A meeting of the Trust Board of Directors – Part 1 To be held on Tuesday, 4 February 2020 at 10.00 am – 12.30 pm in the Main Boardroom, Diana, Princess of Wales Hospital For the purpose of transacting the business set out below 1. Patients’ Stories 1.1 Patients’ Story and Reflection Jo Loughborough, Senior Nurse – Patient Experience (To receive and consider the learning and further actions required from a patient experience story) Verbal 10 mins 2. Business Items 2.1 Chair’s Opening Remarks Linda Jackson, Chair (To note the Chair’s opening remarks) Verbal 2.2 Apologies for Absence Linda Jackson, Chair (To note apologies for absence) Verbal 2.3 Declarations of Interest Linda Jackson, Chair (To note any declarations of interest in any of the agenda items) Verbal 30 mins 2.3.1 Annual Review of Register of Directors’ Interests Wendy Booth, Trust Secretary (To review and note any changes to the Directors’ register of interests following annual review) NLG(20)011 Attached 2.4 To approve the minutes of the previous Public meeting held on the 5 November 2020 Linda Jackson, Chair (To approve or amend the minutes of the September 2019 meeting) NLG(20)012 Attached 2.5 Matters Arising Linda Jackson, Chair (To discuss any matters arising from the minutes that are not on the agenda) Verbal 2.6 Trust Board Action Log – Public Linda Jackson, Chair (To consider progress against actions agreed at the previous meetings) NLG(20)013 Attached 2.7 Chief Executive’s Briefing Dr Peter Reading, Chief Executive (To receive a report on relevant national, regional and local developments to note) Verbal 2.7.1 Progress Against Trust Priorities 2019 / 20 Dr Peter Reading, Chief Executive (To receive and note the progress against the Trust Priorities for 2019 / 20) NLG(20)014 Attached 2.7.2 2019 CQC Inspection Visit Report Dr Peter Reading, Chief Executive & Wendy Booth, Trust Secretary (To receive an update on the timescale for the publication of the CQC Report) Verbal 2.7.3 Changes to Oncology Services Shaun Stacey, Chief Operating Officer (To receive a briefing and changes to Oncology Services) NLG(20)015 Attached 3. Board Assurance 3.1 Board Assurance Framework Wendy Booth, Trust Secretary (To review and challenge the board assurance framework and agree the need for any changes and / or remedial actions) NLG(20)016 Attached 5 mins 3.2 Fit & Proper Persons Requirements – Chair’s Annual Declaration Linda Jackson, Chair (To receive the Chair’s Annual Declaration of the compliance of Directors with the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – Resolution 5: Fit & Proper Proposals) NLG(20)017 Attached 5 mins
Transcript
A meeting of the Trust Board of Directors – Part 1
To be held on Tuesday, 4 February 2020 at 10.00 am – 12.30 pm in the Main Boardroom, Diana, Princess of Wales Hospital
For the purpose of transacting the business set out below
1. Patients’ Stories 1.1 Patients’ Story and Reflection
Jo Loughborough, Senior Nurse – Patient Experience (To receive and consider the learning and further actions required from a patient experience story)
Verbal 10 mins
2. Business Items 2.1 Chair’s Opening Remarks
Linda Jackson, Chair (To note the Chair’s opening remarks)
Verbal
2.2 Apologies for Absence Linda Jackson, Chair (To note apologies for absence)
Verbal
2.3 Declarations of Interest Linda Jackson, Chair (To note any declarations of interest in any of the agenda items)
Verbal
30 mins
2.3.1 Annual Review of Register of Directors’ Interests Wendy Booth, Trust Secretary
(To review and note any changes to the Directors’ register of interests following annual review)
NLG(20)011 Attached
2.4 To approve the minutes of the previous Public meeting held on the 5 November 2020
Linda Jackson, Chair (To approve or amend the minutes of the September 2019 meeting)
NLG(20)012 Attached
2.5 Matters Arising Linda Jackson, Chair (To discuss any matters arising from the minutes that are not on the agenda)
Verbal
2.6 Trust Board Action Log – Public Linda Jackson, Chair (To consider progress against actions agreed at the previous meetings)
NLG(20)013 Attached
2.7 Chief Executive’s Briefing Dr Peter Reading, Chief Executive (To receive a report on relevant national, regional and local developments to note)
Verbal
2.7.1 Progress Against Trust Priorities 2019 / 20 Dr Peter Reading, Chief Executive (To receive and note the progress against the Trust Priorities for 2019 / 20)
NLG(20)014 Attached
2.7.2 2019 CQC Inspection Visit Report Dr Peter Reading, Chief Executive & Wendy Booth, Trust Secretary (To receive an update on the timescale for the publication of the CQC Report)
Verbal
2.7.3 Changes to Oncology Services Shaun Stacey, Chief Operating Officer (To receive a briefing and changes to Oncology Services)
NLG(20)015 Attached
3. Board Assurance 3.1 Board Assurance Framework
Wendy Booth, Trust Secretary (To review and challenge the board assurance framework and agree the need for any changes and / or remedial actions)
NLG(20)016 Attached
5 mins
3.2 Fit & Proper Persons Requirements – Chair’s Annual Declaration Linda Jackson, Chair (To receive the Chair’s Annual Declaration of the compliance of Directors with the Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 – Resolution 5: Fit & Proper Proposals)
Jug Johal, Director of Estates & Facilities (To receive & note the Integrated Performance Report. Key indicators – including assurance about the actions and improvements being taken to recover areas of exception to expected performance – will be considered under the related agenda items and / or board assurance committee highlight reports below)
Challenge – January 2020 Linda Jackson, Acting Trust Chair & Chair of the Finance & Performance Committee
(To report issues from the Finance & Performance Committee requiring escalation by exception to the Trust Board for discussion and agreement of any required actions)
NLG(20)019 Attached
10 mins 5.2 Supporting Papers:
5.2.1 Finance 2019 / 20 – Month 09 Jim Hayburn, Interim Director of Finance (To receive the report of the reported financial position at Month 9 of the 2019/20
reporting period and agree any additional actions required)
NLG(20)020 Attached
6. Strategy & Planning 6.1 Progress Report on the Development & Implementation of Supporting
Strategies Underpinning the Trust’s Strategic Plan Sue Barnett, Strategy & Planning Consultant (To receive a briefing on the timescales for development and implementation of the supporting
November, December 2019 & January 2020 Tony Bramley, Non-Executive Director & Acting Chair of the Quality & Safety Committee and Sandra Hills, Non-Executive Director & Chair of the Quality & Safety Committee
(To report issues from the Quality & Safety Committee requiring escalation by exception to the Trust Board for discussion and agreement of any required actions)
Ellie Monkhouse, Chief Nurse (To note the report & any risk issues requiring escalation to the Trust Board)
NLG(20)022 Attached
7.3 CQC: Quarter 3 Stocktake Kathryn Helley, Improvement Programme Director (To update the Trust Board on progress against the CQC ongoing ‘must do’ and ‘should do’
actions from the 2018 inspection as at Quarter 3)
NLG(20)023 Attached
Comfort Break – 5 mins
8. Leadership, OD & Culture 8.1 Board Development Programme
Linda Jackson, Trust Chair and Wendy Booth, Trust Secretary (To confirm next steps for establishing the 2020 Board Development Programme)
Verbal
15 mins
8.2 Workforce Committee Highlight Report & Board Challenge – January 2020 Jeff Ramseyer, Non-Executive Director and Chair of the Workforce Committee
(To report issues from the Workforce Transformation Committee requiring escalation by exception to the Trust Board for discussion and agreement of any required actions)
Challenge – January 2020 Tony Bramley, Non-Executive Director & Chair of the Audit, Risk & Governance Committee (To report issues from the Audit, Risk & Governance Committee requiring escalation by exception to the Trust Board for discussion and agreement of any required actions)
NLG(20)027 Attached
15 mins 9.2 Annual Accounts 2019/20 – Delegation of Authority Jim Hayburn, Interim Director of Finance
(To ensure the timely sign off of the Trust’s audited accounts, prior to the submission to NHSI, the Trust Board is asked to approve delegated authority to the Audit, Risk & Governance Committee to oversee this work)
NLG(20)028 Attached
9.3 Audit, Risk & Governance Self-Assessment Exercise – January 2020 Tony Bramley, Chair of the Audit, Risk & Governance Committee
(To note the Self-Assessment Exercise)
NLG(20)029 Attached
10. Remuneration Committee 10.1 Outcome of the Review of the Remuneration Committee including the
revised Terms of Reference Wendy Booth, Trust Secretary (To receive the report and Terms of Reference)
NLG(20)030 Deferred to March 2020
meeting
5 mins
11. Health Tree Foundation Trustee’s Committee 11.1 Health Tree Foundation Trustee’s Committee Highlight Report –
January 2020 Neil Gammon, Non-Executive Director & Chair of the Health Tree Foundation Trustees’ Committee (To report issues from the Health Tree Foundation Trustees’ Committee requiring escalation by exception to the Trust Board for discussion and agreement of any required actions)
NLG(20)031 Attached
5 mins
12. Items for Approval 12.1 Gender Pay Gap Report
Claire Low, Acting Director of People & Organisational Effectiveness (To receive and endorse the report)
NLG(20)032 Attached
15 mins 12.2 Review of the Standing Financial Instructions (SFIs) and Scheme of
Delegation (SoD) Jim Hayburn, Interim Director of Finance (To receive and approve the amendments to the SFIs and SoD)
NLG(20)033 Attached
12.3 Audit, Risk & Governance Committee Terms of Reference Tony Bramley, Chair of the Audit, Risk & Governance Committee (To seek formal approval of the updated Audit, Risk & Governance Committee Terms of Reference following ratification at the Audit, Risk & Governance Committee Meeting)
NLG(20)034 Attached
13. Communication Round-Up Ade Beddow, Assistant Director of Communications (To receive a briefing on recent communications issues and developments)
Verbal
5 mins
14. Items for Information / To Note (please refer to Appendix A) Linda Jackson, Chair (To note items for information)
To Note
15. Any Other Urgent Business Linda Jackson, Chair (To discuss any other urgent items of business)
Verbal
16. Board Performance and Reflection Linda Jackson, Chair (To consider the performance of the Trust Board, including asking):
Verbal
• Has the Board focussed on the appropriate agenda items? Are there any item(s) missing or not given enough attention?
• Where appropriate, have relevant items been debated at the relevant Board assurance Sub-Committee prior to being submitted to the Trust Board?
• Are Board members satisfied with the quality of papers: - Is the purpose and content clear? - Are papers clear on the Board action required?
17. Date and Time of the Next Meeting: Linda Jackson, Chair (To note the date and time of the next meeting)
Trust Board Development Session Tuesday, 3 March 2020, Time TBC In the Main Boardroom, Diana, Princess of Wales Hospital Formal Trust Board Meeting Tuesday, 7 April 2020, Time TBC In the Main Boardroom, Diana, Princess of Wales Hospital
PROTOCOL FOR CONDUCT OF BOARD BUSINESS In accordance with Standing Order 14.2 (2007), any Director wishing to propose an agenda item should send it with 8 clear days’ notice
before the meeting to the Chairman, who shall then include this item on the agenda for the meeting. Requests made less than 8 days before a meeting may be included on the agenda at the discretion of the Chairman. Divisional Directors and Managers may also submit agenda items in this way.
In accordance with Standing Order 14.3 (2007), urgent business may be raised provided the Director wishing to raise such business has given notice to the Chief Executive not later than the day preceding the meeting or in exceptional circumstances not later than one hour before the meeting.
Board members wishing to ask any questions relating to those reports listed under ‘Items for Information’ should raise them with the appropriate Director outside of the Board meeting. If, after speaking to that Director, it is felt that an issue needs to be raised in the Board setting, the appropriate Director should be given advance notice of this intention, in order to enable him/her to arrange for any necessary attendance at the meeting.
NB: When staff attend Board meetings to make presentations (having been advised of the time to arrive by the Board Secretary), it is intended to
take their item next after completion of the item then being considered. This will avoid keeping such people waiting for long periods.
APPENDIX A
Listed below is a schedule of documents circulated to all Board members for information. The Board has previously agreed that these items will be included within the Board papers for information. They do not routinely need to feature for discussion on Board agendas but any questions arising from these papers should be raised with the responsible Director. If after having done so any Director believes there are matters arising from these documents that warrant discussion within the Board setting, they should contact the Chairman, Chief Executive or Board Administrator, who will include the issue on a future agenda. 14. Items for Information / To Note
Sub-Committee Supporting Papers:
Quality and Safety Committee:
14.1 Minutes of the Quality & Safety Committee, October, November, December 2019 Tony Bramley, Non-Executive Director & Outgoing Chair of the Quality & Safety Committee and Sandra Hills, Non-Executive Director & Incoming Chair of the Quality & Safety Committee
(To note the October, November, December 2019 minutes of the Quality & Safety Committee for information)
NLG(20)035 Attached
14.2 Guardian of Safe Working Hours Kate Wood, Medical Director (To note the Quarterly Report of the Guardian of Safe Working Hours)
NLG(20)036 Attached
Finance & Performance Committee:
14.3 Minutes of the Finance & Performance Committee, September & October 2019 Linda Jackson, Acting Trust Chair & Chair of the Finance & Performance Committee (To note the September & October 2019 minutes of the Finance & Performance Committee for information)
NLG(20)037 Attached
Health Tree Foundation Trustees’ Committee:
14.4 Minutes from the Health Tree Foundation Trustees’ Committee, October 2019 Neil Gammon, Non-Executive Director & Chair of the Health Tree Foundation Trustees’ Committee (To note the October 2019 minutes of the Health Tree Foundation Trustees Committee for information)
NLG(20)038 Attached
Workforce Committee:
14.5 Minutes of the Workforce Committee, October 2019 Jeff Ramseyer, Non-Executive Director and Chair of the Workforce Committee (To note the October 2019 minutes of the Workforce Committee for information)
NLG(20)039 Attached
Audit Risk & Governance Committee:
14.6 Minutes of the Audit, Risk & Governance Committee, October 2019 Tony Bramley, Chair of the Audit, Risk & Governance Committee
(To note the October 2019 minutes of the Audit, Risk & Governance Committee for information)
NLG(20)040 Attached
14.7 Audit, Risk & Governance Committee – Annual Workplan – 2020/21 Tony Bramley, Chair of the Audit, Risk & Governance Committee (To note the Annual Workplan for 2020/21)
NLG(20)041 Attached
Other:
14.8 Documents Signed Under Seal Wendy Booth, Trust Secretary (To note the report of documents signed under Trust Seal since the date of the previous report)
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The report provides the updated Register of Directo rs’ Interests as at January 2020
NAME & POSITION INTERESTS DATE Linda Jackson Interim Trust Chair
� None 14.11.2019
Dr Peter Reading Chief Executive
� Director, Peter Reading Strategic Consulting Limited (currently being closed down)
� Company Secretary of spouses company, Catherine Reading Limited
� Director Ex officio and Trust CEO of WebV Solutions Ltd and Together plc
19.11.2019
James Hayburn Interim Director of Finance
� Director of own company JHL Associates 29.11.2019
Marcus Hassall Director of Finance
� None: as at 2017 (update not currently available – post currently filled by Interim Director of Finance as detailed above)
15.12.2017
Ellie Monkhouse Chief Nurse
� Husband is foot and ankle Consultant Orthopedic Surgeon at Leeds Teaching Hospitals
23.11.2019
Shaun Stacey Director of Operations
� None 14.11.2019
Dr Kate Wood Medical Director
� None 05.11.2019
Jayne Adamson Director of People & Organisational Development (non-voting director)
� Director of Reach Innovation as at 2019 (update not currently available – post currently filled by Interim Director of People & Organisational Development as detailed below)
08.02.2019
Claire Low Acting Director of People & Organisational Effectiveness
� None 10.12.2019
Wendy Booth Trust Secretary
� Director of Risk & Governance (R&G) Solutions Ltd
� Sister of Director of Resources & Governance at North East Lincolnshire Council
� Board Secretary of WebV Solutions Ltd
14.11.2019
Jug Johal Director of Estates & Facilities (non-voting director)
� Chairman, Asian Sports Foundation 15.11.2019
Tony Bramley Non-Executive Director
� Director and joint-owner of West Marsh Consultancy Ltd, (which provides housing & regeneration consultancy services)
� Member of the Corporation of the Grimsby Institute of Further & Higher Education (equivalent of a non-executive director), which may engage with the Trust for the supply of staff training, traineeships and apprenticeships
NAME & POSITION INTERESTS DATE Neil Gammon Non-Executive Director
� Governor of Grimsby Institute of Further & Higher Education (GIFHE).
28.11.2019
Sandra Hills Non-Executive Director & Senior Independent Director (SID)
� Director and Shareholder - Prime Digital Services Ltd CCTV security company whose customer base includes NHS and independent health sector customers and which bids for NHS work
� Director and Shareholder – Consult Prime Ltd a consultancy business focused on the health and social care sector
� Chairman & Parish Councillor – Bubwith and Breighton (a parish within the catchment area of the Trust)
� Member of the Spaldington Windfarm Community Fund Panel (voluntary role representing Bubwith Parish Council)
� Hotham and Turner Charity – elected representative on behalf of Bubwith Parish Council (the charity delivers £30 vouchers to some 40 older people to spent in local shops at Christmas – this could be deemed as social care)
01.11.2019
Jeff Ramseyer Non-Executive Director
� Owner of apartment in the Linea Apartment Complex, Dunstall Street, Scunthorpe. Trust Employee is currently a tenant
� Governor at Winterton Junior School � Director of JRC Knowledge Associates Ltd,
Winterton based Management Consultancy. There are no current plans on engagement with the NHS at this time
28.11.2019
Michael Whitworth � Interim Chief Executive Officer of Barnet Federated GPs
� Owner/Director of Michael Whitworth Consultancy limited – currently in-active
13.01.2020
Ade Beddows Head of Communications
� None 04.11.2019
NLG(20)012
TRUST BOARD OF DIRECTORS (PUBLIC)
Minutes of the Public Meeting held on Tuesday, 5 November 2019 at 10.00 am
In the Main Boardroom, Diana, Princess of Wales Hospital
For the purpose of transacting the business set out below
Present: Mrs L Jackson Non-Executive Director (Interim Chair) Dr P Reading Chief Executive Officer Mr J Hayburn Interim Director of Finance Mr S Stacey Chief Operating Officer Dr K Wood Medical Director Mr A Bramley Non-Executive Director Mrs S Hills Non-Executive Director In Attendance: Mrs W Booth Trust Secretary Mr J Johal Director of Estates & Facilities Mrs C Low Acting Director of People & Organisational Effectiveness Miss E Coghill Deputy Chief Nurse Mr A Beddow Associate Director of Communications Mrs A Hurley Membership Manager & Assistant Trust Secretary Ms S Barnett Strategy and Planning consultant (Item 6) Mrs J Loughborough Senior Nurse – Patient Experience (Item 1.1) Mrs S Wood Senior Nurse – Nutrition & Hydration & Falls (Item 1.1) Mr M Madeo Lead Nurse – Assistant Director Infection Prevention & Control (Item 7.2.3) Mr C Ferris Head of Safeguarding (Item 7.2.4) Mr R Painter Named Nurse – Mental Capacity & DOLS (Item 7.2.5) Mrs K Helley Improvement Programme Director (Item 7.3.1) Mrs K Farquharson Freedom to Speak up Guardian (Item 8.3.2) Mrs S Meggitt Personal Assistant to the Chair and Trust Secretary (for the minutes) Cumulative Record of Board Director’s Attendance (2019/20) Name Possible Actual Name Possible Actual Mrs L Jackson 4 4 Mrs C Low 4 4 Dr P Reading 4 4 Mrs E Monkhouse 4 3 Mrs J Adamson 4 0 Mr S Stacey 4 4 Mrs W Booth 4 4 Dr K Wood 4 4 Mrs P Clipson 2 0 Mr T Bramley 4 3 Mr R Eley 3 3 Mrs S Hills 4 4 Mr M Hassall 4 0 Mr N Mapstone 1 1 Mr J Hayburn 1 1 Mr J Ramseyer 4 3 Mr J Johal 4 4 Mrs A Shaw 3 2 1. Patient’s Stories . 1.1 Jo Loughborough and Sara Wood shared the Patient’s Story, ‘the unheard voice’
with the Trust Board. They explained that the patient had suffered a stroke after
NLG(20)012
2 | P a g e
recently losing her husband, and whilst she had been an inpatient she had been moved three times due to bed pressures and had spent seven hours waiting in a chair in the discharge lounge for her return to Grimsby. The board was advised that this occurrence was not always captured through the PALS or complaints systems although the Trust was becoming more aware of such occurrences through the 15 Steps Challenge process. Sara Wood advised that greater collaborative working was now evident and would help to address such issues, and this would increase further from December 2019 due to the red flag system which relates to patients who are moved after 10.00 pm at night. Nursing teams would also be made more aware of patients who should not be moved during these times due to their care requirements or personal circumstances. The Board was advised that workshops were being held with ward staff to support them in identifying patients earlier in the day who may need to be moved to allow the move to take place at more reasonable times. Engagement between the wards and operations centre had also improved to support such moves being achieved, and further improvements were planned for discharge management. Sandra Hills queried whether the personal circumstances of patients was also taken into account together with the psychological support offered, as the patient in question had come into hospital whilst still grieving for her husband. Sara Wood advised that during the patient’s stay she had been referred to NAVIGO for appropriate support. Shaun Stacey thanked Jo Loughborough and Sara Wood for presenting the very difficult patient story and bringing the patient flow issues to the attention of the Trust Board. He felt greater commitment was still required for Safer Nursing and was distressed such occurrences were still taking place. He added that it was everyone’s responsibility to recognise the issues around this and queried why the lady was transferred to a further acute establishment, when she should have been given psychological intervention and could have then been cared for at home. The Trust Board was advised that this option was provided in the community but the Trust does not access it as they should. Tony Bramley referred to the PALS and Complaints report presented at the Quality & Safety Committee and queried where such patient flow issues would be shared for oversight if not raised by patients through the PALS and complaints route. Jo Loughborough confirmed such patient stories were shared with the Quality & Safety Committee, but the volume of such issues was not necessarily captured or reported. Linda Jackson referred to the flag system and queried whether this would highlight key areas where such patient flow issues were evident. She added that in her meeting with Anne Ford from the Care Quality Commission (CQC) she had been asked how the Trust Board assure themselves on patient risks in relation to flow and that patients are not coming to harm, confirming this issue required further review. Elaine Coghill advised that the Trust was about to roll out Safe Care Live which covered the safe deployment of staff and patients to the community, and it was hoped this training would be in place by the end of December 2019. Peter Reading felt the red flag system would be helpful to address patients arriving in Accident and Emergency (A&E) late at night and those who are not adequately discharged during the day to support improved discharge management. Shaun Stacey concurred and advised a possible solution would be to open more beds, but in reality he confirmed this would create additional difficulties with safe staffing levels. Linda Jackson thanked both Jo Loughborough and Sara Wood for attending the meeting.
NLG(20)012
3 | P a g e
2. Business Items 2.1 Chair’s Opening Remarks
Linda Jackson declared the meeting open at 10.10 am. She advised some papers had been late this month and requested that everyone ensure they work to the set deadlines in future, explaining the difficulties late papers presented for board members in not allowing sufficient time to review them and provide effective comment or challenge during the meeting. She recognised some papers were late due to meeting schedules which she had been notified of. For future meetings she advised she undertake a review with Sarah Meggitt to note what papers were late.
2.2 Apologies for Absence Apologies for absence were received from Jayne Adamson (represented by Claire Low), Ellie Monkhouse (represented by Elaine Coghill) and Jeff Ramseyer.
2.3 Declarations of Interest There were no declarations of interest received.
2.3.1 Updated Register of Directors’ Interests – NLG(19)253 Wendy Booth shared the paper with the Trust Board and advised that the register had been updated to include the new interim posts. She advised that Adrian Beddow would be added to the report to ensure consistency with the Fit And Proper Persons’ process, and the updated report would then be uploaded to the website.
2.4 To approve the minutes of the previous Public meeti ng held on the 3 September 2019 – NLG(19)254 The minutes of the meeting held on Tuesday, 3 September were approved as a true and accurate record of the meeting and would be duly signed by the Chair. Linda Jackson queried whether the wider circulation of the draft minutes for consideration prior to the meeting was helpful, and Trust Board members supported this approach.
2.5 Matters Arising There were no matters arising to be discussed at this meeting.
2.6 Trust Board Action Log – Public – NLG(19)255 Linda Jackson shared the report with the Trust Board and advised the Remuneration Committee Terms of Reference were overdue and this would be addressed as part of a planned full review of the committee at the next meeting on the 14 November 2019. Linda Jackson queried the process for embedding the Standing Financial Instructions (SFIs) and the Scheme of Delegation at the Audit, Risk and Governance Committee at item 10.1 from the September meeting. Tony Bramley advised a discussion had taken place on how to translate this information to staff, and Jim Hayburn advised the Trust was using the current process due to some further work required. Wendy Booth queried whether reference to the current process referred to the revised version approved by the Trust Board in September 2019, and Jim Hayburn confirmed it was.
NLG(20)012
4 | P a g e
Post meeting note : It was subsequently confirmed that reference to the current process related to the existing SFIs and Scheme of Delegation and not the revised version considered by the Trust Board at its meeting in September 2019.
2.7 Chief Executive’s Briefing Peter Reading advised that since the previous Board meeting the CQC had undertaken a full inspection between the 24 – 27 September, which had included a review of the Trust against the Well Led domain and a Use of Resources assessment. Subsequent to the announced element of the inspection, the CQC had also undertaken some unannounced visits. The Trust had been asked to submit some additional information and had attended a meeting with the CQC on 31 October 2019 around waiting lists. The draft CQC report was expected to be received late November or early December and published in January 2020.
2.7.1
Progress Against Trust Priorities 2019 / 20
Peter Reading took the report as read and advised the Trust was now in a position to provide regular reports on the priorities. He then invited any comments or questions. None were received.
2.8 Trust Meeting Structures – Ratification of the appointment of the Chairs of th e Trust Board Assurance Sub-Committees Linda Jackson confirmed that from October 2019 Sandra Hills would be the Chair of the Quality & Safety Committee and Jeff Ramseyer would be the Chair of the Workforce Committee. She advised Non-Executive Director (NED) interviews would be held over the following two weeks for the NED vacancies, and after these positions had been confirmed a new Chair would be appointed to the Finance & Performance Committee. She thanked all who had been involved.
Wendy Booth shared the BAF report as at October 2019 which she advised included updates on all 13 strategic objectives and the associated risks, and confirmed the details had been subject to challenge through the Trust Management Board (TMB) and relevant board sub-committees. She advised the presentational issue raised about the report had been addressed with the addition of a RAG key to better enable the reader to discern what the RAG ratings mean and to sequentially display the strategic risks. Wendy Booth advised that in month movement of risks and risk gradings included investment and development of the Trust’s leadership which had reduced from a risk rating of 16 down to 12, and the inability to secure sufficient numbers of appropriately trained staff in the short, medium and long term had reduced from 15 to 10 as a result of improved the medical vacancy position, high levels of retention and the deanery fill rate. Tony Bramley confirmed the risk for staff recruitment and retention had been reduced considerably and queried whether this had been reviewed through the Workforce Committee. Sandra Hills advised the committee had not highlighted any issues for concern but agreed to review this in greater detail at the next meeting.
NLG(20)012
5 | P a g e
Linda Jackson confirmed this required discussion at the next Workforce Committee meeting for assurance. Tony Bramley advised that from an Audit Risk & Governance Committee perspective, any movement in month required an explanation via the relevant Board assurance sub-committee to detail the rationale behind the change. Wendy Booth confirmed she had reviewed the sub-committee highlight report template and had added a specific section for commenting on the BAF. Sandra Hills advised that during discussions with the CQC they had queried whether the BAF was considered and challenged in relation to patient experience, and had felt the Trust did not provide sufficient challenge. Peter Reading concurred and added that the Trust does not view itself from the patient perspective. He requested Adrian Beddow and Wendy Booth discuss this further in relation to potentially implementing an additional risk to address this within the BAF. Sandra Hills supported this potential development and suggested also considering how to manage patient opinions and how this could be tested. Shaun Stacey supported this approach and suggested it was a theme that should run throughout the BAF, capturing patient opinion and feedback from using Trust services. Tony Bramley suggested this was captured within the Patient Experience report and the details could be extracted from it. Linda Jackson confirmed that at the Finance & Performance Committee they endeavoured to review the level of risk at the end of each agenda item to consider whether members were content with the information presented, or whether further challenge was required. She advised that Wendy Booth and herself are meeting to ensure the board are sighted on what was required and what the risks are.
Jug Johal explained the operational and quality highlights were at the front of the IPR and advised key performance was being discussed through the sub-committees. Linda Jackson felt the discussions about performance at the sub-committees had been positive. Both Sandra Hills and Tony Bramley concurred and confirmed the executive summary detailing key issues was very helpful. Kate Wood referred to the summary for the Quality & Safety Committee and the need to have sight of the monthly back pages, as per her discussions with Jug Johal. She confirmed Alex Bell was addressing this, and that she was happy with the current detail within the report. Linda Jackson advised there would be a refocus and review of all sub-committees to consider any changes required, and the Quality & Safety Committee would be addressed first.
September & October 2019 – NLG(19)259 Linda Jackson took the report as read and advised the Finance & Performance Committee had had received a report on the Clinical Data Improvement Programme
NLG(20)012
6 | P a g e
at the September 2019 meeting which had achieved £591,000 additional income at that point. The full year trajectory was set at £3 million additional income and the current forecast was predicted to achieve £2.7 million, with a shortfall of £330,000 in year. Concerns had been raised around incorrect categorisation of some patients as short stay elective, which could pose a further financial risk. She then confirmed that work continues within the teams and highlighted the need to effectively resource this project to move it forward. She suggested that the Executive Team (ET) could monitor progress on this project. The committee had been encouraged and felt positive about the information received on the OPD Transformation project, and raised the issue of resourcing this project if the completion date was brought forward and requested that the ET could monitor this also. The committee had asked the Surgery & Critical Care Division to attend the meeting as they had the greatest deficit. They had presented a plan which demonstrated how they could recover slightly based on additional income, although it may not be realistic to achieve if it caused the system to overtrade and could create a further risk. The committee had not felt assured there was sufficient assurance on labour cost reduction by recruiting to vacancies and the implementation of the new anaesthetic rotas, which were the key overspend areas. A further review was planned to focus the division on the key deliverables which would achieve the greatest in year difference. The committee felt additional transparency was required around year end forecasting to allow better judgement to be established, and the forecasting model required greater resilience. With regards to cancer, the committee identified key areas that required greater focus due to the deteriorating position, and it was noted that further discussions are planned at the Trust Management Board (TMB) Meetings. Linda Jackson thanked Sue Barnett, Jug Johal and their teams for their proposals relating to the Acute Admissions Unit (AAU). She noted that the AAU scheme did not consider the infrastructure that it was linking to, and the Trust needed to be aware this posed a risk. Sandra Hills sought assurance around the access and availability of cancer services provided at Hull, and queried whether the Trust was doing enough in relation to patient choice, which was a key point raised at the CQC inspection meetings. Shaun Stacey advised he could assure the board that if the length of wait for treatment was challenging for Hull, then alternative suggestions are offered to patients at various points in the patient journey. He explained that this would also be discussed at a joint planning meeting with the surgeon, oncologist and the clinical nurse specialist. The speciality areas that are challenged at the moment are unfortunately the same for Trusts that are geographically close to the Trust, although other options are available further afield. Shaun Stacey further clarified that delays for treatment were sometimes due to diagnostic access which remained a challenge.
Jim Hayburn provided an overview of the finance report and confirmed the Trust had delivered the financial trajectory for the end of September 2019 and was in line for financial recovery support monies at the end of the year. He added that all divisions
NLG(20)012
7 | P a g e
were currently overspent, with some in financial balance only due to their income and discussions would be held to establish the potential year end income position. He advised that delivery of the Cost Improvement Programme (CIP) was still being forecast, although this remained challenging for the Trust and expenditure required greater management in order to deliver the control total. Sandra Hills referred to the difficulties around cash and queried how this would be managed throughout the year. Jim Hayburn advised that the Trust had just signed off a loan application for over £3 million, the debtors had reduced in relation to the Provider Sustainability Fund (PSF), cash was being managed on a daily basis and discussions were taking place with Clinical Commissioning Groups (CCGs) around income to ensure the cash was maximised. Linda Jackson advised that the Finance & Performance Committee was assured that the Trust was on target to achieve the control total by the year end. Peter Reading advised that the Regional Director’s perspective was that the Trust would support delivery of the control total as a system. He advised that Jim Hayburn had held detailed discussions at the private Trust Board meeting regarding the Financial Delivery Plan for the remainder of the year. This would also be addressed at the Senior Leadership Conference. Linda Jackson advised that when she met Richard Barker, the Regional Director for NHS England & Improvement (NHSE/I), he clarified that the Trust had specifically been awarded the £10 million this year in order to demonstrate good system working and to support achievement of the system control target.
6. Strategy & Planning 6.1 Trust Strategic Plan – Final – NLG(19)261
Sue Barnett apologised for the late paper and took it as read. She advised the key points are highlighted within the report along with the level of risk for the five year period, and this was the pre-cursor to formalising the approach which would align a variety of regional plans. She explained the need to align the quality activity, workforce and finance aspirations. She clarified that work was ongoing to validate the tables within the plan, although there was no expectation they would be changed. Sue Barnett also confirmed that all of the local CCGs and providers would be required to sign up to these numbers by the following day. It was noted that a substantial increase in outpatient follow-ups for 2020/21 was evident and the Trust and system ambition to reduce this back log to 4,000 follow-up appointments by the end of 2021/22 was considered sustainable. This would be two years earlier than initially thought. From a workforce perspective, validation was ongoing to triangulate and review the bank and agency data against a perceived increase. This would include the capital benefits the Trust would receive and exclude anything from the Humber Acute Services Review (HASR) at present. Tony Bramley queried whether efficiencies or transformational change would address the workforce balance as detailed in Appendix 1, which illustrated growth in numbers in all areas. Sue Barnett advised there was would be a mixed approach, with utilisation of Trust operating models to manage ongoing activity. This was particularly evident for the Urgent Treatment Centres (UTCs) and Emergency care, with the plan to increase zero lengths of stay and decrease inpatient length of stay which would include more UTC activity rather than type 1 activity. Tony Bramley
NLG(20)012
8 | P a g e
suggested it would be helpful if the tables showed the net growth effect of staff and established numbers for absorbing the bank and agency staff, in order to consider how realistic it was. Sue Barnett advised Claire Low and her team had been working on this, and aimed to illustrate the increased numbers against specific roles. Tony Bramley queried whether it could be detailed as an equation, against identified funding streams. Sue Barnett clarified that all of the data in the tables would be shown as a bridge charts. Sandra Hills referred to the seven day working plan which had recently been reviewed at Quality & Safety Committee, who had not been assured. She queried the connection between the strategy and the seven day working plan and whether there was any testing between the two. Sue Barnett advised they had not tested every action plan but would be reviewing this in a different way which was yet to be determined. Jim Hayburn advised that at the end of the period the Trust were back in balance but this was with £32 million Financial Recovery Fund (FRF) support. The FRF would also increase significantly next year to £39.8 million and include cashback, but this would be dependent on the delivery from the current year. Kate Wood referred to the quality section of this report with regard to the quality priorities over this year which had not been fully achieved; however, progress was now heading in the right direction. She explained there had been discussions with the commissioners but no further feedback had been received with regard to this. In order to achieve the follow up trajectories this would mean some slippage on the 18 week position to push this back to 26 weeks. She advised she had discussed this with the commissioners and with the CQC as there was a need to balance the risk. Linda Jackson clarified with Sue Barnett that the approval was required for submission the next day and that further work was required before this. The Trust Board was happy to approve the plan based on the additional work being completed. She asked if the final plan could be circulated to the Trust Board members and Sue Barnett agreed to do so. Linda Jackson confirmed that the objectives within the plan would need to be aligned to the relevant Trust Board sub-committees so they can monitor their achievement over the next year. The Trust Board agreed to the second point of the report. Linda Jackson wanted to thank Sue Barnett and her team for the work completed.
& October 2019 – NLG(19)262 Sandra Hills shared the highlight report with the Trust Board and highlighted specific items. She advised that the first phase of the Electronic Prescribing & Medicines Administration had been completed and signed off. The Pathology Department had provided an update on their services to the Committee, which included details of their successful recruitment programme. The service had achieved United Kingdom Accreditation Service (UKAS) accreditation, and were continuing to progress the digital programme. The seven day services audit had received a ‘Limited Assurance’ Level given concern regarding the ability of the Trust to achieve the national requirement of compliance for 90% of its patients by 2020. A need to triangulate other information
NLG(20)012
9 | P a g e
within the Trust remained, in order to address the concern. Kate Wood advised that if Safer was effectively implemented a ‘Limited Assurance’ level would not have been received. Sandra Hills advised that the committee had received an updated report and action plan regarding CNST and although significant progress had been made, maternity services had recently had four incidents reported. Linda Jackson referred to the highlight report as it stated the CNST update was to come to the Trust Board this month and had not. It was confirmed the update was given at the previous meeting in September 2019. The Trust Board was advised the Terms of Reference for the committee had been reviewed and it had been recommended that the Board adopt them. It was agreed they would be shared at the next meeting. Linda Jackson referred to the review and refocus meeting that was scheduled and queried whether the Terms of Reference could be adopted after that meeting. This was agreed by Trust Board members.
7.2 Supporting Papers 7.2.1 Nursi ng Assurance Report – NLG(19)263
Elaine Coghill shared the report with the Trust Board and explained the data within the report was for August and September 2019. She advised new reporting had been introduced for Allied Health Professionals (AHPs) and Nursing Associates and associated reporting was being developed. Monitoring of substantive roles continued on night and day shifts, and newly qualified nurses were now in place in ward areas. She explained that with the newly qualified nurses in post, the vacancy position had reduced from 170.91 whole time equivalents (wte) to 151.61 wte. Elaine Coghill explained the first recruitment and retention open day would be held on the 29 November, and the process would include prospective nurses being given a site tour with an interview also held on the same day. The 15 step process progressed and two wards which had previously been identified as required improvement, had now been revisited and were now classified as good. Linda Jackson queried whether the Trust received feedback on staff leaving, and Elaine Coghill advised that this remained low alongside exit interviews being requested. On a more positive note, she advised some staff had chosen to stay due to the Trust allowing them to move to other areas within the Trust. Peter Reading highlighted the great work the team had undertaken with regard to recruitment and retention of nurses, as the Trust was now higher than the national average in this area. Sandra Hills queried the impact the newly qualified nurses were having on the wards, in relation to the skills mix. Elaine Coghill explained some of the wards had between three to six newly qualified staff, and there had been an increase with supernumerary time which had changed to 4 weeks on the wards, and practice development nurses had also been identified to work with them for support. Sandra Hills queried whether outstanding complaints were sufficiently resourced and Elaine Coghill confirmed there had been a lot of improvements made within team and with work on the wards, although further work was still required.
