to spend more time looking at strategy Committee would benefit from a more refined agenda – the remit of this committee is very wide

Values and culture Whilst broadly the scoring for demonstration of the Trust’s vision and values were high, there was a reduced score in relation to Trust Board (56%). Specific feedback includes:

New Chair and CEO so things need time to evolve Board works well as a unit although I have observed an element of positioning which creates distraction from key activities Effectiveness will improve further once we have a full team of permanent directors in place Number of new CEDs, new Chair and new EDs – this year provides an opportunity and challenge for Board development to ensure the Board can become truly unitary

3. Actions for further improvement The following table outlines the proposed actions for improvement, for discussion and agreement. If accepted, they will be incorporated into the integrated improvement plan Governance and Well-Led section, under objective 2: Establish a stable and effective Trust Board:



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Issue Action Timescale Information quality, timeliness and format

Commence clear requirements for each agenda item when requested

April 2020

Establish new Integrated Performance Report May 2020 Complete Board development on informatics June 2020 Complete informatics task and finish work agreed at January Board

January 2021

Ensure all reports received centrally on time to allow quality assurance check

May 2020

Establish tender report template to ensure consistency May 2020 Frequency of meetings

Reduce Workforce Committee to bi-monthly April 2020 Reduce Performance and Finance Committee to bi-monthly April 2020

Time spent on agenda items, prioritisation of issues and flow to the Board

Constitute Transformation and Change Committee and transfer strategy components from other committees

April 2020

Constitute People Engagement Committee and transfer engagement components from other committees

April 2020

Establish clear escalation criteria and triggers from committees to Board

April 2020

Establish and Implement Corporate Strategy and underpinning sub-strategies, to afford greater focus

May 2020

Values and culture Establish Board development plan for full 2020/21 year May 2020 Establish individual Board member development support May 2020 Complete recruitment to Board posts April 2020

4. Sub-Committee terms of reference and schedules for 2020/21 As a result of the findings from the effectiveness review and the comments received during the last tranche of committee meetings, the terms of reference of each Board Sub-Committee have been reviewed and amended. Key changes are as follows: Audit Committee

• Inclusion of metrics and escalation points • Increased oversight of risks pertinent to the committee

Remuneration and Nomination Committee

• Clear alignment of title to reflect the full role of nomination, remuneration and terms of service

• Expansion of the membership to encompass all Non-Executive Directors in line with schedule 7 of the NHS Act 2006

• Strengthened reporting arrangements to the Trust Board • Increased recognition of succession planning processes and requirements • Inclusion of metrics and escalation points


• Inclusion of metrics and escalation points • Increased oversight of risks pertinent to the committee • Removal of strategic components – transferred to Transformation and Change Committee • Reduction in NED membership to two and incorporation of Executive Director membership


• Inclusion of metrics and escalation points



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• Increased oversight of risks pertinent to the committee • Reduction in NED membership to two and incorporation of Executive Director membership • Removal of strategic components – transferred to Transformation and Change Committee • Inclusion of Estates compliance oversight and assurance – not previously defined in Terms

of reference Workforce Committee

• Inclusion of metrics and escalation points • Increased oversight of risks pertinent to the committee • Removal of strategic components – transferred to Transformation and Change Committee • Reduction in NED membership to two and incorporation of Executive Director membership • Removal of engagement components – transferred to People Engagement Committee • Inclusion of Health and Safety oversight and assurance requirements – transferred from

Quality Governance Committee Additionally, two new Committee’s have been raised – the Transformation and Change Committee and the People Engagement Committee. These new committees are derived from recognition of need, and their terms of reference incorporate those aspects previously overseen by the existing committees:

Transformation and Change Committee People Engagement Committee

Business development activity – tenders for contracts and new business

Overseeing engagement with partners, patients and staff

Lead on strategy development oversight and assurance

Patient feedback data and assurance.

Oversee strategy progress, deployment and benefits realisation of the core programmes for transformation

Oversight and monitoring of key engagement metrics including staff survey, equality & diversity, gender pay gap

Oversee the Estates/infrastructure and IM&T strategies and plans

Community First Responder and Community Engagement Group assurance

Assessment of risks, resource capabilities for delivery and alignment of programmes with the overarching Trust strategy

Assurance on appropriate engagement and collaboration with relevant parties regarding our strategies

Conclusion The items included within this report demonstrate overall good compliance and effectiveness of the Board. However, there are clear areas for further improvement, to continue the improvement programme already well underway. Should the Board approve the recommendations, these will be monitored through the Integrated Improvement Plan and regular Governance and Well Led updates to the Board.



Trust Board Agenda Plan 2020/21 April Jun Aug (Telecon) Oct Dec Feb

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Apologies ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Declarations of Interest ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Minutes of previous meeting ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Actions Log/Matters Arising ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

A Patient’s Experience ✓ ✓ ✓ ✓ ✓ ✓

Chair’s report ✓ ✓ ✓ ✓ ✓ ✓

CEO’s report ✓ ✓ ✓ ✓ ✓ ✓

STRATEGY & BUSINESS PLANNINGHorizon scanning ✓ ✓ ✓ ✓ ✓ ✓

procurement Items for approval (confirm with Heather each meeting)

✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Operational and Financial Performance: annual outturn

Annual Budget and Capital Programme: ~ Draft ✓

~ Sign-off ✓

~ Financial planning for the coming year ✓

~ Contract Negotiation update ✓ ✓ ✓

Operating Plan:~ Annual report ✓

~ Mid-year review (if required) ✓

Strategic Objectives:~ Setting ✓

~ Mid-year review ✓

STP Engagement Progress and Impact ✓ ✓ ✓ ✓

Business Continuity Policy and Procedure (Query)

✓

STRATEGIC GOALSAnnual Staff Survey Report & Plan ✓

Progress Against Corporate Strategy ✓ ✓

Strategy Approval ✓ ✓

Culture Strategy ✓ ✓

WRES 2 submission ✓

FTSU quarterly report ✓ ✓ ✓ ✓

STANDING ITEMS

MarMay NovSeptJul Jan

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Gender Pay Gap reporting ✓

PERFORMANCE MONITORINGService Delivery Plans:Winter Plan and Review ✓ ✓ ✓ ✓ ✓

Public Holiday Contingency Plan ✓ ✓

Bi-Annual Workforce Review ✓ ✓

Integrated Performance Report ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Finance Report ✓ ✓ ✓ ✓ ✓ ✓

QGC report ✓ ✓ ✓ ✓ ✓ ✓

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Audit Committee Report: ✓ ✓ ✓ ✓ ✓ ✓

P&F Committee Report: ✓ ✓ ✓ ✓ ✓ ✓

People Engagement Committee Report ✓ ✓ ✓ ✓ ✓ ✓

Transformation & Strategic Change Committee Report

✓ ✓ ✓ ✓ ✓ ✓

Digital Strategy ✓ ✓

RemCom Report ✓ ✓ ✓ ✓ ✓ ✓

WFC Report: ✓ ✓ ✓ ✓ ✓ ✓

~ Equality & Diversity report ✓

Annual review of policies and procedures ✓

Brexit Update (Query re: Jan 31st) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

Recovery Plan ✓ ✓ ✓ ✓ ✓ ✓

Well Led Progress Report ✓ ✓ ✓ ✓

CQC Quality Improvement Plan ✓ ✓ ✓ ✓ ✓ ✓

For information:Quality Report ✓ ✓ ✓ ✓ ✓ ✓ ✓

Annual Research & Development Report & Strategy

✓

Health & Safety Annual Report ✓

Infection, Prevention & Control Annual Report

✓

Safeguarding Annual Report ✓

Medicines Management Annual Report (including CD accountable officers)

✓

Annual Security Report ✓ ✓

Data Protection and Security Toolkit submission

✓

GOVERNANCE & REGULATORYBoard Assurance Framework ✓ ✓ ✓ ✓

Quality Account ✓

ANNUAL REPORTS

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Annual External Auditor's Management Letter

✓

SOs/SFIs/Scheme of Delegation/ Reservation of Powers to Trust Board

✓

Trust Board Annual Agenda Plan ✓

Annual Evaluation of Board Committees and Terms of Reference

✓

Annual Board Evaluation (self-assessment)

✓

Register of Directors’ Interests ✓

Register of Seals ✓

Self-certification for NHS Trusts ✓

Civil Contingencies Act Compliance ✓ ✓ ✓

CQC RPIR self assessment ✓

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AUDIT COMMITTEE – TERMS OF REFERENCE A Constitution The Board hereby resolves to establish a Committee of the Trust Board to be known as the Audit

Committee (The Committee). The Committee is a non-executive committee of the Board and has no executive powers, other than those specifically delegated in these Terms of Reference. As an assurance committee it may only make recommendations to the Trust Board. The Committee may establish, subject to Board approval, sub-groups to execute the delegated powers within these Terms of Reference.

B Purpose The Trust Board is responsible for ensuring the effective internal control, including:

• Management of the Trust’s activities in accordance with statute and regulations; • The establishment and maintenance of a system of internal control to give assurance that assets

are safeguarded, waste or inefficiency avoided and reliable financial information produced, and that value for money is continuously sought.

• The Committee shall provide the Trust Board with a means of independent and objective review of financial and corporate governance, internal control, assurance processes and risk management across the whole of the Trust’s activities both generally and in support of the Annual Governance Statement.

In addition, the Committee shall:

• Provide assurance of independence for external and internal audit; • Scrutinise the findings of completed audit reports and oversee the delivery of remedial actions • Ensure that appropriate standards are set and compliance with them is monitored, in non-

financial, non-clinical areas that fall within the remit of the Audit Committee; and • Monitor corporate governance (e.g. compliance with the Codes of Conduct, Standing Orders,

Standing Financial Instructions, maintenance of Registers of Interests). C Membership The Committee shall be appointed by the Board from amongst the Non-Executive Directors and shall

consist of not less than three designated Members, at least one of whom should have recent and relevant financial experience. The Board shall appoint the Chair of the Committee from amongst the independent Non-Executive Directors.

In the absence of the Committee Chair, the remaining members present shall elect one of

themselves to chair the meeting. A quorum shall be two members. Members of the Committee must attend at least 75% of all meetings held each financial year but

should aim to attend all scheduled meetings. The Chair of the Board shall not be a member of the Committee but may be invited to attend as

required. Executive Directors are not members of the committee.



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D Attendance at Meetings The Chief Executive, the Director of Finance and Commissioning, a representative of the External

Auditors, the Counter Fraud Service and the Head of Internal Audit and Head of Governance shall normally attend routine meetings of the Committee.

At least once a year, the Committee shall meet with the External and Internal Auditors without

Executive Directors present.. The Chief Executive should discuss at least annually with the Committee the process for assurance

that supports the Annual Governance Statement. He or she should also attend when the Committee considers the draft internal audit plan and the annual accounts.

All other Board Members, Executive Directors, officers and relevant representatives shall also have

the right of attendance, subject to invitation by the Chair, particularly when the Committee is discussing areas of risk or operations that are the responsibility of that individual.

E Secretary

The Head of Governance shall provide independent advice to the Committee Chair and Committee Members on compliance with the law and regulatory matters relevant to the Committee’s delegated authority in accordance with Standing Orders.

The Head of Governance shall be the Secretary to the Committee and the committee administrative

function will be provided through their office which will include: • the agreement of the agenda with the Chair and the collation and circulation of agenda

papers; • minuting the proceedings and resolutions of all meetings of the Committee including recording

the names of those present and in attendance; • keeping a record of matters arising and issues to be carried forward; • draft minutes of the meetings are available within 10 working days from the date of the

meeting. • maintaining a rolling schedule of business to come before the Committee. It is the responsibility of the Head of Governance to advise the Committee in writing when an item fails to meet the scheduled submission, including reasons and a revised date of submission.