NLG(20)012
10 | P a g e
Tony Bramley advised this report was also shared at Q&SC, allowing further discussions. He felt there needed to be greater awareness of Trust Board discussions regarding the report to avoid duplication at Q&SC. Tony Bramley referred to the executive summary of the report which he felt required further improvements. Linda Jackson concurred and asked Elaine Coghill and Sandra Hills to discuss the improvements required with Ellie Monkhouse. She also queried whether this report could be included in the items for information in future, and Peter Reading advised the report was required as part of the statutory requirements, however, he felt it needed to focus only on staff only as it had currently grown into a quality and safety report. This had led to duplication of information within the Integrated Performance Report. Sandra Hills and Elaine Coghill agreed to discuss this evolving document with Ellie Monkhouse. Action: Sandra Hills / Elaine Coghill
7.2.2 Ophthalmology – NLG(19)264 Kate Wood shared the report with the Trust Board, and provided an overview of the significant quality and safety issues over recent years in the Ophthalmology Service, which included a number of Serious Incidents (SIs). She advised that a backlog of appointments remained even though assurance had been received with associated plans on a number of occasions to state this would be resolved. She then referred to the performance and activity issues summarised within the report. Shaun Stacey advised there had been a lot of challenges due to the number of referrals and the need to follow-up specific patients / conditions. He advised that work had been undertaken to improve the flow through the service, with two fail safe officers who had initially been appointed on an interim basis but who are now substantive. He confirmed that despite such improvements being put in place, the Trust was struggling to sustain this service. Tony Bramley confirmed such discussions had taken place at Quality & Safety Committee who remained concerned, and advised a report would be addressed at the private Trust Board meeting later in the day. Linda Jackson noted that the Trust Board remained concerned as a result of this report, and confirmed the Trust would address this issue in the private section of the meeting. Peter Reading felt there had been good tactical approaches to attempt to address these issues, and confirmed this service was expected to continue to grow due to the ageing population. Shaun Stacey advised he was also working closely with the CCGs to realign the arrangements with them.
7.2.3 Annual Infection Control Report 2018/19 – NLG(19)265 Maurice Madeo took the report as read and sought Trust Board approval. The Trust Board approved the report and Tony Bramley confirmed it had been discussed at the Quality & Safety Committee.
7.2.4 Annual Adult & Children Safeguarding Report 2018/19 – NLG(19)266 Craig Ferris took the report as read and sought Trust Board approval. The Trust Board approved the report and Tony Bramley confirmed it had been discussed at the Quality & Safety Committee.
NLG(20)012
11 | P a g e
7.2.5 MCA / DOLS Annual Report 2018/19 – NLG(19)267 Richard Painter took the report as read and sought Trust Board approval. The Trust Board approved the report and Tony Bramley confirmed it had been discussed at the Quality & Safety Committee. Tony Bramley advised there would be changes in relation to the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DOLS), which would bring implications on how the Trust would monitor this going forward. He added that there would also be a transition of additional services from the local authority; which could lead to additional staff requirements. Richard Painter advised from 2020/21, MCA/DOLS would be the responsibility of the Trust instead of the Local Authority, and this service area currently consists of three major teams. He explained he was awaiting further clarification from the Code of Practice which was due to be shared. He added that all acute trusts had concerns due to no additional funding being made available. Linda Jackson requested that the Quality & Safety Committee monitor this from an assurance perspective, and Sandra Hills agreed. Craig Ferris confirmed that although these changes would bring some implications for the Trust, it would also bring a greater control too. He advised a report would be shared early next year regarding the funding requirements, and explained there could be legal challenge if the process was not carried out effectively. Peter Reading asked if Craig Ferris and Richard Painter could liaise with Sue Barnett in relation to additional funding as soon as possible to ensure it is captured in the business planning timetable for next year. The Trust Board supported the plans for 2019/20.
7.3 CQC High Level Feedback following CQC Inspection – NLG(19)268 Wendy Booth shared the report with the Trust Board and advised it provided high level post inspection feedback from the Care Quality Commission (CQC), which was consistent with the verbal feedback already provided. A key issue from the CQC letter related to ongoing concerns with the backlog of outpatient follow-ups and diagnostic imaging. She advised that additional information and assurance had been provided to the CQC on these issues and a subsequent meeting had been held with CQC colleagues the previous week. Wendy Booth explained that the CQC had acknowledged this was a very complex area of work. Shaun Stacey confirmed he felt the meeting had been very positive with a good discussion and Kate Wood concurred. Linda Jackson felt the meeting had provided the CQC with some positive progress and thought they felt assured by this. She asked Shaun Stacey to pass on the thanks from the Trust Board to everyone who had been involved in collating the evidence, which included the operational teams. Sandra Hills felt this should be extended to include Jeremy Daws due to the ongoing work with providing additional evidence. Linda Jackson asked for the names of any other individual staff members to be sent to her so that she could e-mail to thank them.
NLG(20)012
12 | P a g e
7.3.1 CQC: Quarter 2 Stocktake – NLG(19)269 Kathryn Helley took the report as read and advised that although the Trust is awaiting their final CQC report, the oversight of actions from the previous report are still being monitored. She explained that the report detailed the stocktake from the end of September 2019 with the self-ratings from the divisions. She added that some movement had been noted and the report had also been discussed at TMB. Tony Bramley referred to the high level summary tables on page two of the report and queried whether the CQC would have focussed on this during the recent visit. Kathryn Helley advised that if they felt there was significant concerns it would also be included in this report. Peter Reading advised that a lot of the actions are specific to divisions and although some of these actions are being progressed, some were not. He asked Kathryn Helley and Shaun Stacey to liaise and to add the relevant actions to the agenda for the Performance Improvement Meetings (PIMs) to ensure monitoring is undertaken. Kathryn Helley and Shaun Stacey agreed.
7.3.2 Internal Audit Review of Fit & Proper Persons Requirements – NLG(19)270 Wendy Booth shared the report with the Trust Board and advised that the internal audit report had only been received that day but had provided ‘Significant Assurance’ regarding the Trust’s arrangements whilst acknowledging some minor gaps in the information in some files which were being addressed as a matter of priority and some minor recommendations for improving recording processes going forward. She advised that the Trust’s policy had also been updated. an update would be provided to the CQC. Sandra Hills referred to point 3 of the policy as it did not reference the Senior Independent Director in relation to appointing the Chair, and Wendy Booth agreed to review the policy and amend, as appropriate. Tony Bramley queried whether the audit report would be sent for the inclusion of the management response. She advised that the audit report would also be shared with Audit Risk & Governance Committee members once finalised.
8. Leadership, OD & Culture 8.1 Board Development Programme
Wendy Booth referred to the brief discussion at the September 2019 Trust Board meeting where she had sought comments from board members on the Board Development Programme for the following year. She advised she had not received any comments back as yet, and it was therefore agreed to spend some time at the December 2019 Trust Board development / briefing day to discuss this and the Board Maturity Matrix compiled by the Good Governance Institute to review the Trust’s current position and which will, in turn, inform the Board Development Programme. Board members agreed.
8.2 Workforce Committee Highlight Report & Board Challe nge – October 2019 – NLG(19)271 Sandra Hills shared the report on behalf of Jeff Ramseyer. She advised that the NHS People Plan distribution had been delayed which had impacted on the approval and implementation of the Leadership Development Strategy. A decision had been taken to wait for and incorporate the recommendations from the People Plan into the new Strategy. She then provided an overview of the Dido Harding letter which the
NLG(20)012
13 | P a g e
committee had discussed, specifically in relation to the work being undertaken to review the exclusion process.
Claire Low took it as read, and noted there were no issues for escalation.
8.3.2 Freedom to Speak Up Guardian Quarterly Report – NLG(19)273 Kay Farquharson shared the report with the Trust Board and advised there were no concerns to be highlighted. She referred to the improvements noted in the paper detailing the progress made following the July report, which had been discussed at the Workforce Committee. Tony Bramley confirmed detailed discussion had taken place at the Workforce Committee and the quarter on quarter data comparisons were very helpful. Kate Wood noted that timescales had now been added as previously requested. Kay Farquharson advised that the Strategy & Action Plan had been progressed and new guidance had been implemented to review gaps in the Trust’s practice. She advised that NHSE / I were pleased with the progress to date, which would need to be maintained.
8.3.3 Leadership Development Strategy Claire Low advised the Leadership Development Strategy had not been ready for ratification at the Workforce Committee, as the NHS People Plan was key to this report and an agreement had been made to delay it as per the earlier discussion. She advised the strategy would now be ready for approval in January or February 2020.
8.3.4 Flu Vaccination Self -Assessment – NLG(19)275 Claire Low took the report as read and briefed the Board on the current position with the flu vaccination target at the end of October 2019. She advised that the numbers of staff being vaccinated remain low in relation to nurses and medical staff. Kate Wood asked if members of the Trust Board could advise her on anything which could help with regards to increasing the numbers of medical staff being vaccinated. Peter Reading advised the CQUIN target for flu vaccination was 80% but the Trust was aiming to achieve 85%, being an increase on last years’ figures. After some discussion it was agreed to look at how this could be publicised further on the Hub, and Adrian Beddow agreed to liaise with Claire Low outside of the meeting.
October 2019 - NLG(19)276 Tony Bramley shared the report with the Trust Board. He referred to the work undertaken in relation to the Waiver & Standing orders report which had identified 500 contracts running, and 400 of these required action over the following year. He advised the current quarterly report detailed that some of the contracts had been extended and they would require reviewing, which would pose significant risk to the
NLG(20)012
14 | P a g e
Trust over the next year and add extra pressure to the Procurement team. He advised this would need discussing at a future meeting before the end of the financial year.
10. Health Tree Foundation Trustee’s Committee 10.1 Health Tree Foundation Trustee’s Committee Highlight R eport – October 2019
– NLG(19)277 Neil Gammon provided an overview of the report and highlighted that the Committee had agreed a revised protocol for dealing with bids for financial support.
10.2 Briefing of the Role and Work of the Health Tree Fo undation Trustees’ Committee – Presentation Neil Gammon and Andrew Barber deliver the presentation to the Trust Board. Neil Gammon highlighted the successful appeal and subsequent development of the Maternity Bereavement Suite and advised that the Executive Leads for the Health Tree Foundation Trustees’ Committee were now the Medical Director and Chief Nurse. Any comments or questions were then sought. Following a discussion about potential fundraising for community projects, Jim Hayburn advised the Trust should be true to the remit that the committee was given and monies raised should be maintained for the Trust. Neil Gammon confirmed the committee was also very respectful of fulfilling the wishes of donors. Sandra Hills felt the Trust should not forget the Trust covers acute and community services and there could be a greater focus on community based services when fundraising. It was agreed to discuss this further at the next Health Tree Foundation Trustees’ Committee.
11. Items for Approval 11.1 Revision of the Standing Financial Instructions (SF Is) and S cheme of
Delegation The Trust Board was advised this item had been deferred to the January 2020 meeting.
11.2 Finance & Performance Committee Terms of Reference – NLG(19)279 Linda Jackson took the report as read and sought Trust Board approval. The Trust Board approved the report.
11.3 Anti -Slavery Statement – NLG(19)280 Claire Low took the report as read and sought Trust Board approval. The Trust Board approved the report.
12. Communication Round -Up Adrian Beddow advised that a new member of staff had joined the team who had previously worked for them in another role. He also advised that the team had been working on recruitment issues with Elaine Coghill. He then provided an overview of the ‘Our Stars’ event held the previous week which had been well attended, confirmed that the “Ask Peter” had now reached over 1,000 questions and advised social media coverage continued to grow. With regards to publicity; he advised an
NLG(20)012
15 | P a g e
experimental approach had been taken to publicise ‘hidden services’ such as speech therapy etc. Adrian Beddow provided a brief update on the media coverage regarding the smoking shelter and advised that Kate Wood had also been interviewed for the television and radio regarding refugee doctors.
13. Items for Information / To Note (please refer to Appendix A) The sub-committee and other supporting papers were noted. 14. Any Other Urgent Business There were no items of any other urgent business raised at the meeting.
15. Board Performance and Reflection Linda Jackson queried whether Board members thought the agenda was
appropriate; had the appropriate issues been debated and was there anything missing. She asked if the Board felt relevant items had been focussed on along with the quality of papers being appropriate. Trust Board members confirmed they were satisfied with all arrangements. Sandra Hills felt that the Board had appropriately discussed serious items during the meeting as appropriate. Linda Jackson queried whether Board members were supportive of changing the order of the agenda to support staff availability in addressing specific agenda items, and Board members agreed with this proposal. The meeting closed at 1.01 pm.
16. Date and Time of the next meeting: Tuesday, 4 February 2020 10.00 am Main Boardroom, Diana, Princess of Wales Hospital
Version: February 2020 Page 1 of 3
NLG(20)013
TRUST BOARD ACTION LOG - PUBLIC
2019/2020
Version: February 2020 Page 2 of 3
Date of Meeting: Tuesday, 30 August 2018 Minute Ref
Agenda Item Action Point Owner Due Date Completed Date Progress Status
7.1 Remuneration Committee Terms of Reference
To be updated to reflect changes to the UK Corporate Governance Code
Jayne Adamson / Claire Low / Wendy Booth
5 November 2019 7 January 2020 4 February 2020* (*Further revised date)
Formal review of the committee and Terms of Reference undertaken – outcome to be submitted to the Trust Board in January 2020*. *Outcome of the review and revised Terms of Reference to be provided at the 4 February 2020 meeting.
Overdue
Date of Meeting: Tuesday, 3 September 2019 Minute Ref
Agenda Item Action Point Owner Due Date Completed Date Progress Status
2.8 Board Development Programme
Trust Board members to provide topics and activities for future board development
Wendy Booth 5 November 2019 4 February 2020
Initial discussion at the November 2019 meeting. Further update to be provided at the February 2020 meeting.
Update on the sustainability of the Ophthalmology Service to be provided to the Trust Board
Shaun Stacey / Kate Wood
5 November 2019 Progress report provided at the November 2019 meeting Completed
10.1 Revision of the Standing Financial Instructions (SFIs) and Scheme of Delegation
Process for embedding of the SFIs and Scheme of Delegation to be reviewed at the Audit, Risk & Governance Committee
Tony Bramley TBC TBC – once final revised versions approved.
TBC
Version: February 2020 Page 3 of 3
Date of Meeting: Tuesday, 5 November 2020 Minute Ref
Agenda Item Action Point Owner Due Date Completed Date Progress Status
8.3.3 Leadership Development Strategy
Agreement reached to delay the approval of the strategy due to the delay in publication of the NHS People Plan. Trust Board to be kept informed of developments.
Claire Low 4 February 2020 Progress report to be provided at the February 2020 meeting as part of the discussion on the Development & Implementation of the Supporting Strategies underpinning the Trust’s Strategic Plan.
On Track
Note: Where relevant dates have been changed to reflect the move to bi-monthly meetings Key: RED Overdue AMBER On Track GREEN Completed – can
be closed
1
NLG(20)014
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Dr Peter Reading, Chief Executive
CONTACT OFFICER Kathryn Helley, Improvement Programme Director
PURPOSE OF THE REPORT: To receive and note progress
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
In April 2019, the Board approved the key priorities for the organisation for 2019/20. The priorities are centred around six themes:
o Quality and Safety o Culture and Morale o Money o Staffing o Clinical Leadership o Clinical service Redesign and Service Improvement o
The report outlines progress in the first nine months (April to December).
TRUST BOARD ACTION REQUIRED
The Board is asked to receive and note the progress against the Trust Priorities for 2019 / 20
2
IMPROVING TOGETHER
NLAG’s KEY PRIORITIES FOR 2019/20 1. Introduction In April 2019, the Trust Board approved the Trust’s key priorities for 2019/20, centred across six themes, Quality and Safety, Culture and Morale, Money, Staffing, Clinical Leadership and Clinical Redesign and Service Improvement. This report outlines progress up to Q3 against these priorities. 2. Progress Safety Further reduce mortality The Summary Hospital Mortality Index score (SHMI) for the Trust is 118 for the period September 2018 – August 2019 which is in the ‘higher than expected’ bracket. Actions to improve the SHMI include:
o Clinician validation of recording/coding and amendments made in response to improved risk recording within the SHMI numerator. Clinical validation of coding in Medical Admissions Units and in Critical Care is currently being undertaken.
o Development and approval of quality of care screening tool (with embedded coding validation tool) went live in January 2020 with the aim of reviewing a higher proportion of deaths for quality indicators and increasing clinician led validation work with coders.
o There is a focus on recording Charlson comorbidities electronically (within Web-V) to improve risk recording within the SHMI denominator. Ongoing coding/documentation improvement programme.
3
Strengthening care for deteriorating patients National Early Warning System (NEWS) scores conducted on time with a 30 min grace period was 86.45% in December 2019. This is a reduction but is within normal variation as demonstrated via the statistical process control chart below which shows improvement over time. The escalation policy including community and in-patient care has been drafted and is currently out for comment. A sepsis and escalation snap shot audit has been carried out in each division. This demonstrated areas where further improvements were required and work is under way with these divisions. Manual review will continue to take place pending further work on the electronic recording system. Further audit is planned.
Improve medication safety including Electronic Pres cribing and Medication Administration (EPMA) Medication Safety This project aims to improve the safety of insulin prescription and administration for patients in the trust. To date, 85 staff have received additional training on insulin presentation and monitoring and insulin incidents continue to be monitored. It is too early to see whether the training has had a positive effect in reducing the number of incidents. EPMA The EPMA project went live in Goole during November 2019 across 4 wards and theatre recovery without any major issues. We are on course to go live in Scunthorpe General Hospital in February 2020.
4
Improve patient flow and reduce non-elective length of stay
To support the reduction in length of stay and patient flow the following initiatives have been introduced:-
o An Urgent Treatment Centre was introduced at Scunthorpe General Hospital in March 2019 and received formal designation as a UTC in December 2019. The unit at Diana, Princess of Wales Hospital commenced in March 2019 and is expected to receive designation in February 2020.
o An Acute Assessment Unit was introduced in Medicine at both Scunthorpe General Hospital and at Diana, Princess of Wales Hospital in November 2019.
o The Trust have commenced work with NHS Elect to implement Same Day Emergency Care pathways
These have not yet resulted in a significant reduction in length of stay. To support this work and identify further areas for improvement, a ‘Multi-agency Discharge Event (MADE) is currently being planned for February 2020 which will be the forefront of a ‘perfect week’. The aim of which is to review and adjust working practice to ensure service delivery is streamlined for our patients. Improve cancer services including diagnostic report ing
Cancer
3
3.5
4
4.5
5
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Average number of days for non elective patients (number of days)
5
Whilst the Trust continues to deliver 2 week waits on target, compliance with the 62 day cancer metric remains poor. Tertiary capacity also continues to be insufficient for demand. Key risks include:-
o The 62 day backlog has grown from the beginning of December (111) to 126 at 30 December 2019 and 217 as at 20 January 2020. The greatest increase is in Colorectal, from 47 (2/12/19) to 100 (20/1/20)
o 76.7% of breaches in December 202 were in 3 specialties (Colorectal, Upper GI and Urology – prostate)
o 1st appointments booked by day 7 remains an outstanding issue, particularly in Colorectal (35%), Head & Neck (32%), Upper GI (49%). Lung/Haem/Skin (50-52%)
o Endobronchial Ultrasound (EBUS) is scheduled to commence at NLAG by 31 January 2020
To improve cancer performance, the following improvements have been made: o Improvements in first appointment by Day 7 in Breast (96%), Gynaecology (84%),
and Urology (64%) o Improvements in Radiology waiting times (for requests marked 31/62). Request
to exam at 8.4 days (CT) and 6.0 (MRI); and Exam to report 3.1 days (CT) and 2.4 days (MRI)
o Haematology strategy developed with Hull. o Centralisation of oncology clinics: steering group to oversee the oncology
reconfiguration in place (January 2020). o Joint Cancer Board between HUTH and NLAG – agreed stocktake for Prostate,
Lung, Head & Neck, Upper GI pathways undertaken.
Diagnostic reporting In August 2019 the Trust commissioned additional outsourced support to improve radiology reporting times. This has led to the reporting backlog being recovered and under control. The total unreported cases have reduced from 11,000 to 3,000 and there are less than 30 cases overdue for reporting. The graph below shows this improved position.
6
In addition, work continues to improve performance in diagnostics although there are continued pressures across MRI, CT and Non-Obstetric Ultrasound. Key risks include:
o Capacity for CT/MRI o Cancer diagnostics continue to be more than 7 day turnaround although
improvement plans are being developed around a rapid diagnostic centre at HCV level
o Supporting Trust with RTT position (long waiters) is impacting on ability to book diagnostics in chronological order
o Endoscopy rota management. Culture and Morale Pride and Respect 3007 staff have received Pride and Respect training since its launch, including 287 doctors. The Trust uptake rate is 39.54% of current staff having attended the training. 18 further training sessions have been booked to the end of February 2020. 85 staff have accessed the Let's Talk service with a 94% success rate. The recent Staff Survey response rate closed at 39%, just short of the national average, which was an improvement on the previous response rate of 35%. The results are due towards the end of Quarter 4 (2019/20). This will enable the establishment of baselines on questions relevant to culture and morale issues but also allow identification of areas for future focus and action. Medical Engagement Scale Results of the Medical Engagement Scale (MES) were presented to clinicians and managers at an event held in November 2019. Findings clearly demonstrate improvement since the MES was carried out 2 years previously. The highlights below 2017, right 2019) reveal an improvement in engagement scales for specialty grade doctors, with a mix across other grades. This demonstrates an improving picture.
7
2017 Findings
2019 Findings
Following the feedback event the Medical Director’s Office (MDO) has identified 3 key priorities to improve engagement:-
• Developing trust • Improving communication • Empowering clinicians
These form the foundations of the Medical Engagement Strategy, and work to improve engagement will closely align with the recent findings of Professor Michael West and Dame Denise Coia (2019) ‘Caring for doctors, caring for patients’. The MDO has engaged and sought feedback from the Divisional Clinical Directors and Clinical Leads, as well as close working with the Organisational Development team within the Directorate of People & Organisational Effectiveness in developing the strategy, which is in the final stages of approval.
8
April 2020 will also see the MDO working collaboratively with CCG colleagues to host the delivery of an engagement event to further develop relationships between primary and secondary care. Leadership Development Strategy The first draft of the leadership development strategy is prepared. However work is currently on hold until the release of the National People Plan, which will set the national direction going forward. Money Deliver £20m CIP The December 2019 (Month 9) year-to-date delivery for 2019/20 savings is £15,653.7k against a plan of £14,214.7k. In-month delivery was £1.77m against a plan of £1.88m a shortfall of £114k. Current delivery means that the Trust remains on course to deliver its £20m plan.
Gain Treasury approval for £29.26m capital Work has commenced on the development of the Outline Business Case (OBC) for the Acute Assessment Facilities (AAU) for both Scunthorpe General Hospital and Diana, Princess of Wales Hospital. Sub groups have been established to develop the key aspects of the business case. The OBC is due to be presented at the relevant Trust committees in June 2020 before being taken to Trust Board in July 2020. It will be submitted NHS Improvement/DHSC/HM Treasury Approvals via the STP in July 2020.
9
Staffing Ward nursing establishment reviews The Chief Nurse and her team reviewed ward establishments across all adult and children’s wards in spring and summer 2019, presenting a paper to Trust Board in August. Nursing teams across the wards were involved in the review process and the Chief Nurse met with every ward manager to review and discuss the recommendations for investment. In September 2019, the Trust Management Board agreed an initial investment of £1.1 million for the highest risk areas. The £1.1m first phase funds have supported: • Introduction of a twilight shift for registered nurses to help match activity levels
of patient flow into the evening • An increase in staffing at weekends • Better skill mix across wards • Investment in the A&Es during twilight and more senior leadership overnight. Phase 2 Ward Establishment Review process is a high priority in the 2020/21 business plan, which will provide additional funds to support ward establishments. Recruitment has begun, including overseas nurses to ensure rapid appointment to vacancies.
Consultant, middle grade and CNS job plans review
Job planning has been a key priority for 2019/20. The majority of teams have now completed their team job plans, enabling individual consultant job plans to be created. These are going through the sign off process during February 2020 and achievement against this target will be reported in the next update. Awareness sessions were held throughout November and December 2019 as part of continued professional development to help all staff understand the requirements and needs of Medical Job Planning. Sessions were well attended with positive feedback. Quality improvement programme In March 2019, the Trust Board approved its Quality Improvement Strategy which outlined 5 key objectives:-
o Putting patients at the heart of quality improvement o Developing quality improvement leadership o Building and embedding quality improvement skills and competencies o Building a quality improvement culture at all levels o Holistic system adoption of quality improvement
10
Actions taken to delivery these objectives include:-
o Establishing a QI Faculty of four experienced Improvement Managers who are all accredited QSIRAs
o Delivery of ‘Plot the Dots’ sessions to Trust Board, members of the senior team and approximately 70 staff from across the health system
o QI training is now embedded in all internal leadership and management training courses with the QI Faculty delivering QSIR training modules with apprenticeship courses.
o The Faculty has created and launched a QI resource centre for leaders and staff on the HUB.
o Formed a dedicated PGME/QI Training Faculty to deliver QI training to F1/F2 doctors. The PGME/QI Faculty is a partnership between QSIRAs and 4x Consultant F1/F2 Programme Leaders
o Delivered three Quality Improvement Sessions to in excess of 200 staff across the Trust as part of the Leadership Conferences running through Autumn and into Winter of 2019. These sessions focused on the Model for Improvement and featured 3 interactive breakout sessions which saw high levels of engagement.
o QI methodology is being used throughout a number of projects taking place within the Trust such as adult and children in-patient establishment reviews, deteriorating patient, development of the AAUs, maternity/neonatal collaborative work, effective rostering for medical staffing, UTC development, CNS, AHP and medical staff job planning, pressure ulcers, falls, improving junior doctor induction, embedding Thomas splint in A&E for femur fractures, compliance with AKI bundle and falls to name a few.
In January, NHSE/I agreed to fund the short term, 3 days per week appointment of a Deputy Improvement Director from outside the Trust, reporting to the Chief Executive, half of whose role is to review the development of QI in the Trust, advise the Executive on how this may be improved, and then support changes to deliver accelerated and deeper delivery of QI. Clinical Leadership Appoint clinical leads 30 clinical leads have been appointed. Clinical Redesign and Service Improvement North Lincolnshire out of hospital transformation p roject Collaboration within North Lincolnshire remains strong but, as yet, with modest outputs.
11
Move elective work to Goole Theatre session utilisation at GDH continues to be a priority and there has been a slight improvement in recent months. However, further work needs to be undertaken to ensure in-session utilisation is maximised to increase productivity through all theatre activity at GDH.
Urgent Treatment Centres (UTC) In January 2020, at the request of NEL CCG, the Trust took over leadership of the Grimsby UTC from CCL (Core Care Links). This will be visible in terms of rota consistency from mid-January 2020, using a mix of PCN and bank GPs to deliver the model and the possibility of the Trust itself employing GPs is being worked through. Roll out of NHS 111 pre-bookable appointments is behind plan, however, this is expected to commence in February 2020. The chart below demonstrates that the UTC is consistently seeing more patients than was planned.
Sum of Additional (free sessions or WLIs) Sum of Total sessions used
Utilisation of planned sessions Sum of Utilisation (inc. additional)
12
Humber Acute Services Review (HASR) including mater nity service re-design and trans-Humber cardiology and haematology Work continues on the Humber Acute Services Review. The Case for Change has been completed following the clinical design workshops and patient engagement events for:- - Urgent and emergency care, acute assessment, inpatient and critical care - Maternity and Paediatrics - Planned care. The output has created a long list of options for Urgent & Emergency Care and Maternity, Planned Care and Paediatrics. A series of well attended workshops with clinicians from both Trusts have been held looking at each of these areas. Outpatient transformation programme There has been an increase in the backlog of overdue follow-ups due to reduced activity over the Christmas period and cancellations of clinics due to high demand through our non-elective pathways. However, patient numbers without a due date are reducing as seen in the graph below.
The use of virtual clinics is currently being worked through for impact in the 2020/21 operational business plans. Advice and guidance requests from GPs, and responses from the Trust within 48 hours, continue to increase. The Trust was successful in being accepted to take part in the ‘100 day challenge programme’ supported by NHSE/I and a launch event took place on 18 December 2019. This is a regional programme which offers health systems the opportunity to implement and test interventions in rapid ‘sprints’, completing the programme within 100 days and then bring together information and case studies to allow others to learn from their experience.
13
The plan for the transformation programme for 2020/21 is out for discussion with all system partners. Fractured neck of femur The Trust performance on treatment for fractured neck of femur continues to exceed the target of patients receiving surgery within 36 hours from arrival in an emergency department, or time of diagnosis if an inpatient, to the start of anaesthesia. The graphs below show that this has been achieved consistently on both hospital sites since April 2019.
Scanner programme Magnetic Resonance Imaging (MRI) Scunthorpe: Work has commenced with NHSI/E to fast track through the full business case to address the capacity pressures the Trust currently faces. It is anticipated that the new Magnetic Resonance Scanner (MRI) will be fully operational in 2021. Grimsby MRIs: The full business case was approved at Trust Board in December 2019. Construction commences on 10 Feb 2020.
14
Computerised Tomography (CT) The first cut of the Business Justification Case was approved at Trust Board in December 2019 following a procurement and market test through the NHS Supply Chain for the options of a lease or purchase of the CT modular. The approval of the case has enabled the design team to work with the Supply Chain and the Division to finalise the detail on the design incl. groundworks. The programme is aiming for the modular to be installed and operational by late Autumn 2020. Refurbish ward 29 The Royal Institute of British Architects (RIBA) stages 1-4 are already complete - full business case is already approved, the admin move is complete and the contract has been awarded. Construction is under way and remains on track for completion in June 2020. A number of works stoppages have taken place, the contractor is stating a one week delay, however this does not affect the programme and completion date. No over-40 week waiters and reduce (incomplete) waiting list by 2,500 Despite good progress, the number of patients waiting more than 40 weeks increased in December 2019, as seen in the graph below. This was due to operational pressures and cancelling of some elective surgery. This group of patients is monitored on a weekly basis. The target of eliminating over 40 week waiters by the end of March 2020 remains and is a national requirement.
Conclusion and Recommendation As shown above, strong progress has been made across many, but not all priorities. The Board is asked to note and comment on progress. Peter Reading Chief Executive 30 January 2020
NLG(20)015
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Shaun Stacey, Chief Operating Officer
CONTACT OFFICER As Above
SUBJECT Changes to Oncology Services
BACKGROUND DOCUMENT (IF ANY) N/A
PURPOSE OF THE REPORT: For information and assurance
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The report provides a briefing for the Trust Board on changes to Oncology Services, the approach taken to communicat ing those changes to relevant stakeholders and the proposed n ext steps
TRUST BOARD ACTION REQUIRED
The Board is asked to note the report
January 2020 Briefing on changes to oncology services – Scarboro ugh Hospital, Bridlington Hospital, Scunthorpe General and Diana, Princess of Wales Hospital The purpose of this document is to outline the approach to communicating proposed changes to the delivery of oncology services affecting patients on the East Coast served by Scarborough and Bridlington hospitals, part of York Teaching Hospital NHS Foundation Trust and the South bank of the Humber served by Diana Princess of Wales Hospital, Grimsby and Scunthorpe General Hospital, part of the Northern Lincolnshire and Goole NHS Foundation Trust. This is initially a temporary change made on a basi s of patient safety, a further review will take place after three months. A joint approach will be taken by the following organisations:
• York Teaching Hospital NHS Foundation Trust • Hull University Teaching Hospitals NHS Trust • Northern Lincolnshire and Goole NHS Foundation Trust • NHS Scarborough and Ryedale CCG • NHS East Riding of Yorkshire CCG • NHS North East Lincolnshire CCG • NHS North Lincolnshire CCG • Humber, Coast and Vale Health and Care Partnership • Humber, Coast and Vale Cancer Alliance System Board
What is oncology? Oncology is the treatment and management of patients with cancer using treatments such as radiotherapy and chemotherapy. The part of the service that is changing is the location of oncology outpatient appointments at Scarborough, Bridlington and Scunthorpe hospitals, and inpatient oncology at Scunthorpe. At these outpatient appointments, patients will discuss their diagnosis, test results, and treatment options with the oncologist. Patients may undergo an examination, have blood tests, and be referred for further investigation and treatment. For the majority of patients, the provision of chemotherapy will not be affected by this change and will continue to be provided in its current locations. Patients will usually attend multiple oncology appointments, the number will vary dependent on the nature of their disease and their treatment plan.
Background: Hull University Teaching Hospitals NHS Trust (HUTH) provides a range of high quality oncology services at the Queen’s Centre, Castle Hill Hospital in Cottingham for patients from Hull, East Riding and surrounding areas. Under an arrangement with York Teaching Hospital NHS Foundation Trust (YFT), HUTH provides medical oncology outreach services at Scarborough Hospital (four days per week) and some at Bridlington Hospital (one morning every alternate week). This is provided by HUTH with one substantive consultant, one specialty doctor in a locum consultant role and one specialty doctor. Chemotherapy is delivered through the well-established, nurse-led service in Scarborough Hospital and Bridlington Hospital (through the mobile chemotherapy unit). Under an arrangement with Northern Lincolnshire and Goole NHS Foundation Trust (NLAG), HUTH provides medical oncology outreach services at Diana Princess of Wales (DPoW) Hospital in Grimsby (five days per week) and Scunthorpe General Hospital (five days per week). This is provided by HUTH with 10 substantive consultants, one speciality doctor in a local consultant role and two speciality doctors. Chemotherapy is delivered through the well-established, nurse-led service in Scunthorpe General Hospital and at DPoW, Grimsby. All radiotherapy treatment is undertaken within the Queen’s Centre, Castle Hill Hospital. Why is the change necessary? Oncology services have been provided at Scarborough, Bridlington, Diana Princess of Wales and Scunthorpe General hospitals by HUTH for a number of years. The provision of this service has been under increasing pressure for many years due to workforce pressures and recruitment difficulties. Despite every effort to maintain the current mode of consultant-led care, the situation is worsening and now requires an alternative model to be urgently implemented in conjunction with all stakeholders. The Hull oncology team is currently facing significant challenges.
• Vacancies One of the main contributing factors is the significant lack of oncologists (both locum and substantive) nationally to employ. HUTH has advertised on numerous occasions over the past 18 months, for both substantive and locum staff, with limited success. A previous workforce strategy concluded that an additional 5.5 wte consultants are required, simply to cover the existing levels of current activity and complexity ant to be in line with national guidance.
There are currently 4 substantive oncology Consultant vacancies in Hull University Teaching Hospitals. This is a significant proportion of the 21 oncology consultant posts in total at Hull.
• Staff Health and Wellbeing
There is a higher than average level of sickness absence within the substantive consultant oncology workforce and it is important to ensure that staff health and wellbeing is protected.
• National Shortage of Oncologists
There is a national shortage of oncologists and also oncology trainees. The service has advertised numerous times over the past 18 months to recruit both substantive and locum staff with little success.
As a result of these workforce challenges, it is no longer possible for Hull University Teaching Hospitals NHS Trust to maintain a high quality, safe oncology service in all locations that is both consultant-led and delivered. In order to maintain services with the current numbers of consultants it is necessary to consolidate the majority of consultant time within the Queen’s Centre at Castle Hill Hospital in Cottingham. This will reduce the time spent travelling by consultants and ensure that the maximum amount of patient care is obtained from the limited consultant resource. What is changing? Given the current levels of referral and the reduction in available resources, a number of options were considered as to how to deliver oncology services in order to deliver a safe and quality service to patients. Based on patient safety, a temporary change is being made to service provision which will see the following: All first outpatient appointments for new patients will be provided in the Queen’s Centre at Castle Hill Hospital, Cottingham or Diana Princess of Wales Hospital, Grimsby by the relevant oncology team specific to the type of cancer. This will facilitate consultant-led oversight of care and ensure that there is equality of service provision for patients across the wider region. Scarborough and Bridlington: Consultant Oncologist presence within Scarborough Hospital will continue for one day per month in order to provide clinical assurance, managerial oversight and support to service development. This will allow the majority of follow up care to continue to be provided in Scarborough by specialty doctors, according to clinical need. The medical oncology service provided at Bridlington one day per fortnight will be withdrawn. Oncology in-patient services are currently delivered at Scarborough Hospital by local physicians – this will not change and support will continue to be provided from visiting consultants and specialist doctors. All patients requiring more intensive support are already transferred to Castle Hill Hospital and this will continue. Patients in follow up who require significant treatment decisions will either receive a further face to face review with the team at the Queens’ Centre, Castle Hill Hospital or, if clinically appropriate, their case will be reviewed through a virtual clinic link up between clinicians in Scarborough and Castle Hill Hospital. This will maintain consultant oversight at all critical phases of the patients’ journey as well as enabling some treatment change follow up appointments to continue in Scarborough.
All chemotherapy that can be safely delivered at Scarborough Hospital will continue to be delivered locally under the supervision of the local nursing team and visiting speciality doctors. The mobile chemotherapy service at Bridlington Hospital will also continue. Patients with Gynaecological or Renal cancers will have all face to face outpatient appointments at Castle Hill Hospital. Chemotherapy sessions for these patients will take place at Castle Hill Hospital and will not be able to continue at Scarbo rough and Bridlington. It has always been the case that patients requiring particularly specialist or complex therapy have received it at Castle Hill Hospital, and this is currently the case for all cancer pathways. Due to the small numbers of patients with gynaecological or renal cancers, and the complexity and potential complications of their therapy, specialist supervision is required to ensure safe delivery of their treatment. Northern Lincolnshire and Goole NHS Foundation Trus t: To ensure patient safety and the highest levels of patient care, every oncology patient must receive a consultant-led plan with adequate supervision provided for non-consultant grade staff. The only way to facilitate this at this current time is to consolidate onto one site within Northern Lincolnshire and Goole Trust. Whilst the consolidation is being considered in the longer term as part of the Humber, Acute Services Review, it now has to be brought forward on a temporary basis due the need to maintain a safe service. The Diana Princess of Wales Hospital, Grimsby has been temporarily chosen over Scunthorpe General Hospital. This decision has been made because Grimsby has a specialist cancer ward and department and moving there is less disruptive to other services. Where patients’ preference is to have their appointments at the Queen’s Centre, Castle Hill Hospital, Cottingham, then patients may do that. Clinic provision at DPoW, following these proposed changes, will be restructured into ‘disease-site specific’ days. These multi-doctor clinics will substantially increase service resilience and allow speciality doctors to work within a consultant-led environment, improving service equality to match services at HUTH and Scarborough. Patients with Gynaecological or Renal cancers will have their Consultant face to face outpatient appointments at Castle Hill Hospital. This is because it is the only place they will be able to see the highly skilled specialist they need as they work at this hospital. Chemotherapy sessions for these patients will continue at both Scunthorpe and Grimsby. With the proposal that all clinically led oncology care will be delivered at DPoW, it has been decided that all acute inpatient care will also be delivered on the same site. This is to ensure that the clinical team is consultant-led and can facilitate acute inpatient reviews and ward rounds. The longer term plan for the location of all
clinically-led oncology care will form part of the Humber Acute Services Review. Further changes to the management of inpatients may be required to ensure adequate service capacity and quality. Who will be affected? Centralising consultant-led outpatient services to DPoW Hospital, Grimsby and Castle Hill Hospital will affect patients from the following CCG areas:
• NHS Scarborough and Ryedale CCG • NHS East Riding of Yorkshire CCG • NHS North Lincolnshire CCG • NHS North East Lincolnshire CCG
Number of patients impacted
• The impact on the Scarborough population relates to 317 patients over a 12 month period – this is the number of patients accessing their first appointment. The majority of these patients will be able to receive follow up appointments at Scarborough Hospital. This figure includes 47 patients with Gynaecological or Renal cancers who will be required to attend Castle Hill Hospital for all appointments, including chemotherapy.
• The impact on the Bridlington population relates to 149 patients over a 12 month period. This figure includes 15 patients with Gynaecological or Renal cancers who will be required to attend Castle Hill Hospital for all appointments, including chemotherapy.
• The impact on the Goole population relates to approximately 36 patients per month .
• The impact on the Northern Lincolnshire population relates to approximately 267 patients per month .
• The impact on North East Lincolnshire population relates to approximately 8 patients per month – this is the number of patients with Gynaecological or Renal cancers only, as all other services will remain at DPoW Hospital.
When will these changes happen? These changes will be made on a temporary basis due to patient safety on 27 January 2020; letters will be sent to patients affected to inform them of these changes. Patients already in the system with an imminent appointment will be contacted by letter, by their respective hospital trust, either York Teaching Hospital NHS Foundation Trust or Northern Lincolnshire and Goole NHS Foundation Trust. Patients will be told that their oncologist will no longer be providing clinics in Scarborough, Bridlington or Scunthorpe respectively. NLaG patients with an appointment between Monday 27 January 2020 and Friday 14 February 2020 will be contacted by telephone to rearrange it. NLaG patients with an appointment on or after Monday 17 February 2020 will receive a second letter
with a date and time for their next appointment. York Trust patients who have an appointment in the next few weeks will also be contacted by telephone to inform them of the change to the location of their appointment. Further letters will also be sent to confirm the date and time for their next appointment. For inpatients, at Scarborough Hospital, there is no change to the provision of care. For acute oncology inpatients, patients will no longer be admitted to Scunthorpe General Hospital. Instead, patients will be admitted to Diana Princess of Wales Hospital, Grimsby. Hull based Oncologists will continue to provide telephone advice to Scarborough clinicians. They are able to access scans and blood results electronically and, based on the number of referrals and type of referrals seen, they are assured that this would be a safe and workable solution What are the next steps? The priority is to ensure that patients who need to be seen by a highly skilled specialist can do so as quickly as possible, and the only way to do this within the current resources is to centralise the service to the Queen’s Centre, Castle Hill Hospital, for patients currently served by Scarborough Hospital and Bridlington Hospital. For patients currently served by Scunthorpe General Hospital this would mean centralising services at Diana Princess of Wales Hospital, Grimsby. This is a short term measure which is necessary to continue to deliver quality and safe services across Northern Lincolnshire, Goole and the East coast. A review will take place three months after these changes, which will be led by the Humber Cancer Board. We are aware that a key impact of this change is likely to be around transport. We are working very hard to minimise the impact on this by helping patients with alternative arrangements for those who need them. Patients who are not eligible for Patient Transport Services, and who have difficulty in getting to the new location for their appointment, will be assessed for transport support. This support is for patients who do not have access to private transport, either their own or through friends/relatives. In these cases the patient may be able to access taxi services between hospital sites. This is detailed in the letter we are sending to them. A long term strategy for the future provision of oncology services is currently underway as part of the Humber Acute Services Review, led by the Humber, Coast and Vale Health and Care Partnership.
BOARD ASSURANCE FRAMEWORK (BAF)January 2020
Content:
Section 1: Trend over time - Mitigation of Trust's 11 strategic risks;
Section 2: Mitigation of 11 strategic risks - in detail (Part a: Executive summary and heatmap; Part b: BAF detail);
Section 3: Appendix: Full list of underpinning divisional/directorate risks underpinning strategic risks.
TARGET CURRENT TREND TREND TREND TREND TREND TREND TREND TREND
Strategic Risk Number
Linked to Strategic Objective Strategic Risk TitleTARGET
RISK RATING Ja
n-20
Dec-
19
Nov
-19
Oct
-19
Sep-
19
Aug-
19
Jul-1
9
Jun-
19
May
-19
1 1. To give great care
Risk of non-delivery of constitutional performance targets, specifically:
2 1. To give great careRisk of non-delivery of agreed quality and clinical improvements (includes the risk of non-delivery of a reduction in the mortality ratio)
3 1. To give great care Adverse impact of Britain's exit from the European Union on business continuity and the delivery of safe care. 8 8 8 8 16 16 16 16 8 8 Shaun Stacey
4 2. To be a good employer Inability to secure sufficient numbers of appropriately skilled staff in the short, medium and longer term. 8 15 15 10 10 15 15 15 15 15 Jayne Adamson / Claire Low
5 2. To be a good employerIneffective staff engagement and ownership of Trust agenda affects morale and failure to change and improve the culture.
(a) Not achieving the control target total agreed with NHS Improvement for the Trust and failure to achieve the overall Northern Lincolnshire system target;(b) Risk of non-delivery of the long term financial plan to produce a balanced financial position, working in conjunction with everyone else to achieve a system balance.
10 15 15 15 15 15 15 15 15 10 James Hayburn
7a
Risk of failure of the Trust’s infrastructure; specifically:
(a) Ageing estate and equipment: the inability to maintain legislative compliant and improve the current estate and equipment due to a lack of capital and backlog maintenance (includes Legionella);
10 20 20 20 20 20 20 20 20 20 Jug Johal
7b
Risk of failure of the Trust’s infrastructure; specifically:
(b) Longer term estate sustainability: failure to secure a sustainable estate future for SGH (and to a lesser extent DPOWH) this may give rise to buildings or parts of buildings becoming unsafe to occupy;
10 20 20 20 20 20 20 20 20 20 Jug Johal
7c
Risk of failure of the Trust’s infrastructure; specifically:
(c) IT / Digital Strategy / Cyber Security: failure of the IT infrastructure and adverse impact on the delivery of the Digital Strategy and on business continuity and the delivery of safe care; and the lack of adequate controls to defend the Trust’s IT systems when a cyber-attack occurs.
12 16 16 16 16 16 16 16 16 16 Jug Johal
8 4. To work more collaboratively Inability to pursue a clear organisational strategy that staff and stakeholders are aware of and support. 8 12 12 12 12 12 12 12 12 12 Sue Barnett
9 4. To work more collaborativelyLack of a clear service strategy for the area to ensure long term service sustainability (includes the risk of not developing the required external relationships and linked to HASR).
9 15 15 15 15 15 15 15 15 15 Sue Barnett
10 4. To work more collaboratively The risk of ineffective relationships with stakeholders. 8 8 8 8 8 8 8 8 8 8 Peter Reading
11 5. To provide strong leadershipRisk of insufficient investment and development of the Trust’s leadership (including clinical leadership) – capacity and capability.
8 12 12 12 12 16 16 16 16 16 Peter Reading
The potential impact of the above risks materialising include:· Poor quality care / harm · Damage to the Trust’s reputation· Further regulatory action and inability to exit quality and financial special measures· Lack of longer term sustainability
Lead Director
Section 1: Trend over time - Mitigation of Trust's 11 strategic risks
4. To work more collaboratively
Strategic Objective: 1. TO GIVE GREAT CARE
*
a)
b)
c)
d)
Linked Corporate or High Level Risk Rating HEATMAP:
5 RTT: 1851 (opth) RTT: 2118 (col)2515: Data accuracyDiagnostics: 2657
The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk. Following meeting with the executive owner of this strategic risk, it is felt the following are further risks that are currently not fully articulated on local divisional and directorate risk registers, and therefore need to be added:
Risk to Strategic Objective:
Monthly Executive Highlight Report:The Trust is currently unable to deliver these 4 performance targets due to demand and capacity constraints. An agreed trajectory for each to maintain delivery of care has been agreed.
Cancer 62 day target: Aim to meet national target in 2021. Current local agreed target 85%.Performance during November 19: Trajectory: 72.8%. ACTUAL: 69.1%.
A&E target: Aim to meet national target in 2021. Current local agreed target: 90%Performance during November 19: Trajectory: 87.8%. ACTUAL: 73.4%.
RTT - 18 weeks target: Aim to meet national target in 2021/22. Current local agreed trajectory: 92%Performance during November 19: Trajectory: 80.2%. ACTUAL: 80.4%.
6-week wait for diagnostics: Aim 1% of diagnostic requests breach the 6 week target. Performance during November 19: Trajectory: 6.2%. ACTUAL: 12.0%
(To be added: (1) Gaps in Oncology service provision due to staff absence; (2) Oncology capacity [Medicine and surgery]; (3) Cancer performance targets in diagnostics)(To be added: (1) Out-Patient Follow-Up - all divisions; (2) Failure to meeting constitutional targets: RTT in Medicine and Surgery); (3) Haematology RTT risk and emergency access to services (medicine); (4) Immunology RTT risk and emergency access to services (medicine)).
(To be added: (1) Financial risk from diagnostics outsourcing contract (CSS).
1) Risk of non-delivery of constitutional performance targets, specifically: (a) Cancer 62 day, (b) A&E, (c) RTT - 18 weeks, (d) Diagnostics.
Risk Description:
Risk tracking trend over time: Catastrophic consequence: 5 x 4: Likely = RR of 20
Monthly Executive Highlight Report: Plans for next month:
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)
Cancer: Discussion of joint proposal between Trust and HUTH with local OSCs and CCGs to consolidate Oncology services onto a single site within NLAG.Cancer: Single Lung Cancer MDT to be in place, January 2020.
RTT / 18 Weeks: Focus on data quality in connection with clock stops, work commenced on the business rule audit - expected 3 month lead time for meaningful data to be available .Diagnostics: MSK service tender by Trust and partners, change in service delivery will reduce demand on diagnostics resource. Intense pressure faced by Operational team identified as a risk, mitigation of risk has included an additional support post to the Chief Operating Officer in January and February.Include in the February 2020 BAF other diagnostic elements comprising performance against DMO1.
The risk is that the Trust fails to deliver or fails to demonstrate robust improvement plans in delivering constitutional performance targets which impairs the Trust's provision of quality services and adversely impacts on its reputation with service users and regulatory bodies.
IPR. Power BI reporting (including ability to compare tumour site performance).
Not meeting 62 day performance targets (62 day RTT and screening).
PRIM divisional update.
Significant improvement seen in Pathology turnaround times.
Quality Priority: Positive results seen to date from the implementation of triage/straight to test in Lung and Urology.
Capacity and demand. Delays in pathways (NLAG and cross-organisational pathways).
R
Delays in developing faster diagnosis pathway in Colorectal.
Not meeting 62 day cancer performance targets (62 day 1st RTT, and screening).
Diagnostic delays and pathology turnaround times impact on pathway timescales.
Not meeting (Aim) of turning around investigations and pathology within 7 days.
Implement timed and faster pathways, starting first with 4 national priorities, Quarter 3.
Stocktake of cancer pathways by joint cancer Board, Ongoing.
Improved processes in Path Links / additional staff recruitment, Ongoing.
A&E Delivery Board and a system wide focus.
UTC focus on managing minors outside of the A&E/ECC department to free up capacity; Acute Assessment Unit work and focus on ambulatory pathways to pull from A&E model.
Development of winter plans.
Additional staff in A&E and UTC (medical and nursing); establishment review completed and additional establishment agreed; Senior positions in the department extended (i.e. Consultant cover till midnight). Matron of the day present at Ops meetings to consider staffing.
Weekly MDT stranded walk around.
A&E board rounds refocussed to 2 hourly and including Acute Medical Doctors to support pull of patients out of A&E.
Refoucssed twice daily huddle with lead doctor and lead nurse to review in more detail activity/acuity. Escalation to medicine management and ops centre.
(b) A&E
Performance data: Symphony A&E system provides real-time performance; Bed state / Sitrep reports; A&E live dashboard; Integrated Performance Report.
Compared to regional peers performance has been better.
Quality assurance: ED Nursing Dashboard/quality indicators; Matron retrospective review of all patients waiting over 10 hours to assess for clinical harm.
Flow challenges at both Trust sites resulting in capacity challenges for patient's needing to be admitted.
Deputy MD supporting engagement work, Mar 20.
(a) Cancer
Central cancer team, with Cancer lead in post.
PTL:Cancer weekly PTL and escalation process;Weekly Cancer PTL meeting - changed end Oct for 6 weeks to focus on top 5 specialties which account for 80% of breaches;
Oversight:Weekly Divisional General Manager Waiting List Assurance Meetings with all divisions;Weekly attendance by Path Manager to improve turnaround times/escalation;PRIM meetings with divisions includes focus on Cancer;Cancer Board meeting; underpinned by individual tumour specific MDT Business Meetings;Joint Cancer Board established between NLAG and HUTH;
Improvement planning:System wide 62 day improvement plan in place focussing on 7-day 1st appt, 28 day definitive diagnosis, IPT by Day 38, Treatment by Day 62 (approved at Planned Care Board Sept 19); Outsourcing contract for diagnostics has supported reducing turnaround times;Patient Triage arrangements in place for Urology, Lung and Colorectal at begining of pathway;
High new to follow-up ratio is some specialties, relating to poor pathway design
Weekly PTL escalation process (currently in draft for approval in January local governance).
(c) RTT/18 weeks
Daily meetings to review long waiters and overdue follow-up pathways.
Weekly meetings held with specialty leads to review in detail pathways for longest waiting patients. Areas for escalation highlighted to COO and DGM.
Weekly escalation/assurance meeting with Chief Operating Officer to review individual patient pathways.
PRIM performance oversight meetings.
Chief Operating Officer weekly meeting within Divisional General Managers for oversight.
Fortnightly oversight meetings include CCGs.
Planned care board has system wide membership.
Refresh of Capacity and Demand Plans and development of Action Plans to reconcile differences being developed to support 20/21 Business Planning.
Outpatient follow-up - Trajectories revised to maximum 9000 overdue by 2021 and 4000 by 2022
Continue to experience single numbers of over 52 week wait patients (Aim: 0).
Reduction in patients waiting more than 40 weeks (Aim: 0 by Mar 20).
IPR report going to F&P and Board. Data reviewed at PRIM.
RCA's completed for patients who wait > 52w for treatment to understand reasons and share lessons. Process to review RCAs for Harm and escalation to full clinical harm review and SI route if indicated.
Fragile services with significant mismatch between capacity and demand leading to long waiting times in 7 specialties (1) ENT; (2) Ophthalmology; (3) Colorectal Surgery; (4) Gastroenterology; (5) Cardiology; (6) Respiratory; (7) Urology.
Increased number of incidents and SIs in Ophthalmology; Gastroenterology and ENT relating to waiting times. Longer term: Development of a
system-wide 3-year plan for these areas (2022).
Demand and capacity refresh of modelling, Dec 19.
Recruitment underway for data validation team, to be in place by Jan 2020.
Data quality gaps have been identified in connection with 'clock stops' resulting in incorrect waiting list categorisation in some instances.
Not fully assured that admin processes are compliant with operational processes.
Trend RAG Rating:RED
Consequences of Risk Materialising:* Impact on provision of quality services to our patients;* Adverse impact on the Trust's reputation and its standing with patients and regulators; * Adverse impact on ability to exit quality and financial special measures or receiving needed support.
Assurance that the issues impacting on this risk are being managed:
Actions required to improve:
Assurance / Oversight Group
Issues: Controls: Assurance: GAPS in Controls: GAPS in assurance:
Integrated Performance Report including the DMO1 position.
Joint proposals between Trust and HUTH to local OSCs and CCGs to consolidate Oncology services onto a single site within NLAG, Jan 2020.
Tumour site MDTs not focussed on QSIS Standards.
Cancer MDT Business meetings not quorate.Cancer Board meeting but not quorate.
Clinicians not reviewing root causes for breaches monthly.
Develop divisional dashboards containing improvement plan within PowerBI, 2021.
Single Lung Cancer MDT, January 2020.
Quality Surveillance (QSIS) annual submission: no improvements in recent years.
QSIS improvement plans delivery; lack of assurance in monitoring of delivery.
Potential for more patients to be on zero LOS pathways.
Potential for more patients to be discharged within 72 hours.
Potential for SAFER bundle to be utilised more.
Escalation beds opened to mitigate, ongoing review.
SAFER project manager to be recruited for 3 months, ongoing.
Development work for Acute Assessment Unit to further develop zero day LOS/ambulatory pathways, ongoing review.
Trust to take on the commissioning of GPs to staff the UTC. Jan 2020.
UTC gaps in GP rotas.
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Due to expanded remit for reporting, shortage of radiographers identified.
Recruitment and training, ongoing.
Demand management of MRI with CCGs.
CCGs reflecting and considering how they may work with PCNs to manage demand, ongoing.
MSK service tender by Trust and partners, change in service delivery will reduce demand on diagnostics resource, monitor impact, Ongoing.
Radiology Diagnostic capacity
Not yet include within BAF other diagnostic services measured by DMO1 (i.e. audiology) other than radiology.
Include in the February 2020 BAF other diagnostic elements comprising performance against DMO1, Feb 20.
PRIM
against DMO1 position; impact on performance as a result of priority focus on RTT improvement.
financial spend for outsourcing contract, Jan 20
A
Complete full business case for NHSI consideration, timescale TBC.
Additional CT Scanner funding approved and to be in place by Aug 2020 (DPoW).
RAG RATING KEY:
escalation.
Backlog of overdue unreported scans has significantly reduced (to 500).
Power BI data monitored daily.
Longest wait for a report is 5 weeks for all examinations.
Additional CT scanner now in place and operational.
Expanded remit for reporting radiographers which increases reporting capacity.
Outsourcing contract with 3rd party provider now in place for reporting to mitigate delays between scan and reporting, 5 year contract with guaranteed capacity.
Controls in place to escalate any scans not meeting internal KPIs to outsourced 3rd party for reporting (KPIs: suspected cancer, not reported same day - escalate to outsourced 3rd party; routine scans, not reported by day 21 - escalate to outsourced 3rd party).
Full business case approved by Board in December for MRI scanners at Grimsby.
(d) Diagnostics
Financial spend on outsourcing contract not yet clear.
Ongoing efforts to recruit Radiologists. Exploring Radiology fellows programme alongside Morecombe Bay following successful pilot. NLAG to join wave 2. Timescale TBC.
Demand management of MSK on all imaging should be in place via the MCATS soloution, Jan 20.
Strategic Objective: 1. TO GIVE GREAT CARE
*
*
*
*
*
*
* Linked Corporate or High Level Risk Rating HEATMAP:
Joint Cancer Board established between the Trust and HUTH. Stock take underway.
New Quality Priorities for 2020/21 discussed and agreed at Trust Board following consultation.
The strategic risk rating for quality has increased from 15 to 20 as a result of increases in the Trust's SHMI 118 (DPoW: 121; SGH: 116).
Mortality screening tool with embedded Coding Validation tool developed; Pilot extension agreed of clinician validation of coding within AMU and Critical Care.
Peer review visit to Trust's Lung Cancer service during the 4/5 December 2019. Awaiting formal report; Trust response with initial action plan due on 17 January 2020.
External review of medication storage arrangements concluded and draft report received for factual accuracy checking.
NHSi funding received for project management support for SAFER project, recruitment underway.
Risk to Strategic Objective:2) Risk of non-delivery of agreed quality and clinical improvements (includes the risk of non-delivery of a reduction in the mortality ratio)
Risk Description: The risk is that the Trust could fail to deliver consistent levels of service quality which negatively impacts on the Trust's reputation with service users and regulatory bodies.
Monthly Executive Highlight Report: Risk tracking trend over time: Catastrophic consequence: 5 x 4: Likely = RR of 20
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)
(To be added: Risk of not meeting 7 day service standards - W&C)
Likelihood (1-5)
Cons
eque
nce
(1-5
)
(To be added: (1) Gaps in Oncology service provision due to staff absence; (2) Oncology capacity [Medicine and surgery]; (3) Cancer performance targets in diagnostics)
The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk. Following meeting with the executive owner of this strategic risk, it is felt the following are further risks that are currently not fully articulated on local divisional and directorate risk registers, and therefore need to be added:
Monthly Executive Highlight Report: Plans for next month:Update and approval of Trust's mortality strategy via MIG in January.
Cancer: Discussion of joint proposal between Trust and HUTH with local OSCs and CCGs to consolidate Oncology services onto a single site within NLAG.Cancer: Single Lung Cancer MDT to be in place, January 2020.
Action plan following external review of medication storage arrangements to be developed, January 2020.
Meeting during January to review barriers to implementation and embedding of SAFER principles.
STRATEGIC OBJECTIVE: 1. TO GIVE GREAT CAREDate added:Last updated:
Mortality Improvement Group;
Quality Governance Group;
Quality & Safety Committee.
Concerns with clinician time, mortality lead f/b to MIG in Jan 20.
R
Divisional awareness / sharing to enable lessons learnt.
Medication Safety Group;
Quality Governance Group
Disparity between sites - statistical calculation of expected deaths.
Disparity in the 'expected' mortality (statistically calculated) between sites; likely data quality driven.
Incident data for improvement purposes available, but accuracy is questionnable.
Appointed Clinical Leads for Safer Medications Group to be confirmed to QGG, January 20
SMG to review quality and availability of insulin training, awaiting CNS in Diabetes to commence in post.
External medicines management review undertaken, final report received, action plan to be confirmed, Jan 2020.
Action plan from external visit to include: (1) Process mapping
A
Deteriorating Patient Group reporting to Mortality Improvement Group
Critical Care Outreach team collected data following their interaction and 24 hours prior during Dec 19. Analysis in Jan 20.
Limited audit evidence of action taken in response to NEWS scores.
Launch and raise awareness of Oxygen policy, Jan 20.Gaps in assurance that oxygen
is being used in line with best practice. Ongoing Oxygen evaluation to
included within Ward Assurance Tool, Feb 20.
Lack of assurance medicines are
01-May-19
Oversight Group: Quality Governance Group 09-Jan-20
Assurance Committee: Quality & Safety Committee
Actions required to improve:
Assurance / Oversight Group
Trend RAG Rating:RED
Negative impact on the provision of quality services resulting in adverse affect on the Trust's reputation with service users and regulatory bodies.
Assurance that the issues impacting on this risk are being managed:
Controls: Assurance: GAPS in Controls:
Kate Wood / Ellie Monkhouse
GAPS in assurance:
Risk to Strategic Objective: 2) Risk of non-delivery of agreed quality and clinical improvements (includes the risk of non-delivery of a reduction in the mortality ratio)
Lead Executive:
Consequences of Risk Materialising:
Issues:
Reduction in cardiac arrests at SGH correlates NEWS improvements; further understanding needed.
Review cardiac arrest data by location and include peri-arrest data, Feb 2020.
Report for ommitted doses at Goole during January 2020.
Review and replacement of coding software (Encoder), TBC.
Develop a draft community policy, timescale TBC.
Gaps from audit in escalation when NEWS <7.
Monthly snapshot audit to review compliance with Sepsis screening and compliance with Sepsis six, first audit undertaken in Dec 19. To be reported to QSC in Jan 20 IPR.
Sepsis 6 performance not yet being reported via WebV.
Sepsis 6 performance not yet able to be monitored via WebV.
Medical Examiner (ME) model not yet in place.
Business case for ME, timescale TBC.
Differences in palliative care provision between DPoW and SGH; impact on HSMR.
Strengthened EOL strategy group to focus on EOL matters and palliative care input, Timescale TBC.
Mortality strategy to be agreed at MIG in January.
Site based mortality clinical leads in post.
Mortality Improvement Group oversees reporting to QGG.
Additional project management support from October 2019.
Medicine appointed divisional mortality clinical lead from November 2019.
Collaborative review processes established with NEL and NL CCGs to share cases with system wide learning. Greater use of CCG incidents reporting mechanism from Jan 2020 to ensure community/primary care problems in care are more systematically reported.
Mortality analyst in post from November 2019.
Mortality report containing Learning from Death KPIs.
Quality Priority 1a: Increase of SHMI, driven by DPoW site SHMI & OOH SHMI.
Professor Mohammed Mohammed's report on mortality statistics.
Quality Priority 1b: Learning from deaths process: Improvements seen in Division of Surgery, some gaps remain in Medicine, but 2020 specific Quality & Safety Meetings to focus on M&M being established.
Quality Priority 3: Medication Safety
Medication Safety Officer (MSO) in post.
0.2 Medicine Safety Pharmacy Technician supporting MSO.
Safety Medications Group considers the findings from the Safer Medicines dashboard.
Medicine management nurses / work with wards to understand ward level errors.
Some education and training / Induction sessions / Care Camp for medications safety and medical gasses.
Diabetes Nurse Specialist at DPoW working to share lessons learnt / raise awareness regarding insulins.
Datix feedback to individuals.
EPMA live at Goole, phase 1 completed. February roll-out planned at SGH.
Gap within the CNS team for Diabetes recruited to. DPoW CNS undertaking face to face training and follows up on DATIX incidents on the DPoW site.
Central pharmacy audit programme.
Mandatory training medicines management - 89% (no renewal).
Safe use of insulin mandatory training - 81% for November.
Safer Medicines Dashboard feeding the Quality Section of the IPR to QGG / Q&S / Trust Board.
Quality Priority 3a: Omitted doses - no trend seen, quality of data questionnable.
Quality Priority 3b: Insulin related incidents - no trend seen, quality of data questionnable.
Safe and Secure pharmacy audit, reported to SMG.
Benchmarking work against
Lack of E-prescribing system, currently paper based.
Difficult to identify prescriber when errors to feedback to for learning.
Policy for dealing with those bereaved not yet in place.
Different specialist palliative care arrangements at DPoW.
Increasing SHMI statistic and high Out of Hospital (OOH) SHMI / HSMR.
Quality and availability of insulin training needs to be reviewed.
E-NEWS on WebV.
Deteriorating patient and Sepsis working group.
Updated deteriorating patient policy for inpatients ratified by the working group, to be approved by Governance groups.
Sepsis specialist nurse.
Work stream within Improving Together.
Central budget identified for replacement of hand-held devices and workstations on wheels.
Ward areas reissued NEWS escalation toolkits containing guidance and ward based education provided.
Refreshed sepsis training being provided.
New inpatient deteriorating patient policy has not yet been approved.
Separate policy for deteriorating patients in the community is needed.
PowerBI dashboard.
Quality priority 2a: NEWS completed within timescales: positive trends.
Quality priority 2b: Action taken in response to NEWS: Further work needed for escalation of NEWS < 7.
Quality priority 2b: Reduction in the rate of cardiac arrests at SGH.
Quality priority 2c: Sepsis: No assurance presently at site/Trust level; ward based data to be available end of Nov 19 - update.
R
R
Insufficiently trained SJR reviewers
Review SJR training plan with Mortality Clinical Leads, Jan 2020.
Clinician time to review cases.
New Quality & Safety (to encompass M&M) schedule from Jan 2020.
Divisional assurances reported to MIG, Ongoing.
Lack of divisionally owned improvement plans / learning lessons.
Divisional M&M arrangements not fully in place.
Suspected under reporting of inc
EPMA rollout across the Trust, rollout started in Goole, now completed, phase 2: SGH to start in February 2020.
Low number of NQB SJRs requested via complaints/PALS routes.
Draft escalation policy to streamline and simplify, to approve, Feb 20.
Gap in attendance from divisions at medication safety.
Pathway breaches.
Weekly feedback from team meetings.
Validation of patients on PTL without a due date; these are being reviewed as part of the Clinical Harm process and based on risk/urgency, provided with an appointment.
Approximately 150 patients seen via NEWMEDICA service (new patients).
Specialty Business and Governance Meeting.
New Clinical Lead appointed.
Weekly meetings with team members; team leaders and with service lead to focus on backlog waiting list and management of PTL (daily for RTT and weekly for Lucentis).
PTL identification of patient by condition, risk stratification employed to bring the patient forward based on risk/urgency.
Failsafe officers in post.
Steps taken to increase efficiency.
NEWMEDICA - IPT 3rd party provider to support additional capacity for a defined duration/number of new patients.
Clinical service concern (CSC): Ophthalmology
Clinical Harm external review not yet undertaken to
Current pathway does not allow for increased capacity.
R
Quality & Safety Committee; Specialty Business & Governance Meeting.
Short tem: Matron working with member of staff, to commence, Feb 20.
Waiting list initiatives to manage, ongoing. Weekend clinics.
Consultant body to review clinical agreed pathways to assure clinical practice, Clinical Lead. Ongoing.
High overdue follow up rate.
MDT support for OCT capacity for diagnostic purposes. Longer term: (1) D&C planning
(2) Commissioning intentions understood (3) Business plan. Ongoing.
Equipment needed identified and risk assessed. Sent to Equipment Group for funding, awaiting outcome. Any gaps to be added on the risk register, Ongoing.
Older equipment coming to end of usable life.
Clinical Harm external review commences in Jan 20. Clinical expert to review and determine levels of harm. Review ongoing until mitigated overdue follow up waiting lists gap closed.
High number of Serious Incidents relating to the service.
Task and Finish group established, 2nd meeting not attended.
Write again to divisional Tris to review service models, Jan 20.Deputy MD written to all
divisional Tris to review service models, response not received.
Specific gaps in some specialties preventing the meeting of 7Day Service standards.
Verbal assurances from ward managers/matrons from ward performance review sessions.
Quality Priority 4a: Reducing medicine LOS (ward LOS data not available).
7Day Services (7DS) Board Assurance Framework.
Quality Priority 4b: Gaps in specific specialties preventing compliance with standards 2, 6 and 8.
Were part of NHSI Collaborative with Leeds; 4 wards have embedded the principles (2 at each site), another 2 ward areas are embedding.
Other wards, not yet gone live, have picked up elements of SAFER.
Care Navigators in post from late 2018 and are supporting focus on flow and discharge and supporting ward/board rounds.
Bi-monthly performance reviews with medicine ward managers/matrons, where SAFER progress is reviewed.
Cardiology have moved to a consultant of the week model which has supported SAFER principles.
Lead for 7DS identified from the Corporate perspective of the Medical Director's office.
Quality Priority 4: SAFER and 7 Day Service Standards (7DS)
R
Quality & Safety Committee;
Quality Governance Group;
Trust Board
R
Deputy MD to reestablish meeting structure with divisions, Jan 20.
Amend WebV document to include grade of clinician reviewing pt, Dec 19. Trial it, March 2020.
Meeting with Medicine Tri to discuss SAFER and 7DS, Jan 20.
NHSI funding to recruit project manager to support delivery of SAFER & Red to Green. Recruit during Jan 20.
Monthly mini-audit programme being undertaken, ongoing.
of existing processes on ward; (2) Review and tighten current Trust Policy. Timescales to be confirmed in Jan 2020.
Lack of assurance medicines are stored securely in line with Medicines Code.
Lack of documentation to evidence compliance with 7 day standards.
Engagement in the initiative from some medical staff.
g g other Trusts for medication incident reporting (bottom 50%).
Monthly mini-audits being undertaken (ongoing work).
Cancer Board; Planned Care Board; Quality Governance Group
Delays in developing faster diagnosis pathway in Colorectal.
Not meeting 62 day cancer performance targets (62 day 1st RTT, and screening).
LOS data by ward not available to support ongoing project implementation.
Need further data to support understanding of number of discharges before midday.
No impartial assurance data available: LOS data by ward / discharges before noon.
Meeting in January with Associate Director of Operations to review barriers .
Some job plans do not align themselves currently to daily board rounds by senior decision maker.
10% shortfall due to illegible and/or undated entries.
Cancer MDT Business meetings not quorate.
Delays in pathways (NLAG and cross-organisational pathways).
Capacity and demand.
Diagnostic delays and pathology turnaround times impact on pathway timescales.
R
Cancer Board meeting but not quorate.
Clinicians not reviewing root causes for breaches monthly.
Tumour site MDTs not focussed on QSIS Standards.
Quality Surveillance (QSIS) annual submission: no improvements in recent years.
Deputy MD supporting engagement work, Mar 20.
Single Lung Cancer MDT, January 2020.
QSIS improvement plans delivery; lack of assurance in monitoring of delivery.
Develop divisional dashboards containing improvement plan within PowerBI, 2021.
Quality Priority 5: Cancer
Central cancer team, with Cancer lead in post.
PTL:Cancer weekly PTL and escalation process;Weekly Cancer PTL meeting - changed end Oct for 6 weeks to focus on top 5 specialties which account for 80% of breaches;
Oversight:Weekly Divisional General Manager Waiting List Assurance Meetings with all divisions;Weekly attendance by Path Manager to improve turnaround times/escalation;PRIM meetings with divisions includes focus on Cancer;Cancer Board meeting; underpinned by individual tumour specific MDT Business Meetings;Joint Cancer Board established between NLAG and HUTH;
Improvement planning:System wide 62 day improvement plan in place focussing on 7-day 1st appt, 28 day definitive diagnosis, IPT by Day 38, Treatment by Day 62 (approved at Planned Care Board Sept 19); Outsourcing contract for diagnostics has supported reducing turnaround times;Patient Triage arrangements in place for Urology, Lung and Colorectal at begining of pathway;
IPR. Power BI reporting (including ability to compare tumour site performance).
Not meeting 62 day performance targets (62 day RTT and screening).
PRIM divisional update.
Significant improvement seen in Pathology turnaround times.
Quality Priority: Positive results seen to date from the implementation of triage/straight to test in Lung and Urology.
Implement timed and faster pathways, starting first with 4 national priorities, Quarter 3.
Stocktake of cancer pathways by joint cancer Board, Ongoing.
Not meeting (Aim) of turning around investigations and pathology within 7 days.
Improved processes in Path Links / additional staff recruitment, Ongoing.
Joint proposals between Trust and HUTH to local OSCs and CCGs to consolidate Oncology services onto a single site within NLAG, Jan 2020.
Gaps in oncology due to staff absence / vacancy.
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Work with strategic Humber Services review to plan for sustainablility of services. Ongoing.
not yet undertaken to determine if any harm caused.
Lack of system wide ophthalmology approach.
up waiting lists gap closed.
RAG RATING KEY:
Strategic Objective: 1. TO GIVE GREAT CARE
*
*
*
*
Linked Corporate or High Level Risk Rating HEATMAP:
5 2426 (Pharm supply)
*4 2462 (Bus Cont)
* 2579 (W&C)
*
*3 330 (Maj Inc) 2571 (Medicine)
* 2567 (Surgery)
2
*
1
1 2 3 4 5
High RiskModerate
RiskLow Risk
Very Low Risk
Likelihood (1-5)
Key: 15-25. 8-12. 4-6. 1-3.
Cons
eque
nce
(1-5
)
The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk. Following meeting with the executive owner, and given the changes at a national level, local divisional and directorate risk registers need to be reviewed and risk ratings amended.
Monthly Executive Highlight Report: Plans for next month:Stand down internal project group and monitor national developments and guidance from the centre.
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)
Risk to Strategic Objective:3) Adverse impact of Britain's exit from the European Union on business continuity and the delivery of safe care.
Trust's SHMI 118 (DPoW: 121; SGH: 116).
General Election held and a new Government has been formed. 31 January 2020 is the deadline for the UK to leave the EU starting a transition period between the UK and the EU until the 31 December 2020.
Internal 'Brexit' project group will be stood down and be ready to react when further direction and guidance is available later during 2020 as the transition period draws to a close.
Future relationship with the EU will be clarified by the end of 2020.
Risk Description: Risks to the Trust following a ‘no-deal’ exit from the European Union (EU) in March 2019 for access to medicines/medical devices, the workforce and access to some forms of diagnostics.
Monthly Executive Highlight Report: Risk tracking trend over time: Severe (Major) consequence: 4 x 2: Unlikely = RR of 8
STRATEGIC OBJECTIVE: 1. TO GIVE GREAT CAREDate added:Last updated:
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Local Brexit planning group, stood down at present to await national developments.
Brexit Clinical Group to support clinical prioritisation of medicines and medical supplies, stood down at present to await national developments.
Consequences of Risk Materialising:
* Medicines and medical supplies with a short shelf life could become short in supply; * Shortage of radiopharmaceuticals would impact adversely on diagnostics and cancer care; * Shortages of over the counter medicines could lead to increased demand for urgent and emergency services.
Assurance Committee:
Project groups in place and regular desktop planning exercises undertaken.
Assurance received that local plan has been revised whereby the location of any 'Stack' operations on key access roads will not impact on the Trust's hospital site locations.
Audit, Risk and Governance
Issues: Controls:
Local Brexit planning group, stood down at present to await national developments.
Escalation mechanisms in place to trigger Trust Emergency Preparedness and Business Continuity arrangements.