Trust standing orders and Standing Financial Instructions apply to the operation of the Committee.

F Frequency of Meetings Meetings shall be held not less than four times a year, with additional meetings where necessary. The Appointed Auditors or the Head of Internal Audit may request a meeting if they consider one is

necessary. G Authority The Committee is authorised by the Board to investigate any activity within its Terms of Reference.

It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Committee.

The Committee is authorised by the Board to obtain outside legal or other independent professional

advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary or expedient to the carrying out of its functions.

The Committee is authorised by the Board to liaise, as necessary, with other sub-committees of the

Board. Chairs of the formal sub-committees have a responsibility for ensuring that the Audit Committee and the Board are advised of any risks or potential conflicts.



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H Duties The duties of the Committee shall be to:

(i) Governance, Risk Management and Internal Control

The Committee shall review the establishment and maintenance of an effective system of governance, risk management and internal control, across the whole of the organisation’s activities (both clinical and non-clinical) that support the achievement of the organisation’s objectives. In particular, the Committee will review the adequacy of:

• All risk and control related disclosure statements, in particular the Annual Governance Statement and declarations of compliance with the Care Quality Commission, together with any accompanying Head of Internal Audit statement, external audit opinion or other appropriate independent assurances, prior to endorsement by the Board

• Monitoring and scrutinising the approved risk management framework to ensure that Trust policies, systems and processes are effective in the management of all risks within the Trust and escalating risk management issues appropriately. This should include routine deep dives into specific risk register areas in order to gain assurance on the risk management process

• Considering the resource implications for risk control and advising the Board accordingly • The underlying assurance processes that indicate the degree of the achievement of corporate

objectives, the effectiveness of the management of principal risks and the appropriateness of the above disclosure statements.

• The policies for ensuring compliance with relevant regulatory, legal and code of conduct requirements.

• The policies and procedures for all work related to fraud and corruption as set out in Secretary of State Directions and as required by NHS Protect.

• Monitor the work of the Executive Leadership Team with regard to the finance, governance and mandatory services which form the core of the Trust’s business and with regard to the identification, analysis and mitigation of risk and provide independent assurance on both of these areas to the Board.

• The Trust’s arrangements by which Trust staff may, in confidence, raise concerns about possible improprieties in matters of financial reporting and control and related matters or any other matters of concern via the Freedom to Speak Up and other related processes.

• The data behind the reports received by the Committee and Trust Board to gain assurance of robustness and quality. In carrying out this work the Committee will primarily utilise the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these audit functions. It will also seek reports and assurances from directors and managers as appropriate, concentrating on the over-arching systems of integrated governance, risk management and internal control, together with indicators of their effectiveness. This will be evidenced through the Committee’s use of an effective Board Assurance Framework to guide its work and that of the audit and assurance functions that report to it.

(ii) Internal Audit

The Committee shall ensure that there is an effective internal audit function established by management that meets mandatory NHS Internal Audit Standards and provides appropriate independent assurance to the Committee, Chief Executive and the Board. This will be achieved by:

• Consideration of the provision of the Internal Audit service, the cost of the audit and any questions of resignation and dismissal

• Review and approve the Internal Audit strategy, operational plan and more detailed programme of work, ensuring that this is consistent with the audit needs of the organisation.

• Consideration of the major findings of internal audit work (and management’s response), and their implications and monitor progress on the implementation of recommendations.



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• Ensuring, on an on-going basis, the effective operation of internal audit in respect of: − Adequate resourcing; − Its co-ordination with external audit; − Meeting mandatory NHS Internal Audit Standards; − Providing adequate independent assurances; − Having appropriate standing within the Trust; and − Meeting the internal audit needs of the Trust. • an annual review of the effectiveness of internal audit

(iii) External Audit

The Committee shall review the work and findings of the External Auditor appointed by the Trust and consider the implications and management’s responses to their work. This will be achieved by:

• Consideration of the appointment and performance of the External Auditor, as far as the rules governing the appointment permit.

• Discussion and agreement with the External Auditor, before the audit commences, the nature and scope of the audit as set out in the Annual Plan, and ensure coordination, as appropriate, with other External Auditors in the local health economy.

• Discussion with the External Auditors of their local evaluation of audit risks and assessment of the Trust and associated impact on the audit fee

• Review all External Audit reports, including the report to those charged with governance, agreement of the annual audit letter before submission to the Board and any work undertaken outside the annual audit plan, together with the appropriateness of management response and monitor progress on the implementation of recommendations.

• Develop and implement a policy on the engagement of the external auditor to supply non-audit services.

(iv) Other Assurance Functions

The Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications to the governance of the organisation. These will include, but will not be limited to, any reviews by Department of Health Arm’s Length Bodies or Regulators/Inspectors (e.g. Care Quality Commission, NHS Resolution, etc.), professional bodies with responsibility for the performance of staff or functions (e.g. Royal Colleges, accreditation bodies, etc.). In addition, the Committee will review items referred by other Committees, whose work can provide relevant assurance to the Committee’s own scope of work. In particular the Audit Committee will rely on the assurance provided by other committees in respect of specific sections of the Board Assurance Framework that underpin the duties of those committees. This will specifically include the Quality Governance Committee and will include a review of an annual report of each of the Committees against their terms of reference. In reviewing the work of the Quality Governance Committee, and issues around clinical risk management, the Audit Committee will seek to satisfy itself on the assurance that can be gained from the clinical audit processes. The Committee will also review issues around the management of charitable funds and will seek to satisfy itself on the assurance that can be gained from the Charitable Funds Annual Report and Financial Statements before submission to the Board. The Committee will also:

• Examine any other matter referred to the Committee by the Board and to initiate investigation as determined by the Committee.

• On behalf of the Board seek assurance on the appointment of outside contractors for financial services e.g. Internal Audit, Banking, Payroll Services, etc



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(v) Counter Fraud

The Committee will:

• Ensure the appointment of the Counter-Fraud service provider; • Ensure that the provider is adequately resourced and has appropriate standing within the Trust; • Monitor the performance of the in the provision of both reactive and proactive fraud work in line

with the terms of the Standard NHS Contract and in accordance with the NHS Counter Fraud Authority (NHSCFA) Standards for Providers: Fraud, Bribery and Corruption, to ensure that appropriate counter fraud measures are in place. Review the reports from the Counter-Fraud service provision, consider the major findings of fraud investigations, and management’s response, and ensure co-ordination between the LCFS, internal and external auditors.

Consider the annual report of the Trust to the NHS Counter Fraud Authority Consider and take appropriate action regarding any NHSCFA quality assurance recommendations arising from the assessment process.

(vi) Management

The Committee shall request and review reports and positive assurances from directors and managers on the overall arrangements for governance, risk management and internal control. It may also request specific reports from individual functions within the organisation (e.g. clinical audit), as they may be appropriate to the overall arrangements.

(vii) Financial Reporting

The Committee shall review the Annual Report and Financial Statements before submission to the Board to determine their completeness, objectivity, integrity and accuracy. This review will cover but is not limited to:

• The wording in the Annual Governance Statement and other disclosures relevant to the Terms of Reference of the Committee

• Changes in, and compliance with accounting policies, practices and estimation techniques • Unadjusted mis-statements in the financial statements • Significant judgements in preparation of the financial statements • Significant adjustments resulting from the audit • Letter of Representation • Qualitative aspects of financial reporting • The schedule of losses and special payments • Any reservations and disagreements between the External Auditors and management which have

not been satisfactorily resolved.

The Committee will also:

• Annually review the accounting policies of the Trust and make appropriate recommendations to the Trust Board.

• Ensure that the systems for financial reporting to the Board, including those of budgetary control, are subject to review as to completeness and accuracy of the information provided to the Board.

(viii) Standing Orders, Standing Financial Instructions and Standards of Business Conduct

The Committee will also:

• Review all suspensions of standing orders and variation or amendment to standing orders. • Review, on behalf of the Trust Board, the operation of, and proposed changes to, the Standing

Orders and Standing Financial Instructions, Codes of Conduct and Standards of Business Conduct; including maintenance of Registers.

• Examine the circumstances of any significant departure from the requirements of any of the foregoing, whether those departures relate to a failing, an overruling or a suspension.



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• Review the Scheme of Delegation.

(ix) Information Governance

The Committee will also: • Review compliance and assurance for all aspects of Information Governance.

I. Methods of Assurance

What will we measure Method for measurement Frequency Statement of internal control – Internal and External Audit Assurance

Audit results Quarterly

Fraud losses Number of cases and cost Quarterly Freedom of Information compliance Percentage Monthly Subject Access Request and DPA compliance Percentage Monthly Information Governance Training compliance Percentage Monthly Information Governance breach adverse incidents Number Monthly Tender process compliance Number/value Quarterly Waivers and losses against trajectory Number/value Quarterly Risk Key Performance Indicators Percentage Bi-Annually DSPT compliance Review Annually Station security assessments Report Bi-Annually Policy review compliance Percentage Annually

J. Escalatory Triggers The following triggers outline the framework to be used for escalating from the Committee to the Trust Board:

• Non-compliance with compliance indicators for 2 consecutive months, or off track against trajectory • Governance and Compliance risks scoring 15 or higher residually, with inadequate mitigating actions

in place, or with actions overdue with no assured plan to resolve • Lack of assurance on risks or systems of control reported to the Audit Committee from other

committees, with no clear mitigating approach • Any qualified opinion from the External Auditors • Limited Assurance arising from any Internal Audit • Losses of over £100k, or that will have a significant impact upon the Trust. This includes, fraud,

damages or other such issues • Any Internal Audit actions overdue for more than two committees • 10% deviation from information governance compliance targets

K Telephone Conferencing

Members can participate in meetings by two-way live audio link whereby all persons participating in the meeting can hear each other, and participation in the meeting in this manner shall be deemed to constitute presence in person at such meeting and count towards the quorum.

L Voting

Wherever possible, decisions will be reached by consensus of the Members. When a vote is required, the following apply: • Every question put to a vote at a meeting shall be determined by a majority of votes of Members

present and voting on the question. In the case of an equal vote, the person presiding (i.e. the Chair of the meeting) shall have a second, or casting vote.

• At the discretion of the Chair all questions put to the vote shall be determined by oral expression or by a show of hands, unless the chair directs otherwise, or it is proposed, seconded and carried that a vote be taken by paper ballot. If a Member so requests, their vote shall be recorded by name.



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• In no circumstances may an absent member vote by proxy. Absence is defined as being absent at the time of the vote, subject to the provisions of I above.

• For the voting rules relating to Joint Members, Standing Order 2.5 of the Trust will apply. M Reporting Procedures Committee meetings are held in private. The Chair of the Committee shall provide a report to the

next Trust Board after each Committee meeting, drawing to their attention: • any issues that require disclosure to the full Board or require executive action • any formal recommendations by the Committee, the requirements for action to implement these,

any resource implications and the timescale considered appropriate by the Committee for implementation.

The minutes of each meeting of the Committee shall be recorded by the Secretary.

The Committee will report to the Board annually in respect of the fulfilment of its functions in connection with these terms of reference. Such report shall include but not be limited to functions undertaken in connection with the Annual Governance Statement; the assurance framework, how it has assessed the effectiveness of the external and internal audit service, the effectiveness of risk management within the Trust; the integration of and adherence to governance arrangements; its view as to whether the self-assessment against the Care Quality Commission Registration is appropriate; and any pertinent matters in respect of which the Audit Committee has been engaged. The Committee shall annually prepare a report on its role and responsibilities and the actions it has taken to discharge those responsibilities for inclusion in the Annual Report and Accounts . In line with the centrally set guidance, the report will include: • a summary of the role of the Committee; • the names and relevant qualifications of all members of the Committee during the period; • the number of Committee meetings held and attendance by each member; and • the way the Committee has discharged its responsibilities.