Issue 1: Transport arrangements to the Trust's hospitals in the event of road closures in the local area for both staff and goods.
Risk to Strategic Objective: 3) Adverse impact of Britain's exit from the European Union on business continuity and the delivery of safe care.
Business continuity plans revised and updated in connection with 'Brexit'.
G
Trend RAG Rating:AMBER
Assurance / Oversight Group
Actions required to improve:
Assurance: GAPS in Controls: GAPS in assurance:
Assurance that the issues impacting on this risk are being managed:
RAG RATING KEY:
Trust Board
Issue 5: Financial risk from non-UK patients becoming chargeable as the Trust leaves the EU Single Market.
G
Issue 2: Impact on the timely access to medicines.
Reduced access to general sales medicines could increase patients accessing urgent care services for support with normally self-managed conditions.
Issue 3: Impact on the timely access to medical devices.
G
Regional EPRR scenarios to support planning exercises in preparation for 'Brexit' have been undertaken alongside regional and national partners, including local scenarios involving transportation, freight and traffic around docks at Goole and Immingham, with resulting action plan development - Operation Wellington.
G
Issue 4: Impact on the timely access to non-medical consumables.
Local Brexit planning group, stood down at present to await national developments.
Strategic Objective: 2. TO BE A GOOD EMPLOYER
*
*
*
*
*
* Recruitment and Retention Strategy (approved by Trust Board, Dec 19).
Linked Corporate or High Level Risk Rating HEATMAP:
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk. There are a large number of underpinning or related risks captured on divisional and directorate risk registers. See appendix for the full list.
Cons
eque
nce
(1-5
)
Monthly Executive Highlight Report: Plans for next month:Further mitigation of risks from stretched capacity at a senior level in the Directorate of People and Organisational Effectiveness with additional funding secured to focus on key operational HR backlogs from
Key: 15-25. 8-12. 4-6. 1-3.
Risk to Strategic Objective:4) Inability to secure sufficient numbers of appropriately skilled staff in the short, medium and longer term
Risk Description: The risk of having insufficient staff or staff who are not suitably trained which could prevent the Trust providing care to its patients, lead to poor care outcomes which could adversely affect actual care quality as well as damage the Trust's reputation.
Monthly Executive Highlight Report: Risk tracking trend over time: Catastrophic consequence: 5 x 3: Possible = RR of 15Risk rating increased and remains at 15 - high risk.
Revised Nursing establishments agreed to be phased in over time.
Recruitment pipeline agreed to recruit additional overseas nurses, business case needed for associated costs of recruitment, post April.
Increased establishment (phased approach) will impact on vacancy rates for nursing.
New establishment control process for recruitment controls requiring Director approval for non-clinical roles enacted.
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Releasing staff (in particular those in front line departments) to attend mandatory training.
Core mandatory training and PADR targets not being met in frontline services.
HRBP to support divisions planning future staffing needs as part of Divisional engagement plans, ongoing.
Leadership Strategy drafted, but on hold until publication of NHS People Plan, Feb 2020.
Manager self service project: Manager oversight of core training and include Electronic PADR process. ESR data cleanse needed to support self service. Roll-out plan, 3 years from May 2019.
Training sessions for workforce planning. Timescale TBC.
Deloittes work - now at engagement phase, Mar 20.
Additional funding awarded in principle to focus on key operational HR backlogs from Interim HR professionals, Feb 20.
Bid submitted for 3 NHS graduates, outcome of bids due, March 2020.
Lack of capacity in workforce planning as well as wider POE team.
Adverse impact on nursing vacancy rates whilst recruitment underway.
Overseas nurses pipeline agreed.
Business case needed to resource recruitment activities, Feb 20.
Workforce Committee
Workforce Committee
Recruitment / Workforce Planning
Operational plan (5 year planning) includes workforce and outlines plan for transformational role development with STP.
POE central talent acquisition team in post and supporting with hard to recruit to vacancies.
HR Business Partners from central team supporting divisions/directorates.
Vacancy rates KPI.
External assurance from NHSI that time taken to recruit is good compared to peers.
Advert to recruitment timescales.
Workforce Committee
Staffing report outlining vacancy rates.
Outcome of nursing establishment review agreed and increase agreed for phased implementation.
Increasing establishment and approval/costs of overseas recruitment
R Workforce Committee
Workforce Committee; PRIM
A
Continued work to improve vacancy position, ongoing.
AFuture Talent Management
Working with schools/local education regarding future employment options and supporting careers fairs.
Internal Transfer panel to support flexible internal movements to support retention (limited to nursing staff as a pilot).
Effective Roster Committee established to review system gaps and maximisation of system resource.
Operational Deployment Centre to improve flexibility of employment working with MD/CN and COO. Lead appointed in September 19. Bank, E-Rostering, Rota Co-ordinators and Medical Staffing Managers centralised within the Operational Deployment Centre with budgets aligned.
Assurance from retention reported as part of Use of Resources.
High retention rate of staff.
R
Employee benefits package better understood by workforce (Total Reward Statement).
Recruitment and Retention Strategy (approved by Trust Board, Dec 19).
Retention rates are market leading amongst peers and continue to improve.
Monthly staffing report to Workforce Committee.
Retention / Turnover G
Mandatory training & PADR
PIM monitoring as part of Workforce focus.
Workforce committee reviews key data.
Review completed to evaluate the level of mandatory training required and determined appropriate.
Core mandatory training meeting target (all staff).
PADR compliance meeting target (all staff).
Identified training needs for future workforce planning activities.
Lack of integrated data systems to join up finance and recruitment approaches and workforce planning.
Trend RAG Rating:RED
Assurance / Oversight Group
Risk to Strategic Objective: 4) Inability to secure sufficient numbers of appropriately skilled staff in the short, medium and longer term
Lead Executive: Jayne Adamson / Claire Low 01-May-19
Oversight Group: PIM / POE SMT 08-Jan-20
Assurance Committee: Workforce
Consequences of Risk Materialising:
* Inability to safely provide services to the local population;* Unable to cover key posts within the Trust due to a lack of succession planning / future talent identification;
Assurance that the issues impacting on this risk are being managed:
Issues:
Monthly reporting to management teams (Triumvirates / Heads of dept. / HR Business Partners).
Access to e-learning and a standard PADR template.
TMB approval of revised targets for both PADR and Mandatory Training (Core and Role specific).
Recruitment process and retention of information within staff personnel files.
Centralising of process for Medical Personnel Files, ongoing.Develop plan to centralise other staff personnel files, timescale TBC.
Controls: Assurance: GAPS in Controls: GAPS in assurance:Actions required to improve:
Options for innovative improved access to core training for staff in front line roles, Feb 20.
HR Business Partners to monitor update rates of core training, specific focus on front line departments, Ongoing.
Paper based PADR system.
E-learning platform not user friendly.
RAG RATING KEY:
POE away day to support development of POE strategy linked to Trust's 5 year strategy, Ongoing.
Better understanding of future staffing needs for key posts.
Inflexibility in supporting improved work life balance balanced against vacancies.
Roster system gaps.
Nursing Recruitment and Retention Strategy, ongoing development.
Strategic Objective: 2. TO BE A GOOD EMPLOYER
*
*
*
*
Linked Corporate or High Level Risk Rating HEATMAP:
5
*4 2424: Culture
*
*
3 2353: C&T Morale
2
*
1
*
1 2 3 4 5
Key: 15-25. 8-12. 4-6. 1-3.
High RiskModerate
RiskLow Risk
Very Low Risk
Likelihood (1-5)
Cons
eque
nce
(1-5
)
Monthly Executive Highlight Report: Plans for next month:Leadership Development strategy has been drafted, but has been placed on hold, whilst the NHS People Plan is published. February 2020. National Freedom to Speak Up Guardian to formally visit the Trust with NHSI/E during February 2020. New Trust FTSUG appointed, to take up post.PRIM focus of PADR and Mandatory Training within divisions.
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk. Following meeting with the executive owner of this strategic risk, it is felt the following risks and the current risk rating needs to be reviewed and potentially amended in addition, a further risk is felt to be currently missed from the divisional/directorate risk registers:
To be added: Staff morale risk for all divisions linked to Individual Engagement Action Plans following the Leadership Development Sessions which included outcomes from staff survey. In place and being tested via PIM
Risk to Strategic Objective:5) Ineffective staff engagement and ownership of Trust agenda affects morale and failure to change and improve the culture
Risk Description: Ineffective staff engagement in the Trust's agenda risks delivery of the Trust's strategic objectives by adversely affecting the ability to retain staff, reduce sickness absences and improve morale.
Monthly Executive Highlight Report: Risk tracking trend over time: Moderate 3 x 4 Likely = RR of 12Third Leadership Development Conference, which included QI, held. Good attendance with a mix of clinicians and senior managers. Positive feedback received.
Substantive Pride and Respect lead appointed with dedicated admin support.
More than 38% participation rate in the NHS staff survey to date, with results expected early 2020.
Risk rating increased linked to not meeting targets for core training and PADR in some specific front line departments.
STRATEGIC OBJECTIVE: 2. TO BE A GOOD EMPLOYER Date added:Last updated:
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Lack of staff training opportunities.
Gaps in not having a leadership development strategy in all bands.
Mandatory leadership qualification for new managers.
KPIs to support measuring progress during 2019/20.
Role conversion approach for difficult to recruit to vacancies (i.e. use of Physician Associate roles and associate Advanced Clinical Practitioners) not yet embedded approach.
A part of the Improving Together programme, under the Leadership and Culture heading.
Improved communications from Senior Leadership Community.
Pride and Respect Programme focusses on anti-bullying and offers a mediation service. Substantive lead for programme.
Vision and Values consulted upon by workforce and now agreed and shared.
HR Business Partners working with divisions to implement plans for further improvement on the back of the NHS Staff Survey and feeding back to the central team specific issues.
FTSU Guardian in post.
Establishment control process revised process to support delivery of Trust's finance objective.
Ask Peter can be escalated to.
Existing staff who have not yet had Pride and Respect training.
Perceptions that Trust policy regarding recruitment and selection not always followed / adhered to.
Board development sessions run by Deloittes and leadership development courses and conferences held, with more planned to support strengthening of leadership arrangements.
Appointment of substantive Medical Director and Chief Nurse.
Findings from MES survey discussed with senior clinicians and mangers at time out session during November to identify gaps and necessary actions needed.
Change in process meaning any staffing/workforce related consultations now go through PIM / Executive Team meetings to ensure oversight arrangements.
Pride and Respect Training now a part of Junior Doctor Induction programme.
Recruitment and Retention Strategy approved by Trust Boad (December 2019).
Inclusion of Pride and Respect into all new staff members induction (from December 2019).
Workforce Committee; POE SMT
Workforce Committee
Leadership Development Strategy, delayed until publication of NHS People Plan, Feb 20.
Apprenticeship Levy promoting training opportunities which the Trust has taken full advantage of meeting the target for apprenticeships.
A
Include within the Leadership Development Strategy, Feb 20.
Workforce Committee
Workforce Committee
Workforce Committee
Action plan being developed from clinician led review of the MES results, Jan 20.
Development of Medical Engagement strategy and alignment with the Trust's Leadership Development Strategy, Feb 20.
Hard to target staff being identified and P&R training being delivered in their place of work, ongoing.
A
G
Risk to Strategic Objective: 5) Lack of staff engagement and ownership of Trust agenda affecting morale and failure to change and improve the culture
Lead Executive: Jayne Adamson / Claire Low
Directorate of POE vision
Uncertainty / apathy from staff resulting from poor consultations, pockets of bullying and lack of speaking up arrangements in the past. Working to demonstrate improvements in the Trust's approach to these issues.
* Failure to retain staff;* Higher sickness levels;* Poor morale.
Assurance that the issues impacting on this risk are being managed:
Issues: Controls: Assurance: GAPS in Controls: GAPS in assurance:Actions required to improve:
RAG RATING KEY:
Higher fill rate from deanery.
100% staff accomodation fill rate.
Improvements identified from the Medical Engagement Survey.
Recommendations paper to Workforce Committee and TMB regarding the plan and vision going forward for the ACP role, Nov 19 (Workforce Committee).
G
3,000 staff have been through Pride and Respect Training in the last 8 months, positive evaluations of the training and content.
Deloittes review undertaken, now in engagement phase with Heads of Service in POE, Mar 20.
Lack of long-term vision for Pride and Respect and Freedom To Speak Up
G
Trust shortlisted for a career confidence award and plans during 2019 to hold a career confidence conference for local youths to promote NHS / Trust careers.
Regional ACP lead visit to the Trust, Oct 19.
FTSUG role and process covered as part of P&Respect Training.
Increased take-up of the FTSUG role.
Staff have support from mediation service with 90% success rate.
Medical engagement has been a challenge.
Reliance on interim / acting arrangements for senior leadership positions.
Strategic Objective: 3. TO LIVE WITHIN OUR MEANS
*
*
*
*
*
Linked Corporate or High Level Risk Rating HEATMAP:
15-25. 8-12. 4-6. 1-3.(To be added: CQUIN Performance risks: Medicine)
Key:
Likelihood (1-5)
Cons
eque
nce
(1-5
)
Monthly Executive Highlight Report: Plans for next month:Confirm and challenge individual divisional risk registers relating to CIP delivery.
Unknown impact of CQUIN achievement for Quarter 2 2019/20.
Consider process for longer term CIP planning and development of CIP programmes at Finance Recovery Board (FRB).Understanding impact of non-elective increase in activity in January 2020.
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)
The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk. Following meeting with the executive owner of this strategic risk, it is felt the following linked and underpinning risks are in need of review and the mitigation and risk rating updated by owning divisions: To confirm/challenge RR: 2577: Risk of not achieving CIP target (W&C) (RR: 16; C4xL4)
To confirm/challenge RR: 2599: Unable to meet CIP deliver (Surgery) (RR: 16; C4xL4)
To confirm/challenge RR: 2560: Failure to meet agreed CIP (Medicine) (RR: 12; C3xL4)
Risk to Strategic Objective:
6) Finance risk, specifically:(a) Not achieving the control target total agreed with NHS Improvement for the Trust and failure to achieve the overall Northern Lincolnshire system target;(b) Risk of non-delivery of the long term financial plan to produce a balanced financial position, working in conjunction with everyone else to achieve a system balance.
Risk Description: Failure to deliver financial improvement plans, lack of support to the Trust and System and the risk of regulatory action and intervention.
Monthly Executive Highlight Report: Risk tracking trend over time: Catastrophic consequence: 5 x 3: Possible = RR of 15Agreed way of dealing with CIP plan across health systems leaving Trust with additional CIP of £330k.
Delivery of first three quarters target and as a consequence, Trust eligible for PSF/MSF monies.
Surgery & Critical Care and Medicine divisions attending Finance and Performance Committee to ensure actions to deliver forecast outturn position.
Agreed list of responsibilities, priorities and actions agreed at Board.
Agreeing income with commissioners and focussing on managing expenditure.0
STRATEGIC OBJECTIVE: 3. TO LIVE WITHIN OUR MEANSDate added:Last updated:
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Trust Board,
Finance & Performance Committee
KPIs determine if possible to provide above-planned activity (profit): Reducing LOS, Theatre efficiency, freeing up beds.
Agreed systems and process for reporting to make more robust.
Finance and Performance Committee.
Board oversight.Regular contract meetings and reporting on income.
Plans required to turn around T&O and Ophthalmology position.
Meeting the budgets - lack of sufficient plans to overcome financial challenges.
G
A
Use of intensive measures to assist, ongoing until evidence of improvement. Agreed actions approved by Board, ongoing.
A
Report performance and take stock, Ongoing.
Existing scheme of delegation, linked to the wider executive/ governance restructuring. Feb 2020.
Delivery support and monitoring of CIP through Improvement.
Monthly CIP report produced with management accounts feeding in.
Individual divisional plans (CIP) in place with divisional leads established.
Divisional Finance Improvement and CIP meetings have been established with divisional leads which is reviewing CIP performance, frequency dependant on delivery.
CIP on PIM meeting agenda (including medical and nurse staff expenditure).
Monthly Finance Recovery Board to oversee progress, chaired by CEO.
Closer working with CCGs.
5 year plan submitted to focus on these challenges and delivery, Mar 20.
(2) Long term planning
Costing coding work to be undertaken, ongoing.
Regular discussion with CCGs, ongoing.
A
Trust Board,
Finance & Performance Committee
Improved / redesigned service planning processes to support longer term control, templates in place, to be agreed, review Jan 20, Director of S&P.
G
Workforce & Planning Committee,
Trust Management Board
Overall review of income, ongoing.
(5) Income - agreement of income position
Finance and Performance Committee, Board oversight.
Corporate financial planning and budget setting process linked to the business cycle overseen by TMB.
Business planning weaknesses & Significant cost pressures based on quality concerns. 5 year plan still to be developed.
Ongoing divisional finance improvement and CIP meetings with divisional leads to review performance.
G
Risk to Strategic Objective:
Consequences of Risk Materialising:
6) Finance risk, specifically:(a) Not achieving the control target total agreed with NHS Improvement for the Trust and failure to achieve the overall Northern Lincolnshire system target;(b) Risk of non-delivery of the long term financial plan to produce a balanced financial position, working in conjunction with everyone else to achieve a system balance.
Lead Executive:Oversight Group:
Issues: Controls:
System of financial governance controls including SFIs and scheme of delegation overseen by Audit, Risk and Governance Committee.
Business Case Review Group now established.
Oversight governance assurance through Audit, Risk & Governance backed up by internal audit and external audit.
Clear system of finance performance reporting to management, Finance & Performance and Trust Board and PIM.
Timeline for confirming scheme of delegation agreed at Board.
CQUIN Targets not being met.
Nursing ward review estimated to cost between £0.8m and £2.3m in a full year, with no mitigation.
Audit, Risk and Governance Committee (with feeds from Counter Fraud and Internal Audit plans).
Finance and Performance Committee, Board oversight.
(1) Financial controls;
(1) Assurance and oversight;
(1) Performance.
Assurance: Assurance / Oversight Group
Finance & Performance Committee
Trend RAG Rating:GREEN
Assurance that the issues impacting on this risk are being managed:
GAPS in Controls:
Assurance Committee:
01-May-19
13-Jan-20
(3) Improvement planning and support;
(3) CIP / Financial Improvement Plan.
Financial improvement plan overprogrammed by £2.6m.
Progress reports.
Monthly reporting to Finance and Performance Committee.
Monthly meetings with NHSI.
Not all divisions are forecasting to deliver CIP targets for 19/20.
Finance & Performance Committee,
Finance Recovery Board.
Consider process for longer term CIP planning and development of CIP programmes, end of Dec 19 at Finance Recovery Board (FRB).
G
James HayburnPerformance Improvement Meeting (PIM), Finance Review Group (FRP)
GAPS in assurance: Actions required to improve:
* Potential lack of support to the system, regulatory action and inability to exit quality and financial special measures;* Lack of longer term sustainability.
RAG RATING KEY:
(4) Market share (Longer term sustainability)
Longer term sustainability dealing with significant challenges: HASR; CIP Delivery and Estate.
Above programme plans (if delivered) would support Trust's financial improvement.
A
Trust Board, Finance & Performance Committee and TMB.
Surgery Divisional Finance Improvement and CIP Meeting,PIM.
R
Strategic Objective: 4. TO WORK MORE COLLABORATIVELY
*
*
*
Linked Corporate or High Level Risk Rating HEATMAP:
* **NEW**: 2623: Failure of windows trust wide (RR: 20; C5xL4)* **NEW**: 2624: Pressurised System Safety Valves (RR: 15; C5xL3)* **NEW**: 2637: Switch Room Access (Blocked) (RR: 12; C4xL3) 1 2 3 4 5* **NEW**: 2656: Trip Hazard Car Park adjacent to West Arch (RR: 12; C3xL4)* **NEW**: 2365: Patient Beverage & Breakfast Trolley - x44 Units Trustwide (RR: 16; C4xL4)* **NEW**: 2636: Insecure Clinical Waste Bins (RR: 15; C3xL5)
The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk. The following risks have been removed during the month from the divisional risk register:
Facilities Services Risks [Yellow text]
Fire Risks [Blue text]
Estates Engineering Risks [White text]
Key: 15-25. 8-12. 4-6. 1-3.
High RiskModerate
RiskLow Risk
Very Low Risk
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)
The following are new divisional risks recently added to the risk register:
Likelihood (1-5)
Cons
eque
nce
(1-5
)
Monthly Executive Highlight Report: Plans for next month:BLM and capital schemes continue for 2019/20.
Monthly estates assurance report is sent to F&P committee.
AE audits continue throughout 2019/20.
Risk to Strategic Objective:7) Risk of failure of the Trust's infrastructure; specifically:(a) Ageing estate and equipment.
Risk Description: The risk is the Trust will be unable to deliver care to patients and also lead to enforcement action by regulators.
Monthly Executive Highlight Report: Risk tracking trend over time: Severe (Major) consequence: 4 x 5: Certain = RR of 20BLM and capital schemes continue for 2019/20.
Monthly estates assurance report is sent to F&P committee.
Annual AE audits completed throughout the year on all specialist engineering services.
STRATEGIC OBJECTIVE: 4. TO WORK MORE COLLABORATIVELY
Date added:Last updated:
G
R
G
R
A
R
G
R
R
R
G
R
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Staff led individualised risk assessment of patient and environment risk, supported by Specialist Mental Health Practitioner, update to Q&S Jan 20.
E&F Governance group; Quality Governance Group
Electrical services - Low Voltage - Infrastructure is aging and in poor material condition
5 year fixed wiring and test in place. Annual service contract in place for generators. Thermal monitoring of switch gear.
Annual external AE audit. Policy, procedures and staff training in place
No funding to replace infrastructure
NoneSecure funding to upgrade/replace infrastructure and equipment
E&F Governance group
Ligature risks posed from the estate (EFA Safety Alert).
No estates controls in place No estates assurance in place None None
Secure funding to upgrade infrastructure E&F Governance group
Facilities infrastructure and equipment - ward kitchens domestic and fitted in 2010, they are in poor material condition and need replacement. Facilities equipment needs replacing, including tugs, dishwashers and ovens
Capital equipment group replaces the most do equipment items on an annual basis. Adhoc repairs and maintenance contracts on infrastructure and equipment
External inspections by EHO. Internal inspections by Facilities teams, IPC and environmental audits
No funding to replace infrastructure or equipment. No equipment replacement plan
None
Secure funding to upgrade/replace infrastructure and equipment. Create an equipment replacement plan
E&F Governance group
Building infrastructure - fabric of the buildings is deteriorating affecting other engineering services (electrical supplies) with roofs collapsing/failing to cause damage and water ingress
Adhoc repairs completed as required Internal inspections completedNo funding to replace infrastructure or equipment.
None
Secure funding to upgrade/replace infrastructure and equipment
E&F Governance group
Water systems - Infrastructure and associated equipment is in poor material condition
Flushing routine of LUO with electronic monitoring. Random and planned water sampling. Use of Silver/copper ionisation systems. Adhoc remedial works as required
Annual external AE audit. Policy, procedures and staff training in place
No funding to replace infrastructure
NoneSecure funding to upgrade/replace infrastructure and equipment
E&F Governance group
Heating Ventilation and Air Conditioning systems - majority of infrastructure in poor material state
Maintenance contract in place. Reactionary adhoc repairs complete. Annual inspection and testing carried out on critical equipment including laminar flow
Annual external AE audit. Policy, procedures and staff training in place
No funding to replace infrastructure
None
Pressure Systems - infrastructure and equipment is in poor material condition
Reactionary adhoc repairs complete
Annual external AE audit. Policy, procedures and staff training in place. Insurance contract in place
No funding to replace infrastructure
AE only in place one year, policy and procedures need updating
Medical Gas Piped Services - Infrastructure and equipment is aging and in poor material condition
Reactionary adhoc repairs complete
Annual external AE audit. Policy, procedures and staff training in place. Full sites RA commissioned 2018 due to complete 2019 to identify capacity and plant issues
No funding to replace infrastructure
None
Electrical services - High Voltage - Site capacity and ongoing investment
Monitoring of site usage. Monitoring of infrastructure and 5 yearly compliance maintenance completed. Estates included in capital equipment projects.
Use electronic asbestos register E&F Governance group
Consequences of Risk Materialising:* Risk of harm to staff, patients and visitors; * Regulatory action and adverse effect on Trust's reputation.
Assurance that the issues impacting on this risk are being managed:
Risk to Strategic Objective: 7) Risk of failure of the Trust's infrastructure; specifically:(a) Ageing estate and equipment.
Lead Executive: Jug Johal
Audit, Risk and Governance Committee
Actions required to improve:
Assurance / Oversight Group
Trend RAG Rating:AMBER
Strategic Objective: 4. TO WORK MORE COLLABORATIVELY
*
Linked Corporate or High Level Risk Rating HEATMAP:
5 2429: Premises and engineering
*4
3
2
*
*
* 1
*
1 2 3 4 5
The following are new divisional risks recently added to the risk register:
**NEW** 2655: Replacement of primary heat source and associated infrastructure and equipment to include the Steam Raising Boilers [Scunthorpe General Hospital] (risk rating: 16; **NEW** 2654: Replacement of primary heat source and associated infrastructure and equipment to include the Steam Raising Boilers [Goole District Hospital] (risk rating: 12; C4xL3)
2654: Primary Heat Source (GDH)
High RiskModerate
RiskLow Risk
Key: 15-25. 8-12. 4-6.
2655: Primary heat source (SGH)
1-3.Very Low
Risk
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)
Likelihood (1-5)
Cons
eque
nce
(1-5
)
Monthly Executive Highlight Report: Plans for next month:Undertake 2019 6 Facet survey.
The above risks have been added to provide greater detail of the risks at individual sites, replacing the former risk (1487).
Risk to Strategic Objective:7) Risk of failure of the Trust's infrastructure; specifically:(b) Longer term estates sustainability.
Risk Description: The risk is that insufficient backlog maintenance funding will impact on the delivery of care to patients and also lead to enforcement.
Monthly Executive Highlight Report: Risk tracking trend over time: Severe (Major) consequence: 4 x 5: Certain = RR of 20Continue to complete annual AE audits.
STRATEGIC OBJECTIVE: 4. TO WORK MORE COLLABORATIVELYDate added:Last updated:
G
R
A
R
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Awaiting feasibility study from HUTH sustainability team. Complete detailed design on preferred replacement engineering solution and identify funding source
E&F Governance Group
Energy Centre at Goole - Coal fired boilers providing primary heat source on hospital site, failure would result in possible loss of heat source dependent on external temperatures, one gas fired boiler on site.
Extensive maintenance program and adhoc repairsMonitoring by NLaG in-house engineering team
No engineering solution to replace steam boilers. No funding source identified
None
Awaiting feasibility study from HUTH sustainability team. Complete detailed design on preferred replacement engineering solution and identify funding source
E&F Governance Group
Energy Centre at SGH - 25 year ESCO contract expired 2 years ago with ENGIE. Primary heat source for the hospital, failure would result in loss of heating and hot water on entire site
ENGIE complete adhoc repairs, funded via the Trust. Annual maintenance and insurance inspections.
Monitoring by ENGIENo engineering solution to replace steam boilers. No funding source identified
None
E&F Governance Group
Sustainability of current estateExternal AE audits. HFRS inspections. Policy and procedures. Staff training. Action plan monitoring. Insurance and external verification testing.
Model Hospital benchmark. ERIC. PAM
Capital funding to reduce/eliminate risk
None
6 Facet survey, AE audits, Insurance and external verification testing
Model Hospital benchmark. ERIC. PAM
Capital funding to reduce/eliminate risk
NoneTo secure capital funds to reduce/eliminate risk
Trend RAG Rating:AMBER
Assurance / Oversight Group
Audit, Risk and Governance Committee
To secure capital funds to reduce/eliminate risk
E&F Governance Group
01-May-19
Oversight Group: Estates & Facilities Governance Group 16-Dec-19
Risk to Strategic Objective: 7) Risk of failure of the Trust's infrastructure; specifically:(b) Longer term estates sustainability.
Lead Executive: Jug Johal
Consequences of Risk Materialising:* Risk of harm to staff, patients and visitors; * Regulatory action and adverse effect on Trust's reputation;* Lack of longer term sustainability.
Assurance that the issues impacting on this risk are being managed:
Issues: Controls: Assurance: GAPS in Controls: GAPS in assurance:Actions required to improve:
Level of BLM: Statutory = £4.1m, Physical condition = £52.6m, Functional suitability = £17m, Space utilisation = £0.880m, Quality = £0.167m, Environmental management = £0.021m. Total = £74.768m (Year to review - numbers to be verified)
Strategic Objective: 4. TO WORK MORE COLLABORATIVELY
*
*
*
Linked Corporate or High Level Risk Rating HEATMAP:
5 2516: Data Quality 2463: Cyber 2515: Data Quality
*4 2409: Cyber 2408: Cyber 2433: IT Equip
* 2495: WebV 2461: Cyber
3 2440: Strategy 2369: Cyber 2501: Data Quality
2 2084: DPA
*
*1
1 2 3 4 5
The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk. The following risk has had its risk rating increased to high risk of 20:
2461: Requirement for Qualified IT Security Officer for compliance of the Data Security Toolkit - increased risk to 20 given the need for this post as part of the DSP toolkit.
Key: 15-25. 8-12. 4-6. 1-3.
High RiskModerate
RiskLow Risk
Very Low Risk
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)
Likelihood (1-5)
Cons
eque
nce
(1-5
)
Monthly Executive Highlight Report: Plans for next month:Digital Strategy Board Task and Finish Group review and development of a plan for roadmap of digitalisation.
Business case to be submitted for qualified IT Security Officer.
Risk to Strategic Objective:7) Risk of failure of the Trust's infrastructure; specifically:(c) IT / Digital Strategy / Cyber Security.
Risk Description: The risk of failure in the Trust's infrastructure would impact on the organisation's ability to undertake its business as usual resulting from a loss of access to digital information and also the risk to data security.
Monthly Executive Highlight Report: Risk tracking trend over time: Severe (Major) consequence: 4 x 4: Likely = RR of 16TSSM NHS Digital Phase 3 interview preparations for site visit on 6th/7th January 2020.
Data Security and Protection Toolkit submission at the end of October has been completed. Status currently remains unmet due to being an mid year update. Work continues toward full compliance by March 2020.
The Patching Policy was approved at the WebV, IT and Information Governance meeting on 26 November 2019.
STRATEGIC OBJECTIVE: 4. TO WORK MORE COLLABORATIVELYDate added:Last updated:
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
01-May-19
Oversight Group: WebV, IT & Information Governance Group 16-Dec-19Assurance Committee: Finance & Performance Committee
Audit, Risk and Governance Committee
Consequences of Risk Materialising:Data security breaches, regulatory action and a loss of public confidence in the Trust damaging its reputation; Not meet national digital strategy timescales, risk of running dual paper and electronic systems and risks to patient safety and the Trust's sustainability.
Assurance that the issues impacting on this risk are being managed:
Issues: Controls: Assurance: GAPS in Controls: GAPS in assurance:Actions required to improve:
Risk to Strategic Objective: 7) Risk of failure of the Trust's infrastructure; specifically:(c) IT / Digital Strategy / Cyber Security.
Lead Executive: Jug Johal
NHSI support review of efficiency and CIP and review of the plan for the Digital Strategy Board/associated task and finish groups, ongoing.
A
3 task and finish groups in operation; Digital Strategy Board (DSB) in place; DSB approves requests for digital changes;
No task and finish groups yet established for key areas where input/engagement is needed i.e. Medicine;
Digital Delivery Plan vs. risks overseen by Digital Strategy Board with links to the forward capital plan and business planning arrangements, ongoing.
A
Engagement exercise underway with divisional triumvirates to focus on this area.
NLAG / NHSI and NHSD review to be undertaken following TMB agreement.
R
Tech shop process support ordering and approval by lead directors
Lack of clarity around the digital strategy and plan.
Map new DSP requirements to work programme.
Refreshed posture assessment needed
Rationalising current available IT equipment to ensure shared out;
WebV, IT & Information Governance Group; Digital Strategy Board
Implementation of board approved cyber security procurement (ongoing).
Lack of adequate controls to defend against a cyber attack; risk of a cyber attack as a result of increased prevalence world-wide
Board approval of cyber security procurement.
Anti-virus, malware scanners, firewalls etc. in place.
Security Operations Centre (SOC) Service 24/7 Remote Monitoring.
Cyber security incident management contract.
CareTower; Business continuity plans in place.
Annual Penetration Testing.
Patching policy approved and now in place.
Continue to focus on mandatory training compliance, ongoing.
Staff training not meeting national target (95%).
Lack of qualified IT Security Officer.
Submit business case to TMB for approval, Jan 2020.
Trend RAG Rating:AMBER
G
A
Undertake refreshed posture assessment once implementation of cyber procurement completed, 2020/21.
Complete procurement of cyber security arrangements and implement, 2020/21.
IG Steering Group; WebV, IT & Information Governance Group; Digital Strategy Board
Assurance / Oversight Group
A lack of strategic direction and engagement in digital projects resulting in a failure to deliver improved and innovative systems of care that could lead to patient safety and financial risks
Digital Strategy Board
Independent validation of data is not in place; Lack of integration on some systems effects data quality from being improved by single input source which prevents duplication;True enterprise data management not available.
Business Case for third party data assurance being developed for RTT and PAS data.
Limited resource in IG central team.
Approval process underway to recruit administrator post, Jan 20.
Risk on non-compliance with the Data Protection Act 2018
Data Security & Protection toolkit submissions; Substantive Data Protection Officer in post; IG Steering group oversees DSP toolkit improvement plan; Web V, IT & Information Governance Group.
DSP Toolkit submitted;
NHSD approved Trust DSP improvement plan;
Audit Yorkshire Internal Audit of DSP: Significant assurance.
Shortage of IT equipment to support the Trust achieve its objectives
DSB inconsistent attendance/divisional representation which delays decision making;
Inadequate resource available resulting in a shortfall of equipment;
IG Steering Group; WebV, IT & Information Governance Group; Digital Strategy Board
ANew DSP toolkit mapping of leads delivering and resource required into work programme.
RAG RATING KEY:
AFinance & Performance Committee
Procurement of data warehouse tools or solutions will be undertaken, delays in progressing procurement looking at completion Q1 2020/21.
Trust's PAS system and data quality issues adversely impacting on business decision making.
Limited assurance reporting is available for some data sources .
Strategic Objective: 4. TO WORK MORE COLLABORATIVELY
*
Linked Corporate or High Level Risk Rating HEATMAP:
5
*4
*
3
2
*
1
1 2 3 4 5
Key: 15-25. 8-12. 4-6. 1-3.
High RiskModerate
RiskLow Risk
Very Low Risk
Likelihood (1-5)
Cons
eque
nce
(1-5
)
Monthly Executive Highlight Report: Plans for next month:Alignment of specialty level strategy to the strategic framework and 5 year plan over the next quarter.
Quality strategy to be approved at TMB and Quality & Safety Committee.
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)There are no linked corporate or high level risks that underpin this strategic risk.
Risk to Strategic Objective:8) Inability to pursue a clear organisational strategy that staff and stakeholders are aware of an support
Risk Description:The risk of not having a clear strategy for the Trust within the Northern Lincolnshire system and the HCVHCP that is known, understood and translated into day to day working practice and delivery of this is owned by staff. A clear strategy will enable the Trust and its staff to more effectively prioritise investment and facilitate more effective decision making.
Monthly Executive Highlight Report: Risk tracking trend over time: Severe (Major) 4 x 3 Possible = RR of 12Continuation of alignment of key corporate and divisional strategies with the strategic framework.
STRATEGIC OBJECTIVE: 4. TO WORK MORE COLLABORATIVELYDate added: Last updated:
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Clarity of plan for ICS development, Quarter 4 2019/20.
Agreed approach across HCVHCP, Ongoing - 5 year plan.
A
A
Draft strategies available for all supporting strategies.
Translation of strategies into action needed each year, which are aligned to strategic plan.
A
Mutual development of Urgent Treatment Centres which demonstrates pathway redesign across hospital and community. Improved position in Model hospital and benchmarking.
Progress to IPCP/ICS.
Development of collaborative MSK service.
Not enough resource currently identified for Northern Lincolnshire system.
Demonstrate tangible improvements in outcomes: (a) Finance, (b) Performance, (c) Pathway redesign, Ongoing year on year.
The need to manage tensions between some of the Trust's strategies i.e. finance and quality, Ongoing.
01-May-19
Oversight Group: Trust Board; TMB; Finance and Performance 06-Jan-20
Assurance Committee: Trust Board - reporting on a 6-monthly basis
Trend RAG Rating:AMBER
Trust Board;Trust Management Board; Finance and Performance Committee
Clear strategies to be developed, with formal sign off required for each Strategy.
Clarity on strategy contents and alignment.
Other priorities have taken precedence.
Trust Board
Clear direction and alignment across northern Lincolnshire.
NEL GPs withdrawal from the Integrated Care Partnership
A
Trust Board;Trust Management Board; Finance and Performance Committee
GAPS in Controls:Actions required to improve:
Assurance / Oversight Group
GAPS in assurance:
Current financial position.
Current operational performance outcomes.
Risk to Strategic Objective:8) Inability to pursue a clear organisational strategy that staff and stakeholders are aware of an support
Lead Executive: Peter Reading & Sue Barnett
* Ineffective decision making;* Prevents changes being made aligned to organisational priorities;
* Undermines the confidence and morale of staff;* Reduced ability to attract staff.Consequences of Risk Materialising:
Assurance that the issues impacting on this risk are being managed:
RAG RATING KEY:
Issues:
Transition within the NHS from competition to collaboration.
Effective management of stakeholder and partner relationships through: Joint planning meetings, Out of hospital transformation board, Planned and unplanned care boards, place boards.
CCGs moving away from tendering.
Organisational legislative framework not yet aligned to the transition from competition to collaboration.
Executive, NED and Board time to build relationships to encourage NHS Improvement / NHS England to foster alignment between the Trust and its system partners.
Support already received (financial and other) from regulators based on evidence of the systems collaborative working together and effective working relationships.
Controls: Assurance:
Collective system programme of work with one plan.
Aligned strategy for next 5 years agreed.
Delivery of individual underpinning strategies (i.e. Quality).
Review and refresh strategies each year.
Strategic Objective: 4. TO WORK MORE COLLABORATIVELY
Capital:* Wave 4 Capital bids submitted to Treasury. * Consideration with Capital and Cash team of approval route going straight to FBC.
HASR:* Long list of options for Urgent and Emergency Care and Maternity.* Redefining long list of options with clinical leads. * Intelligence gathered from other Trust reorganisation programmes.* Workshop with 40+ attendees to apply professional judgement to a group of options.* Data modelling principles completed.
Linked Corporate or High Level Risk Rating HEATMAP:
5
*4 2565: Surgery
*
*
*3 2563: Medicine
* 2578: W&C
*
2
*
* To confirm & challenge: 2563: Lack of divisional strategy [Medicine] (RR: 9; C3xL3) 1* To confirm & challenge: 2565: Surgical Division 5 Year Strategy (RR: 12; C4xL3)* To confirm & challenge: 2578: Risk of not having an agreed W&C division 5 year strategy (RR: 9; C3xL3)
* (NEW - to be added) No community and therapies strategy.* (NEW - to be added) Refresh needed of radiology strategy.* 1 2 3 4 5
* (NEW - to be added) Sufficient capital to address ongoing estate concerns. Key: 15-25. 8-12. 4-6. 1-3.
High RiskModerate
RiskLow Risk
Very Low Risk
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk. Following meeting with the executive owner of this strategic risk, it is felt the following risks require review and rebasing of the risk ratings:
(NEW - to be added) Ensuring external relationships across the Humber develop to enable the service changes proposed in HASR to be realised. Likelihood (1-5)
Cons
eque
nce
(1-5
)
Monthly Executive Highlight Report: Plans for next month:Six additional specialty specific workshops for planned care.
Draft modelling to be completed for a variety of service options.
Draft proposals for resourcing Humber wide services for next phase.
Draft proposals for a Humber wide Capital team.
Draft report for options development.
Clarification of model output with Deloittes.
Risk to Strategic Objective:9) Lack of a clear service strategy for the area to ensure long term service sustainability (includes the risk of not developing the required external relationships and linked to HASR)
Risk Description:The risk of not having a clear collaborative strategy for the Trust and the HASR that is known, understood and translated into day to day working practice and delivery of this is owned by staff. A clear strategy will enable the Trust and its staff to more effectively prioritise investment and facilitate more effective decision making.
Monthly Executive Highlight Report: Risk tracking trend over time: Catastrophic 5 x 3 Possible = RR of 15
STRATEGIC OBJECTIVE: 4. TO WORK MORE COLLABORATIVELYDate added:Last updated:
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Year on year aligned sub strategies for next 5 years, Ongoing.
The need to manage tensions between some of the Trust's strategies i.e. finance and quality, Ongoing.
Consequences of Risk Materialising:Assurance that the issues impacting on this risk are being managed:
RAG RATING KEY:
Organisational legislative framework not yet aligned to the transition from competition to collaboration.
Executive, NED and Board time to build relationships to encourage NHS Improvement / NHS England to foster alignment between the Trust and its system partners.
Support already received (financial and other) from regulators based on evidence of the systems collaborative working together and effective working relationships.
NEL GPs withdrawal from the Integrated Care Partnership
Transition within the NHS from competition to collaboration.
Collective system programme of work with one plan.
Mutual development of Urgent Treatment Centres which demonstrates pathway redesign across hospital and community. Improved position in Model hospital and benchmarking. Progress to IPCP/ICS.
Not enough resource currently identified for Northern Lincolnshire system.
Current financial position.
Current operational performance outcomes.
Current workforce configuration.
Issues: Controls: Assurance:
Risk to Strategic Objective:9) Lack of a clear service strategy for the area to ensure long term service sustainability (includes the risk of not developing the required external relationships and linked to HASR)
Lead Executive: Sue Barnett
GAPS in Controls: GAPS in assurance:Actions required to improve:
01-May-19
Oversight Group: Trust Board; TMB; Finance and Performance 06-Jan-20
Assurance Committee: Trust Board - reporting on a 6-monthly basis
* Ineffective decision making;* Prevents changes being made aligned to organisational priorities;
* Undermines the confidence and morale of staff;* Reduced ability to attract staff.
Assurance / Oversight Group
A
Trust Board;Trust Management Board; Finance and Performance Committee
Clarity of plan for ICS development, Dec 19
Agreed approach across HCVHCP, Nov 19.
Clear direction and alignment across northern Lincolnshire and HCVHCP.
Effective management of stakeholder and partner relationships through: Joint planning meetings, Out of hospital transformation board, Planned and unplanned care boards, place boards.
Trust Board;Trust Management Board; Finance and Performance Committee
Strategic Objective: 4. TO WORK MORE COLLABORATIVELY
*
*
*
*
*
Linked Corporate or High Level Risk Rating HEATMAP:
5
*4
1) New MPs - following the General Election;2) Local CCGs – consolidate relationships and arrangements as a system management approach is key for the NHS 3) National leaders in the NHS (NHSE/I and ministerial) - the Trust needs to develop new relationships at a nation 4) GPs and PCNs – the Trust needs to be more structured in its relationships;5) Patient and voluntary groups; 6) Humber Coast and Vale (HCV) and ICPs in NL and NEL. 3
2
*
1
1 2 3 4 5
Key: 15-25. 8-12. 4-6. 1-3.
High RiskModerate
RiskLow Risk
Very Low Risk
Likelihood (1-5)
Cons
eque
nce
(1-5
)
Monthly Executive Highlight Report: Plans for next month:Discussion at Board and focus on further development of key relationships within 6 areas of focus:
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)There are no linked corporate or high level risks that underpin this strategic risk.
Risk to Strategic Objective: 10) The risk of ineffective relationships with stakeholders Risk Description:As a public sector organisation, the Trust is accountable as an organisation to many different stakeholders, including the public. It is critical therefore to develop and maintain effective relationships with stakeholders. Failure to do so effectively results in the risk to the Trust's reputation and risks achievement of strategic objectives.
Monthly Executive Highlight Report: Risk tracking trend over time: Severe Consequence: 4 x 2: Unlikely = RR of 8Executive team met with North East Lincolnshire Council CEO.
Meeting with East Riding of Yorkshire Health Scrutiny Panel alongside CCG and Hull University Teaching Hospitals NHS Trust officers regarding proposed changes to oncology services.
Stakeholder map developed in draft and to be discussed at Board meeting in January.
Intensive senior leaders and senior clinical leaders engagement with Humber Coast and Vale service development and associated activities and meetings with clinical senate.
Teleconference with Dean of Hull York Medical School (HYMS).0
STRATEGIC OBJECTIVE: 4. TO WORK MORE COLLABORATIVELYDate added:Last updated:
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
* Inability to work effectively with stakeholders as a system leading to a lack of progress against objectives;* Failure to obtain support for key changes needed to ensure improvement or sustainability;* Damage to the organisation's reputation, leading to reactive stakeholder management, impacts on the Trust's ability to attract staff and reassure service users.
Assurance that the issues impacting on this risk are being managed:
Issues: Controls: Assurance: GAPS in Controls: GAPS in assurance:Assurance / Oversight
Group
Consequences of Risk Materialising:
Actions required to improve:
Risk to Strategic Objective: 10) The risk of ineffective relationships with stakeholders Assurance Committee:
RAG RATING KEY:
Opportunity for closer working relationships between the Trust and councillors in Local Authorities.
Attended NEL / NL Health Scrutiny Panel and ongoing development of working relationship.
Meeting held with ERoY.
Executive directors have structures in place to enable effective support arrangements in place to enable them to have capacity to perform their duties, including working collaboratively with stakeholders.
1:1 arrangements between Executive Directors and the CEO to identify any capacity challenges.
Head of Contracting and Chief Operating Officer (COO) working with Lincolnshire, Ongoing.
Regular operational action between Executives and counterparts at HUFT regarding key issues.
Ensuring that the CEO, Executive and Non-Executive Directors have sufficient capacity to prioritise effective stakeholder relationship development.
1:1 arrangements between Non-Executive Directors and the Chair to identify any capacity challenges.
Absence of negative feedback regard the Trust's lack of engagement.
Opportunity for closer working relationships between the Trust and stakeholders in greater Lincolnshire.
Area of additional focus 2: Local CCGs;
Close working relationships between Executive teams.Continued evidence of effective relationships.
Commentaries received from stakeholders provides the Trust with assurance that effective relationships with stakeholders have been established.
6 Areas identified from stakeholder mapping where additional focus is required.
Board review of stakeholder map and agreement of 6 areas where additional focus is required, Trust Board/CEO, January 2020
Area of additional focus 1: New MPs - following the General Election;
Proactive engagement work with MPs following General Election, Ongoing.
There is a large number of stakeholders that NHS/Public organisations need to effectively work alongside and that hold to account the organisation.
There are currently no formal controls, however the CEO, Executive and Non-Executive Directors are working effectively to manage and build relationships with stakeholders, as a result the risk rating is low/meeting target set.
Stakeholder map developed and considered by Trust Board.
Area of additional focus 3: National leaders in the NHS (NHSE/I and ministerial);
Area of additional focus 4: GPs and PCNs;
Area of additional focus 5: Patient and voluntary groups;
Area of additional focus 6: Humber Coast and Vale (HCV) and ICPs in NL and NEL.
Strategic Objective: 5. TO PROVIDE STRONG LEADERSHIP
*
*
*
Linked Corporate or High Level Risk Rating HEATMAP:
5
*4
3
2
*
1* To be added: Directorate of Operations: Intense pressure on Operational Team Management.
1 2 3 4 5
Key: 15-25. 8-12. 4-6. 1-3.
High RiskModerate
RiskLow Risk
Very Low Risk
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk. Following meeting with the executive owner of this strategic risk, it is felt the following are further risks that are currently not fully articulated on local divisional and directorate risk registers, and therefore need to be added:
Likelihood (1-5)
Cons
eque
nce
(1-5
)
Monthly Executive Highlight Report: Plans for next month:Recruitment for the post of Chief Information Officer to begin during January, following approval of Board paper in December.
Risk to Strategic Objective:11) Risk of insufficient investment and development of the Trust's leadership (including clinical leadership) - capacity and capability
Risk Description: Effective leadership is fundamental for any organisation to achieve their strategic objectives. Inadequate leadership therefore puts at risk the delivery of the Trust's strategic objectives.
Monthly Executive Highlight Report: Risk tracking trend over time: Moderate Consequence: 3 x 4: Likely = RR of 12Approval of paper presented to December Trust Board. Recruitment underway with interviews in January 2020 for the posts of Trust Secretary and the Director of Strategic Development.
Further mitigation of risks from stretched capacity at a senior level in the Directorate of People and Organisational Effectiveness with additional funding secured to focus on key operational HR backlogs from
Intense pressure faced by Operational team identified as a risk, mitigation of risk has included an additional support post to the Chief Operating Officer in January and February.
STRATEGIC OBJECTIVE: 5. TO PROVIDE SKILLED LEADERSHIPDate added:Last updated:
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.A Amber: Partially assured, progress is being made in mitigating the issues.R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Workforce Committee
Risk to Strategic Objective: 11) Risk of insufficient investment and development of the Trust's leadership (including clinical leadership) - capacity and capability
Lead Executive: Peter Reading 01-May-19
Oversight Group: Trust Board 06-Jan-20
Assurance Committee: Workforce Committee
Trend RAG Rating:GREEN
Evidence that Trust leadership arrangements have been insufficient to adequately manage quality and finance risks resulting in a CQC rating of inadequate for 'well led' and the Trust being within both quality and finance special measures.
CQC Re-inspection of Well Led Framework and Trust ratings.
Trust remains in Quality Special Measures.
Financial improvements needed.
Consequences of Risk Materialising:
* Non-delivery of the Trust's strategic objectives;* Continued quality/financial special measures status;* CQC well-led domain remains 'inadequate'.
Assurance that the issues impacting on this risk are being managed:
Issues: Controls: Assurance: GAPS in Controls: GAPS in assurance:Actions required to improve:
G
Approval of a formal Leadership development strategy, February 2020 (delayed until after publication of NHS People Plan).
Focus on PADR compliance levels via PRIM, ongoing.
RAG RATING KEY:
Assurance / Oversight Group
There is a need for leaders to develop new leadership skills within an NHS that is now much more geared towards collaboration and working together.
There is a low level of medical engagement and there are opportunities for improved leadership within nursing, operational management and financial management.
Standing board agenda item dedicated to the board focus on leadership and organisational culture.
Significant investment in strengthened structures, specifically (a) Organisational structure, (b) Board structure, (c) a number of new senior leadership appointments.
Development programmes for clinical leaders, ward leaders and more programmes in development.
Increased focus on communication with the Trust's senior leaders to ensure they are aware of key developments and to support effective decision making and communication within their teams.
Informal leadership development strategy has resulted in strengthening of organisational structures.
NHSI Well Led Framework has been used to support the Trust reflect and self-assess.
Deloitte's Board Leadership development sessions to refine leadership qualities at Board level.
Strengthening of PRIMS arrangements.
36 Clinical Leads appointed and in post.
Regular reporting to Trust Board.
Workforce committee has been re-established and is now meeting monthly.
Latest NHS Staff Survey demonstrated some improvements, whilst recognising further improvement work is underway still.
Medical engagement scale results available which demonstrate improvement from previous survey results.
Continued transition from improvement to Business as Usual to develop and embed sustainable change, 3 years.
A Trust Board
No investment specifically for staff training / courses to support leaders work within a different context and to be effective in their roles as leaders within wider systems.
Include within the Leadership Development Strategy, February 2020 (delayed until after publication of NHS People Plan).
A Workforce Committee
Formal leadership development strategy approved by Board.
PADR compliance shortfall of target set.
Section 3: Appendix: Full list of underpinning divisional/directorate risks underpinning strategic risks.
Strategic Risk 1: PERFORMANCE: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:(a) Cancer 62 day target:* 2448: Failure to reach cancer targets [Gynae] (risk rating: 12; C4xL3)* 2160, 2261: Risks of non-delivery of constitutional performance: Histology (RR 15 & 12)* 2008: Diagnostic PTLs meeting the cancer standards (risk rating: 12; C4xL3)* 2244: Risk to Overall Performance: Cancer Performance Target 62 day (RR: 12; C3xL4)* 2524: Delay of CT reports for oncology patients (risk rating: 9; C3xL3)* 2569: Failure to meet cancer targets [Medicine] (risk rating: 12; C3xL4)* 2592: Cancer waiting / 62 day target [Surgery] (risk rating: 16; C4xL4)* 2601: National Bowel Cancer Audit: 18 Month Stoma outlier (RR: 12; C4xL3)* 2650: Lung Cancer QSIS submission 2019. Gaps in compliance [Medicine] (RR: 12; C3xL4)* 2605: National Lung Cancer Outlier Alert [Medicine] (RR: 12; C3xL4)* 2282: Haematology Oncology Pharmacy Screen [CSS] (RR: 12; C3xL4)* 2310: Haemato-Oncology Peer Review: Risk of haemato-Oncology [Medicine] (RR: 12; C4xL3)(b) A&E target:* 2562: Failure to meet constitutional targets in A&E (Risk rating: 16; C4xL4)* 2564: Risk to A&E performance from UTC medical staffing gaps (RR: 16; C4xL4)* 2561: Reduction in the average length of stay (Risk rating: 9; C3xL3)* 2576: Paediatric medical support pathway for ECC (Risk rating: 15; C3xL5)* 1991: Working with Children - A&E Staff (Risk rating: 12; C3xL4)(c) RTT - 18 weeks target:* 1851: Shortfall in capacity with the Ophthalmology service (risk rating: 15; C5xL3)* 2118: Overdue Follow Up Colorectal Patients (risk rating: 12; C4xL3)* 2048: Instability of ENT service (risk rating: 16; C4xL4)* 2347: Risk to Overall Performance: Overdue Follow-ups (RR: 16; C4xL4)* 2400: Capacity & Demand (risk rating: 8; C4xL2) * 2401: Clinical Harm Review Process (risk rating: 12; C4xL3)* 2245: Non compliance with RTT incomplete target (risk rating: 12; C4xL3)* 2583: Risk to 18w target due to long waiters and overdue pt f/u (RR: 6; C2xL3)* 2515: Accuracy of Data of Business Decision Making (risk rating: 20; C5xL4)*
(d) Diagnostics:* Include in the February 2020 BAF other diagnostic elements comprising performance against DMO1.* 2307: Shortage of Radiographers (RR: 12)* 1800: Shortage of Radiologists (RR: 20; C4xL5)* 2499: SGH Main MRI Scanner Capacity and Waiting Lists (risk rating: 15; C3xL5)* 2522: One CT Scanner at DPoW (risk rating: 12; C4xL3)* 1631: MRI Equipment - Philips Intera 1.5T Achieva DPoW (risk rating: 20; C4xL5)* 2141: Nuclear Medicine Reporting Software (risk rating: 12; C3 x L4)* 2646: Replacement of Xray room 1 at Goole (risk rating: 20; C4 x L5)* 2657: Replacement of x20 Endoscopy Patient Monitoring (RR: 20; C5 x L4)* (To be added: (1) Gaps in Oncology service provision due to staff absence; (2) Oncology capacity [Medicine and surgery]; (3) Cancer performance targets in diagnos* (To be added: (1) Financial risk from diagnostics outsourcing contract (CSS)).
Strategic Risk 2: QUALITY: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:(1). Quality Priority 1: Mortality:* QP1a: 2418 Mortality Performance (risk rating: 20; C5xL4)* QP1a: 2434 CQC Mortality Review: Heart Valve Disorders (risk rating 8; C4xL2)* QP1b: 2598 Lack of timely mortality SJR reviews [Surgery] (risk rating: 12; C3xL4)* QP1a: 2597 NELA outlier alert for mortality (risk rating: 12; C4xL3)* QP1a: 2602 NHFD outlier alert for mortality (risk rating: 8; C4xL2)* QP1b: 2111 Lack of 7-day services for palliative care at SGH (risk rating: 6; C2xL3)* QP1a: 2653 Ceilings of care and advance care planning [C&T] (risk rating: 20; C4xL5)(2). Quality Priority 2: Deteriorating patient and Sepsis:* QP2a: 2308 The risk of deteriorating patients not being escalated (RR: 12; C4xL3)* QP2a: 2388 Risk of deteriorating patients not being escalated [Medicine] (RR: 15; C5xL3)* QP2a: 2390 Risk of deteriorating patients not being escalated [Paediatrics] (RR: 15; C5xL3)* QP2a: 2393 Risk of deteriorating patients not being escalated [Maternity] (RR: 6; C3xL2)* QP2a: 2389 Risk of deteriorating patients not being escalated [Surgery] (RR: 12; C3xL4)* QP2a: 2582 Care of critically ill children (risk rating: 16; C4xL4)* QP2a: 2576 Paediatric medical support pathway to ECC (risk rating: 15; C3xL5)* QP2a: 2661 Maternity Datascopes [Maternity] (risk rating: 20; C4xL5)(3). Quality Priority 3: Medication Safety:* QP3a: 2600 Omitted doses (risk rating: 9; C3xL3)* QP3b: 2537 Diabetes Nurse Specialist vacancy (risk rating: 9; C3xL3)* QP3b: 2568 Safe and secure storage of medicines (risk rating: 12; C4xL3)* QP3b: 2559 Medicine division: Secure storage of medicines (risk rating: 4; C2xL2)
(To be added: (1) Out-Patient Follow-Up - all divisions; (2) Failure to meeting constitutional targets: RTT in Medicine and Surgery); (3) Haematology RTT risk and emergency access to services (medicine); (4) Immunology RTT risk and emergency access to services (medicine)).
* QP3b: 2525 Access and Supply of Medications to NRC [CSS] (risk rating: 12; C4xL3)(4). Quality Priority 4: SAFER and 7 Day Services:* QP4: 2566 7DS risk [Surgery] (risk rating: 12; C4xL3)* QP4: 2640 7DS risk [CSS] (risk rating: 6; C3xL2)* QP4: 2620 7DS risk - Medical Directors Office (risk rating: 12; C3xL4)* (To be added: Risk of not meeting 7 day service standards - W&C)(5). Quality Priority 5: Cancer:* QP5: 2244 Divisional delay in cancer pathways risk (risk rating: 12; C3xL4)* QP5: 2261 Delays in biopsy reporting (risk rating 12; C3xL4)* QP5: 2160 Delays in biopsy reporting (risk rating 15; C3xL5)* QP5: 1800 Shortage in radiologists (risk rating 20; C4xL5)* QP5: 2210 Failure to meet 6 week target for CT / MRI (risk rating 15; C3xL5)* QP5: 2592 Cancer waiting / performance against 62 day target (risk rating 16; C4xL4)
2448: Failure to reach cancer targets (risk rating: 12; C4xL3)2008: Diagnostic PTLs meeting the cancer standards (risk rating: 12; C4xL3)2524: Delay of CT reports for oncology patients (risk rating: 9; C3xL3)2569: Failure to meet cancer targets [Medicine] (risk rating: 12; C3xL4)2601: National Bowel Cancer Audit: 18 Month Stoma outlier (RR: 12; C4xL3)2650: Lung Cancer QSIS submission 2019. Gaps in compliance [Medicine] (RR: 12; C3xL4)2605: National Lung Cancer Outlier Alert [Medicine] (RR: 12; C3xL4)2282: Haematology Oncology Pharmacy Screen [CSS] (RR: 12; C3xL4)2310: Haemato-Oncology Peer Review: Risk of haemato-Oncology [Medicine] (RR: 12; C4xL3)
(6). Clinical Service Concern (CSC): Ophthalmology:* CSC: 1851 Shortfall in Ophthalmology (risk rating 15; C5xL3)* CSC: 2347 Failure to review patients in specified timescales (risk rating 16; C4xL4)* CSC: 2186 Space in Ophthalmology outpatients (risk rating 12; C3xL4)
Strategic Risk 3: BREXIT: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:To review risk ratings of divisional risk registers in response to latest developments:* 2426: Business continuity (risk rating: 10; C5xL2)* Review and confirmation of Risk Rating needed: 330: Risk of lack of preparedness for coping with major incident (risk rating: 6; C3xL2)* Review and confirmation of Risk Rating needed: 2462: Supply of radiopharmaceuticals and nuclear medicine ‘cold kits’ (risk rating: 12, C4xL3)* Review and confirmation of Risk Rating needed: 2567 Brexit [Surgery] (risk rating: 12; C4xL3)* Review and confirmation of Risk Rating needed: 2571 Transport arrangements linked to Brexit [Medicine] (RR: 12; C3xL4)* Review and confirmation of Risk Rating needed: 2579 Transport arrangements linked to Brexit [W&C] (RR: 12; C4xL3)* Review and confirmation of Risk Rating needed: 330: Risk of lack of preparedness for coping with major incident (risk rating: 6; C3xL2)
Strategic Risk 4: SKILLED STAFF: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:Medical Staffing Risks:
* 2419: Medical staff Recruitment and retention (risk rating: 15; C3xL5)* 2420: Medical staff job planning (risk rating: 12; C3xL4)* 2018: Lack of substantive Acute Care Physicians [Medicine] (risk rating 10; C2xL5)* 2359: Doctor vacancies in Medicine (risk rating 16; C4xL4)* 2564: Risk to A&E perf from UTC medical staffing gaps Medicine (RR: 16; C4xL4)* 2279: Risk to Overall Performance: Medical Workforce in Surgery (RR: 16; C4xL4)* 2596 Job plans in W&C (risk rating: 10; C2xL5)* 2449: Paediatric staffing (not meeting national guidance) W&C (risk rating: 15; C3xL5)* 2261: Histology Reporting due to staffing CSS (risk rating: 12; C3xL4)* 1800: Shortage of Radiologists CSS (risk rating: 20; C4xL5)
Nursing Staffing Risks:* 2421: Nurse Staffing (risk rating: 25; C5xL5)* 2530: Poor registered nursing skill mix on wards (risk rating: 25, C5xL5)* 2145: Nurse Staffing and Vacancy Position Medicine (risk rating: 12; C3xL4)* 2537 Diabetes Nurse Specialist vacancy Medicine (risk rating: 9; C3xL3)* 2140: Registered Nurse Vacancy Position Ward 25 and 28 Surgery (RR: 20; C4xL5)* 2490: Midwifery Staffing W&C (risk rating: 16; C4xL4)* 2479: CNS Staffing Levels Medicine (risk rating: 15; C3xL5)
Other Staffing Risks:* 2576: Paediatric Medical Support Pathway for ECC (risk rating: 15; C3xL5)* 2189: Admin W/F in Pink Rose Suite Surgery (RR: 12; C3xL4)* 2166: Breast care: Imaging team W/F in Pink Rose Suite Surgery (RR: 12; C3xL4)* 2553 Obstetric theatre staffing model for mat services W&C (RR: 10; C2xL5)* 2580 Lack of divisional workforce plan in W&C (risk rating: 9; C3xL3)* 2581 Lack of leadership/succession plan in W&C (risk rating: 9; C3xL3)* 2163: Estates Workforce Shortfall E&F (risk rating: 16; C4xL4)* 2492: 60 hour labour ward cover W&C (risk rating 16; C4xL4)* 2352: Vacancies and Recruitment - Acute Therapy Staff NEL C&T (RR: 6; C2xL3)* 2255: Staffing issues in Nutrition and Dietetics C&T (risk rating 12; C3xL4)* 2397: Rehab Medicine staffing C&T (risk rating: 6; C2xL3)* 2356: Community & Therapy staff sickness C&T (risk rating 12; C3xL4)
(To be added: (1) Gaps in Oncology service provision due to staff absence; (2) Oncology capacity [Medicine and surgery]; (3) Cancer performance targets in diagnostics)
Strategic Risk 5: STAFF ENGAGEMENT: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:* To confirm and challenge: 2353: Staff Morale - Community and Therapies Services (risk rating: 12; C3xL4)*
* 2424: Organisational Culture, Systems and Processes (RR: 20; C4xL5)
Strategic Risk 6: FINANCE: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:* 2040: Delay in payment of invoices (risk rating: 16; C4xL4)* 913: Late Submission of Termination of Employment Forms (risk rating: 12; C3xL4)* 2534: Tender for new financial ledger (risk rating: 16; C4xL4)* 2535: Loss of income if Trust does not achieve the 2019/20 deficit as agreed with NHSI (risk rating: 16; C4xL4)
CIP Savings:* 2508: Risk of not-achieving CIP (Medical Directors Office) [Reduced] (risk rating: 9; C3xL3)* 2526: Delivery of 2019/20 CIP (Community & Therapies) (risk rating: 12; C4xL3)* To confirm/challenge RR: 2577: Risk of not achieving CIP target (W&C) (RR: 16; C4xL4) * 2543: Risk of not achieving CIP plan (CSS) (RR: 12; C4xL3)* To confirm/challenge RR: 2599: Unable to meet CIP deliver (Surgery) (RR: 16; C4xL4)* To confirm/challenge RR: 2560: Failure to meet agreed CIP (Medicine) (RR: 12; C3xL4)
Other financial risks:* 2541: Risk if fines for non-disclosure (risk rating: 9; C3xL3)* (To be added: Financial controls in surgery)
Strategic Risk 7a: ESTATES AND EQUIPMENT: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:Estates Engineering risks:* 2425: Health & Safety Compliance: Water Safety Compliance (risk rating: 20; C5xL4)* 2038: Fire Compliance (risk rating: 20; C5xL4)* 2293: Fire Ring Main Deadlegs and Condition Risk (risk rating: 20; C4xL5)* 1223: Replacement/Repairs of flat roof (risk rating: 16; C4xL4)* 2200: Door entry/intercom system (risk rating: 16; C4xL4)* 2212: Nurse Call System (risk rating: 16; C4xL4)* 1774: Poor condition of Fuel Oil Storage Tanks (SGH) (risk rating: 16; C4xL4)* 2374: Medical Air Compressor Plant Replacement – SGH (RR:15; C5xL3)* 2452: Northside Buildings Roofs (risk rating: 16; C4xL4)* 2088: Building Management Systems (BMS) Controller failure/upgrade (risk rating: 20; C4xL5)* 2377: Sterile Pack Bulk Storeroom (risk rating: 20; C5xL4)* 2317: SGH & Pathology Air Tube POD System (risk rating: 20; C4xL5)* 1601: Clock Tower (Northside Development) (risk rating: 15; C5xL3)* 1620: Medical Gas Pipeline System outlet and plant (risk rating: 20; C5xL4)* 2281: Low Voltage Electrical Infrastructure (risk rating: 20; C5xL4)* 2035: Equality Act 2010 compliance (risk rating: 16; C4xL4)* 2538: Non Compliant with the Combustion Plant Directive (MCPD) (RR: 15; C3xL5)* **NEW**: 2623: Failure of windows trust wide (RR: 20; C5xL4)* **NEW**: 2624: Pressurised System Safety Valves (RR: 15; C5xL3)
**NEW**: 2637: Switch Room Access (Blocked) (RR: 12; C4xL3)* **NEW**: 2656: Trip Hazard Car Park adjacent to West Arch (RR: 12; C3xL4)Facilities Services risks:* 2381: Scunthorpe Main Kitchen Dishwasher (risk rating: 16; C4xL4)* 2383: Hand Wash Sink Configuration SGH Kitchen (risk rating: 16; C4xL4)* 2481: Cleaning trolleys and equipment (risk rating 16; C4xL4)* 2539: Deterioration of the CCTV System leading to loss of functionality (RR 20; C4xL5)* 2614: 1 x Pan Dishwasher (risk rating: 16; C4xL4)* 2547: Multi-cook regen oven (GDH) (risk rating: 16; C4xL4)* **NEW**: 2365: Patient Beverage & Breakfast Trolley - x44 Units Trustwide (RR: 16; C4xL4)
To be added: Staff morale risk for all divisions linked to Individual Engagement Action Plans following the Leadership Development Sessions which included outcomes from staff survey. In place and being tested via PIM arrangements.
Strategic Risk 7b: ESTATES SUSTAINABILITY: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:* All specialist engineering risk entered on the register are relevant to this risk* 2429: Premises and engineering services (risk rating: 20; C5xL4)*
Strategic Risk 7c: DIGITAL: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:(a) Cyber Security:* 2463: Cyber Security Risk - (Windows 10 Implementation) (risk rating: 15; C5xL3)* 2408: Data & Cyber Security: (2) Cyber Infrastructure [Risk One] (risk rating: 16; C4xL4)* 2409: Data & Cyber Security: (2) Cyber Infrastructure [Risk Two] (risk rating: 12; C4xL3)* 2461: Need for qualified IT Security Officer for Data Security Toolkit (RR: 20; C4xL5)* 2369: Unsupported software, hardware and applications (risk rating: 12; C3xL4)(b) Risks of non-compliance with the Data Protection Act:*
* 2084: Management of A&E Notes inc Scanning; Destruction and Forwarding of paper records (risk rating: 8; C2xL4)(c) Shortage of IT Equipment:* 2433: Switchboard (Management of on-call rotas for hospital services) (RR: 20; C4xL5)(d) Strategic Direction:* 2440: Development of the Digital 2020 Strategy (risk rating: 9; C3xL3)e) WebV* 2495: WebV Server Warranty Renewal (risk rating: 16; C4xL4)(e) Trust's PAS and data Quality:* 2515: Accuracy of Data of Business Decision Making (risk rating: 20; C5xL4)* 2501: Delay in outpatient summary letters reaching recipient < 7 days (RR: 15; C3xL5)* 2516: Delays sending letter incorrect functioning of the Dictate IT system (RR: 10; C5xL2)
Strategic Risk 8: STRATEGY: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:* There are no linked corporate or high level risks that underpin this strategic risk.
Strategic Risk 9: CLINICAL STRATEGY: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:* To confirm & challenge: 2563: Lack of divisional strategy [Medicine] (RR: 9; C3xL3)* To confirm & challenge: 2565: Surgical Division 5 Year Strategy (RR: 12; C4xL3)* To confirm & challenge: 2578: Risk of not having an agreed W&C division 5 year strategy (RR: 9; C3xL3)* (NEW - to be added) No community and therapies strategy.* (NEW - to be added) Refresh needed of radiology strategy.* (NEW - to be added) Ensuring external relationships across the Humber develop to enable the service changes proposed in HASR to be realised.* (NEW - to be added) Sufficient capital to address ongoing estate concerns.
Strategic Risk 10: STAKEHOLDERS: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:* There are no linked corporate or high level risks that underpin this strategic risk.
Strategic Risk 11: LEADERSHIP: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:To be added to divisional risk registers:
* To be added: People and Organisational Effectiveness: Stretched capacity at a senior level.* To be added: Directorate of Operations: Intense pressure on Operational Team Management.
2376: The risk of breaching the Data Protection Regulation re. reporting serious data protection incidents to the Information Commissioners Office (ICO) (RR: 12; C4xL3)
**NEW** 2655: Replacement of primary heat source and associated infrastructure and equipment to include the Steam Raising Boilers [Scunthorpe General Hospital] (risk rating: 16; C4xL4)
**NEW** 2654: Replacement of primary heat source and associated infrastructure and equipment to include the Steam Raising Boilers [Goole District Hospital] (risk rating: 12; C4xL3)
NLG(20)016
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Wendy Booth, Trust Secretary
CONTACT OFFICER Jeremy Daws, Head of Quality Assurance
SUBJECT Board Assurance Framework – January 2020
BACKGROUND DOCUMENT (IF ANY) Board briefing and approval of strategic objectives , strategic risks and revised approach to the Board Assurance Framework
PURPOSE OF THE REPORT: For Assurance
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The BAF focusses on the risks identified that impac t on the Trust achieving its strategic objectives and is designed to:
• provide the Board and Board Sub-Committees with as surance as to the actions being taken to mitigate the strat egic risks; and
• provide an executive overview of achievements each month alongside priorities for the forthcoming month
The BAF, whilst providing assurance on how well the Trust’s 11 strategic risks are being managed, also provides links to and greater visibility of the risks that are being managed divisionally that underpin the work to mitigate against the related strategic risk. These are demonstrated pictorially in a Heatmap summary, grouped wherever possible to demonstrate relationships across divisions between similar or related risks. The full list of related divisional risks is available for information as an appendix to this report The January 2020 edition continues to feature trend ing RAGs for each strategic risk to demonstrate, at a glance, how the lead Director(s) sees the mitigation of the risk. Also included for grea ter clarity is a key to better enable the reader to discern what the RAG ra tings mean Confirm and challenge in relation to the controls a nd assurances in place to mitigate the risk and in respect of the risk rat ings continues to occur through the Trust Management Board and the Board as surance sub-committees As the framework is updated regularly, the risk rat ing trend diagrams will demonstrate performance against the management of t hese risks over time For January’s BAF, all 11 strategic risks have been reviewed and updated. The highest rated strategic risks are:
• Risk of non-delivery of constitutional performance – 20 • Risk of non-delivery of agreed quality and clinical
improvements – 20 • Risk of failure of the Trust’s infrastructure: agei ng estate and
equipment – 20 • Risk of failure of the Trust’s infrastructure: long er term estate
sustainability – 20 • Risk of failure of the Trust’s infrastructure: IT / Digital Strategy /
Cyber Security – 16 • Finance risk – 15 • Lack of clear service strategy – 15
Movement in month:
• Risk of non-delivery of agreed quality and clinical improvements strategic risk increases from a risk r ating of 15 to 20 as a result in the Trust’s increasing SHMI posit ion
• Inability to secure sufficient numbers of appropria tely trained staff in the short, medium and long term reverted b ack from a risk rating of 10 to 15 given the work required to recruit staff linked to the increased nursing establishments. Thi s is a high risk
• Ineffective staff engagement reverts back to a risk rating of 12
linked to current PADR and core training rates for staff working in front line roles
• Brexit, following greater clarity nationally, remai ns at the target risk rating of 8
TRUST BOARD ACTION REQUIRED
The Board is asked to note the contents of the assu rance framework and use the contents to challenge the risk ratings and to seek further assurances, as required, as part of the Trust’s ove rsight and assurance arrangements
BOARD ASSURANCE FRAMEWORK (BAF)
January 2020
Content:
Section 1: Trend over time - Mitigation of Trust's 11 strategic risks;
Section 2: Mitigation of 11 strategic risks - in detail (Part a: Executive summary and heatmap; Part b: BAF detail);
Section 3: Appendix: Full list of underpinning divisional/directorate risks underpinning strategic risks.
TARGET CURRENT TREND TREND TREND TREND TREND TREND TREND TREND
Strategic Risk
NumberLinked to Strategic Objective Strategic Risk Title
TARGET
RISK
RATING Jan
-20
De
c-1
9
No
v-1
9
Oct
-19
Se
p-1
9
Au
g-1
9
Jul-
19
Jun
-19
Ma
y-1
9
1 1. To give great care
Risk of non-delivery of constitutional performance targets, specifically:
(a) Cancer 62 day,
(b) A&E,
(c) RTT - 18 weeks,
(d) Diagnostics.
8 20 20 20 20 20 20 20 20 20 Shaun Stacey
2 1. To give great careRisk of non-delivery of agreed quality and clinical improvements (includes the risk of non-delivery of a reduction
in the mortality ratio)10 20 15 15 15 15 15 15 15 15 Kate Wood / Ellie Monkhouse
3 1. To give great care Adverse impact of Britain's exit from the European Union on business continuity and the delivery of safe care. 8 8 8 8 16 16 16 16 8 8 Shaun Stacey
4 2. To be a good employer Inability to secure sufficient numbers of appropriately skilled staff in the short, medium and longer term. 8 15 15 10 10 15 15 15 15 15 Jayne Adamson / Claire Low
5 2. To be a good employerIneffective staff engagement and ownership of Trust agenda affects morale and failure to change and improve
(a) Not achieving the control target total agreed with NHS Improvement for the Trust and failure to achieve the
overall Northern Lincolnshire system target;
(b) Risk of non-delivery of the long term financial plan to produce a balanced financial position, working in
conjunction with everyone else to achieve a system balance.
10 15 15 15 15 15 15 15 15 10 James Hayburn
7a
Risk of failure of the Trust’s infrastructure; specifically:
(a) Ageing estate and equipment: the inability to maintain legislative compliant and improve the current estate
and equipment due to a lack of capital and backlog maintenance (includes Legionella);
10 20 20 20 20 20 20 20 20 20 Jug Johal
7b
Risk of failure of the Trust’s infrastructure; specifically:
(b) Longer term estate sustainability: failure to secure a sustainable estate future for SGH (and to a lesser extent
DPOWH) this may give rise to buildings or parts of buildings becoming unsafe to occupy;
10 20 20 20 20 20 20 20 20 20 Jug Johal
7c
Risk of failure of the Trust’s infrastructure; specifically:
(c) IT / Digital Strategy / Cyber Security: failure of the IT infrastructure and adverse impact on the delivery of the
Digital Strategy and on business continuity and the delivery of safe care; and the lack of adequate controls to
defend the Trust’s IT systems when a cyber-attack occurs.