N Monitoring The Chair of the Board will receive a copy of all meeting papers and will attend at least one meeting

per annum for monitoring and assurance purposes. The Terms of Reference of the Committee shall be reviewed by the Board at least annually. O Relationship to other Board Committees

The Board has determined that the Audit Committee will have an oversight role for all risks, to gain assurance that appropriate systems of internal control are in place and are operating as intended, and that the Board Committee system is working appropriately. For this purpose only, the other board committees will report quarterly to the Audit Committee on the following areas: • Progress in delivering the strategic objectives aligned to each Board Committee • The BAF risks monitored by that Committee for those strategic objectives • Annual Plan key objective action plans • Changes to the accountability and responsibility of the Committee • Effectiveness of the Committee, per the annual self-assessment process

In the event of the Audit Committee having concerns regarding the operation of the internal controls processes through any of these Committees, they shall report the same to the Board for resolution. Approved Audit Committee: Approved Trust Board:



May 06.05.20 May 26.05.20 Sept 16.09.20 Nov 18.11.20 Feb 27.02.20

THE TRUST: Lead:Draft Annual Accounts, Annual Report, Annual Governance Statement and Quality Account

Director of Finance and Commissioning, Head of Governance, Director of Clinical Quality and

✓ ✓

Annual Accounts production timetable Director of Finance and Commissioning

✓

Annual Review of Effectiveness of Internal Audit, External Audit and Counter Fraud

✓

Annual Review of Individual Board Sub-Committees’

Effectiveness AssessmentsHead of Governance ✓

Annual Review of Effectiveness and Terms of Reference Head of Governance ✓

Annual Review of Standing Orders/Standing Financial Instructions/Scheme of Delegation/Reservations Retained by Trust Board

Head of Governance/ Director of Finance and Commissioning

✓

Charitable Fund - Annual Report & Accounts ✓

Review of Hospitality Register Head of Governance ✓

Losses & Special Payments: Quarterly Report Director of Finance and Commissioning

✓ ✓ ✓ ✓

Tenders & Waivers: Quarterly Reports Director of Finance and Commissioning

✓ ✓ ✓

Tenders: Annual Report Director of Finance and Commissioning

✓

Exception/Risk Report – Quality Governance Committee Head of Governance

Treasury Management Policy Annual Review Director of Finance and Commissioning

✓

Security Management Annual report Director of Clinical Quality and Improvement

✓

Security Management Strategy Director of Clinical Quality and Improvement

✓

Annual Review of Policies and Procedures Head of Governance ✓

FOI Deep Dive (once yearly) ✓

Improvement Plan Head of Strategy and Transformation

✓ ✓ ✓ ✓ ✓

Data Quality Compliance Review ✓ ✓

RISK MANAGEMENTBoard Assurance Framework Head of Governance ✓ ✓ ✓ ✓

Operational Risk Register Update ✓ ✓

Risk Deep Dive Head of Governance to Confirm area

✓ ✓ ✓ ✓ ✓

Risk Management Strategy Head of Governance ✓

INFORMATION GOVERNANCE

Data Security Protection Toolkit update Director of Clinical Quality and Improvement

~ Update ✓ ✓ ✓

~ Submission ✓

INTERNAL AUDIT:Annual Report and HIAO Internal Audit ✓

Follow-Up Report Internal Audit ✓ ✓ ✓ ✓

Progress Report Internal Audit ✓ ✓ ✓ ✓

Strategy & Annual Plan Internal Audit ✓

Annual Audit Letter (Final) External Audit ✓

Approval of Annual Report External Audit ✓

Audit Plan and Fees External Audit ✓

Progress Reports External Audit ✓ ✓ ✓ ✓

Strategy & Annual Plan Counter Fraud ✓

Counter Fraud Progress Report Counter Fraud ✓ ✓ ✓ ✓ ✓

Annual Report Counter Fraud ✓

Members' private discussion with auditors ✓ ✓

Annual Review of Committee Terms of Reference and Annual Agenda Plan

✓

AUDIT COMMITTEE: AGENDA PLAN 2020-21

OTHER

Third Party Monitoring Reports – Those with statutory

enforcement powers/statutory role but no enforcement powers/no statutory role but legitimate interest – Referral to

Audit Committee/Trust Board of exception reports (as required) on the monitoring of action plans managed by the Quality Governance Committee.

REPORTS RECEIVED WILL BE SCHEDULED INTO THENEXT AVAILABLE MEETING FOR CONSIDERATION

COUNTER FRAUD/SECURITY MANAGEMENT SERVICE:

As Required

EXTERNAL AUDIT:



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NOMINATION, REMUNERATION & TERMS OF SERVICE COMMITTEE – TERMS OF REFERENCE A Constitution

Pursuant to Standing Orders the Board of Directors ("the Board") hereby resolves to establish a committee of the Board to be known as the Remuneration & Terms of Service Committee (“the Committee”).

B Purpose

The purpose of the Committee will be to determine appropriate remuneration and terms of service for the Chief Executive and other Executive Directors (to include voting and non-voting executive directors of the board) and to regularly review the structure, size and composition (including the skills, knowledge and experience) required of the Board and make recommendations to the Board of Directors or NHS Improvement, as appropriate, with regard to any changes. For the avoidance of doubt this provision applies to the appointment/removal, remuneration and terms of service for the Head of Governance

The Committee has no authority to determine appointment or remuneration arrangements for Non-Executive Directors, as this is the responsibility of NHS Improvement. All reference to recruitment of Board level posts in this document should be taken to exclude Non-Executive post holders. The committee is responsible for consideration of succession planning for the Trust Board (including both Executive and Non-Executive Director roles) to facilitate an effective Board skill mix.

C Membership

The Committee shall be appointed by the Board and shall consist of all Non-Executive Directors, which will include the Chair of the Trust Board.

When appointing or removing the Chief Executive Officer, the Committee shall be the Committee described in Schedule 7, 17(3) of the National Health Service Act 2006 (that is all the Non-Executive Directors). When appointing or removing the other Executive Directors, the Committee shall be the Committee described in Schedule 7, 17(4) of the Act (that is the Trust Chair, the Chief Executive Officer and the Non-Executive Directors).

The Board of Directors will appoint a Non-Executive Director as Chair of the Committee and another Non-Executive member to be Vice Chair from the outset. The Vice Chair will automatically assume the authority of the Chair should the latter be absent.

A quorum shall be three members of the Committee

D Attendance



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Meetings of the Committee shall be conducted in private. Only members of the Committee are entitled to be present, although others may attend at the express invitation of the Committee. The Committee should consult the Chair of the Board and/or the Chief Executive about their proposals relating to the remuneration of other executive directors.

The Chief Executive and/or the Workforce Director shall attend meetings as required by the Committee, subject to the proviso that no director shall be present for discussions on or otherwise involved in decisions affecting his or her own remuneration or terms of service.

It is expected that members of the Committee will attend a minimum of 75% of the Committee Meetings each year but should aim to attend all scheduled meetings. The Head of Governance will monitor this. Any non-member, including the secretary to the Committee, will be asked to leave the meeting should their own conditions of employment be the subject of discussion.

E Secretary

The Head of Governance shall provide independent advice to the Committee Chair and Committee Members on compliance with the law and regulatory matters relevant to the Committee’s delegated authority in accordance with Standing Orders.

The Head of Governance shall be the Secretary to the Committee and the committee

administrative function will be provided through their office which will include:

• the agreement of the agenda with the Chair and the collation and circulation of papers;

• minuting the proceedings and resolutions of all meetings of the Committee including recording the names of those present and in attendance;

• keeping a record of matters arising and issues to be carried forward; • draft minutes of the meetings are available within 5 working days but no longer

than 10 working days from the date of the meeting. • creating, maintaining and a rolling schedule of business to come before the

Committee. It is the responsibility of the Head of Governance to advise the Committee in writing when an item fails to meet the scheduled submission, including reasons and a revised date of submission.

Trust standing orders and standing financial instructions apply to the operation of the Committee.

F Frequency

Meetings will be held as and when required to fulfil the business of the Committee, with at least two meetings per financial year.

G Authority

The Committee is authorised by the Board to: • carry out any activity within its terms of reference



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• request any information it requires from any employee, and all employees are directed to co-operate with any request made by the Committee

The authority of the Committee is limited as follows: • It is not the duty of the Committee to carry out functions that properly belong to

the Board itself or to other Board Committees

• Material issues must be notified to the Board for consideration

• The Committee may not delegate executive powers to sub-committees unless expressly authorised by the Board.

The Board authorises the Committee to obtain outside legal or professional advice at the cost to the Trust including obtaining advice on benchmarking remuneration and the terms and conditions policies and practices within these terms of reference. The Committee is also authorised to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary.

H Duties

The duties and responsibilities of the Committee are as follows:

Remuneration and Terms of Service • To determine arrangements on matters relating to remuneration and terms and

conditions for the Chief Executive and other Executive Directors (to include voting and non-voting executive directors of the board); and specifically to determine:

o all aspects of salary (including any performance-related or non-contractual elements);

o provisions for other benefits, including pensions and cars;

o arrangements for termination of employment and other contractual terms.

o overseeing appropriate contractual arrangements for such staff

o ensure that there is proper calculation and scrutiny of any termination payments, ensuring appropriate authority and taking account of such national guidance as is appropriate; and in all cases seeking to minimise the amount to be paid on terminations such remuneration or benefits to be in accordance with any formal NHS guidance available.

o To approve all termination agreements and all non-contractual payments for the Chief Executive, Executive Directors.

• To approve the performance criteria of the Chief Executive and other Executive Directors (to include voting and non-voting executive directors of the board).

• To regularly consider the performance of the Chief Executive following feedback from the Chair of the Board on the outcomes of appraisals and performance reviews against measures agreed by the Committee and have access to the appraisal summary.



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• To regularly consider the performance of Executive Directors (to include voting and non-voting executive directors of the board) following feedback from the Chief Executive on the outcomes of executive director appraisals and performance reviews against measures agreed by the Committee and have access to the appraisal summaries of each of those post holders.

• To oversee for all staff, under delegated powers, arrangements for any non-contractual payment, in line with Department of Health and NHS guidance. The Committee shall also monitor the payment of contractual severance payments for individual members of staff to ensure compliance with due process.

Nominations and Appointments • To regularly review the structure, size and composition (including the skills,

knowledge and experience) required of the Board and make recommendations to the Board of Directors or NHS Improvement, as appropriate, with regard to any changes.

• To give full consideration to succession planning to ensure continuity in the executive team, including the Chief Executive, taking into account the challenges and opportunities facing the Trust and the skills and expertise particularly needed on the Board in future.

• Before such an appointment is made evaluate the balance of skills, knowledge and experience on the Board, and, in the light of this evaluation, prepare a description of the role and capabilities required for a particular appointment.

• To appoint an interview panel which must include the Chief Executive and a Non-Executive Director which shall be responsible for identifying and nominating for appointment candidates to fill posts for vacancies in respect of the Chief Executive, other Executive Directors (to include voting and non-voting executive directors of the board) and the Trust Secretary as and when they arise.

• In identifying suitable candidates the panel shall:

o use open advertising or the services of external advisers to facilitate the search;

o consider candidates from a wide range of backgrounds;

o consider candidates on merit against objective criteria.

o To consider any matter relating to the continuation in office of the Chief Executive, other Executive Directors (to include voting and non-voting executive directors of the board) and Head of Governance at any time including the suspension or termination of service of an individual as Director or an employee of the Trust.

I. Methods of Assurance What will we measure Method for measurement Frequency Agency and Consultancy spend – band 8c+ Value and cumulative Monthly Salary data and benefits for Executive Directors and Band 9 staff

Benchmarking Annually



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Dismissals not conforming to due process

Number Quarterly

Executive Director and Band 9 appraisal completion Report Annually

Executive and Band 9 appraisal ratings Report Annually Delivery against annual objectives Report Bi-annually Non-Contractual payments Number and value Quarterly Number of compromise agreements implemented Number Quarterly Exec highest salary v median staff member Ratio Annually Contractor/Non-Director highest salary v highest Exec salary

Ratio Annually

Financial value - termination benefits Number and cumulative Quarterly Number contractual payments in lieu of notice Number Quarterly Number compensation/exit packages Number and cumulative Quarterly Number off-payroll board member engagements Number Quarterly J. Escalatory Triggers The following triggers outline the framework to be used for escalating an item from the Committee to the Trust Board:

• Remuneration, Executive recruitment or succession planning risks scoring 15 or higher residually, with inadequate mitigating actions in place, or with actions overdue with no assured plan to resolve

• Unplanned deterioration in any of the metrics associated with the committee (see methods of assurance).

K Telephone Conferencing

Members can participate in meetings by two-way audio link including telephone, video or computer link (excepting email communication) whereby all persons participating in the meeting can hear each other and participation in this way shall be deemed to constitute presence in person at the meeting and count towards the quorum.

L Voting

Wherever possible, decisions will be reached by consensus of the Members. When a vote is required, the following apply:

Every question put to a vote at a meeting shall be determined by a majority of votes of

Members present and voting on the question. In the case of an equal vote, the person presiding (i.e. the Chair of the meeting) shall have a second, and casting vote.

At the discretion of the Chair all questions put to the vote shall be determined by oral

expression or by a show of hands, unless the Chair directs otherwise, or it is proposed, seconded and carried that a vote be taken by paper ballot. If a Member so requests, their vote shall be recorded by name.

In no circumstances may an absent member vote by proxy. Absence is defined as being absent at the time of the vote.

For the voting rules relating to Joint Members, Standing Order 2.5 of the Trust will

apply. M Reporting Procedures

The Chair of the Committee will report to the Trust Board on the work of the Committee at least twice each financial year, following each formal meeting.



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The Chair of the Committee (or one other of its members) shall be available to answer questions on remuneration policy, principles and practice in respect of Board members at the Annual Members’ Meeting of the Trust.

The minutes of all Committee meetings shall be made available to all its members, the Trust Chair, the Chief Executive and the Director of People and Culture, unless it is inappropriate to do so.

The Committee shall ensure that Director’s remunerations are accurately reported in the required format in the Trust's annual report.

The Committee will undertake an assessment of its overall effectiveness and compliance with these terms of reference at least annually. This review process will be in the form of a self-assessment checklist and will include the development of the following year’s reporting cycle.

N Monitoring The Terms of Reference of the Committee shall be reviewed by the Board at least

annually. Approved by Remuneration Committee: 18 December 2019 Approved by Trust Board:



REMUNERATION AND APPOINTMENTS COMMITTEE: AGENDA PLAN 2020/21

Q1 Q3

Executive Directors Appraisal and pay award Executive Directors Remuneration Review Directors Pay and Terms and conditions Benchmarking Setting performance criteria for Executive Directors Severance Payment requests NOMINATIONS AND APPOINTMENTSExecutive Director AppointmentsBoard Executive Directors succession planning

Employment Tribunal JudgementBusiness Travel Policy and emissions review Annual Review of Committee Effectiveness and Objectives Annual Review of Committee Terms of Reference and Annual Agenda Plan

Annual review and approval of the remuneration report

REMUNERATION AND TERMS OF SERVICE

As required

As required

OTHER:As required



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QUALITY GOVERNANCE COMMITTEE – TERMS OF REFERENCE A Constitution The Board hereby resolves to establish a Committee of the Trust Board to be known as the Quality

Governance Committee (The Committee). The Committee is a non-executive committee of the Board and has no executive powers, other than those specifically delegated in these Terms of Reference. As an assurance committee it may only make recommendations to the Board. The Committee may establish, subject to Board approval, sub-groups to executive the delegated powers within these Terms of Reference.

B Purpose The Trust Board is responsible for ensuring the delivery of high quality care that is as safe and

effective as possible, with patients treated with compassion, dignity and respect. The Trust’s quality governance framework provides assurance to the Trust Board that the essential standards of quality and safety are being delivered by the organisation. It also provides assurance that the processes for the governance of quality are embedded throughout the organisation.

The Committee shall provide the Trust Board with a means of independent and objective review of the assurance processes and risk management across the whole of the Trust’s activities in support of clinical effectiveness, patient safety and patient experience. The Committee will be focussed on the patient voice in ensuring that the governance of the Trust has a clear purpose and outcome. The Committee will focus on reviewing and monitoring assurance and will not operate as a management/operational committee. It will establish a clear and unified role with other board committees. In particular the Committee shall:

• Advise the Board on current levels of assurance available in respect of the clinical effectiveness

and patient safety provided by the Trust, and the measures in place to mitigate and manage risks in those areas

• Advise the Board on current levels of assurance available in respect of the Trust’s work to improve the experience of its patients.

C Membership

The Committee shall be appointed by the Chair of the Trust Board from amongst the Executive Directors, Non-Executive Directors and Associate Non-Executive Directors, and shall consist of not less than three designated Members, at least one of whom should have recent and relevant clinical or quality experience. The Board shall appoint the Chair of the Committee from amongst the independent Non-Executive Directors. The Director of Clinical Quality and Improvement, and Medical Director shall be members of the meeting. In the absence of the Committee Chair, the remaining members present shall elect one of themselves to chair the meeting.

Any non-executive director may deputise for an appointed member of the Committee with the permission of the Chair of the Board. A quorum shall be two members, one of whom should be a Non-Executive Director. Members and attendees are expected to attend all meetings. Failure of each individual to attend 75% of meetings will be reviewed by the Committee.



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The Chair of the Board shall not be a member of the Committee but may attend meetings. D Attendance at Meetings

The Chief Executive, Director of Clinical Quality and Improvement and the Medical Director or a designated deputy shall normally attend meetings.

The following shall also normally attend meetings:

• Chief Operating Officer • Deputy Director of Clinical Quality •

The following may also attend, as required, for specific items of business:

• Safeguarding Lead • Safety and Risk Lead • Infection Prevention and Control Lead • Compliance and Standards Lead • Medicines Management Lead • Head of Quality Improvement

By exception, where the members or attendees cannot attend the meeting, deputies may attend as

set out below. The minutes will record whether meetings were attended by the Executive Director or their nominated representative.

Members unable to attend a particular meeting should appoint a deputy to represent them, provided that the deputy is from the same Directorate and engaged in the management of the Directorate. A list of designated deputies is appended. Deputies need to have an appropriate level of seniority within the Trust and must be approved in advance with the Chair of the Committee.

Other Board Members, officers and relevant representatives shall have the right of attendance,

subject to invitation by the Committee Chair, particularly when the Committee is discussing areas of relevance.

E Secretary

The Head of Governance will act as the Secretary to the Committee and shall provide independent

advice to the Committee Chair and Committee Members on compliance with the law and regulatory matters relevant to the Committee’s delegated authority in accordance with Standing Orders.

The committee administrative function will be provided through the Head of Governance’s office,

which will include; • the agreement of the agenda with the Committee Chair and the collation and circulation of

papers • minuting the proceedings and resolutions of all meetings of the Committee including recording

the names of those present and in attendance; • keeping a record of matters arising and issues to be carried forward; • draft minutes of the meetings are available within 10 working days from the date of the

meeting. • Creating and maintaining a rolling schedule of business to come before the Committee. It is the responsibility of the Secretary to advise the Committee in writing when an item fails to meet the scheduled submission, including reasons and a revised date of submission.

Trust standing orders and standing financial instructions apply to the operation of the Committee.

F Frequency of Meetings Meetings shall be held as necessary, but not less than six times a year.



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G Authority The Committee is authorised by the Board to investigate any activity within its Terms of Reference.

It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Committee.

The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary or expedient to the carrying out of its functions.

The Committee is authorised by the Board to liaise, as necessary, with other sub-committees of the

Board and Chairs of the formal sub-committees have a responsibility for ensuring that the Quality Governance Committee and the Board are advised of any risks or potential conflicts.

H. Duties

The Committee is responsible for: (i) Patient Safety

• Monitoring and scrutinising assurance on specific areas of the Board Assurance Framework as

delegated to the Committee by the Audit Committee (including those referred from other committees), monitoring progress made in mitigating those risks, identifying any areas where additional assurance is required, and escalating to the Board of Directors as agreed by Committee members.

• Scrutinising the outcomes and monitoring action plans associated with serious incidents, accidents, claims and litigation and ensure learning is embedded across the Trust.

• Receiving assurances, via regular exception reports, that appropriate systems are in place to ensure patient safety and clinical quality.

• Monitoring and facilitating compliance against external standards, good practice guidance and legislation.

• Providing oversight and challenge to policies, and ensuring the Trust’s compliance with the relevant regulatory and statutory bodies.

• Monitoring levels of risk associated with all external inspections and reviews; in particular to oversee the progress and compliance with NHS Resolution and Clinical Negligence Scheme for Trusts’ risk management standards and to take action where necessary.

• Seeking assurance that the Trust works collaboratively with relevant external statutory bodies in line with national legislation and implements appropriate guidance and requirements e.g. Care Quality Commission, NHS Improvement (NHSI) NHS England (NHSE) NHS Resolution, National Institute for Health and Clinical Excellence (NICE), the Health Professions Council (HPC), and the findings of local Health Overview and Scrutiny Committees (HOSCs).

• Receiving assurances that appropriate systems are in place for the development and review of care pathways, clinical policies and the implementation of national clinical guidelines from all relevant professional bodies and regulators

• Ensuring that the Trust, by gathering information effectively, analysing and using it appropriately, takes actions to improve patient safety and creates the environment to continuously learn.

(ii) Clinical Effectiveness • Monitoring and evaluating clinical quality and performance within the Trust based on review of

a dashboard of agreed performance indicators. • Scrutinising the Trust’s Quality Report/Accounts and recommending them to the Trust Board • Ensuring there is corporate and directorate level review of all enquiries, national service

frameworks and other national clinical guidance from the relevant external agencies and regulators, and receiving assurances in respect of the Trust’s response.

• Assessing governance, clinical and quality impact assessments of financial decisions within the Trust e.g. impact of cost improvement programmes.

• Reviewing assurance on the outcomes of Clinical Audit (in liaison with the Audit Committee), in particular on how those outcomes relate to Patient Experience.

• Reviewing the Trust’s CQUIN quality metrics across all service lines delivered by the Trust.



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(iii) Patient Experience • Receiving the quarterly Complaints, Litigation, Incidents and Patient Advice and Liaison Service

(PALS) Reports to outline learning from themes and trends. • Receiving the summary results of surveys relating to patient experience and action plans in

response. (iv) Estate Compliance • Monitoring and evaluating compliance with core estate and maintenance requirements to ensure

a safe environment and medical devices to enable staff to deliver the service

(v) Other duties • Monitoring quality assurance for all third-party service delivery (e.g. sub-contracted services). • Receiving feedback from the Audit Committee and other Board Committees as appropriate. • Working in association with the Audit Committee in matters of corporate governance.