12 16 16 16 16 16 16 16 16 16 Jug Johal
8 4. To work more collaboratively Inability to pursue a clear organisational strategy that staff and stakeholders are aware of and support. 8 12 12 12 12 12 12 12 12 12 Sue Barnett
9 4. To work more collaborativelyLack of a clear service strategy for the area to ensure long term service sustainability (includes the risk of not
developing the required external relationships and linked to HASR).9 15 15 15 15 15 15 15 15 15 Sue Barnett
10 4. To work more collaboratively The risk of ineffective relationships with stakeholders. 8 8 8 8 8 8 8 8 8 8 Peter Reading
11 5. To provide strong leadershipRisk of insufficient investment and development of the Trust’s leadership (including clinical leadership) –
capacity and capability.8 12 12 12 12 16 16 16 16 16 Peter Reading
The potential impact of the above risks materialising include:
· Poor quality care / harm
· Damage to the Trust’s reputation
· Further regulatory action and inability to exit quality and financial special measures
· Lack of longer term sustainability
Lead Director
Section 1: Trend over time - Mitigation of Trust's 11 strategic risks
4. To work more collaboratively
Strategic Objective: 1. TO GIVE GREAT CARE
*
a)
b)
c)
d)
Linked Corporate or High Level Risk Rating HEATMAP:
Risk tracking trend over time: Catastrophic consequence: 5 x 4: Likely = RR of 20
Monthly Executive Highlight Report: Plans for next month:
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)
Cancer: Discussion of joint proposal between Trust and HUTH with local OSCs and CCGs to consolidate Oncology
services onto a single site within NLAG.
Cancer: Single Lung Cancer MDT to be in place, January 2020.
RTT / 18 Weeks: Focus on data quality in connection with clock stops, work commenced on the business rule audit -
expected 3 month lead time for meaningful data to be available .Diagnostics: MSK service tender by Trust and partners, change in service delivery will reduce demand on diagnostics
resource. Intense pressure faced by Operational team identified as a risk, mitigation of risk has included an additional support
post to the Chief Operating Officer in January and February.Include in the February 2020 BAF other diagnostic elements comprising performance against DMO1.
The risk is that the Trust fails to deliver or fails to demonstrate robust improvement plans in delivering constitutional performance targets
which impairs the Trust's provision of quality services and adversely impacts on its reputation with service users and regulatory bodies.
The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk.
Following meeting with the executive owner of this strategic risk, it is felt the following are further risks that are
currently not fully articulated on local divisional and directorate risk registers, and therefore need to be added:
Risk to Strategic Objective:
Monthly Executive Highlight Report:
The Trust is currently unable to deliver these 4 performance targets due to demand and capacity constraints. An
agreed trajectory for each to maintain delivery of care has been agreed.
Cancer 62 day target: Aim to meet national target in 2021. Current local agreed target 85%.
Performance during November 19: Trajectory: 72.8%. ACTUAL: 69.1%.
A&E target: Aim to meet national target in 2021. Current local agreed target: 90%
Performance during November 19: Trajectory: 87.8%. ACTUAL: 73.4%.
RTT - 18 weeks target: Aim to meet national target in 2021/22. Current local agreed trajectory: 92%
Performance during November 19: Trajectory: 80.2%. ACTUAL: 80.4%.
6-week wait for diagnostics: Aim 1% of diagnostic requests breach the 6 week target.
Performance during November 19: Trajectory: 6.2%. ACTUAL: 12.0%
(To be added: (1) Gaps in Oncology service provision due to staff absence; (2) Oncology capacity
[Medicine and surgery]; (3) Cancer performance targets in diagnostics)
(To be added: (1) Out-Patient Follow-Up - all divisions; (2) Failure to meeting constitutional targets:
RTT in Medicine and Surgery); (3) Haematology RTT risk and emergency access to services
(medicine); (4) Immunology RTT risk and emergency access to services (medicine)).
(To be added: (1) Financial risk from diagnostics outsourcing contract (CSS).
1) Risk of non-delivery of constitutional performance targets, specifically: (a) Cancer 62
Linked Corporate or High Level Risk Rating HEATMAP:
5
*
4 2543: CIP (CSS) 2040: Invoices
* 2534: Finance ledger
2526: CIP (C&T)
* 2577: CIP (W&C)
2535: NHSI deficit
*
3 2541: Fines (MD) 913: Employ forms
2508: CIP (MD) 2560: CIP (Medicine)
2599: CIP (Surgery)
2 2573: CQUIN (Surg)
*
* 1
*
*
* 1 2 3 4 5
*
*
Risk to Strategic Objective:
6) Finance risk, specifically:
(a) Not achieving the control target total agreed with NHS Improvement for the Trust and failure to achieve the
overall Northern Lincolnshire system target;
(b) Risk of non-delivery of the long term financial plan to produce a balanced financial position, working in
conjunction with everyone else to achieve a system balance.
Risk Description: Failure to deliver financial improvement plans, lack of support to the Trust and System and the risk of regulatory action and intervention.
Monthly Executive Highlight Report: Risk tracking trend over time: Catastrophic consequence: 5 x 3: Possible = RR of 15
Agreed way of dealing with CIP plan across health systems leaving Trust with additional CIP of £330k.
Delivery of first three quarters target and as a consequence, Trust eligible for PSF/MSF monies.
Surgery & Critical Care and Medicine divisions attending Finance and Performance Committee to ensure actions to
deliver forecast outturn position.
Agreed list of responsibilities, priorities and actions agreed at Board.
Agreeing income with commissioners and focussing on managing expenditure.
Co
nse
qu
en
ce (
1-5
)
Monthly Executive Highlight Report: Plans for next month:
Confirm and challenge individual divisional risk registers relating to CIP delivery.
Unknown impact of CQUIN achievement for Quarter 2 2019/20.
Consider process for longer term CIP planning and development of CIP programmes at Finance Recovery Board
(FRB).Understanding impact of non-elective increase in activity in January 2020.
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)
The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk.
Following meeting with the executive owner of this strategic risk, it is felt the following linked and underpinning
risks are in need of review and the mitigation and risk rating updated by owning divisions:
To confirm/challenge RR: 2577: Risk of not achieving CIP target (W&C) (RR: 16; C4xL4)
To confirm/challenge RR: 2599: Unable to meet CIP deliver (Surgery) (RR: 16; C4xL4)
To confirm/challenge RR: 2560: Failure to meet agreed CIP (Medicine) (RR: 12; C3xL4)
Risk to Strategic Objective:7) Risk of failure of the Trust's infrastructure; specifically:
(a) Ageing estate and equipment.Risk Description: The risk is the Trust will be unable to deliver care to patients and also lead to enforcement action by regulators.
Monthly Executive Highlight Report: Risk tracking trend over time: Severe (Major) consequence: 4 x 5: Certain = RR of 20
BLM and capital schemes continue for 2019/20.
Monthly estates assurance report is sent to F&P committee.
Annual AE audits completed throughout the year on all specialist engineering services.
Likelihood (1-5)
Co
nse
qu
en
ce (
1-5
)
Monthly Executive Highlight Report: Plans for next month:
BLM and capital schemes continue for 2019/20.
Monthly estates assurance report is sent to F&P committee.
AE audits continue throughout 2019/20.
The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic risk.
The following risks have been removed during the month from the divisional risk register:
Facilities Services Risks [Yellow
text]
Fire Risks [Blue text]
Estates Engineering Risks
[White text]
Key: 15-25. 8-12. 4-6. 1-3.
High RiskModerate
RiskLow Risk
Very Low
Risk
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)
The following are new divisional risks recently added to the risk register:
Limited capital investment in detector head replacement and
clinical schemes
External audit conducted by
HFRS covering all sites on a 5
year rolling programme. Policy,
procedures and staff training in
place
No funding to replace
infrastructureNone
Asbestos Remedial inspections carried out annually
External audit in June 18. Policy,
procedures and staff training in
place
No electronic asbestos register No external AE services
Secure funding to
upgrade/replace infrastructure
and equipment
E&F Governance group
Secure funding to
upgrade/replace infrastructure
and equipment
E&F Governance group
Pressure Systems - infrastructure and
equipment is in poor material conditionReactionary adhoc repairs complete
Annual external AE audit.
Policy, procedures and staff
training in place. Insurance
contract in place
No funding to replace
infrastructure
AE only in place one year, policy
and procedures need updating
Medical Gas Piped Services - Infrastructure
and equipment is aging and in poor
material condition
Reactionary adhoc repairs complete
Annual external AE audit.
Policy, procedures and staff
training in place. Full sites RA
commissioned 2018 due to
complete 2019 to identify
capacity and plant issues
No funding to replace
infrastructureNone
Adhoc repairs completed as required Internal inspections completedNo funding to replace
infrastructure or equipment. None
Secure funding to
upgrade/replace infrastructure
and equipment
E&F Governance group
Water systems - Infrastructure and
associated equipment is in poor material
condition
Flushing routine of LUO with electronic monitoring. Random
and planned water sampling. Use of Silver/copper ionisation
systems. Adhoc remedial works as required
Annual external AE audit.
Policy, procedures and staff
training in place
No funding to replace
infrastructureNone
Secure funding to
upgrade/replace infrastructure
and equipment
E&F Governance group
Heating Ventilation and Air Conditioning
systems - majority of infrastructure in poor
material state
Maintenance contract in place. Reactionary adhoc repairs
complete. Annual inspection and testing carried out on critical
equipment including laminar flow
Annual external AE audit.
Policy, procedures and staff
training in place
No funding to replace
infrastructureNone
Staff led individualised risk
assessment of patient and
environment risk, supported by
Specialist Mental Health
Practitioner, update to Q&S Jan
20.
E&F Governance group;
Quality Governance
Group
Electrical services - Low Voltage -
Infrastructure is aging and in poor material
condition
5 year fixed wiring and test in place. Annual service contract in
place for generators. Thermal monitoring of switch gear.
Annual external AE audit.
Policy, procedures and staff
training in place
No funding to replace
infrastructureNone
Secure funding to
upgrade/replace infrastructure
and equipment
E&F Governance group
Ligature risks posed from the estate
(EFA Safety Alert).No estates controls in place No estates assurance in place None None
Secure funding to upgrade
infrastructureE&F Governance group
Facilities infrastructure and equipment -
ward kitchens domestic and fitted in 2010,
they are in poor material condition and
need replacement. Facilities equipment
needs replacing, including tugs,
dishwashers and ovens
Capital equipment group replaces the most do equipment
items on an annual basis. Adhoc repairs and maintenance
contracts on infrastructure and equipment
External inspections by EHO.
Internal inspections by Facilities
teams, IPC and environmental
audits
No funding to replace
infrastructure or equipment.
No equipment replacement
plan
None
Secure funding to
upgrade/replace infrastructure
and equipment. Create an
equipment replacement plan
E&F Governance group
Building infrastructure - fabric of the
buildings is deteriorating affecting other
engineering services (electrical supplies)
with roofs collapsing/failing to cause
damage and water ingress
Strategic Objective: 4. TO WORK MORE COLLABORATIVELY
*
Linked Corporate or High Level Risk Rating HEATMAP:
5 2429: Premises and engineering
*
4
3
2
*
*
* 1
*
1 2 3 4 5
Risk to Strategic Objective:7) Risk of failure of the Trust's infrastructure; specifically:
(b) Longer term estates sustainability.Risk Description: The risk is that insufficient backlog maintenance funding will impact on the delivery of care to patients and also lead to enforcement.
Monthly Executive Highlight Report: Risk tracking trend over time: Severe (Major) consequence: 4 x 5: Certain = RR of 20
Continue to complete annual AE audits.
Likelihood (1-5)
Co
nse
qu
en
ce (
1-5
)
Monthly Executive Highlight Report: Plans for next month:
Undertake 2019 6 Facet survey.
The above risks have been added to provide greater detail of the risks at individual sites, replacing the former risk
(1487).
The following are new divisional risks recently added to the risk register:
**NEW** 2655: Replacement of primary heat source and associated infrastructure and equipment to
include the Steam Raising Boilers [Scunthorpe General Hospital] (risk rating: 16; C4xL4) **NEW** 2654: Replacement of primary heat source and associated infrastructure and equipment to
include the Steam Raising Boilers [Goole District Hospital] (risk rating: 12; C4xL3)
2654: Primary Heat Source
(GDH)
High RiskModerate
RiskLow Risk
Key: 15-25. 8-12. 4-6.
2655: Primary heat source
(SGH)
1-3.Very Low
Risk
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)
STRATEGIC OBJECTIVE: 4. TO WORK MORE COLLABORATIVELY
Date added:
Last updated:
G Green: Fully assured that progress is being made in mitigating issues, impacting on strategic risk.
A Amber: Partially assured, progress is being made in mitigating the issues.
R Red: Not assured; limited signs of progress being made to mitigate issues leading to increased risk.
Area of additional focus 6: Humber
Coast and Vale (HCV) and ICPs in NL
and NEL.
Area of additional focus 5: Patient
and voluntary groups;
Area of additional focus 4: GPs and
PCNs;
Area of additional focus 3: National
leaders in the NHS (NHSE/I and
ministerial);
Commentaries received from
stakeholders provides the
Trust with assurance that
effective relationships with
stakeholders have been
established.
6 Areas identified from
stakeholder mapping where
additional focus is required.
Board review of stakeholder
map and agreement of 6 areas
where additional focus is
required, Trust Board/CEO,
January 2020
Area of additional focus 1: New
MPs - following the General
Election;
Proactive engagement work
with MPs following General
Election, Ongoing.
There is a large number of
stakeholders that NHS/Public
organisations need to effectively
work alongside and that hold to
account the organisation.
There are currently no formal controls, however the CEO,
Executive and Non-Executive Directors are working effectively
to manage and build relationships with stakeholders, as a
result the risk rating is low/meeting target set.
Stakeholder map developed and considered by Trust Board.
Area of additional focus 2: Local
CCGs;Close working relationships between Executive teams.
Continued evidence of
effective relationships.
RAG RATING KEY:
Opportunity for closer working
relationships between the Trust and
councillors in Local Authorities.
Attended NEL / NL Health Scrutiny Panel and ongoing
development of working relationship.
Meeting held with ERoY.
Executive directors have structures in place to enable effective
support arrangements in place to enable them to have
capacity to perform their duties, including working
collaboratively with stakeholders.
1:1 arrangements between Executive Directors and the CEO to
identify any capacity challenges.
Head of Contracting and Chief
Operating Officer (COO)
working with Lincolnshire,
Ongoing.
Regular operational action
between Executives and
counterparts at HUFT
regarding key issues.
Ensuring that the CEO, Executive
and Non-Executive Directors have
sufficient capacity to prioritise
effective stakeholder relationship
development.
1:1 arrangements between Non-Executive Directors and the
Chair to identify any capacity challenges.
Absence of negative feedback
regard the Trust's lack of
engagement.
Opportunity for closer working
relationships between the
Trust and stakeholders in
greater Lincolnshire.
Trust Board
Trend RAG Rating:
GREEN
* Inability to work effectively with stakeholders as a system leading to a lack of progress against objectives;
* Failure to obtain support for key changes needed to ensure improvement or sustainability;
* Damage to the organisation's reputation, leading to reactive stakeholder management, impacts on the Trust's
ability to attract staff and reassure service users.
Assurance that the issues impacting on this risk are being
managed:
Issues: Controls: Assurance: GAPS in Controls: GAPS in assurance:Assurance / Oversight
Group
Consequences of Risk
Materialising:
Actions required to
improve:
Risk to Strategic Objective: 10) The risk of ineffective relationships with stakeholdersAssurance Committee:
Peter Reading 01-May-19
Oversight Group: Trust Board 06-Jan-20
Lead Executive:
G Trust Board
Strategic Objective: 5. TO PROVIDE STRONG LEADERSHIP
*
*
*
Linked Corporate or High Level Risk Rating HEATMAP:
5
*
4
3
2
*
1
* To be added: Directorate of Operations: Intense pressure on Operational Team Management.
1 2 3 4 5
Risk to Strategic Objective:11) Risk of insufficient investment and development of the Trust's leadership
(including clinical leadership) - capacity and capabilityRisk Description:
Effective leadership is fundamental for any organisation to achieve their strategic objectives. Inadequate leadership therefore puts at
risk the delivery of the Trust's strategic objectives.
Monthly Executive Highlight Report: Risk tracking trend over time: Moderate Consequence: 3 x 4: Likely = RR of 12
Approval of paper presented to December Trust Board. Recruitment underway with interviews in January 2020
for the posts of Trust Secretary and the Director of Strategic Development.
Further mitigation of risks from stretched capacity at a senior level in the Directorate of People and Organisational
Effectiveness with additional funding secured to focus on key operational HR backlogs from Interim HR
Intense pressure faced by Operational team identified as a risk, mitigation of risk has included an additional
support post to the Chief Operating Officer in January and February.
Underpinning Risks: Executive Summary (For full list of underpinning risks - see Section 3 Appendix)The heatmap demonstrates the current local risks that relate to or underpin the management of this strategic
risk. Following meeting with the executive owner of this strategic risk, it is felt the following are further risks that
are currently not fully articulated on local divisional and directorate risk registers, and therefore need to be
added:
Likelihood (1-5)
Co
nse
qu
en
ce (
1-5
)
Monthly Executive Highlight Report: Plans for next month:
Recruitment for the post of Chief Information Officer to begin during January, following approval of Board paper
* 2141: Nuclear Medicine Reporting Software (risk rating: 12; C3 x L4)
* 2646: Replacement of Xray room 1 at Goole (risk rating: 20; C4 x L5)
* 2657: Replacement of x20 Endoscopy Patient Monitoring (RR: 20; C5 x L4)
* (To be added: (1) Gaps in Oncology service provision due to staff absence; (2) Oncology capacity [Medicine and surgery]; (3) Cancer performance targets in diagnostics)
* (To be added: (1) Financial risk from diagnostics outsourcing contract (CSS)).
Strategic Risk 2: QUALITY: Linked Corporate or High Level Risks that underpin this STRATEGIC RISK:
* 2479: CNS Staffing Levels Medicine (risk rating: 15; C3xL5)
Other Staffing Risks:
* 2576: Paediatric Medical Support Pathway for ECC (risk rating: 15; C3xL5)
* 2189: Admin W/F in Pink Rose Suite Surgery (RR: 12; C3xL4)
* 2166: Breast care: Imaging team W/F in Pink Rose Suite Surgery (RR: 12; C3xL4)
* 2553 Obstetric theatre staffing model for mat services W&C (RR: 10; C2xL5)
(To be added: (1) Gaps in Oncology service provision due to staff absence; (2) Oncology capacity [Medicine and surgery]; (3) Cancer performance targets in
diagnostics)
* 2580 Lack of divisional workforce plan in W&C (risk rating: 9; C3xL3)
* 2581 Lack of leadership/succession plan in W&C (risk rating: 9; C3xL3)
* 2538: Non Compliant with the Combustion Plant Directive (MCPD) (RR: 15; C3xL5)
To be added: Staff morale risk for all divisions linked to Individual Engagement Action Plans following the Leadership Development Sessions which included outcomes
from staff survey. In place and being tested via PIM arrangements.
NLG(20)017
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Linda Jackson, Acting Trust Chair & Wendy Booth, Tr ust Secretary
CONTACT OFFICER Wendy Booth, Trust Secretary
SUBJECT Fit & Proper Persons Test: Chairman’s Annual Decla ration
BACKGROUND DOCUMENT (IF ANY) None
PURPOSE OF THE REPORT: For Information & Assurance
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The report provides the Chairman’s Annual Declarati on in respect of compliance with the Fit & Proper Persons Test by th ose individuals who are board directors, board members and individuals who perform the functions equivalent to the functions of a board di rector and member
TRUST BOARD ACTION REQUIRED
The Board is asked to note the report
Fit and Proper Persons Requirements: Chair’s Annual Declaration
In line with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the Trust is required to ensure that all relevant individuals meet the requirements of the Fit and Proper Persons Test (Regulation 5). Regulation 5 recognises that individuals who have authority in organisations that deliver care are responsible for the overall quality and safety of that care. For the purpose of this regulation, these individuals are board directors, board members and individuals who perform the functions equivalent to the functions of a board director and member (whether existing, interim or permanent and irrespective of their voting rights). Regulation 5 states that a provider must not appoint or have in place an individual as a director who:
• is not of good character; • does not have the necessary qualifications, competence, skills and experience; • is not physically and mentally fit (after adjustments) to perform their duties.
Regulation 5 also decrees that these individuals cannot have been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or discharging any functions relating to any office or employment with a service provider.
These requirements play a major part in ensuring the accountability of leaders of NHS bodies and outline the requirements for robust recruitment & employment, appraisal and performance management processes for Board level appointments and for ensuring that there are appropriate checks that leaders have the skills, knowledge, experience and integrity that they need – both when they are appointed and on an ongoing basis. [In exceptional circumstances, Trusts may allow an individual to continue as Director without having met the requirements following approval of the Chairman and following an assessment of all elements of risk.] As Acting Chair of Northern Lincolnshire and Goole NHS Foundation Trust, I confirm that all(*) existing board directors, board members and individuals who perform the functions equivalent to the functions of a board director and member (both permanent and interim), as defined within the Trust’s Fit & Proper Persons Policy, meet the requirements of the Fit & Proper Persons Test. My declaration has been informed by:
• the annual Fit & Proper Persons Test self-declarations completed by all board directors, board members and individuals who perform the functions equivalent to the functions of a board director and member;
• the outcome of the 2018/19 annual appraisals of those individuals and the agreement of objectives and, where required, the agreement of personal development plans;
• monitoring of sickness absence;
• monitoring of mandatory training compliance;
• the recent re-audit by Internal Audit of the Trust’s systems and processes for ensuring
compliance with the Fit & Proper Persons Requirements, which included review of the files of relevant individuals and which provided ‘significant assurance’ overall regarding
the arrangements in place although some minor gaps in information contained within the files was identified;
• my own sample testing (30%) of files of the relevant individuals against the Trust’s Fit &
Proper Persons Policy; specifically the Fit & Proper Persons checks required on recruitment and those required on an ongoing basis, to ensure capture of the required information and assurances. From my sample testing it is clear that completion of the required checks and the recording of those checks are comprehensive and thorough although some minor gaps in information were found with two particular themes identified. One of the themes was similar to the findings from the Internal Audit which found that in some instances there was no signed contract on file. This was the case in four of the five files sampled. A further theme relates to delays in some instances in the annual self-declarations being submitted and placed on file. Whilst I am satisfied that neither of these issues impacts on the fitness of any of the individuals covered by the Fit & Proper Persons Requirements, work is underway to strengthen the processes in place to ensure timely submission / completion and recording in future.
[*There are currently two Directors on extended absence. Whilst I am confident that the files of those members of staff record the correct processes and checks undertaken on recruitment, some of the annual requirements e.g. annual review and updating of the Register of Directors’ Interests, are not up to date due to the length of the absences. Steps are in place to ensure these requirements are brought fully up to date as and when the relevant staff return to work.] MRS LINDA JACKSON ACTING CHAIR JANUARY 2020
NLG(20)018
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Jug Johal – Director of Estates & Facilities and In terim Director of IT, Information & WebV
CONTACT OFFICER Alex Bell – Head of Information Services Jeremy Daws – Head of Quality Assurance
SUBJECT Integrated Performance Report
BACKGROUND DOCUMENT (IF ANY) Appendix A – Integrated Performance Report
PURPOSE OF THE REPORT: Approval and Assurance against key Trust performanc e metrics
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The Committee is asked to note deliver y to date; Operational Performance
RTT – Seen a decrease in performance in waiting lis t size and RTT performance.
Cancer – Continued to deliver 2WW, however pressure regarding 62 day Cancer metrics. Tertiary capacity continues to be c hallenging.
Diagnostic – Continued pressures within diagnostics specifically across MRI, CT and Non-Obs Ultrasound.
A&E – Increase in demand seen within A&E, with a de crease in performance. QP1a: SHMI: • Trust SHMI improves slightly to 118.1; remains ‘h igher than expected’. • Benchmarking undertaken comparing Trust to local peers and identified disparity between peer Trust improvement s in capture of Charlson comorbidity risk recording. SGH comparable , gaps recording of 6+ risk factors at DPoW seen. • Clinician led coding validation pilot agreed by M IG and commenced in ITU/ICU and MAU/AMU, to measure impact as part of pilot work. • Coding validation audit tool and quality of care screening tool combined and agreed at Mortality Improvement Group in January. Use of the new document has commenced. • Mortality strategy approved at Mortality Improvem ent Group in January focussing on EOL, patient flow, learning fr om deaths and coding quality. QP1b: Learning from deaths: • Whilst reduced, there are a number of ‘priority N QB’ cases outstanding a review still. These have been escalat ed to Surgery and Medicine management teams. • DPoW Surgery team have launched a weekly M&M meet ing to review all deaths. SGH Surgery teams weekly M&M con tinues with no backlog of case reviews outstanding and reviewing a ll deaths using screening tool. • SGH orthopaedics M&M process to be established du ring January. • Medicine M&M (Quality & Safety meetings) due to c ommence in January, but impacted by operational pressures resu lting in meetings needing to be cancelled. QP2a-b: Deteriorating patient: • NEWS Escalation: Performance peaked – currently a t ~86%. • Critical Care Outreach team undertook audit of ac tion taken in response to NEWS during December to review the data and analyse during January for reporting in IPR in February. • Work underway to review deteriorating patient pol icy and to roll-out for raised awareness revised oxygen policy and guidance. QP2c: Deteriorating patient: Sepsis: • One day snapshot audit undertaken across the Trus t during
December and summary of findings available. • Majority of patients requiring sepsis screening h ad their care escalated, limited evidence of a formal sepsis scre ening process, although 90% of patients not having a screening had circumstances that would suggest it was not needed. • Improvements in the process/system for collecting the data identified and to be fed into the deteriorating pat ient group for consideration of next steps. QP3a: Omitted doses: • EPMA now live in Goole, working to develop accura tely baseline data for instances were doses have been omitted and mock up reporting from EPMA to support understanding of this area wit h more accurate data. QP3b: Insulin incidents: • Diabetes CNS teams are looking at this area and d iscussion had regarding the types of incidents being seen and rep orted. • Safer Medications Group are reviewing the quality and availability of training in insulin. • Diabetes CNS vacancy in medicine has been recruit ed to. QP4a: SAFER: • Ward based LOS data to determine progress not ava ilable. Medicine non-elective length of stay has reduced be neath the mean for 5 consecutive months (7 is significant of statistical change – in this case – improvement. • NHSi funding provided to recruit a project manage r to support implementation of SAFER principles and roll out ove r a 6 month period. Recruitment underway within Medicine. QP4b: Priority 4 standards for 7DS: • Web-V handover record amended to better evidence compliance with standard 8, working to use in practice. • Limited response to Deputy MD writing to division s regarding the need to review service models. To write again d uring January 2020. QP5a-b: Cancer pathways: • Signs of improvement in the 28 day pathway for Ur ology and Lung, both increasing performance. • Timed pathway for colorectal cancer drafted and o ut for consultation with the clinical team. Triage system in place but not currently meeting national definition for straight to test as a face to face clinic appointment is needed first with the service which delays the pathway. No significant change in performance repor ted from colorectal cancer pathway. • Gaps in oncology service provision identified by HUTH and the Trust leading the significant change to centralise oncology provision of service within NLAG onto one site during January 20 20.
TRUST BOARD ACTION REQUIRED
The Board is asked to:
• Note the content of the report for November & December’s Performance
• Ongoing strengthening of medical staffing cover with third middle grade
overnight 00:00-08:00, 7 days a week
• Ongoing strengthening of senior clinical leadership with Consultant cover
08:00-00:00, 7 days a week
• Improved use of 2 hourly board rounds with EPIC role and responsibilities
relaunched
• Improved monitoring with reaffirmation of 2 hours management plans
and 3 hours treatment ambitions
• ED Consultant leadership in the UTC on weekdays
• SGH UTC formally designated during December 2019
• Continued AAU short term plan mobilisation which has contributed to the
0LOS continuing to improve
• Frequent attenders meetings established at both sites
To do next month
• DPOWH UTC awaiting formal designation
• Transition of CCL withdrawal at DPOWH UTC
• To continue to embed AAU principles
• Increase public communications re appropriate use of ED
• To refresh SAFER principles
• To pilot fracture clinic use for minors
• To continue discussions with Lincolnshire to improve flow
• To plan MADE events at both sites
• To relaunch virtual ward (health element)
• To support ambulance conveyance avoidance through SPA attending
EMAS control room
• Use of early supportive discharge to assess continues to
be challenging – progressing discussions through
A&EDB and planning meeting
• Transfer of patients to Hull continues to be a challenge
given their demand on service, particularly around
vascular and neuro
• Outlying medical patients still in place
• Escalation beds at DPOWH remain open
• Challenges for middle grade skill mix and cover
particularly at DPOWH
• GP skill mix in UTC and number of patients being seen
remains a challenge
• Exceptional demand in both A&E and admissions,
against decrease in non-elective length of stay. Even
with decrease in LOS, bed day usage up
Actions Issues/Risk
A&E % v Trajectory A&E Performance with Peers
Performance Summary
A&E – Performance v Trajectory
Unplanned Care – A&E
10
QP1: Mortality reduction (Clinical Effectiveness)
Summary
The mortality reduction priority is comprised of 3 key elements:
1. Summary Hospital Mortality Indicator (SHMI). SHMI is not a measure of quality, but can identify differences in
care provision and recording/coding. A review undertaken in 2019 identified some differences between the
two main hospitals recording/coding processes.
2. Learning from deaths review process. These are the processes that support clinicians reflect on and learn from
the review of mortality cases for both care quality and quality of recording keeping, recording and coding.
3. Patients at end of life stage being able to die in their preferred place of death.
A summary of these key elements is presented on this and the following page.
1a: SHMI Graph • Trust SHMI is 118 for the period of September 18-August 19; in the ‘higher than expected’ range.
• SHMI includes deaths within 30 days of discharge; 36% of all deaths where following discharge, this is above
the UK average of 30%.
• The SHMI calculates observed vs. expected. The Trust’s recording and coding of risk factors (on which the SHMI
statistically calculates the ‘expected’ number of deaths) has remained static. Peer comparators have increased
their recording and coding of SHMI influencing risk factors, as illustrated below.
SHMI Site details:
• DPoW: 121; SGH: 116
Recording of Risk:
• Peer Trust (dotted line) shows a reduction in
zero score and increase 6+ risk (green) vs.
DPoW.
• SGH similar performance vs. peer.
Actions Issues/Risk
• Mortality Improvement Group (MIG) approved clinician led
validation of coding proposal, commenced during January
2020 to review ITU/ICU and AMU/MAU ward deaths with
clinical teams.
• Mortality quality of care screening tool with coding
validation tool built within developed and approved by
MIG, pilot use commenced.
• Refreshed mortality strategy which includes a focus on
coding along with EOL, learning from deaths and flow has
been approved at MIG.
• Higher than UK average proportion of deaths (36%)
occurring out of hospital following discharge.
• Findings from the learning from death reviews identify a
key theme of a lack of advance care planning leading to
potentially avoidable admissions to hospital.
• NLaG recording of risks that influence SHMI has not kept
pace with improvements made at other peer comparator
sites resulting in a disparity between observed deaths
and those, according to the SHMI model, which are
‘expected’.
• There is a risk to the organisation’s reputation.
• Mortality performance is on the risk register with a risk
rating of 20.
11
QP1: Mortality reduction (Clinical Effectiveness)
1b: Learning from deaths process
• Surgery & Critical Care:
• Weekly DPoW General Surgery M&M commenced in
January 2020; SGH process in place and working well.
• M&M arrangements in place within T&O at DPoW,
plan for SGH to be enacted during January.
• Medicine:
• Have been achieving the 20% target for reviews
(when allowing for the 6-8 weeks for cases to be
completed)
• New M&M meeting structure approved and
commencing during January 2020, operational
pressures have led to the first few being cancelled.
• National Quality Board:
• Not all cases have been reviewed, with some historic
cases still outstanding.
• Work is underway within medicine and surgery to
eradicate this backlog of reviews and to ensure these
cases are reviewed more timely in line with revised
M&M process/structure.
• Patients at EOL dying in preferred place of death:
• From the audit and those on the ‘Last Days of Life’
document, for Q1 55%, Q2 56% and Q3 50%
recorded their preferred place of death.
• In Q1 27%, Q2 28% and Q3 42% of cases the
preferred place of death was not discussed.
• Preferred place of death was not achieved in 13%
(Q1), 19% (Q2) and 11% (Q3) of deaths.
Actions Issues/Risk
• Backlog priority cases to be reviewed by Clinical
Leads in Medicine and Surgery.
• Monitor pilot use of the screening tool and impact
on the numbers of cases being reviewed (aim to
increase the proportion of reviews).
• Risk of non-conformance with learning from
deaths guidance for Trusts, this is a part of the
Trust’s risk register, risk rating of 20.
• Issue around time to undertake mortality reviews
in some specialties.
• Mortality analyst now in post, in the intervening
time whilst a vacancy, this has impacted on the
ability to support reporting and analysis.
12
13
2019-20 Q4
PLEASE NOTE: THERE IS ALWAYS A DELAY IN LEDER REVIEWS AS PROCESS IS COMPREHENSIVE
Current Month:
(Dec-19)
Current Month:
(Dec-19)
Current Month:
(Dec-19)
0 0 0
Current Quarter: Current Quarter: Current Quarter:
1 1 0
Current Financial
Year:
Current Financial
Year:
Current Financial
Year:
4 4 0
1
0 0 0
Previous Quarter: Previous Quarter: Previous
Quarter:
Total Number of LD
Deaths in scope
(In Hospital only)
Total Deaths 'In Progress'
through LeDeR Methodology
(or equivalent).
Total Deaths
considered potentially
Avoidable
Previous Month:
(Nov-19)
15
Previous Month:
(Nov-19)
Previous
Month: (Nov-
19)
Total Learning Disability Deaths and total reviewed under the LeDeR methodology: End dateQ12017-18Start date
5 1
0
Previous Quarter:
0
Previous Financial Year:
0
Previous Quarter:
3
Previous Financial Year:
0
Current Quarter:
1
Current Financial Year:
Current Month: (Dec-19)
1
Current Financial Year:
7 7 0
The Trust and partners including local CCGs and other secondary providers work collaboratively to identify patients with Learning Disabilities who have died within local
services. LEDER deaths presented as above are reviews undertaken where NLAG is the primary investigator. External LEDER death are reviewed by community partners and are
NOT included in the summary above.
3 3 0
Previous Financial
Year:
Previous Financial Year: Previous Financial
Year:
Current Month: (Dec-19) Previous Month: (Nov-19)
Current Quarter: Previous Quarter:
Current Financial Year: Previous Financial Year:
0 2
Total Deaths Reviewed: Since Dec-18 to current
Total Number of Deaths using Perinatal Mortality Review Tool (PMRT):
Total Death under SI framework: (based on date of death) Confirmed SI Prior-SJR:
Previous Month: (Nov-
19)Previous Month: (Nov-19)
Confirmed SI Post-SJR
Current Month: (Dec-19)
Considered for SI Post-SJR
Current Month: (Dec-19)Previous Month: (Nov-19)
0
0
Current Financial Year:
4
Current Quarter: Previous Quarter:
Previous Financial Year:
0
Current Quarter:
0
2
12
Total Deaths: Since Dec-18 to current
Below are the Key Performance Targets that have to be adhered to by relevant groups:
1.KPI 1: 95% of all deaths of babies suitable for review using the Perinatal Mortality Review Tool (PMRT)
occuring from Wednesday 12th December 2018 to have been started within four months of each death.
2. KPI 2: : 50% of all deaths of babies who were born and died in the trust (including any home births where
baby died) occuring from Wednesday 12th December 2018 to be reviewed by an MDT team and a draft
report generated within 4 months of each death.
3. KPI 3: 95% of all deaths of babies who were born and died in the trust (including any home births where
the baby died) occuring from Wednesday 12th December 2018, the parents were told that a review of their
baby’s death will take place and their perspectives and any concerns about their care and that about their
baby have been sought.
4. KPI 4: Quarterly reports to be submitted to the trust Board that include consequent action plans.
Previous Month: (Nov-19)Current Month: (Dec-19)
20
Previous Quarter:Current Quarter:
23
Previous Financial Year:
136
Current Financial Year:
6 13
0
1
2
3
4
5
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2017-18 2018-19 2019-20
Tota
l Dea
ths:
Date Period:
LD Mortality over time, Total deaths Reviewed and Deaths considered to have been potentially Avoidable > 50%:
(NB: LEDER data presented are reviews undertaken where NLAG is the primary investigator.External LEDER deaths are reviewed by Community partners and NOT included
in this data)
Total LD deaths Reviewed/In progress Total Considered Avoidable >50%
Page 14 of 23
Mortality themes: Thematic Analysis – Financial Year 2019/20
From completed SJR forms to date, the following charts demonstrates the high level themes presented in
‘chapters’ to provide an overview of the key themes emerging from the completed reviews completed
within this financial year; April – September 2019. (Note: Thematic Analysis is underway for outstanding months)
FY 2019/20: (April – September 2019)
Top themes – year to date:
Main themes from the completed SJR reviews during 2019/20 to date relate to the following chapters:
o End of life (encompassing themes such as “No advanced plan, admission potentially avoidable” and
“DNaCPR could have been commenced sooner”);
o Communication (i.e. “excellent communication with family” and “poor documentation”) feature
prominently;
o Oxygen use is a theme from Q1 (including: “oxygen administered but not prescribed”, “no alters test
prior to ABGs being taken” and “oxygen not monitored appropriately”);
o Planning (“failed discharge – readmitted within 48 hours” and “no prophylaxis for VTE”);
o Waiting (“delay in a bed becoming available”, “ delay in referring for surgical review” and “delay in
procedure being undertaken”);
o Deteriorating patient (“concern patient not seen by clinical team”, “Escalation actions for
deteriorating patient not undertaken” and “late escalation”);
o Fluid management (includes “fluid balance not monitored”, “lack of fluids given” and fluid
management issues when patient in AKI);
o Staffing is identified in few completed SJRs as a theme, however, it should be noted, retrospective
case review is likely to be an unreliable methodology to assess the impact of staffing on quality /
mortality outcomes.