I. Methods of Assurance

What will we measure Method for measurement Frequency Serious Incidents – number and harm Number and cumulative Monthly Infection, Prevention and Control – 24 hour Interim cleans

Compliance Monthly

Infection, prevention and control – service vehicle cleans

Compliance Monthly

Safeguarding training compliance Compliance levels 1-3 Monthly

Safeguarding staff allegations Number, qualified v non-qualified

Monthly

Delivery of external provider visits Compliance Quarterly Compliance/quality of external provider visits Compliance Quarterly Ambulance Clinical Quality Indicators Performance Monthly Drug bag audits Compliance Monthly Controlled Drug Audits Compliance Monthly Medicines administration adverse incidents Number and trend Monthly Completion of Serious Incident actions within time Compliance Monthly Compliment to complaint ratio Ratio Monthly Complaint and concern trends and themes analysis Report Quarterly Complaint closure within 25 working days Percentage Monthly Fire, and first aid compliance Report Bi-annually Estate and infrastructure compliance – asbestos, legionella etc

Report Bi-annually

J. Escalatory Triggers The following triggers outline the framework to be used for escalating an item from the Committee to the Trust Board:

• Non-compliance with compliance indicators for 2 consecutive months, or off track against agreed trajectory

• Clinical, patient safety or estates risks scoring 15 or higher residually, with inadequate mitigating actions in place, or with actions overdue with no assured plan to resolve

K. Telephone Conferencing Members can participate in meetings by two-way audio link including telephone, video or computer link (excepting email communication) whereby all persons participating in the meeting can hear each other, and participation in the meeting in this manner shall be deemed to constitute presence in person at such meeting and count towards the quorum.



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L Voting Wherever possible, decisions will be reached by consensus of the Members. When a vote is required, the following apply:

Every question put to a vote at a meeting shall be determined by a majority of votes of Members present

and voting on the question. In the case of an equal vote, the person presiding (i.e. the Chair of the meeting) shall have a second, and casting vote.

At the discretion of the Chair all questions put to the vote shall be determined by oral expression or by a

show of hands, unless the Committee Chair directs otherwise, or it is proposed, seconded and carried that a vote be taken by paper ballot. If a Member so requests, their vote shall be recorded by name.

In no circumstances may an absent member vote by proxy. Absence is defined as being absent at the time of the vote.

For the voting rules relating to Joint Members, Standing Order 2.5 of the Trust will apply.

M Reporting Procedures

The Chair of the Committee will provide a Chair’s report to the next available Board meeting drawing to their attention any issues or risks that require disclosure to the full Board or require executive action.

The Chair of the Committee shall draw the attention of the Board to any formal recommendations by the Committee, the requirements for action to implement these, any resource implications and the timescale considered appropriate by the Committee for implementation.

The Committee will report to the Audit Committee on its work in support of the Annual Governance Statement, the board assurance framework, the effectiveness of risk management within the Trust; its view as to whether the self-assessment against the Care Quality Commission Registration is appropriate; and any pertinent matters in respect to which the Committee has been engaged.

The Committee will receive a summary report of key issues and decisions taken following each meeting of

the underlying groups for assurance purposes. The Chairs of these groups may be required to attend the Committee meetings at the request of the Committee Chair or may ask to attend a Committee meeting to present or lead debate on a topic related to the work of the group.

The Trust’s annual report shall include a section describing the work of the Committee in discharging its responsibilities.

The Committee will undertake an annual review of its performance effectiveness against its duties in order to evaluate its achievements and will report on its findings annually to the Board. Items presented for business should be those provided for assurance or decision and not information items, unless this is supporting assurance. N Monitoring The Chair of the Board will receive a copy of all meeting papers and will attend at least one meeting per annum for monitoring and assurance purposes. The Terms of Reference of the Committee shall be reviewed by the Board at least annually. The monitoring of the NHS Resolution criteria has been incorporated into the Risk Management Strategy monitoring table which can be found on the Trust’s internet. O Relationship to Audit Committee The Board has determined that the Audit Committee will have responsibility for risk management, to gain assurance that appropriate systems of internal control are in place and are operating as intended, and that



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the Board Committee system is working appropriately. As such the Audit Committee has overall responsibility for the Board Assurance Framework and will delegate any appropriate areas to this Committee as required.

For this purpose only, the Committee will quarterly to the Audit Committee on the following areas for assurance:

• The strategic objectives aligned to the Committee • The BAF risks monitored by that Committee for those strategic objectives • Assurances in relation to the risks within the committee’s remit • Effectiveness of the Committee

Approved by: Quality Governance Committee: Approved by: Trust Board:



Lead April 01.04.20 June 03.06.20 Aug 26.08.20 Oct 28.10.20 Dec 16.12.20 Feb 27.02.21

Quality Report headline summary report Director of Clinical Quality and Improvement

✓ ✓ ✓ ✓ ✓ ✓

Quality Report [provided for information] Director of Clinical Quality and Improvement

✓ ✓ ✓ ✓ ✓ ✓

Clinical dashboard [provided for information] Director of Clinical Quality and Improvement

✓ ✓ ✓ ✓ ✓ ✓

Infection Prevention and Control annual report ✓

Safeguarding Annual report ✓

Safeguarding Strategy ✓

Progress Against Safeguarding Work Plan Director of Clinical Quality and Improvement

✓ ✓ ✓ ✓ ✓ ✓

Medicines Management Annual Report Medical Director ✓

Medicines Management Update Medical Director ✓ ✓ ✓ ✓ ✓

Clinical Strategy KPIs ✓ ✓ ✓

Quality Impact Assessment(Monitor the quality impact assessment of all financial decisions including CIPs where the risk score is 15 or above)

Medical Director

✓ ✓

SIs and Adverse Incidents ✓ ✓ ✓ ✓

Review of all enquiries, national service frameworks from all other external agenciesProgress report on any resulting action plans and/or recommendations from any external enquiries/reviewsNational Clinical Guidelines: Review clinical standards and implementation of all national clinical guidelines

Claims and Litigation Report Director of Clinical Quality and Improvement

✓ ✓ ✓

Flu Update Director of Clinical Quality and Improvement

✓ ✓ ✓

Clinical Audit: Director of Clinical Quality and Improvement

~ Progress report ✓ ✓ ✓ ✓

~ Annual Report ✓

~ Annual Plan for coming financial year ✓

Progress Against CQC Action Plan Director of Clinical Quality and Improvement

✓ ✓ ✓ ✓ ✓

Board Assurance Framework/Clinical Risks Head of Governance ✓ ✓ ✓ ✓ ✓

Communications & Engagement:

Complaints and PALs Trends and Themes Director of Clinical Quality and Improvement

✓ ✓ ✓ ✓ ✓ ✓

PAS/PTS update Chief operating Officer ✓ ✓ ✓ ✓ ✓ ✓

Quality Account: Director of Clinical Quality and Improvement

~ Annual report Director of Clinical Quality and Improvement

✓

~ Review of current year position and propose priorities for coming financial year

Director of Clinical Quality and Improvement

✓

~ Progress report Director of Clinical Quality and Improvement

✓ ✓

Annual Review of Committee Effectiveness and Objectives

Head of Governance ✓


Head of Governance ✓

Items referred by other Committees

DRAFT: QUALITY GOVERNANCE COMMITTEE AGENDA PLAN 2020-21

CLINICAL EFFECTIVENESS

EXTERNAL REVIEWS, ENQUIRIES AND HORIZON SCANNING

PATIENT SAFETY

PATIENT EXPERIENCE

OTHER

RISK AND GOVERNANCE

As required

As required

As required



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WORKFORCE COMMITTEE TERMS OF REFERENCE A Constitution

Pursuant to Standing Orders the Board of Directors ("the Board") hereby resolves to establish a committee of the Board to be known as the Workforce Committee (“the Committee”).

B Purpose

The purpose of the Committee will be to:

• Monitor implementation of the workforce plans and delivery • Monitor performance against key workforce metrics • Scrutinise the achievement of workforce resourcing and performance management

framework. • Provide oversight and challenge to strategies, ensuring they are developed to foster the

attraction, development, engagement, wellbeing, retention and deployment of a high quality workforce and ensure essential standards of quality and safety are maintained.

• Provide oversight and challenge to workforce change, ensuring that this will drive through legislative and best practice human resource management to support achievement of Trust objectives within a robust governance framework.

C Membership

The Committee shall be appointed by the Board from amongst both the Non-Executive Directors and Executive Directors, two of whom shall be Non-Executive Directors, one of whom will act as Chair of the Committee.

A quorum shall be two members with one being a Non-Executive Director

The Workforce Director and Chief Operating Officer are members.

Members of the Workforce Committee must attend at least 75% of all meetings each financial year but should aim to attend all scheduled meetings.

The Chair of the Board shall not normally be a member of the Committee. He/she will have automatic rights as a member of the Committee at times when the quorum cannot be met or vacancies at Non-Executive Director level warrant temporary committee membership.

D Attendance at Meetings

The Chief Executive and Medical Director shall normally attend all meetings.

The Chair of the Board will attend at least one formal meeting per annum for monitoring and assurance purposes.

Other Board Members, Executive Directors, officers and relevant representatives shall have the right of attendance, subject to invitation by the Committee Chair, particularly when the Committee is discussing areas of risk or operations that are the responsibility of that individual.



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E Secretary

The Head of Governance shall be the secretary of the Committee. They will provide appropriate support to the Chair and Committee members and ensure that: • ensure that the Agenda and supporting papers will be circulated to members at least five

working days prior to any meeting; • draft minutes of the meetings are available within 5 working days but no longer than 10 working

days from the date of the meeting. • keep a record of matters arising and issues to be carried forward; • create, maintain and update a rolling schedule of business to come before the Committee. It is

the responsibility of the Secretary to advise the Committee in writing when an item fails to meet the scheduled submission, including reasons and a revised date of submission.

The Head of Governance will act as the Secretary to the Committee and shall provide independent advice to the Committee Chair and Committee Members on compliance with the law and regulatory matters relevant to the Committee’s delegated authority in accordance with Standing Orders Standing Orders of the Trust as appropriate apply to formally established committees. As such, members of this committee may requisition a meeting in writing in line with Standing Orders.

F Frequency The Committee will bi-monthly. G Authority

The Trust Board has overriding responsibility for the delivery of the Trust’s strategic objectives and the monitoring of the principal risks that may threaten the achievement of these objectives. The Committee is authorised by the Board for tracking the strategic delivery of the Trust’s objectives in respect of improvements in recruitment and retention, training and education, culture and all workforce related issues.

The Committee is authorised by the Board to investigate any activity within its Terms of Reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Committee.

The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary or expedient to the carrying out of its functions.

The Committee is authorised by the Board to liaise, as necessary, with other sub-committees of the Board and Chairmen of the formal sub-committees have a responsibility for ensuring that the Audit Committee and the Board are advised of any risks or potential conflicts.

The Committee: • may only make decisions within the remit set out in these Terms of Reference, as specified by

the Trust’s Scheme of Delegation or as delegated by the Trust Board. • has no authority to reverse decisions made by the Trust Board or another Committee. • has no authority to incur expenditure.

H Duties

The duties and responsibilities of the Committee are as follows:

• To monitor achievement against the goals and objectives of the Workforce Plan.



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• To monitor and challenge the risks and associated actions allocated in the Board Assurance Framework to this committee.

• Ensure organisational change is implemented in accordance with legislation, best practice and partnership working

• Agree workforce change programmes and work packages within a robust governance framework.

• Agree and monitor the Trust’s Workforce and Education Plans and ensure that workforce plans are in line with Trust’s strategy and service contractual delivery obligations.

• To review, monitor and challenge the Trust’s workforce plans, including training and education programmes in order to assure the implementation of strategies and/or improvement plans.

• Review and gain assurance on the effectiveness of the Trust’s performance management process.

• Develop, monitor and challenge performance against workforce metrics and key performance indicators and in particular the key performance indicators allocated in the Integrated Board Report to this committee.

• Review employee statistical information and to monitor / benchmark positive or adverse variances and agree improvements where necessary.

• Ensure there is compliance with employment best practice and legislation. • Ensure action is initiated in response to Agenda for Change, Pay and Recruitment and

Retention issues. • Consider Equality and Diversity and health and wellbeing issues. • Reviewing and assuring the Board on compliance with the Health and Safety Strategy and

Policy and consider any annual report on health and safety. I. Methods of Assurance

What will we measure Method for measurement Frequency Workforce trajectory – net staff in post against plan (paramedic, non-paramedic, AOC, PTS, support)

Number and cumulative Monthly

Sickness level versus trajectory (QCIP) (Short term and long term

Percentage and causation themes

Monthly

Mandatory training compliance – whole and by region

Compliance Monthly

Professional Update compliance – whole and by region

Compliance Monthly

Appraisal compliance – whole and by region Compliance Monthly Equality, Diversity and Inclusion benchmarking Benchmarking Annual Gender pay gap benchmarking Benchmarking Annual Training Course fill rate Percentage Quarterly OFSTED compliance Assessment Annual Staff turnover – paramedic, non-paramedic, AOC, PTS, support)

Percentage Monthly

Employment Tribunal Cases Volume and cost Quarterly Employee Relations Cases – Dignity at Work, Bullying and Harassment, grievance, disciplinary

Number, longest case Monthly

Dismissals Number Monthly Occupational Health – compliance with mental health triage timescales

Percentage Monthly

Occupational Health – new starter clearance timescale

Number Monthly

RIDDOR reports Number, compliance Monthly Violence and aggression against staff incidents Number, trend Monthly Manual Handling incidents Number, trend Monthly


• Non-compliance with indicators for 2 consecutive months, or off track against agreed trajectory



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• Workforce and health and safety risks scoring 15 or higher residually, with inadequate mitigating actions in place, or with actions overdue with no assured plan to resolve

• Non-compliance with legislation K Telephone Conferencing

Members can participate in meetings by two-way audio link including telephone, video or computer link (excepting email communication) whereby all persons participating in the meeting can hear each other and participation in this way shall be deemed to constitute presence in person at the meeting and count towards the quorum.

L Voting

Wherever possible, decisions will be reached by consensus of the Members. When a vote is required, the following apply:

• Every question put to a vote at a meeting shall be determined by a majority of votes of Members

present and voting on the question. In the case of an equal vote, the person presiding (i.e. the Chair of the meeting) shall have a second, and casting vote.

• At the discretion of the Chair, all questions put to the vote shall be determined by oral expression or by a show of hands, unless the Chair directs otherwise, or it is proposed, seconded and carried that a vote be taken by paper ballot. If a Member so requests, their vote shall be recorded by name.

• In no circumstances may an absent member vote by proxy. Absence is defined as being absent at the time of the vote.

• For the voting rules relating to Joint Members, Standing Order 2.5 of the Trust will apply. M Reporting Procedures

The Chair of the Committee shall provide a report to the next Trust Board after each Committee meeting. This should include details of any matters in respect of which adequate actions or improvements are needed. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the full Board or require executive action.

The Chair of the Committee will give a formal report to the Trust Board on the work of the Committee at least once each financial year.

The Committee will monitor its performance and undertake a self-assessment annually, to be formally submitted to the Trust Board, through the Annual Report. The report will include:

• Frequency of meetings. • Attendance at meetings. • Alignment of the committee’s work to the Trust Board requirements. • Monitoring of the objectives and duties of the Committee as per the Terms of Reference. • Identification of the key issues considered by the Committee during the year and those

highlighted to the Board • Self-assessment by the Committee.

N Monitoring The Chair of the Board will receive a copy of all meeting papers and will attend at least one meeting

per annum for monitoring and assurance purposes. The Terms of Reference of the Committee, including membership, shall be reviewed by the Trust

Board at least annually.

The Trust’s Annual Report shall include a section describing the work of the Workforce Committee in discharging its responsibilities.



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O Relationship to the Audit Committee

The Board has determined that the Audit Committee will have an oversight role for all risks, to gain assurance that appropriate systems of internal control are in place and are operating as intended, and that the Board Committee system is working appropriately. For this purpose only, the Committee will report four times per year to the Audit Committee on the following areas; • The strategic objectives aligned to each Board Committee • The BAF risks and underpinning monitored by that Committee for those strategic objectives • Annual Plan key objective action plans • Accountability and responsibility of Committee • Effectiveness of Committee

Approved by Workforce Committee Approved by Trust Board



JUNE 03.06.20 JULY 28.07.20 SEPT 30.09.20 NOV 25.11.20 JAN 27.01.21 MARCH 31.03.21

Get Real Change Programme Update ✓ ✓ ✓ ✓ ✓ ✓

People and Culture Metrics ✓ ✓ ✓ ✓ ✓ ✓

RISKBoard Assurance Framework ✓ ✓ ✓ ✓ ✓ ✓

Improvement Plan - workforce workstream ✓ ✓ ✓ ✓ ✓ ✓

PROGRESS REPORTSRetention ✓ ✓ ✓ ✓ ✓ ✓

Recruitment ✓ ✓ ✓ ✓ ✓ ✓

Statutory Mandatory training including Appraisals ✓ ✓ ✓ ✓ ✓ ✓

Employment tribunal cases - (as required) ✓ ✓ ✓ ✓ ✓ ✓

ER Casework ✓ ✓ ✓ ✓ ✓ ✓

Staff Development and Career Progression ✓ ✓

Training and Education Progress Report ✓ ✓ ✓ ✓ ✓ ✓

STRATEGYWellbeing Strategy ✓ ✓

✓ ✓ ✓ ✓ ✓ ✓

Annual Review of Committee Effectiveness (to include a reivew of the Committee's costs)

✓


✓

PERFORMANCE MONITORING

OTHER:

EXCEPTION REPORTS BASED ON TRIGGERS (as Required)

WORKFORCE COMMITTEE: AGENDA PLAN 2020-21

Annual C


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PERFORMANCE AND FINANCE COMMITTEE – TERMS OF REFERENCE A. Constitution The Board hereby resolves to establish a Committee of the Trust Board to be known as the Performance and Finance Committee (The Committee). The Committee is a non-executive committee of the Board and may only exercise delegated the powers specified herein. The Committee may establish, subject to Board approval, sub-groups to execute the delegated powers within these Terms of Reference. B. Purpose

To review the financial statements, the activity and performance information of the organisation and provide assurance to the Board summarised below: • Financial performance against plans and forecasts, highlighting and seeking assurance on

deviation or recovery. • Oversight, scrutiny and assurance on delivery of the recovery plan and critical path • Achievement against the Integrated Improvement Plan • Performance against Cost Improvement Plan and review forecast plans. • Budget planning process. • Activity against contractual plans. • Delivery of operational performance in relation to all operational contracts and national

requirements C. Membership

The Committee shall be appointed by the Board from amongst both the Executive Directors, Non-Executive Directors and Associate non-Executive Directors and shall consist of not less than three designated Members. One Non-Executive member will act as Chairman of the Committee. The Director of Finance and Commissioning and Chief Operating Officer will be members. A quorum shall be two members, one of whom will be a non-executive Director Members of the Performance and Finance Committee must attend at least 75% of all meetings each financial year but should aim to attend all scheduled meetings. The Chair of the Board shall not normally be a member of the Committee. He/she will have automatic rights as a member of the Committee at times when the quorum cannot be met or vacancies at Non-Executive Director level warrant temporary committee membership. D. Attendance at Meetings The Chief Executive, Director of Finance and Commissioning Chief Operating Officer shall normally attend all meetings. The Chair of the Board will attend at least one formal meeting per annum for monitoring and assurance purposes. Other Board Members, Executive Directors, officers and relevant representatives shall have the right of attendance, subject to invitation by the Chairman, particularly when the Committee is discussing areas of risk or operations that are the responsibility of that individual.



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The Head of Governance will act as the Secretary to the Committee and shall provide independent advice to the Committee Chair and Committee Members on compliance with the law and regulatory matters relevant to the Committee’s delegated authority in accordance with Standing Orders E Secretary

The committee administrative function will be provided by the Head of Governance office which will include:

• the agreement of the agenda with the Chair and the collation and circulation of papers; • minuting the proceedings and resolutions of all meetings of the Committee including

recording the names of those present and in attendance; • keeping a record of matters arising and issues to be carried forward; • draft minutes of the meetings are available within 10 working days from the date of

the meeting. • Creating and maintaining a rolling schedule of business to come before the Committee.

It is the responsibility of the Secretary to advise the Committee in writing when an item fails to meet the scheduled submission, including reasons and a revised date of submission.

Trust standing orders and standing financial instructions apply to the operation of the Committee. F. Frequency of Meetings Meetings shall be held not less than six times a year, with additional meetings where necessary. G. Authority The Trust Board has overriding responsibility for the delivery of the Trust’s strategic objectives and the monitoring of the principal risks that may threaten the achievement of these objectives. The Committee is authorised by the Board for tracking the strategic delivery of the Trust’s objectives in respect of improvements in productivity, efficiency and financial planning as well as supporting each of the Committees with the strategic delivery of the Trust’s objectives assigned to them. The Committee is authorised by the Board to investigate any activity within its Terms of Reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary or expedient to the carrying out of its functions. Any costs incurred must be within the remit of the Scheme of Delegation and Standing Financial Instructions The Committee is authorised by the Board to liaise, as necessary, with other sub-committees of the Board and Chairmen of the formal sub-committees have a responsibility for ensuring that the Audit Committee and the Board are advised of any risks or potential conflicts. H. Duties The duties of the Committee will be: Performance:

Review and gain assurance on:

• Actions to ensure that activity levels are in line with contracted levels, financial limits and quality standards to meet contractual compliance for mandatory services.



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Finance: Review and gain assurance on:

• The effectiveness of the annual budget planning cycle. • Forecast financial position of the Trust, including CIPs. • Each Directorate’s and Sector’s financial performance against agreed budget including

achievement of CIPs. • Judgemental areas with regard to full year forecasting. • The movement on reserve accounts. • Cash flow and balance sheet. • Monitoring of capital expenditure. • The effectiveness of appropriate policies.

I. Methods of Assurance The below metrics will provide assurance on performance, PTS, Finance and CIPs and will trigger escalation according to the criteria. What will we measure Method for measurement Frequency C1-C4 performance, including C1 mean and C2 90th percentile

Performance against national target and trajectory

Monthly

PTS performance for patient groups – cancer, end of life, renal

Performance Monthly

Longest PTS wait against trajectory Time Monthly Use of Private ambulance service provision – actual versus planned

Ratio Monthly

Private ambulance service provision – expenditure against plan

Ratio Monthly

Overtime payment against trajectory Performance against trajectory Monthly Financial plan forecast versus actual spend Value Monthly Achievability of financial forecast Against plan Monthly Cash balance and cash flow forecast Report Monthly


• Performance or finance risks scoring 15 or higher residually, with inadequate mitigating actions in place, or with actions overdue with no assured plan to resolve

• Variation of 10% from target or agreed trajectory • Variation from the year end projection

K. Telephone Conferencing Any Director or member of a committee of the Board may participate in a committee of the

Board by means of telephone conferencing, video conferencing or similar communications equipment whereby all persons participating in the meeting can hear each other, and participation in the meeting in this manner shall be deemed to constitute presence in person at such meeting.