Page 15 of 23
QP2: Deteriorating Patient (Patient Safety)
Summary
The deteriorating patient quality priority is comprised of two specific areas of focus: (1) the monitoring and action
being taken in response to Early Warning Scores (EWS) and (2) compliance with the sepsis six care bundle.
The Trust uses the National Early Warning Score or NEWS and records this electronically, using the Web-V system. The
first element of this priority is to evidence improvement in the number of observations being recorded on time in line
with the Trust’s policy. The second element is to begin to measure, for improvement purposes, the action being taken
in response to NEWS observations, for those patients who exhibit signs of deterioration.
The second part of this indicator deals with compliance against the sepsis six care bundle. Whilst this has been
recorded electronically as part of Web-V, since November 2018, the information to measure compliance against this
indicator is not yet fully available.
2a: NEWS recorded on time
• NEWS Recorded on time (including 30 mins grace period):
• The chart demonstrates significant improvements in the number of NEWS observations recorded on time, in
line with the policy achieving 88% in November and 86.45% in December (including 30 minutes grace period).
2b: NEWS appropriate action taken in line with the policy
• Action taken in line with Policy:
• NB: The above data is based on a snapshot of manual case note reviews during Q1, looking at a sample of 44
episodes of deterioration in patient records. The sample size is therefore very small compared to the number of
NEWS observations recorded and the data should be used as an indication of current performance only.
• Medium Risk (NEWS 5-6, 3 in one parameter): In 47% of cases the registered nurse informed the medical team
caring for the patient. In 20% there was a plan or other actions were carried out. In 26% of cases there were no
clear actions documented. 80% of patients had a plan for escalation of care. It was not able to be ascertained
from the documentation whether actions/alerts were within 30 minutes as per the policy.
• Patient at High Risk (NEWS 7 or more): 79% of patients had the medical team looking after them informed by
ward staff. 7% were identified for ward based, 7% EoL and 7% for fast track. All patients had a plan for
escalation of care.
Page 16 of 23
Actions Issues/Risk
• Critical Care outreach team have undertaken a further audit of action taken
in response to NEWS prior to their assessing the patient (24 hours prior) to
determine escalation action taken during December. A summary of the
findings will be presented in the February Integrated Performance Report.
• Draft escalation policy has been shared with nursing colleagues for
consultation. Final approval to be confirmed following consultation,
February 2020.
• Working with community teams to ensure policy/pathway for NEWS
observations is appropriate.
• Risk of non-escalation of
care in line with the policy.
• Limited assurance available
regarding action taken in
response to NEWS
observations in line with
the Trust’s policy.
QP2: Deteriorating Patient (Patient Safety)
2c: Sepsis Six Compliance
Summary
• Data has been collected for the sepsis six care bundle electronically automatically for those patients meeting the
criteria where sepsis screening should be considered (specifically each set of observations resulting in a NEWS
score above 5 or 3 in any one parameter). Whilst this data is available, it is not yet possible to tell from the
electronic data those patients who were clinically assessed by ward staff as requiring a formal screening. This has
led to a gap in assurance.
• During December 2019, a specific audit was undertaken to assess performance with sepsis screening and
treatment.
Findings from the audit: • The audit identified that the majority of patients with observations that should have been considered for sepsis
screening had appropriate escalation (72% in Medicine, 78% in Surgery and 50% in Women’s and Children’s).
• Whilst escalation action was taken in the majority of cases, the evidence of a formal sepsis screen being
undertaken was not found. In 10% of these cases, there was no clinical reason for why no formal screening was
undertaken. In 90% of cases there was an identified reason for why the NEWS was raised and sepsis screening was
not required (i.e. awaiting cardioversion or they were already on intravenous antibiotics for an infection).
• Observations from the audit identified: (1) Staff are struggling to go into the sepsis tool on WebV to indicate where
sepsis screening is not appropriate i.e. where the patient is at end of life and infection is not suspected, is already
on intravenous antibiotics. There is a need to revisit the system to determine if it can be more intuitive and time
efficient for staff. (2) This is a difficult area to measure accurately from patient observations given that a sepsis
screen lasts for 24 hours and can be conducted up to an hour after the triggering NEWS observation, and during
this time a patient will have had multiple observations. This makes patient level reporting challenging.
Actions Issues/Risk
Page 17 of 23
• Consider the findings from the audit and feed these
into the deteriorating patient group for consideration
as to next steps (new actions or to support existing
knowledge and plans to address).
• Risk is that the Trust is unable to gauge, at this time,
what performance against the Sepsis Six bundle is
across all areas of the Trust, without the need for
manual audits.
QP3: Medication Safety (Patient Safety)
Summary
During 2018/19 the Trust were unable to obtain satisfactory assurances regarding medication safety in two specific
areas, specifically (1) omitted medication doses, identified from audit work undertaken and reported to the Trust’s
Quality & Safety committee and (2) errors involving insulin medications, as identified from incident reporting. The Trust
has therefore included these areas within the Trust’s quality priorities for 2019/20.
3a: Reduction in omitted doses
Page 18 of 23
• An increase is seen during November, at both sites, within medicine, surgery and clinical support services, driven
mainly by omission of antibacterial medicines.
• The majority of omissions occur when the dose is available, but not given followed by the dose not being available.
• 54% of omitted doses involved a critical medication, however, the majority result in no harm to the patient.
Actions Issues/Risk
• New clinical leads have been appointed and have
been invited to attend Safer Medications Group.
• This data is Incident data, therefore may not be fully
representative of all omissions/insulin errors, only
those reported via DATIX. EPMA will be used to
produce missed dose reports more quickly and
accurately, starting with Goole who are the first site
to roll out EPMA. Baseline data to be obtained from
EPMA roll out at Goole to get more accurate
incidence information during January 2020.
• Lack of assurance at Safer Medications Group that
action is being taken at divisional level (poor
attendance from all divisions/not all represented at
present).
• This data is Incident data, therefore may not be
fully representative of all omissions/insulin errors,
only those reported via DATIX. The Trust
encourages a high incident reporting, so therefore
any improvements need to be viewed in the
context of reducing the severity of risk, not
reducing the overall number of incidents.
• The number of missed doses will increase
significantly when EPMA goes live as we will have
access to real time data for all medicine charts and
we currently just look at a sample from each ward.
QP3: Medication Safety (Patient Safety)
3b: Reduction in errors involving insulins
Page 19 of 23
• The number of incidents reported involving
insulins has fluctuated each month, with DPoW
having the highest level of reported insulin
incidents. Insulin incidents equate to 8% of all
medication incidents.
• The majority of insulin incidents relate to
failure to administer, followed by incorrect
medication followed by incorrect dose.
• The majority of incidents result in low harm.
Actions Issues/Risk
• Safer Medications Group to review the availability
and quality of insulin training available. Improve
compliance with safer use of insulin mandatory
training.
• Prescribing and dispensing of insulin within EPMA has
been agreed and policies to be amended to update
these changes.
• Datix involving insulin at DPOW are currently
investigated and followed up by the diabetes
specialist nurse.
• Diabetes CNS recruited, to commence in post and
support site based review of incidents and necessary
learning.
• There is a risk from incidents reported that insulins
are not always available and the errors often relate
to incorrect dosages.
• There is a risk that insulin mandatory training may
not be appropriate and that the correct staff may
not be attending.
• Safer use of insulin mandatory training compliance
for the trust in November 2019 is 81%.
• Implementation of EPMA may create additional
risks in the dispensing of insulins from pharmacy.
Page 20 of 23
QP4: Patient Flow (Patient Experience)
Summary
The Trust recognises that efficient patient flow around its acute hospitals is an important element in ensuring high
quality care is provided. To support this focus, the Trust are currently working to embed a number of initiatives around
this area including (1) the SAFER patient flow bundle (a series of work programmes to support efficient flow and early
discharge, developed by NHS Improvement) and (2) meet the requirements for seven day services, specifically,
compliance with 4 priority standards, that all NHS Acute Trusts are working on to meet the governments ambition that
seven day services will be available to all patients by 2020. The Trust has recently submitted the findings of its most
recent 7DS audit during October 2019, this latest data is included here. The following summarises compliance with these
indicators.
4a: Embedding the use of SAFER bundle to improve flow
• SAFER focus within the Trust has been focussed on 4 wards (2 at each site).
• Priority is to focus on 4 key principles: (1) discharge by 12 midday, (2) EDD for every patient, (3) safety huddle by
2pm and (4) education.
• At present there is a gap in the availability of information for ward level LOS, therefore the data presented as follows
is Medicine LOS.
Actions Issues/Risk
• NHSI funding for 6 months for senior project
management role to embed principles for SAFER
and Red to Green.
• Meeting in January 2020 with Associate Director of
Operations to review barriers.
• Difficulty in obtaining data to fully support
understanding of the impact of SAFER interventions,
specifically: Length of Stay information at ward level
and discharge before noon data by ward.
• Engagement in the initiative from some medical staff
and the difficulties of job plans not aligning to daily
board rounds by senior decision maker.
Page 21 of 23
QP4: Patient Flow (Patient Experience)
4b: Improved performance against the priority 4 standards for seven day services
• Clinical Standard 2: Emergency Admissions seen and thorough
assessment by consultant within 14 hours of admission to
hospital.
Weekday Weekend Overall
April 2019 >90% Not
achieved
>90% Not
achieved Not met
September 19 >90% Not
achieved
>90% Not
achieved Not met
• Deterioration from previous report (Apr 19, 74%) to 68%.
• Site breakdown: 60% at DPoW vs. 76% at SGH.
• No obvious weekend effect was seen; rather less likely to be
seen within 14 hours if admitted late afternoon / early
evening.
• Surgery & Critical Care model does not have consultant cover
till 8pm; Paediatrics model of care is also not set up to deliver
7DS standard 2 or ‘Facing the Future’ standard.
• Clinical Standard 5: Inpatients must have scheduled 7-
day access to diagnostic services and be available within
1 hour for critical and 12 hours for urgent patients. Diagnostics Weekday Weekend Overall
Microbiology Achieved Achieved
Standard
Met
(same as
April 2019)
CT Achieved Achieved
Ultrasound Achieved Achieved
Echocardiography Achieved Not
Achieved
MRI Achieved Achieved
Upper GI endoscopy Achieved Achieved
• Echocardiography is the only diagnostic test not
available over the weekend, as a result of establishment
issues; this appears to be a national problem due to a
lack of cardiac physiologists.
• Clinical Standard 6: Inpatients have access to 24/7 to key
REPORT FROM Linda Jackson, Acting Trust Chair / Chair of Finance & Performance Committee
CONTACT OFFICER Jim Hayburn, Interim Director of Finance
SUBJECT Finance & Performance Committee Highlight Report – January 2020
BACKGROUND DOCUMENT (IF ANY) -
PURPOSE OF THE REPORT: Issues from the Finance & Performance Committee meeting requiring escalation by exception to the Trust Board.
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The attached highlight report summarises the key issues presented to, and discussed by the Finance & Performance Committee at its meeting on the 27 January 2020.
TRUST BOARD ACTION REQUIRED The Board is asked to note the report and consider the need for any further actions to address issues highlighted in the report
Northern Lincolnshire and Goole NHS Foundation Trust NLG(20)019 ____________________________________________________________________________________________________________
Highlight Report to the Trust Board Report for Trust Board Meeting on:
4 February 2020
Report From: Finance & Performance Committee held on 27 January 2020.
Highlight Report: Divisional Attendance Surgery and Critical Care Division Attendance – for escalation
The committee asked the S&CC Division to attend the meeting to update on their progress since their last attendance in October 2019. The division is now running a deficit of (2,200) at the end of M09 and has a full year forecast of (2,744).This is against figures of (1069) and (808) respectively for M06. This is a significant deterioration. The division’s main areas of variance are (1575) year to date on medical staffing – of which 500k is attributable to overspend and the rest to unrealised CIP. The other largest variance is on the under delivery of CIP to the value of 979k.
There appeared to be a significant improvement in recruitment of medical staff with commencement dates between the end of January into April which was encouraging. Nursing vacancies are also at their best position for some time but the benefit of this has been swallowed up in the significant sickness levels being experienced with 174 staff under sickness monitoring review which needs to be critically reviewed. The support of the HR Business Partner needs to be addressed to assist the division in this work.
The focus on the committee was on what is achievable in the next two months for consideration in the year end forecast. The division were advised to focus on reducing expenditure by 250k by the end of the year, realising the recruitment pipeline and the real need to start looking at operating differently for next year to improve follow ups to OPD procedure, better theatre utilisation so that the division can operate with the same income at less operating cost.
The committee still did not feel assured with the financial grip within the division.
Medicine Division Attendance
The committee asked the Medicine Division to attend the meeting to update on their progress since their last attendance in November 2019. The division is now running a surplus of 1445 at the end of M09 and has a full year forecast of (357). This is against figures of 424 and (1788) respectively for M07. This is a significant improvement in both actual performance and the year-end forecast position.
The committee’s key concern with the division was the increase in expenditure between months 07 to 09 by (1634) primarily increasing on labour spend. The committee was presented with a list of initiatives that were being progressed to try and bring this down before the year end. It was unclear how much of this overspend was attributable to decisions the Trust has made to ensure winter pressures were addressed and the division was advised to identify this value.
The committee advised the division to refocus and prioritise where their efforts are best spent in reducing costs in the last two months, particularly surrounding the reduction in escalation beds and optimising the ED rotas.
Due to the increase in the last two months on labour spend the committee did not feel assured there was yet sufficient financial grip by the division. _____________________________________________________________________________________________________________ Finance Directorate, February 2020 Page 2 of 4
Northern Lincolnshire and Goole NHS Foundation Trust NLG(20)019 ____________________________________________________________________________________________________________ Performance - for escalation RTT M09 performance saw an RTT position of 78.8% versus a trajectory of 80.8% which is slightly down on last month but still holding well considering the pressures in December.
40 Week waits have increased from 262 in November to 352 in December, 50 week waiters remain static at 9 for the two months. The reduction of these waiters needs to be real focus for the remainder of the year to achieve agreed targets.
OPD Follow Up Position The OPD follow up combined with no due date patients totalled 34,938 in December versus the performance of 33,181 in November representing an increase of 1759 patients. The performance has been affected by increased holidays, sickness and a change in project management in December and needs a real refocus to achieve the target of 33,228 by 31st March. The committee will be looking at the OPD follow up position by speciality in the February committee
Diagnostics – DMO1 Performance The DMO1 performance in November was 12% which has then increased dramatically in December to 17.8% against an internal target of 7.8%. This is now a special cause variation as the performance has gone out of the upper control limit (UCL). The committee found it difficult to challenge the performance due to the lack of effective commentary and actions in the report which will be addressed next month. 62 day Cancer The M09 position is 71.0% against a trajectory of 73.9% which has been steadily improving since September. The committee are concerned at the increase in the 62 day backlog which has increased from 111 in December to 217 by 20th January. The committee were informed that the main area of focus to recover this position is the colorectal service and an NHSI initiative is being rolled out by the end of January called the 100 day challenge.
Unplanned Care – A&E The performance for M09 was 66.7% versus a trajectory of 87.4% compared to 73.4% in M08. The challenges being faced at a local level, and indeed a national level have been well discussed. The committee thought it was encouraging to see that throughout November and December the Trust tracked above or on the England average and that the performance was back up to 88.7% at the time of the meeting. The committee wished to commend the hard work put into this area by all staff in this difficult period and indeed the improvement in the UTC performance of seeing circa 100 patients per day in the last week. Finance
I&E Position The M09 I&E position was £3k adverse this month against the NHSI plan, and £170k favourable ytd. The committee felt assured that the Trust was on course to achieve the control total by the end of March as long as the demands for winter could be contained.
Income The Trust is over performing against its income targets due to the increased activity in several areas This will need to be closely managed to ensure that the system also achieves its target. Good discussions have been had with CCG partners with some work still to be undertaken with NLCCG in the coming weeks
_____________________________________________________________________________________________________________ Finance Directorate, February 2020 Page 3 of 4
Northern Lincolnshire and Goole NHS Foundation Trust NLG(20)019 ____________________________________________________________________________________________________________
CIP The CIP delivery was 114k below trajectory for M09 and year to date is 1439 ahead achieving 15654 at Month 09. The full year forecast position is still to achieve the 20m CIP target. There was concern about the ytd achievement of 41K against agency management CIP against a ytd target of 512k and the lack of progress made with theatre productivity CIP.
Confirm or Challenge of the Board Assurance Framework: The Committee were assured all of the risk ratings within the BAF relating to the Finance & Performance Committee were appropriate. Action Required by the Trust Board: The Trust Board is asked to note the key points raised by the Committee, and consider any further action needed. Linda Jackson Acting Trust Chair / Chair of Finance & Performance Committee
_____________________________________________________________________________________________________________ Finance Directorate, February 2020 Page 4 of 4
NLG(20)020
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors
REPORT FROM Jim Hayburn, Interim Director of Finance
CONTACT OFFICER Matt Clements, Assistant Director of Finance, Financial Management
SUBJECT Finance Report 2019/20 – M09
BACKGROUND DOCUMENT (IF ANY) -
PURPOSE OF THE REPORT: For discussion
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
This report highlights the reported financial position at Month 09 of the 2019/20 reporting period.
TRUST BOARD ACTION REQUIRED The Board is requested to note the reported financial position, identify key areas for challenge and review, and suggest further actions that they consider appropriate.
Finance Report Month 9
December - 2019/20
Executive Summary Month 9 2019/20 • The Trust’s financial position was £3k adverse in the month of December against its NHSI plan, and £170k favourable year-to-date. • The Trust is over-performing on its income targets. This is primarily as a result of an increase in activity - non-elective, outpatients,
day cases, A&E and direct access. Additionally the acuity of patients is increasing, resulting in extra costs within the Trust e.g. the number of 1:1 nursing requirements. This additional income will be key if the Trust is to deliver its control total.
• This increase in income is offsetting additional expenditure, primarily on clinical staff and clinical non-pay. • PSF, MRET and FRF funding of £17.4m is deemed to have been achieved year-to-date. Cash payments are made quarterly in arrears
dependent on year-to-date financial performance compared to plan. • Cash management remains extremely difficult. The Trust remains reliant on central cash support. A bid for a working capital loan has
been drafted. • The trust is planning to deliver its control total. It still faces a challenging end to the financial year, with efforts being focussed on
reducing expenditure.
The key variances in the month are described below: • Income was £685k above plan. Clinical income was £518k above plan, mostly due to continued over-performance on non-elective
and A&E activity, and partly due to increased critical care activity. Other income was £167k above plan, primarily due to additional educational income for ACPs.
• Pay continues to be an issue (£717k overspent). Medical staffing was £237k overspent, mainly due to medical and surgical temporary staffing costs covering vacancies and sickness, ED pressures, escalation beds, December annual leave and additional ED cover for GP bank holiday closures. Medical staff spend was £74k higher than prior month averages. Nursing staffing was £250k overspent due to additional A&E shifts and escalation beds, and additional nursing WTE on wards not yet offset by efficiencies identified in September’s nursing paper. There was also a £254k overspend on other staff due to unidentified CIP in the Medicine and Women and Children divisions.
• Non-Pay was £24k overspent. Clinical non-pay was £519k overspent, mostly due to Cardiology consumables, theatres consumables, Pathology tests and Community wheelchair spend. Other non-pay was £496k underspent because of one-off benefits, including £226k due to a Carbon Footprint monthly billing change, £152k due to NHS Property Services rent disputes, a £55k CNST incentive rebate, and £109k other underspends due to a credit note for CCG prior year charges.
• CIPs were £114k below plan in month, predominantly due to access and flow (theatre/outpatient productivity, length of stay), procurement and unidentified schemes. Fortnightly meetings are occurring with all divisions to ensure the full delivery of the £20m plus £2m target.
Income & Expenditure to 31st December 2019 Income & Expenditure Annual
Plan Plan Actual Variance Plan Actual Variance£'000 £'000 £'000 £'000 £'000 £'000 £'000
Clinical Income 331,625 27,152 27,670 518 248,370 252,607 4,237Other Income 34,435 2,870 3,036 167 25,827 26,988 1,161Total Operating Income 366,060 30,022 30,706 685 274,197 279,595 5,398
NHSI Control Total 391,768 (417,185) (25,417) 291,268 296,428 5,160 (312,333) (317,323) (4,990) (21,065) (20,895) 170
YEAR-TO-DATE
Annual Budget INCOMEExpenditure
(Pay + Non-pay + EBITDA) NET POSITION
Clinical Income to 31st December 2019 INCOME
Annual Plan £'000 Plan £'000 Actual £'000 Var £'000 Plan £'000 Actual £'000 Var £'000 Comments
Elective 16,842 1,359 1,306 (53) 12,950 12,853 (97)Underperformances in Trauma & Orthopaedics (£265k) and Cardiology (£219k), mitigated by over performances in Colorectal Surgery £128k and Gynaecology £275k
Day Cases 26,385 2,078 1,727 (351) 19,739 20,671 932
Expected over performance is showing on Pain Management £202k due to non recurrent demand. Underperformance on Ophthalmology (£993k), mitigated by over performances in Cardiology £526k, Colorectal Surgery £418k, Oral Surgery £178k, Urology £203k, and Upper GI £394k.
Non Elective 98,062 8,223 9,621 1,398 73,359 77,868 4,509
Underperformances on General Surgery (£399k) and Urology (£276k) mitigated by over performances on General Medicine £1,733k, Respiratory Medicine £1,591k, Gastroenterology £319k, Upper GI Surg £133k, Oncology £275k, Paediatrics £393k, Trauma & Orthopaedics £329k and Obstetrics £396k.
Ambulatory Assessments 2,301 192 223 31 1,726 1,666 (60) Underperformance is due to Ambulatory unit at SGH (£96k)
Outpatients 39,409 3,107 2,875 (232) 29,484 30,980 1,496Outpatients are over performing in most areas, the exceptions to this are Clinical Haematology (£93k) and Cardiology (£152k)
A&E 22,358 1,815 2,075 260 17,027 17,671 644 Over performance has increased due to winter pressures at both sites.
Critical Care 17,018 1,428 1,660 232 12,728 12,635 (93)Adult critical care underperformance (£570k) mitigated by over performance in Paeds critical care of £519k
Direct Access 38,559 3,045 2,824 (221) 28,850 29,863 1,013Mainly related to Pathology over performance, £1,151k with a corresponding reduction in the block reprice value. Audiology (£38k), Imaging (£41k) and Cardiology (£63k) all showing underperformances.
High Cost Drugs & Devices 25,455 2,036 2,207 171 19,056 19,054 (2)Underperformances for Hep C and high cost drugs mitigated by over performances in high cost devices and cancer drug fund income
Maternity Pathways 8,127 677 624 (53) 6,095 5,973 (122) In the main, due to underperformance in maternity antenatal pathways
Other 26,011 2,139 2,115 (24) 19,495 18,854 (641) Reduction to Pathology repricing (£474k), 1819 freeze reconcil iation (£397k), mitigated by £303k pay award funding
CIP 5,238 590 97 (493) 3,469 875 (2,594) (£1,969K) due to NHSI plan CIP profil ing and (£625k) due to additional systems savings.
CQUIN 3,557 290 274 (16) 2,670 2,296 (374) CQUIN has been reduced to take account of the year to date under-achievement for associate CCGs.
Private Patient 1,090 82 34 (48) 815 700 (115) Plan for both private patients and overseas visitors set too high.
Other Clinical Income 1,213 91 7 (84) 907 647 (260) Reduction in new claims and increased withdrawals.
TOTAL 331,625 27,152 27,670 518 248,370 252,607 4,237
CURRENT MONTH YEAR TO DATE
Temporary Staffing Costs Temporary Staffing (Locum, Bank & Agency): • Expenditure on temporary staffing for the month of December totalled £3.64m,
which represents an increase of £64K on the levels seen in November (£3.57m). • Agency spend was £1.49m in December, compared to £1.51m in November.
Nursing in-month spend increased by £24k to £622k, £34k higher than monthly YTD averages. Medical spend decreased by £50k to £773k.
• Locum expenditure increased by £127K in December to £1.19m. The increase was due to higher spend on locum consultants.
• Bank spend decreased by £46k to £0.96m in December, but was still higher than the YTD monthly average spend of £0.94m. Qualified nursing bank spend was £19k lower than November, but £15k higher than YTD monthly averages. Unqualified nursing bank spend decreased by £12k compared to November, but was £20k higher than YTD monthly averages.
Capital & Cash Capital Programme 2019/20
• Capital spend at 31st December was £1.89m behind plan. • Facilities spend is in line with plan. • IM&T and Equipment spend continues to be behind plan, capital
spend has increased during December. • Contracts have now been awarded for Ward 29 at SGH and the MRI
scheme at DPOW, the spend for these schemes will continue to be behind the original plan set in May.
• The Trust received funding of £1m for UEC, orders have been placed for the £1m, £0.83m of equipment have arrived on site.
• Donated capital spend is above it’s full year target.
Cash
• The cash balance at 31st December was £9.92m, an in month reduction of £1.14m.
• The cash balance is to support payments to be made in at the beginning of January and slippage in the capital plan.
• The draw down request for January has been agreed by NHSI and DHSC.
NHSI Plan YTD Plan YTD Actual YTD Variance£mil £mil £mil £mil
• Debtors has increased this month, due the continued overtrading with our commissioners, £6.63m of the balance relates to PSF and FRF income due for 2019/20.
• Stock has increased by £0.24m during December, £0.21m of this relates to pharmacy stock. • Revenue creditors and accruals in total have increased by £0.57m in month, as no payment runs were processed over
the Christmas period. • The reduction in deferred income is the release of December’s MRET funding. • Following the completion of the month 9 interim accounts, the loan balances due within one year have been re-
profiled. The loan balances also include the interest accrual £1.76m.
Last Month This Month Year end Plan Variance From Plan
Net Current Assets/(Liabilities) (19.76) (63.17) (45.42) (32.19)
Debtors Due > 1 Year 0.00 0.00 0.00 0.00Creditors Due > 1 Year 0.00 0.00 0.00 0.00Loans > 1 Year 200.01 158.61 184.54 (36.50)Finance Lease Obligations > 1 Year 0.01 0.01 0.00 0.01Provisions - Non Current 4.47 4.27 3.56 0.14TOTAL ASSETS/(LIABILITIES) (50.80) (52.44) (57.31) 0.46TOTAL CAPITAL & RESERVES (50.80) (52.44) (57.31) 0.46
Cost Improvement Plans EXECUTIVE SUMMARY :
YEAR TO DATE POSITION :
• Fortnightly meetings continue with Divis ions a l though these have not been required with the Corporate Directorates due to there continued s trong performance.
• Recurrent schemes account for £16.7 mi l l ion (83%) of the ri sk adjusted del ivery
• Regular meetings continue to be held with Divis ions to support ful l del ivery of the plan and each Divis ion has identi fied support.
• Del ivery in December was £114k below the planned level of £1.88m but year to date the programme has del ivered £15.65m against the plan of £14.22m. In-month del ivery levels , a l though s l ightly below tra jectory remain wel l above the levels required to help del iver the £20 mi l l ion. Al though workforce and productivi ty have s truggled throughout the year these have been mitigated by Corporate, Es tates and Faci l i ties , Procurement and Income
• Al though year to date del ivery i s s trong there remain ri sks to current del ivery e.g. CPG contract, Cl inica l Coding, i t i s therefore essentia l that mitigation schemes continue to be developed to cover these ri sks i f necessary but just as importantly to s tart to develop the 2020/21 programme.
• In December nurs ing del ivery did improve but remains below plan, AHP vacancies increased providing further benefi t. Di rect access income did dip but this i s seasonal and was ful ly anticipated with recovery expected in the fina l quarter. Strong del ivery continues in Estates , corporate areas and income mitigating the pressured areas of workforce and the ri sk adjusted cl inica l coding. Gain share savings relating to Bios imi lars have been adjusted to only reflect North and North East Lincs CCGs drugs .• The principle areas of under del ivery continue to be Medica l Staffing, Nurs ing, LoS productivi ty and Theatres productivi ty.-Medica l s taffing i s due to under-recrui tment at middle grade level and s l ippage on the middle grade scheme in Medicine. Recent recrui tment i s impacting and the overspend has begun to reduce a l though only margina l ly.-Nurs ing i s s truggl ing to del iver i ts agency reduction costs despi te the price reductions with TFS being rea l i sed. This i s due to the increased usage of premium cost agencies . Recrui tment i s partia l ly mitigating the loss of agency rate reduction.-Theatres productivi ty i s now being driven forward by the Theatres Transformation Board. Currently a s tructured savings plan has not been developed but costs in anaesthetics have been reduced and are currently providing for this scheme-The Cl inica l Strategy has improved with movement on the CPG contract a l though this s ti l l comes with ri sk and wi l l be rel iant on the CPG paying these invoices . Renegotiation of a number of SLAs hasn't occurred to date and may wel l be 2020/21 schemes
• The Trust’s cost improvement target for 2019/20 of £20m, plus an additional £2m across the heal th community i s required to support the achievement of the year end control tota l .
• Forecast del ivery remains £20 mi l l ion and continuation of current del ivery trends i s essentia l to enable this . There remains ri sks around the cl inica l workforce del ivery as wel l as the cl inica l coding programme
• At the end of Quarter three the Trust had del ivered savings of £15.65m against a plan of £14.22m an over del ivery of £1.43m
• The programme has benefi tted s igni ficantly from income schemes in Cl inica l Support Service and in particular pathology to supplement the continued over-del ivery in Estates and Faci l i ties (pay vacancies , Roost income and non-pay, the Roost income is now forecasting £280k in year aga inst an origina l plan of £108k), corporate vacancies and procurement.Further procurement savings have been reported for the work done by NHS supply cha in (category towers ). This was highl ighted las t month and there has now been robust data provided and va l idated by our procurement department
• The pipel ine currently holds in excess of 40 potentia l projects . These need to be developed further ei ther to act as potentia l mitigation for the current financia l year or to support del ivery of the 2020/21 programme
• At the end of Quarter three the Trust had del ivered savings of £15.65m against a plan of £14.22m an over del ivery of £1.43m
• Divis ional & Corporate targets tota l led £22.6m giving £2.6m of additional cover aga inst the £20m programme. To date Divis ions and Directorates are expecting to del iver the £20.0 mi l l ion. Although overs ight continues on in-year del ivery, development of the 2020/21 programme ready for the new financia l year i s a a lso a primary focus .
• Di fferent schemes have been identi fied to del iver the £2m system wide saving programme. Progress to date has been good on Bios imi lars £500k and Medicines management £500k. Although pressure management (£1 mi l l ion) i sn't going to be del ivered as origina l ly planned there i s confidence that mitigating schemes wi l l be found.
Cost Improvement Plans 2019/20 CIP DELIVERY BY WORKSTREAM AND DIVISION
Annual Year to Date at December 19 Current Month - December 19 Risk Adjusted Forecast Year-end
Risks • Cost Drift/Developments – This continues to be the most significant risk given the previous year`s performance. The level of cases has
reduced following the introduction of the Business Case Review Group. There are some potentially significant costs pressures. ward staffing, medical winter pressures and consultant tax issues from the pension scheme, in addition to a number of smaller pressures.
• CIPs – The level of CIP continues to be challenging for the Trust given it`s previous year`s achievements. There is still a shortfall in the level of schemes required to achieve the £20m plus £2m, but divisions are continuing to fill the gaps in the schedules. The overall programme is ahead of target YTD.
• Estate – The Estate is a major risk. This is not just from the costs of repair but particularly from the loss of capacity. Estates continue to carefully manage the position but there remain significant problems that could emerge at any time.
• Impairments - the current forecast excludes any asset revaluation impacts (impairments or impairment reversals); these are also excluded when comparing performance to control totals. There is a planned revaluation on 31st March 2020, with a valuation review commencing in January.
• Income – the Trust remains committed to delivering the system control total and is working with the CCGs to confirm income levels for
the Trust. • Specific Budgets – The specific budget currently causing concern is Surgery. As a consequence it was put into Internal special measures
to improve its financial position. There is a smaller problem in the Community budget.
• MSF/PSF – Not delivering the agreed control total of £25.4m deficit, will mean the loss of part of the £22.1m of MSF/PSF. Part of this funding has been obtained for the first two quarters, thus mitigating the overall risk. The risks to non achievement lie in many of the above risks not being mitigated. The plan is, set very tight in order to achieve the Control Total and thus there is little to compensate if plans deviate adversely.
NLG(20)021
DATE OF MEETING 4th February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Tony Bramley, Vice-Chair of Quality & Safety Committee
CONTACT OFFICER Angie Legge, Associate Director for Quality Governance
SUBJECT Quality & Safety Committee Highlight Report – January 2020
BACKGROUND DOCUMENT (IF ANY) -
PURPOSE OF THE REPORT: Issues from the Quality & Safety Committee meeting requiring escalation by exception to the Trust Board.
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The attached highlight report summarises the key issues presented to, and discussed by the Quality & Safety Committee at its meeting on the 24th January 2020.
TRUST BOARD ACTION REQUIRED
The Board is asked to note the report and consider the need for any further actions to address issues highlighted in the report
Northern Lincolnshire and Goole NHS Foundation Trust NLG(20)021 ____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________ Finance Directorate, February 2020 Page 2 of 3
Highlight Report to the Trust Board
Report for Trust Board Meeting on:
4th February 2020
Report From: Quality & Safety Committee held on 24th January
2020
Highlight Report: 1. Ligature Risk Assessment
The Committee noted the progress towards compliance with the national Estates & Facilities Alert (ESA)
and that given the scale of the challenge we are still some distance from being able to achieve full
assurance that all the risks have been quantified and mitigated.
Action: The risk assessment on compliance to be re-formatted by impact, probability, and mitigation
timetable and re-presented as soon as practical.
2. IPR – Seven Day Services
The Committee noted that the Trust appeared to be at continuing risk of failing to meet the national
requirement to deliver the four priority standards by April 2020; and the broader concern that meeting
these standards should be a key component of delivering the ‘SAFER’ bundle.
Action: The Committee wishes to obtain assurance from QGG that Divisional management teams have
recognised and quantified the gaps to compliance and the actions required to rectify these.
3. Ophthalmology Service Risk
The Committee was concerned to note that the impact of the recent short-term outsourcing of services in
order to create internal capacity in this very challenged service had fallen well short of expectation in
terms of the number of cases being successfully transferred and treated, due to shortcomings in the
service specification. Moving forward a fresh tendering exercise is required which, due to procurement
rules, is unlikely to be delivering treatments before June 2020.
Action: The Committee will be seeking assurance in April 2020 that the new procurement process is well
advanced for the replacement service provision and that lessons learnt from the current exercise have
been clearly applied.
4. SI Progress Update
While the Committee was pleased to note the greatly improved rate of ‘assured at first review’ SI
reporting; this was tempered by concerns at the continuing challenge in performance in the number of
those SI investigations (a) complete within national timeframes; (b) requiring extensions, and; (c)
submitting actions plans to the CCGs on time.
The Committee recognised that during 2019/20 greatly improved quality control of the SI process was
becoming evident, but the reported flip-side of this is the time commitment required to achieve this and
the consequent impact on timely case progression and therefore backlogs
Actions: The Committee intends to maintain its focus on this and will be looking for assurance from QGG
that we can deliver capacity improvements alongside quality ones.
5. CNST Maternity Incentive Scheme
The Committee was pleased to note that significant progress now appears to be being made in working
towards the achievement of all the required standards, with the Trust now meeting 8 of the 10 standards,
with the hope that we may be able to report full compliance by April 2020.
Action: None – reported to the Trust Board for information only.
Northern Lincolnshire and Goole NHS Foundation Trust NLG(20)021 ____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________ Finance Directorate, February 2020 Page 3 of 3
6. SI Review Group
The Committee reviewed the Group’s latest highlight report (themed on ‘Never Events’) and noted that:
(a) While reassurance was received in relation to improved use of the WHO checklist that further work
will be undertaken to establish robust assurance, and secondly, (b); that a broader thematic concern was
the general quality of documentation recording. Action: To await an update from QGG on proposals to improve these situations.
Confirm or Challenge of the Board Assurance Framework (BAF):
The Committee noted that colorectal cancer performance was continuing to flag as an outstanding concern and was informed that the service was about to embark on a ‘100 day’ improvement challenge process which should be concluding in mid-April 2020. Action: Divisional and Clinical leads for this service to present progress to the Committee in March 2020.
Action Required by the Trust Board:
The Trust Board is asked to note the key points raised by the Committee, and consider any further action needed. Tony Bramley Non-Executive Director and Vice-Chair of Quality & Safety Committee
BACKGROUND DOCUMENT (IF ANY) National Quality Board (NQB) report “How to ensure the right people, with the right skills, are in the right place at right time” 2013 NHS England
PURPOSE OF THE REPORT: To provide assurance to the Board on staffing and nursing quality
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
Key points and risks:- • This report provides two months of information • Receiving data on time continues to be a problem for the directorate, this
is highlighted on the Chief Nurse risk register as the dashboard has not developed at the pace requested.
• The red flag reporting is improving which is providing more insight into staffing incidents
• Vacancy position has improved to less than 8% with international recruitment commenced and a successful nursing recruitment open day with more planned for 2020
• Multi-disciplinary bedside huddles continue which are having positive impact on falls
TRUST BOARD ACTION REQUIRED The Board is asked to note the content of the paper for assurance.