L. Voting Wherever possible, decisions will be reached by consensus of the Members. When a vote is required, the following apply:



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• Every question put to a vote at a meeting shall be determined by a majority of votes of Members present and voting on the question. In the case of an equal vote, the person presiding (i.e. the Chairman of the meeting) shall have a second, and casting vote.

• At the discretion of the Chairman all questions put to the vote shall be determined by oral expression or by a show of hands, unless the chairman directs otherwise, or it is proposed, seconded and carried that a vote be taken by paper ballot. If a Member so requests, their vote shall be recorded by name.

• In no circumstances may an absent member vote by proxy. Absence is defined as being absent at the time of the vote

M. Reporting Procedures The Chair of the Committee shall provide a report to the next Trust Board after each Committee meeting.

This should include details of any matters in respect of which adequate actions or improvements are needed. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the full Board, or require executive action.

N. Monitoring The Trust’s Annual Report shall include a section describing the work of the Performance and Finance Committee in discharging its responsibilities. For independent assurance purposes, the Committee will report on an annual basis to the Audit Committee on its performance against its Terms of Reference and on an ad-hoc basis any risks which have inadequate assurance on performance. The Chair of the Board will receive all meeting papers and will attend at least one meeting per annum for monitoring and assurance purposes. The Terms of Reference of the Committee shall be reviewed by the Board at least annually. O Relationship to Audit Committee The Board has determined that the Audit Committee will have responsibility for risk management, to gain assurance that appropriate systems of internal control are in place and are operating as intended, and that the Board Committee system is working appropriately. As such the Audit Committee has overall responsibility for the Board Assurance Framework and will delegate any appropriate areas to this Committee as required.

For this purpose only, the Committee will quarterly to the Audit Committee on the following areas for assurance:

• The strategic objectives aligned to the Committee • The BAF risks monitored by that Committee for those strategic objectives • Assurances in relation to the risks within the committee’s remit • Effectiveness of the Committee

Approved by the Performance and Finance Committee: Approved Trust Board:



May 27.05.20 July 29.07.20 Sept 30.09.20 Nov 25.11.20

Review of the winter performance ✓ ✓ ✓ ✓

Finance Report ✓ ✓ ✓ ✓

Cash flow forecast ✓

Financial planning ✓

Year-end forecast

2020/21 Budget and Plan

CIP Update ✓ ✓ ✓ ✓

Operational Performance Report ✓ ✓ ✓ ✓

Improvement plan ✓ ✓ ✓ ✓

Deep Dive: improvement plan areas of concern ✓ ✓ ✓ ✓

Quarterly report from the Capital Planning andManagement Group (changes to capital plan,impact, cost associations)

✓ ✓ ✓

BAF ✓ ✓ ✓ ✓

Annual Review of Committee Effectiveness (to include a reivew of the Committee's costs)


Topical, legal and regulatory issues

As delegated by Trust Board TRUST BOARD

PERFORMANCE AND FINANCE COMMITTEE: DRAFT AGENDA PLAN 2020-21

EXCEPTION REPORTS

ANNUAL REVIEWS/REPORTS

PROGRESS REPORTS

RISK

OTHER:

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TRANSFORMATION AND CHANGE COMMITTEE – TERMS OF REFERENCE A. Constitution The Board hereby resolves to establish a Committee of the Trust Board to be known as the Transformation and Change Committee (The Committee). The Committee is a non-executive committee of the Board and may only exercise delegated the powers specified herein. The Committee may establish, subject to Board approval, sub-groups to execute the delegated powers within these Terms of Reference. B. Purpose

• To support the Trust Board by monitoring the delivery of the Trust’s portfolio of strategic change programmes relating to the achievement of the Trust’s strategic objectives as set out in the Integrated Business Plan.

• To drive the strategic change programmes forward and provide oversight of the effectiveness of changes that are implemented to ensure that the outcomes and benefits of these are realised, sustained and embedded within the organisation.

C. Membership The Committee shall be appointed by the Board from amongst both the Executive Directors, Non-Executive Directors and Associate non-Executive Directors and shall consist of not less than three designated Members, two of whom will be appointed from within the Non-Executive Directors, of which one of whom will act as Chairman of the Committee. The Director of finance and Commissioning will be a member. A quorum shall be two members, at least one of which shall be a non-executive director. Members of the People Engagement Committee must attend at least 75% of all meetings each financial year but should aim to attend all scheduled meetings. The Chair of the Board shall not normally be a member of the Committee. He/she will have automatic rights as a member of the Committee at times when the quorum cannot be met or vacancies at Non-Executive Director level warrant temporary committee membership. D. Attendance at Meetings The Chief Executive and Head of Strategy and Transformation shall normally attend all meetings. The Chair of the Board will attend at least one formal meeting per annum for monitoring and assurance purposes. Other Board Members, Executive Directors, officers and relevant representatives shall have the right of attendance, subject to invitation by the Chairman, particularly when the Committee is discussing areas of risk or operations that are the responsibility of that individual. The Head of Governance will act as the Secretary to the Committee and shall provide independent advice to the Committee Chair and Committee Members on compliance with the law and regulatory matters relevant to the Committee’s delegated authority in accordance with Standing Orders E Secretary



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• keeping a record of matters arising and issues to be carried forward; • draft minutes of the meetings are available within 10 working days from the date

of the meeting. • Creating and maintaining a rolling schedule of business to come before the

Committee. It is the responsibility of the Secretary to advise the Committee in writing when an item fails to meet the scheduled submission, including reasons and a revised date of submission. Trust standing orders and standing financial instructions apply to the operation of the Committee. F. Frequency of Meetings Meetings shall be held not less than quarterly (four times per year) with additional meetings where necessary. G. Authority The Trust Board has overriding responsibility for the delivery of the Trust’s strategic objectives and the monitoring of the principal risks that may threaten the achievement of these objectives. The Committee is authorised by the Board for tracking the strategic delivery of the Trust’s objectives in respect of improvements in productivity, efficiency and financial planning as well as supporting each of the Committees with the strategic delivery of the Trust’s objectives assigned to them. The Committee is authorised by the Board to investigate any activity within its Terms of Reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary or expedient to the carrying out of its functions. Any costs incurred must be within the remit of the Scheme of Delegation and Standing Financial Instructions The Committee is authorised by the Board to liaise, as necessary, with other sub-committees of the Board and Chairmen of the formal sub-committees have a responsibility for ensuring that the Audit Committee and the Board are advised of any risks or potential conflicts. H. Duties The duties of the Committee will be: Business Development

• To have oversight of the Trust’s approach to bidding for new business, via the Commercial strategy

• To review, recommend and oversee planning and preparation for bids for new business, making recommendations to Board

• To oversee the implementation of new business contracts to ensure sufficient risk mitigation during go live

Transformation



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• To oversee the trust transformation programme and receive assurance against key business cases including, but not limited to the Infrastructure and Capacity Transformation programme

• To oversee delivery and planning for Quality Cost Improvement Programme (QCIP) and receive assurance on associated quality impact assessments

• To monitor the risk profile of the transformation programme and gain assurance on mitigation, or recommend amendments to the transformation should the risks be deemed too great

• To consider and gain assurance on the capacity, capability and resourcing to deliver the transformation programme

• Gain assurance on management of the interdependencies between components of the transformation programme

Strategy

• Develop and recommend strategy and strategic programmes to the Trust Board for approval and implementation

• Ensuring the strategic change programmes deliver within their agreed parameters in terms of costs, organisational impact, rate and scale of adoption and expected/actual benefits realisation.

• To support and monitor progress of key trust strategies including Estates, Wellbeing, Workforce, Culture and IM&T

• To consider and gain assurance on the capacity, capability and resourcing to deliver the Board-approved strategies in place

• Gain assurance on management of the interdependencies between the corporate strategy and its composite sub-strategies

I. Methods of Assurance The below metrics will provide assurance on performance, PTS, Finance and CIPs and will trigger escalation according to the criteria. What will we measure Method for measurement Frequency Delivery of Strategy Actions Performance Bi-Yearly Performance against programme plans Performance Quarterly Estates compliance with legal requirements Compliance Quarterly


• Transformation risks scoring 15 or higher residually, with inadequate mitigating actions in place, or with actions overdue with no assured plan to resolve

• QCIP milestone non-delivery with no clear plan – red RAG rating • Trajectory for financial or efficiency gain from QCIP programme off track by more than 10% • Identification of unmanaged and/or conflicting interdependencies between transformation

schemes or strategy • Transformation milestone non-delivery with no clear plan • Strategy or Transformation metrics off track for two or more months

K. Telephone Conferencing Any Director or member of a committee of the Board may participate in a committee of the Board by means of telephone conferencing, video conferencing or similar communications equipment whereby all persons participating in the meeting can hear each other, and participation in the meeting in this manner shall be deemed to constitute presence in person at such meeting.



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L. Voting Wherever possible, decisions will be reached by consensus of the Members. When a vote is required, the following apply:





This should include details of any matters in respect of which adequate actions or improvements are needed. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the full Board or require executive action.

N. Monitoring The Trust’s Annual Report shall include a section describing the work of the Transformation and Change Committee in discharging its responsibilities. For independent assurance purposes, the Committee will report on an annual basis to the Audit Committee on its performance against its Terms of Reference and on an ad-hoc basis any risks which have inadequate assurance on performance. The Chair of the Board will receive all meeting papers and will attend at least one meeting per annum for monitoring and assurance purposes. The Terms of Reference of the Committee shall be reviewed by the Board at least annually. Approved by the Transformation Change Committee: Approved Trust Board:



April 22.04.20 July 22.07.20 October 21.10.20 January 20.01.21

STRATEGYInformation Management and TechnologyStrategy

Sustainability Strategy Leadership Strategy Engagement Strategy Estates Strategy

Fleet Strategy

People and Culture Strategy

PROGRESS REPORTSInformation Management and Technology update

CIP Development for Coming Year Quality Impact Assessment(Monitor the quality impact assessment of all financial decisions including CIPs where the risk score is 15 or above)

Improvement Plan

STP Engagement Progress and Impact

Infrastructure and Capacity Transformation Programme Update

RISKBoard Assurance Framework OTHERAnnual Review of Committee Effectiveness (to include a reivew of the Committee's costs)


Transformation and Strategic Change Committee Agenda Plan 2020‐21

CIP Deep Dive (By Exception)



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PEOPLE ENGAGEMENT COMMITTEE – TERMS OF REFERENCE A. Constitution The Board hereby resolves to establish a Committee of the Trust Board to be known as the People Engagement Committee (The Committee). The Committee is a non-executive committee of the Board and may only exercise delegated the powers specified herein. The Committee may establish, subject to Board approval, sub-groups to execute the delegated powers within these Terms of Reference. B. Purpose The Trust fully recognises the importance of consulting, involving and listening to people involved with our services, be that our staff, patients, volunteers or communities, and responding appropriately to their views and experiences. The Committee’s purpose is to provide the Board with assurance on the Trust’s overall approach to people participation and ensure that there is a culture of continuous, positive improvement within the Trust, which is driven by meaningful engagement with staff, patients, volunteers or community representatives. C. Membership The Committee shall be appointed by the Board from amongst both the Executive Directors, Non-Executive Directors and Associate non-Executive Directors and shall consist of not less than three designated Members, two of whom will be appointed from within the Non-Executive Directors, of which one of whom will act as Chairman of the Committee. The Workforce Director will be a member. A quorum shall be two members, at least one of which shall be a Non-Executive Director. Members of the People Engagement Committee must attend at least 75% of all meetings each financial year but should aim to attend all scheduled meetings. The Chair of the Board shall not normally be a member of the Committee. He/she will have automatic rights as a member of the Committee at times when the quorum cannot be met or vacancies at Non-Executive Director level warrant temporary committee membership. D. Attendance at Meetings The Chief Executive and Director of Communications and Engagement shall normally attend all meetings. The Chair of the Board will attend at least one formal meeting per annum for monitoring and assurance purposes. Other Board Members, Executive Directors, officers and relevant representatives shall have the right of attendance, subject to invitation by the Chairman, particularly when the Committee is discussing areas of risk or operations that are the responsibility of that individual. The Head of Governance will act as the Secretary to the Committee and shall provide independent advice to the Committee Chair and Committee Members on compliance with the law and regulatory matters relevant to the Committee’s delegated authority in accordance with Standing Orders



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E Secretary




• keeping a record of matters arising and issues to be carried forward; • draft minutes of the meetings are available within 10 working days from the date

of the meeting. • Creating and maintaining a rolling schedule of business to come before the

Committee. It is the responsibility of the Secretary to advise the Committee in writing when an item fails to meet the scheduled submission, including reasons and a revised date of submission. Trust standing orders and standing financial instructions apply to the operation of the Committee. F. Frequency of Meetings Meetings shall be held not less than quarterly (four times per year) with additional meetings where necessary. G. Authority The Trust Board has overriding responsibility for the delivery of the Trust’s strategic objectives and the monitoring of the principal risks that may threaten the achievement of these objectives. The Committee is authorised by the Board for tracking the strategic delivery of the Trust’s objectives in respect of improvements in productivity, efficiency and financial planning as well as supporting each of the Committees with the strategic delivery of the Trust’s objectives assigned to them. The Committee is authorised by the Board to investigate any activity within its Terms of Reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Committee. The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of outsiders with relevant experience and expertise if it considers this necessary or expedient to the carrying out of its functions. Any costs incurred must be within the remit of the Scheme of Delegation and Standing Financial Instructions The Committee is authorised by the Board to liaise, as necessary, with other sub-committees of the Board and Chairmen of the formal sub-committees have a responsibility for ensuring that the Audit Committee and the Board are advised of any risks or potential conflicts. H. Duties The duties of the Committee will be: Equality, Diversity and Inclusion

• Reviewing and ensuring the Trust’s progress to support the organisation’s diversity including receiving updates from the five diversity groups and supporting the equality diversity and inclusion strategy and annual report



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• Consider key equality, diversity and inclusion metrics to support analysis of engagement and accessibility for all staff, patients and the public.

Engagement and Patient Experience

• To ensure learning from Engagement is embedded in day-to-day service delivery, service redesign, transformation and estates development

• Ensure that patient experience data and information is collected and delivered in a proactive and efficient way, and effectively used to driving improvements in patient experiences.

• Receive assurance on progress to progress and resolve complaints and PALs cases • Ensure patient and public involvement is inclusive throughout the Trust and ensure

involvement across improvements within our business

Staff Wellbeing

• To monitor staff and volunteer wellbeing and progress to address themes arising from the staff survey

Stakeholder Engagement

• To oversee engagement with key external stakeholders including the media, partners, third parties and the wider NHS

• To receive assurance on engagement undertaken within the STP’s • Receive and monitor reports from the community engagement group

I. Methods of Assurance Staff and volunteers

What will we measure Method for measurement Frequency Recruitment and Retention rate within staff and volunteers

Rate of turnover – workforce dashboard

Monthly

Staff intending to leave the Trust within 12 months

NHS staff survey Pulse survey

Annual Six-monthly

The number of staff who would recommend the Trust as a place to work


Annual Six-monthly

The number of staff who feel able to make suggestions to improve the work of their team


Annual Six-monthly

The number of staff who believe that their manager encourages them at work


Annual Six-monthly

The number of staff who believe that career progression is fair at the Trust


Annual Six-monthly

The number of staff who believe that communication between senior management and staff is effective


Annual Six-monthly

The number of staff who believe that senior managers try and involve staff in important decisions


Annual Six-monthly

The number of staff who believe that senior managers act on staff feedback.


Annual Six-monthly

Current v preferred sources of information; usage of Need to Know and EEAST24 and most visited pages

NHS staff survey Intranet/NTK analytics

Annual Monthly

Student survey Bespoke student survey Six-monthly



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External stakeholders

What will we measure Method for measurement Frequency Improved familiarity with Trust priorities among key stakeholders

Qualitative stakeholder survey (to be set up)

Annual

Improved favourability of the Trust among key stakeholder groups


Annual

Feedback on our brand and the associations with it


Annual

EEAST presence at STP and ICS key meetings, HOSCs etc

Attendance figures Feedback from Business Dev Managers

Tone and favourability of media coverage Attitudes of key journalists towards the Trust

Analysis of media coverage of the Trust Journalists survey

Quarterly to the Board Annual

Patients and public

What will we measure Method for measurement Frequency Patient experience

Patient survey Complaints, concerns and compliments Ombudsman referrals Friends and Family Test

Annual Monthly

Feedback from Community Engagement Group

Through CEG meetings Bi-monthly

Engagement with Trust messaging on the website and social media channels

Engagement statistics (eg views, retweets etc) for targeted campaigns

Social media and web analytics

Tone and favourability of media coverage

Analysis of media coverage of the Trust

Quarterly


• Engagement, involvement or EDI risks scoring 15 or higher residually, with inadequate mitigating actions in place, or with actions overdue with no assured plan to resolve

• Deterioration of more than 5% in any of the metrics associated with engagement (see methods of assurance)

K. Telephone Conferencing Any Director or member of a committee of the Board may participate in a committee of the Board by means of telephone conferencing, video conferencing or similar communications equipment whereby all persons participating in the meeting can hear each other, and participation in the meeting in this manner shall be deemed to constitute presence in person at such meeting. L. Voting Wherever possible, decisions will be reached by consensus of the Members. When a vote is required, the following apply:



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This should include details of any matters in respect of which adequate actions or improvements are needed. The Chair of the Committee shall draw to the attention of the Board any issues that require disclosure to the full Board or require executive action.

N. Monitoring The Trust’s Annual Report shall include a section describing the work of the Transformation and Change Committee in discharging its responsibilities. For independent assurance purposes, the Committee will report on an annual basis to the Audit Committee on its performance against its Terms of Reference and on an ad-hoc basis any risks which have inadequate assurance on performance. The Chair of the Board will receive all meeting papers and will attend at least one meeting per annum for monitoring and assurance purposes. The Terms of Reference of the Committee shall be reviewed by the Board at least annually. Approved by the People Engagement Committee: Approved Trust Board:



April 29.04.20 July 29.07.20 October 21.10.20 January 20.01.21

PROGRESS REPORTSPatient Public Involvement Update CFR Quarterly Report (Agreed WFC 22.08.19) Community Engagement Group Update

Improvement Plan

Complaints and PALs Update

Staff Survey Update (DoCE)

ANNUAL REPORTSEquality, Diversity and Inclusion Annual Report Patient Public Involvement and Community Engagement Annual Report

EQUALITY AND DIVERSITYEquality, Diversity and Inclusion Strategy Update

Update from Multi Faith Group Update from BME Group Update from Disability Group Update from AWEEAST Update from LGBT Group RISKBoard Assurance Framework OTHERAnnual Review of Committee Effectiveness (to include a reivew of the Committee's costs)


People Engagement Committee Agenda Plan 2020‐21



Name and PositionFrom To

Sarah Boulton Director – Healthy Board Services Ltd 10/03/2014 31/03/2018Trust Board Chair Director – WMB Steele (2009) & Co Ltd Mar-18 01/04/2018

Trustee to the NHS Providers Board as the representative for the Ambulance Services. Jul-18Nigel BeverleyInterim Chair

Chair - Basildona nd thurrock NHS TrustWife is CNO for England - Ruth MayNiece is a paramedic in EEAST

Jul-19 01/07/2019 17/11/2019

Nicola ScrivingsTrust Chair

Chair of CHS GroupIndependent Lay member - HCPS Remuneration CommitteeIndependent Panel member JACVolunteer C.N.P for YHAMember of CNP for YHA

Oct-19 18/11/2019 17/11/2022

Wendy ThomasNon-Executive Director

Director of Quality and Governance at Essex Cares LtdMagistrate for the North Essex Bench

Jul-19Jul-19

04/07/2019 03/07/2021

Neville HounsomeAssociate Non-Executive Director

Member - NHS Pay review BodyNED-Suffolk Housing SocietySelf employed as HR ConsultantFormer Chair - Anchorage Trust0 hours associate with Chameleon People Solutions Associate with LHH and Gatesby Sanderson

Dec-19Dec-19Dec-19Dec-19Dec-19Dec-19

10/07/2019 09/07/2021

Carolan DavidgeNon-Executive Director

Executive Director for Marketing and Engagement - British Heart FoundationTrustee at ASH Action on Smoking and Healthg

Jul-19Jul-19

04/07/2019 03/12/2020

Andrew Egerton-SmithAssociate Non-executive Director

Honorary President – East Anglian Air Ambulance 07/10/2013 10/07/2019

John SysonInterim Director of HR

Nil Jan-20

Lizzy FirminNon-Executive Director

Works for Waddington Brown, a supplier of the TrustConsultancy work for ESNEFT

Jul-18May-19

15/01/2018 14/01/2020

Mental Health Act Manager – Central & North West London NHS Foundation Trust Jan-19 02/12/2013 01/06/2017Lay Board Member – Milton Keynes Clinical Commissioning Group Jan-19 02/06/2017

Ravi Mahendra Trustee - Rain Forest Foundation UK Dec-19 01/05/2019 06/02/2020Non-executive Director Audit Committee member, Goldsmiths University Dec-19Tom SpinkNon-executive Director

Director - AvivaWife midwife at norfolk and Norwich Hospital

Dec 19Dec 19

15/01/2018 14/01/2022

Alison WiggAssociate Non-Executive Director

Partner works for BT - Trust Supplier Dec-19 15/01/2018 14/01/2022

Wayne Bartlett-SyreeDirector of Strategy and Sustainability

Wife is a nurse for NHS Blood and Transplants. Mar-19 05/07/2016 18/08/2019

Marcus BaileyChief Operating Officer

Nil Dec-19 01/03/2019

Peter KaraNon-executive Director

Declaration of Interest Board Term of OfficeResignation declared

Declarations made

30/06/2019

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Name and PositionFrom To

Declaration of Interest Board Term of OfficeResignation declared

Declarations made

Gillian HooperInterim Director of Clinical Quality and Improvement

Director of HealthHelp Ltd Kings LangleyOwner of Healthhelp Ltd Kings LangleyNational professional Advisor to CQC

Oct-19 19/11/2019

Yasmin RafiqInterim Director of People and Culture

Director of Appono Ltd Jul-19 10/07/2019 30/11/2019

Dr Tom Davis Board member, Hertfordshire Independent Living Service (HILS, social enterprise) Dec-19Dec-19

02/02/2018 Medical Director Retainer of GP status at Wendover Health Centre Mar-19

Governor - Great Morwood C of E Primary School Mar-19Tracy Nicholls Vice Chair and Trustee, College of Paramedics Mar-19 01/04/2018 22/11/2019

Director of Clincal Quality and Improvement

Company Secretary for dormant company, Challenge your Thinking; Mar-19Kevin SmithDirector of Finance and Commissioning

Nil Dec-19 01/06/2014

Dorothy Hosein Chief Executive

Nil Jan-20

Lindsey Stafford-ScottDirector of People and Culture

Nil 29/03/2016 04/07/2019

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