2
Background
This is a routine report in accordance with the requirements of the updated National Quality Board (NQB) Safe Sustainable and Productive Staffing Guidance (July 2016) and the National Institute for Health and Care Excellence (NICE) guidance issued in July 2014 and Developing Workforce Safeguards (2018). Trusts must ensure the three components are used in their safe staffing processes:
• evidence-based tools (where they exist) • professional judgement • outcomes
The Trust is committed to providing safe, effective, caring, responsive and well led care that meets the needs of our patients. It is recognized that decisions in relation to safe clinical staffing require a triangulated approach which consider Care Hours per Patient Day (CHPPD) together with staffing data, acuity, patient outcomes and clinical oversight. This report provides evidence that processes are in place to record and manage Nursing and Midwifery staffing levels on a shift by shift basis across both hospital and community settings and that any concerns around safe staffing are reviewed and processes put in place to ensure delivery of safe care. This paper covers 2 months due to board reporting timelines for the months of November and December 2019. This is due to the timeliness of provision of data. Introduction
The report seeks to bring data together to provide analysis and assurance regarding the Nursing and Midwifery workforce, quality and safety risks, enabling the Trust to demonstrate compliance with safer staffing guidance. It also seeks to include information on vacancy rates and nursing metrics across all ward areas. The Nursing Metrics Review Panel is chaired by the Chief Nurse and meets monthly and is attended by the senior nursing team for the organisation. The panel review the information provided by the nursing dashboard, sand commission any work required to investigate and support any areas of concern. A matrix has been developed to identify and record risk ratings for all ward areas, in order that progress can be tracked against actions and the re-assessment of risk monthly. Safe Staffing November 2019 1.0 Shift Fill Rates
This data is used to populate the monthly Hard Truths return, previously referred to as the Unify return, which is submitted to NHS Digital. The data is taken from the Allocate Eroster system. The fill rate submission currently requires information on in-patient areas only. Ambulatory Care, Short Stay and Emergency Departments are excluded. The full NHS Digital upload is provided in Appendix 1, and a review of the substantive breakdown can be seen in Appendix 2.
3
The figure below (table 1) shows the average fill rate for November 2019 which is 99.1%. This demonstrates an improvement in the overall fill rate which was 97.1% in October. There is still a downward trend in both the total average and day average but a slight increase in the night average which can be seen in the 11 month graph below. Table 1: Average fill rate for November (all staff)
Graph 1: Eleven month trend Trust average fill rates
Forty one inpatient areas at NLAG have reported their fill rate for November 2019, which now include AMU and CDU. The shift fill rate for Registered Nurses (RN) in November 2019 was as follows; • Sixteen areas recorded less than 95% shift fill rate on days for RN, this is the
same as October, these were, Amethyst, C1 Glover, ITU, NICU DPoW, Rainforest, Stroke DPoW, B4, C5, B7, CCU, Disney,, Ward 16, 22, 23, 24 and 28.
• Two wards had a substantive day fill rate of <50%, these were B4, and ward 28 these shifts are supported by bank and agency staff which is reflected in the all source fill rate percentages and ongoing recruitment to vacancies. Ward 28 staffing return also includes ambulatory which needs to be altered.
• On nights, six areas recorded less than 95% shift fill rate for RN’s; these were
ITU DPoW, NICU DPoW, and Ward 26 SGH, ward 3, 6 and NRC Goole. This is a decrease from the seven areas reported in October 2019. Ward 3, 6 and NRC is due to the site roster creation.
• In November there were six wards with a fill rate <50% for substantive staff on nights, which is a reduction from the 11 in October. These were, B4, ward 22, 23, 24, 28 which reported the same in the previous month and & Goole NRC, who are new reporter. These shifts are supported by bank and agency staff which is reflected in the all source fill rate percentages (see appendix 2) and ongoing recruitment to vacancies.
The tables on the next two pages show the substantive staff average fill rate by division.
88.00%
90.00%
92.00%
94.00%
96.00%
98.00%
100.00%
102.00%
104.00%
106.00%
Jan-
19
Feb-
19
Mar
-19
Apr-
19
May
-19
Jun-
19
Jul-1
9
Aug-
19
Sep-
19
Oct
-19
Nov
-19
Average Day fill rate
Average Night fill rate
Total fill rate
Linear (Average Day fill rate)
Linear (Average Night fill rate)
Linear (Total fill rate)
5
Table 2- Medicine substantive fill rate
Medicine Wards Substantive Staff % CHHPPD
RN Days Carer Days RN Nights Carer Nights RN Carer/TNA Total
Disney 57.5% 99.7% 97.6% 93.19% 3.8 2.4 6.1 NICU 97.4% 92.0% 96.7% 76.67% 9.4 5.6 15.0 SGH
GYNAECOLOGY WARD 85.7% 93.6% 60.3%
- 5.4 1.6 6.9
Ward 26 81.8% 82.2% 75.5% 23.33% 5.5 1.5 7.0 Table 5- Community service substantive fill rate
Community Services
Substantive Staff % CHHPD
RN Days Carer Days RN Nights Carer
Nights RN Carer Total
NRC Goole 78.9% 75.9% 48.3% 66.67% 3.8 3.5 7.3
Percentage Colour rated <95% 85-94% <50% >50%
2.0 Care Hours per Patient Day Data (CHPPD) The Care Hours per Patient Day (CHPPD) data is reported monthly and is included in the Trust’s NHS Digital return (Appendix 1). CHPPD is the total hours per day of Registered Nurses (RN), Midwives (MW) and care staff divided by the number of patients in the ward/department at 23.59 hours each night. This provides a score of the average care hours per patient per day. The overall CHHPD for Registered Nurses trust wide is 4.6 in November which is an increase from the 4.2 in October 2019. The overall CHPPD for care staff trust wide shows a slight improvement at 2.9 compared to 2.8 in October The total CHPPD (RN and care staff combined) has increased to 7.5 in November from 7.0 in October 2019. The trust figures remain below the national benchmarking model hospital data and are showing an overall downward trend. The Trust data for November can be seen in table 6 below and an 11 month trend of data seen in the graph below.
7
Table 6: Trust CHPPD data November 2019
Care Hours Per Patient Per Day (CHPPD)
Site Nurses Care Staff Overall Ratio RN’s to HCA’s
Grimsby 4.6↑ 2.9↑ 7.5↑ 61%↑
Scunthorpe 4.6↑ 2.9↓ 7.5↑ 61%↑
Goole 3.8 2.8↓ 6.6↓ 58%↑
Trust Overall 4.6↑ 2.9↑ 7.5↑
61%↑
Graph 2: Trust 11 month trend of Trust CHPPD
3.0 Staffing Incidents In November 2019 there were 54 incident reports submitted to the Trust incident reporting system (Datix) regarding Nursing and Midwifery staffing compared to 49 in October 2019. 47 of these relate to inpatient & ECC covered by this report. The remaining seven incidents related to 2x medical staffing, 1x midwifery community, 1x nursing community, 1 x Paediatric Assessment Unit, 2x Maternity unit DPoW. These were reported in the following divisions: • Medicine 17/54↑ • Surgery and Critical Care 8/54 ↑ • Women and Children 21/54↓ • Community 1/54↑
0
1
2
3
4
5
6
7
8
9
RN CHPPPD
Carer CHPPPD
Total CHPPD
Linear (Carer CHPPPD)
Linear (Carer CHPPPD)
Linear (Total CHPPD)
8
Red Flags There were ten red flag incidents reported in November 2019. Four of these were Emergency care red flags due to the volume of patients in the department. Three midwifery red flags incidents were reported. There were three red flags for less than 2 registered nurses on the shift: • Laurel had one nurse off sick which left one nurse on night shift, supported by a
supernumerary newly qualified nurse and site.
• Ward B3 had one registered nurse for Night shift for 22 patients supported by RN from Hobs.
• Ward 3 had one registered nurse to cover the ward, additional HCA on shift to
support the Registered Nurse and site. There were 3 red flags for less than 50% substantive staff on shift all from ward 25. Education continues with the ward to promote the red flags to ensure all wards start to record these. 4.0 Safer Nursing Care Tool (SNCT) The 2nd round of review meetings have commenced using the SNCT data from the 2nd cycle of data collection. A report is anticipated to go to the Trust Board In April 2020. 5.0 Vacancies The Trust vacancy position for Registered Nurses in October is 126.33 whole time equivalent (wte) which equates to 7.80% of the Registered Nursing workforce. This is an improvement from 136.13wte (8.53%) in October 2019. The highest area of RN vacancies remains in the Medicine Division with 77.98wte or 13.68% in November 2019, compared to 73.79, or 13.44% in October 2019, which is deterioration in month. The Surgery & Critical Care Division has a vacancy of 39.18 or 9.32% in November 2019, which is an improvement from 45.51 or 10.83% in October 2019. The HCAs Trust vacancy position for HCAs in November 2019 is 26.20 (3.20%) compared to an over establishment of 9.63wte or -1.18%% in October 2019. Medicine currently has 24.21wte HCA vacancies because of a change to their service requirements.
9
Table 7: Vacancy report as at 31st November 2019
6.0 Quality
6.1 Falls In November 2019 there were 35 falls across inpatient areas under the category minor harm; compared to 33 in October and 36 in September 2019. See graph 3 and table 3. Graph 3
Table 3 June 19 July 19 August 19 Sept 19 October 19 Nov 19 No Harm 83 76 84 96 97 86 Low Harm 40 21 36 36 33 35 Moderate Harm
0 1 1 1 1 0
Severe Harm
0 2 0 1 1 0
In November 2019, there were no falls reported with moderate or severe harm. AMU, Wards B4 and 16 and both Stroke Units have reported a greater number of falls in November than the previous month, however, these were all predominantly single falls demonstrating that appropriate preventative measures were instigated thus preventing further falls. The new ‘MDT huddle’ process of responding when patients who have fallen more than once, or those who have sustained a moderate, or greater harm, has been in place since the beginning of October 2019. Feedback remains positive with ward sisters reporting that this is a far more responsive and supportive approach which has led to improved outcomes for patients. This new process will be evaluated in January. 6.2 Harm Free Care On the second Wednesday in every month prevalence data is collected which is then submitted to NHS Digital on Harm Free Care. The data that is collected is the average across four harms; falls, pressure ulcers, VTE (Venous Thromboembolism) and CAUTI’s (Catheter Associated Urinary Tract Infection). This data is a snapshot and therefore needs to be reviewed along with other data sources. In November 2019 the new harm free care rate was 97.5%. This is a slight deterioration from 97.8% in October and 98.1% in September. This is the third consecutive month of deterioration since the highest rate of 98.5 % in August 2019. In the Acute setting, there were two areas, C5 at DPOW, and Ward 18 at SGH that triggered a red indicator (equal to or below 90% harm free care). This is a decrease from four areas in October. It should be noted that Ward 18 has a smaller sample size than most wards. This will have affected the new harm free care rate and therefore the RAG rating. Both wards triggered red in October 2019 and will be discussed in more detail at the Nursing Metrics Panel. There were seven areas (up from five areas in October 2019) that triggered an amber indicator (equal to, or below 95% harm free care). Of these, five areas, Ward B4, Amethyst, Laurel Ward and Ward B6 at DPOW and Ward 28 at SGH, have flagged as an outlier over the previous months. All three community networks were rated as green (greater than 95%) for November 2019 and the preceding two months.
11
Work is on-going within the Acute divisions to ensure that there is accurate data entry at ward level and validation by Matrons. The harm free care data is monitored alongside other indicators (including incident reporting) at the Nursing Metric Panel. 6.3 Pressure Ulcers Acute sites In November, 90 hospital acquired pressure ulcers were reported across the 3 hospital sites which is an increase from the previous month (Table 4). Table 4 Hospital acquired pressure ulcer incidents by month (data validated by TVN) Jan 19
Feb March April May June July August Sept Oct Nov
63 72 47 48 58 64 64 53 68 83 90 There were no category 4 pressure ulcers reported, however there was an increase in the number of category 2, 3 and unstageable pressure ulcers for the second consecutive month (Table 5) Table 5 Hospital acquired pressure ulcer incidents by category Category 2 75 ↑ (of which 7 were medical device related) Category 3 9 ↑ (of which 1 was medical device related) Unstageable 6 ↑ (of which 1 was medical device related)
Graph 4 Hospital acquired pressure ulcers incidents by site and per 1000 occupied bed days (data extracted from Datix)
12
Ward C5 reported one category 3 pressure ulcer and two category 3 pressure ulcers were reported on both C6 and Amethyst ward in November. The areas of high incidence continue to be monitored through the Harm Free Care Board and the Nursing Metrics Panel. In December 2019 the focused ward based training by the Tissue Viability Team is being provided to the Stroke Unit at DPoW. This training will be delivered three days per week over one month. During December there are planned “bite size” education sessions on all acute sites. These are around equipment for pressure ulcer prevention and management and are being supported by Community React to Red Team. Community 37 pressure ulcers were acquired on community caseloads in November across the three Community Networks. Of the 37 pressure ulcers identified and reported, 21 (57%) were identified in Care / Residential Homes whilst under the care of the Community Nursing Teams, this is an increase from 17 in October 2019. Graph 5 Pressure ulcers acquired on community nurse caseload
Seven Category three Pressure Ulcers were identified and reported in November which is an increase from the four in October 2019, however a significant decrease from 14 in September 2019 (Table 6). Six unstageable pressure ulcers were identified. Table 6 Community acquired pressure ulcers by category Category 2 24 = (Oct - 24) Category 3 7 ↑ (Oct - 4) Category 4 0 ↓ (Oct - 1) Unstageable 6 ↑ (Oct - 5)
13
The West Network continues to report the highest incidence of pressure ulcers and remains an area where focused support is being given. Mis-categorisation of pressure ulcers is a common theme and bite size bespoke sessions are been delivered by community TVN twice weekly to small groups of community and therapy staff. 6.4 Patient Experience During November 2019, 27 new formal complaints were received and 120 new PALs concerns, this data, along with the split across divisions, can be seen below in graphs 6, 7 & 8. The Patient Experience team is seeing increased number of complaints closed which is indicative improved engagement within divisions. There is also a focus on closure of longest standing complaints. Graph 6
Graph 7
Graph 8
0
50
100
150
200Formal Complaints
Pals
Linear (FormalComplaints)
Linear (Pals)
Divisional Split for Formal Complaints in November
Med
Surg
CSS
CTS
W&C
Themes Treatment
Care
Delays
Attitude &BehavioursCommunication
Access to Services
14
The headline themes within the formal complaints for November are equally split across Care, Treatment and Delays. Work has begun with the Complaints and Pals team to improve coding of data entry on Datix, using agreed theme headings. There is a notable shift of attitude and behaviours as a dominant theme, which was seen at the beginning of the year. This positive change is reassuring that the impact of Pride and Respect and a cultural emphasis on the Trust values is making an impact. The Friends and Family Test changes are being gently transitioned over, with new cards being designed and questions changed accordingly. Engagement with maternity and services users continues, as this will be the more significant change. The Friends and Family Test response rates continue to be influenced by the lack of adequate systems to support its progression, especially in areas such as ECC, Outpatients and Day Case. This has been escalated and is on the Chief Nurse directorate risk register. Graph 9
6.5 15 Steps Challenge In November seven areas were visited on the 15 steps challenge (see table 7). Of these visits, one area received Outstanding – which was Ward 3. All elements of the 15 steps challenge were exceeded. Four areas received good – two areas which were Ward 17 and Theatres DPOW were revisits as they had previously been rated as Requires Improvement and improved to a Good rating. Two areas received Requires Improvement, one of these being a revisit (SGH A&E) and remained at Requires Improvement. The elements of the 15 steps challenge are being addressed by the A & E team and the medicine division. Table 7
0.00%1.00%2.00%3.00%4.00%5.00%6.00%7.00%8.00%
Overall
Linear (Overall)
05 November 2019 Endo DPOW Good 06 November 2019 Ward 3 GDH Outstanding 13 November 2019 19 Good 19 November 2019 A&E SGH revisit Requires Improvement 20 November 2019 17 revisit Good 27 November 2019 Theatres DPoW Good 28 November 2019 Theatres SGH Requires Improvement
15
6.6 Infection Control and Prevention
There have been no detected Trust acquired MRSA bacteraemia cases as such we remain on 1 case for the year so far.
C.difficile infections
The Trust reporting criteria changed in April and this has been previously mentioned it would result in additional cases being allocated to the Trust. There have been 27 cases attributed to the Trust with 5 lapses in practice / care identified. The main findings from the Post Infection Review are the antibiotic course lengths and choices. This is to be discussed at the Infection Prevention & Control committee in December to review whether the use of coamoxiclav can be curtailed. To further help prescribers a new antimicrobial app/website will be presented at IPCC to seek approval.
Gram negative blood stream infections
There are a number of workstreams being undertaken by our CCG partners to help support the 50% reduction ambition by 2024. This requires collaboration with the acute IPC team to help support education and system change practice especially the diagnosis and treatment of urinary tract infections.
The number of Gram negative E.coli bacteraemia cases detected so far show similar numbers to last year (see graph 10)
Graph 10
Influenza vaccination using the peer vaccinators approach appears to have plateaued. As a result further support has been granted to support Occupational Health vaccinators visiting wards and ensuring data has been submitted. Overall the data analysis has been problematic. As such the data is currently being reviewed for inputting accuracy by the People and Organisational effectiveness team.
16
7.0 Divisional summaries and oversight provided by Heads of Nursing
7.1 Children’s
The Children’s Division remain in a position of having limited vacancies in November for any specialty – RN/RSCN and HCA’s. All approved vacancies are at various stages of the recruitment process, with the expectation that all substantive vacancies will be filled by November/December 2019. All substantive vacancies now recruited to with start dates, remaining vacancies coming up over next few months relate to maternity leave.
All areas continue to risk assess acuity and activity routinely twice daily and when the situation changes and staffing resource is allocated across the specialties and sites to ensure safety is maintained in all areas. The Division are trialing a model of ‘unit coordination’ which will enable there to be a much more co-ordinated and in-depth understanding across the clinical areas as to where there are issues and risks, which will in turn allow a more effective utilisation of our total staff base and support patient safety and flow.
There is an increased level of short term and long term sickness and a sustained level of Maternity Leave which is being managed appropriately and backfilled utilising bank/substantive staff when needed. Agency spend is negligible and considered as a ‘last resort’. Bank Staff are utilised as needed to keep the areas safe and usage/spend is being analysed at the weekly Divisional Quadumvirate Meetings in order to understand and manage our Bank spend more robustly. There were a total of five open PALS in November 2019, with two new PALS concerns received in month. The longest open PALS is from September 2019. All PALS relate to concerns on the DPOW Site and three of the five are in relation to clinical care delivery/decisions (medical). With respect to formal complaints, there was a new complaint received in month with two outstanding complaints being investigated. This is no change on last month’s position.
There continues to be a weekly divisional complaints meeting with the complaints facilitator to ensure that all complaints are investigated and managed succinctly. This works well and ensures that areas of concern are dealt with timely. There was a new CCG incident in month, for DPOW and one remaining open at SGH. Both incidents relate to insufficient referrals. 7.2 Surgery and Critical Care
Within the S&CC division the Registered Nurse vacancy position is offset by an ODP over establishment of 24.22 WTE within the theatre environment leaving an actual Registered Nurse vacancy of 14.96 WTE. This over establishment of ODPs meets the required standard needed within the theatre setting as most are dual trained and able to work flexibly between anaesthetics, scrub and recovery areas. The Safety Thermometer for New Harm Free Care for all wards was above 95% with the exception of ward 25 at 88.3%, B6 & B7 at 85% due to UTI who had an indwelling catheter in situ.
17
Falls across the division remain static, with all falls being categorised as ‘no’ or ‘low’ harm. B7 at the DPOW site has the highest number of falls for the division at 6 in month and is a ward which has been identified as requiring extra support. Some of these were repeat fallers, therefore, bedside Multidisciplinary huddles for repeat fallers are being undertaken and B7 have actively participated in these with positive outcomes, all staff are engaged within this. National Early Warning Scores are available live via the Power BI system. The results for November continue to be on the positive trend with all DPOW nearly or over 90% and SGH all over 90% and Goole consistently around 90%. The area of focus is now on compliance with Sepsis screening and actions in line with the Sepsis 6 Tool, discussions have been held with Ward Managers on both sites and the Improvement Team to understand barriers and to agree how to work together to improve compliance. Full audit undertaken on 16th December and awaiting results. Work on going regarding lying and standing Blood pressure to assist in the falls and also oxygen prescribing. We also have two ward managers retiring during the next 6 months – adverts are currently being formatted to recruit. Significant issues with sickness across Surgery and Critical Care and within the acute areas currently 174 staff under the sickness monitoring process. Support being sought from human resources and organisational development. The Senior nursing time out day on 6th December had an aim to embed the following with all ward managers, deputy and clinical sisters - finance, complaints, power Bi, audit, roster perform, HR, governance and Kay Fillingham is joining us to support with education and training. Very well received day and attended by over 40 senior nurses, the next is planned for March.
7.3 Medicine
The Newly qualified nurses who started in Medicine have now moved out of their supernumerary period and are embedded in the establishments on their wards. This has gone some way to reducing the number of vacancies in Medicine. The Chief Nurse establishment review identified the need for additional Registered Nurse hours within a number of establishments, Phase 1 of this review, focusing on those areas identified as having a high risk in terms of Registered Nurse numbers and skill mix, has been actioned and posts created by this are in the recruitment phase. There continues to be recruitment challenges for the both sites and this has meant ongoing use of Bank or Agency staff.
The change in model of acute medicine began its 1st Phase on the 27th November with a change from an Admission Unit to an Acute Assessment Unit on both sites and a refocus on Ambulatory Care with it taking on the title of Same Day Emergency Care (SDEC). There continue to be escalation beds open at the DPoW site which creates challenges with staffing resulting in additional duties and significant redeployment of substantive staff in order to maintain safety. This movement of staff impacts on the ability to provide consistent continuation of care across a patients pathway.
18
Medicine NEWS on time current compliance is 87.29% which is a slight increase on the previous month. There were 3 areas below 80%, Amethyst / C5 / Ward 17, which are monitored through Ward Performance reviews, the site differences are still evident and there is continued focus on the dip at lunchtime.
Two areas scored below 90% on the Safety Thermometer in except Ward C5 and Ward 18 in relation to New Harm Free Care. Pressure Ulcer data for October shows five areas with category three Pressure Ulcers Ward 17, Ward 22 at SGH and Wards, C5, C6 and Amethyst at DPoW. PU numbers in total have decreased across medicine 7.4 Community and Therapies
The dashboard for Community Network Teams (see appendix 4) and the Unscheduled Care Team is produced monthly and will be developed for other teams as information becomes available now that a Systmone reporting tool has been procured (testing and data validation in progress). Community staffing ‘red flags’ have been finalised and the processes for staff to implement are currently being developed. A number of productivity projects are underway in community teams and a business case to purchase an Intelligent Scheduling System is being finalised. A staffing review with the Chief Nurse is planned for later in the year when the scheduling system is available. Team and Visit assurance tools have been developed and currently being piloted by the team leads and matrons.
The number of Registered Nurse vacancies across the Division has decreased slightly to 13.95 WTE in November 2019 as the number of appointments start their roles across community teams. NRC Goole remains an area of concern for Registered Nurse staffing with 3.74 WTE RN vacancies and long term sickness resulting in a reliance on the use of bank and agency staff to provide the second RN on duty each shift. Interviews for the B6 deputy post were successful with the recruitment of the interim deputy.
7.5 Maternity
Midwife:Birth Ratio The ratio of midwives per site and by Trust is as follows, as per Midwifery Safe Staffing Review 2019 based on November 2019 calculations. Table 8
Site Ratio DPOW 1:28 SGH 1:24 Total Midwife : Birth Ratio
1:26
Continuity of Carer There is to be 35% of pregnant women at 28/29 weeks on a Continuity of Carer pathway. There are robust plans for 8 Continuity case loading teams to be in
19
operation by the end of March 2020 and we have a trajectory at that time of 24.5% of women. It is envisaged that the trajectory will reach the 35% of women on a pathway by the end of May 2020. Following the successful bid for monies from the LMS, we have advertised and appointed a project team that are currently coming into post. This is for a band 3 administrator, Band 7 lead midwife and a Band 8a project lead. Additional monies is being utilised for equipment which is being ordered in preparation for the inception of the teams. We have had fantastic support from the Improvement Team and everyone is eager to commence the teams. Data is being collected in readiness of the teams commencing as many women are already being booked on a pathway as their midwife will remain caring for them throughout their pregnancy. During November 2019, there were no diverts to the opposite site or full maternity closures. The Maternity Escalation Policy is used at times of high acuity and the process followed and documented as necessary but does not always convert to needing to divert or close. Unfortunately there was a necessity to go to agency for some midwifery shifts when all other efforts to cover shifts to maintain a safe service were not possible. However, there are robust escalation plans in place to cover shifts and agency is the very last resort. Red Flags – November 2019 Table 9
Site Red Flags DPOW 9 (6) SGH 11 (11)
Community 0 (0) Total Red
Flags 20 (17)
Themes of Red Flags Table 10
Reason for Red Flag Number Unit / department acuity – Escalation Tool commenced 4 (3)
Delay in Induction of Labour 5 (6) Delay in Administering Medication due to acuity 0 (1)
Delay in Transfer to Theatre for Cat 2 LSCS 0 (1) Community midwife / Specialist Midwife working
clinically 0 (4)
Staffing issue due to acuity 6(0) Delay in care 3 (0)
Delay in Anaesthetist 2 (0) All Red Flags are monitored on a weekly basis and escalation processes are escalated at the time of the issue. The figures for November 2019 show an increase on October but half that of September 2019.
20
8.0 Area’s identified with triggers this month
• B4 continue with a substantive fill rate below 50% on night shifts. . This remains an area of concern, supported by a 15 steps assessment which recommended that the ward requires improvement.
• Ward 28 had a substantive fill rate on both days and nights, although have no triggered any other nursing metrics.
• A & E at SGH was revisited and continues with a ‘requires improvement’ rating through 15 steps.
9.0 Actions
• The nursing matrix will be continue used to identify areas of concern and acknowledge when areas have improved and reduced their levels of risk
• Closely monitor the direct impact of staffing levels on pressure ulcer acquisition and falls.
• Continue to monitor the substantive shift fill rates, particularly on nights. A lot of our temporary staffing staff are regular workers for the trust, but we continue to monitor this.
10.0 Conclusion
• Newly–qualified nurses are now in post and being supported through preceptorship by the practice development team.
• Registered Nursing vacancies down to 7.8% • Increase in fill rate to 99.1 % overall • Multi-disciplinary bedside huddles pilot in progress commenced for falls
having positive impact and received well by ward staff. • The nursing recruitment open day held on the 29th November saw over 50
nurses attending. On the day three registered nurses were appointed with 25 unconditional offers made to third year student nurses who will join the trust after they’ve completed their degree in September 2020. This is part of the Chief Nurses recruitment and retention strategy.
21
Appendix 1: NHS Digital safer staffing return November 2019
Copy of Safer Staffing Return - November 20
22
Appendix 2: Nursing Fill rates November 2019
23
Appendix 3
24
25
Appendix 4
Nursing Assurance Report December 2019
Safe Staffing
1.0 Shift Fill Rates
This data is used to populate the monthly Hard Truths return, previously referred to as the Unify return, which is submitted to NHS Digital. The data is taken from the Allocate Eroster system.
The fill rate submission currently requires information on in-patient areas only. Ambulatory Care, Short Stay and Emergency Departments are excluded. The full NHS Digital upload is provided in Appendix 1, and a review of the substantive breakdown can be seen in Appendix 2.
The figure below (table 1) shows the average fill rate for December 2019 which is 96.6%. This demonstrates deterioration in the overall fill rate which was 99.1% in November. There is however a downward trend showing in the 12 month graph below. Table 1: Average fill rate for December (all staff)
Graph 1: Twelve month trend Trust average fill rates
Forty one inpatient areas at NLAG have reported their fill rate for December 2019. The shift fill rate for Registered Nurses (RN) in December 2019 was as follows; • Twenty areas recorded less than 95% shift fill rate on days for RN, this is an
increase from the 16 in November, these were, Amethyst, C1 Glover, ITU, NICU DPoW, Laurel, Rainforest, B4, C5,C6, B7, CCU, Disney, Ward 19, 22, 26, 27 and Goole NRC. Some of the low fill rates and new wards reporting is attributable to the change in the establishments to add in twilight shifts.
• No wards had a substantive day fill rate of <50% on days. This is an improvement from the two wards in November 2019. This is because of the over improvement in vacancy.
• On nights fifteen areas recorded less than 95% shift fill rate for RN’s; these
were Amethyst, Blueberry/Holly, C1Glover, Honeysuckle/Jasmine, ITU DPoW, NICU DPoW, Stroke DPoW, B4, C6, Disney, 16,17, 23, 24 and 26. This is an increase from the six areas reported in November 2019.
• In December there were five wards with a fill rate <50% for substantive staff on nights, which is a reduction from the six in November. These were ward 22, 23, 24, which reported the same in the previous month and & wards 16 & 6, who are new reporters.
88.00%
90.00%
92.00%
94.00%
96.00%
98.00%
100.00%
102.00%
104.00%
106.00%
Jan-
19
Feb-
19
Mar
-19
Apr-
19
May
-19
Jun-
19
Jul-1
9
Aug-
19
Sep-
19
Oct
-19
Nov
-19
Dec-
19
Average Day fill rate
Average Night fill rate
Total fill rate
Linear (Average Day fill rate)
Linear (Average Night fill rate)
Linear (Total fill rate)
28
Below are tables by division for substantive staff average fill rate. Table 2- Medicine substantive fill rate & CHPPD
Medicine Wards Substantive Staff % CHHPPD
RN Days Carer Days RN Nights Carer Nights RN TNA/Carer Total
3.0 Care Hours per Patient Day Data (CHPPD) The Care Hours per Patient Day (CHPPD) data is reported monthly and is included in the Trust’s NHS Digital return (Appendix 1). CHPPD is the total hours per day of Registered Nurses (RN), Midwives (MW) and care staff divided by the number of patients in the ward/department at 23.59 hours each night. This provides a score of the average care hours per patient per day. The overall CHHPD for Registered Nurses trust wide is 4.5 in December which is a decrease from the 4.6 in November 2019. The overall CHPPD for care staff trust wide shows a slight decrease at 2.8 compared to 2.9 in November. The total CHPPD (RN and care staff combined) has decreased to 7.3 in December from 7.5 in November 2019. The trust figures remain below the national benchmarking model hospital data and are showing an overall downward trend. The Trust data for December can be seen in table 6 below and a 12 month trend of data seen in the graph below.
30
Table 6: Trust CHPPD data December 2019
Care Hours Per Patient Per Day (CHPPD)
Site Nurses Care Staff Overall Ratio RN’s to HCA’s
Grimsby 4.5↓ 2.8↓ 7.4↓ 61%
Scunthorpe 4.4↓ 2.7↓ 7.2↓ 61%
Goole 3.7↓ 2.8 6.5↓ 57%↓ Trust
Overall 4.5↓ 2.8↓ 7.3↓
62%↑
Graph 2: Trust 12 month trend of Trust CHPPD
3.1 Staffing Incidents In December 2019 there were 100 incident reports submitted to the Trust incident reporting system (Datix) regarding Nursing and Midwifery staffing compared to 54 in November 2019. This is a significant increase. 86 of these relate to inpatient & ECC covered by this report (86%). The remaining 14 incidents related to 1x medical staffing, 2x midwifery community, 5x nursing community, 1 x Paediatric Assessment Unit, 3 x maternity unit, 1 x pharmacy & 1 ward not identified in Datix.
0
1
2
3
4
5
6
7
8
9
RN CHPPPD
Carer CHPPPD
Total CHPPD
Linear (Carer CHPPPD)
Linear (Carer CHPPPD)
Linear (Total CHPPD)
31
These were reported in the following divisions: • Medicine 61/100↑ • Surgery and Critical Care 10/100 ↑ • Women and Children 15/100↓
Red Flags
There were forty one red flags reported in December this is an increase from the ten red flag incidents reported in November 2019. Thirteen of these were Emergency care red flags due to the volume of patients in the department during the times the department had increased attendances and acuity of patients. Eight midwifery red flags incidents were reported. Four Paediatric red flags on the neonatal intensive care unit SGH. 16 Nursing red flags: There was one red flag on ward B2 for delay in Administration of iv medications by 1 hour to more than 3 patients. There were two red flags for less than 2 registered nurses on the shift • Ward B3 1 registered nurse for Night shift for 22 patients supported by RN from
Hobs. • CCU one registered nurse to cover the ward due to RN taken ill at start of shift.
Support sent form ITU but RN had to return to ITU due to admission of another patient to ITU.
There were two red flags for less than 50% substantive staff on shift:
• C1 Glover • Ward 22
There three red flags for more than 50% of staff under 12 months qualified:
• Stroke unit DPOW • Ward 25 • AMU
There were 9 red flags for trained nurse less than 12 months qualified, or still in preceptorship left in charge:
• x 3 occasions on the Stroke unit DPOW • x 6 occasions on the Stroke unit SGH. The majority of these were from short
notice sickness. The nurses were supported by the stroke responder when able.
The increase reporting is partly due to the education with the wards to promote the red flags to ensure all wards start to record these and some due to high sickness rates in December in nursing and increased attendances and acuity in ECC.
32
4.0 Safer Nursing Care Tool (SNCT) The 2nd round of review meetings have commenced using the SNCT data from the 2nd cycle of data collection. A report is anticipated to go to the Trust Board In April 2020 with the maternity staffing review paper. 5.0 Vacancies The Trust vacancy position for Registered Nurses in November is 129.38 whole time equivalent (wte) which equates to 7.99% of the Registered Nursing workforce. This is a slight deterioration from 126.33wte (7.8%) in November 2019. The highest area of RN vacancies remains in the Medicine Division with 78.81wte or 13.83% in December 2019, compared to 77.98, or 13.68% in November 2019, which is slight deterioration in month, however there has been an increase in their establishments following the staffing reviews. The Surgery & Critical Care Division has a vacancy of 39.16 or 9.32% in November 2019, which is the same as November 2019. The HCAs Trust vacancy position for HCAs in December 2019 is 36.88 (4.50%) compared to 26.20 wte or 3.2% in November 2019. Medicine currently has 31.65wte HCA vacancies. These posts have not been recruited to due to changes in the nursing establishments in some areas of medicine. Table 7: Vacancy report as at 31st December 2019
4.1 Falls In December 2019 there were 23 falls across inpatient areas under the category minor harm; compared to 35 in November and 33 in October.
July 19 August 19 Sept 19 October 19 Nov 19 Dec 19
No Harm 76 84 96 97 86 94
Low Harm 21 36 36 33 35 23
Moderate Harm
1 1 1 1 0 1
Severe Harm 2 0 1 1 0 2
In December 2019, there was one fall reported with moderate harm on Ward B3 at Grimsby. The patient sustained a fractured clavicle as a result of the fall. At the MDT huddle, no lapses in care were identified and appropriate interventions were in place. Two falls with severe harm were reported in December 2019 one by Ward C6 (spiral fracture of the shaft of femur) and one by Ward C2 (fractured neck of femur). These have both been escalated as serious incidents due to the severity of the harm. C1Glover, C2, C6 and CDU have reported a greater number of falls in December. With the exception of C6, these were all predominantly single falls demonstrating that appropriate preventative measures were instigated thus preventing further falls. There were no recurrent themes identified on review of the repeat falls on C6. The ‘MDT huddle’ process of responding when patients who have fallen more than once, or those who have sustained a moderate, or greater harm, has been in place since the beginning of October 2019. Feedback remains positive with ward sisters
0
10
20
30
40
50
60
70
80
90
100
July Aug Sept Oct Nov Dec
No Harm
Minor Harm
Moderate Harm
Severe Harm
34
reporting that this is a far more responsive and supportive approach which has led to improved outcomes for patients. This new process is now being evaluated. 4.2 Harm Free Care On the second Wednesday in every month prevalence data is collected which is then submitted to NHS Digital on Harm Free Care. The data that is collected is the average across four harms; falls, pressure ulcers, VTE (Venous Thromboembolism) and CAUTI’s (Catheter Associated Urinary Tract Infection). This data is a snapshot and therefore needs to be reviewed along with other data sources. In December 2019 the new harm free care rate was 96.4%. This is a deterioration from 97.5% in November and 97.8% in October. This is the fourth consecutive month of deterioration since the highest rate of 98.5 % in August 2019. In the Acute setting, there were eight areas, C5, Amethyst, C2 and B4 at DPOW, and Ward 22, Ward 28, Stroke Unit and ICU at SGH that triggered a red indicator (equal to or below 90% new harm free care). This is an increase from two areas in November. It should be noted that ICU has a smaller sample size than most wards. This will have affected the new harm free care rate and therefore the RAG rating. All wards that trigger red are discussed in more detail at the Nursing Metrics Panel and triangulated with other intelligence. There was one area, Ward 6 at GDH, (down from seven areas in November 2019) that triggered an amber indicator (equal to, or below 95% harm free care). The ward had not triggered in the previous two months. All three community networks were rated as green (greater than 95%) for December 2019 and the preceding two months. Work is on-going within the Acute divisions to ensure that there is accurate data entry at ward level and validation by Matrons, this includes each matron validating the entries before they are submitted. The harm free care data is monitored alongside other indicators (including incident reporting) at the Nursing Metric Panel. 4.3 Pressure Ulcers Acute sites In December, 104 hospital acquired pressure ulcers were reported across the 3 hospital sites which is an increase from the previous month (Table 9). Table 9 Hospital acquired pressure ulcer incidents by month (validated by TVN)
Jan 19
Feb March April May June July August Sept Oct Nov Dec
63 72 47 48 58 64 64 53 68 83 90 104
35
There were 1 category 4 pressure ulcer reported in ED at DPoW and an investigation is underway to determine if this was acquired whilst in the department or if the patient was admitted with this damage already. There was an increase in the number of category 2, 3 and unstageable pressure ulcers for the third consecutive month (Table 10). Table 10. Hospital acquired pressure ulcer incidents by category
Category 2 79 ↑ (of which 8 were medical device related)
Category 3 11 ↑ (of which 2 were medical device related)
Category 4 1 ↑ (not medical device related) Unstageable 13 ↑ (of which 1 was medical device related)
The highest incidence of pressures continues to be reported at DPoW which also has the highest incidence per 1000 occupied bed days (see Graph 4 below). Graph 4 - Hospital acquired pressure ulcers incidents by site & per 1000 bed days
Ward C6 reported one Category 3 and one Unstageable pressure ulcer in December (Two category 3 pressure ulcers in November) and will be an area for focused support from the TVN team. This ward has commenced a new style of shift leadership to enable focus on high risk patients and registered nurse input right at the beginning of every shift. Other areas of high incidence include Ward B4 with six reported category 2’s and two reported category 3’s. Ward C5 reported nine category 2 ulcers, all identified early enough not break down any further.
36
The areas of high incidence continue to be monitored through the Harm Free Care Board and the Nursing Metrics Panel. December hosted equipment training and drop in sessions on all three sites to upskill staff in mattress selection and pressure area care, to support the newly qualified nurses and newer staff to the Trust. The sessions were led by the Matron teams ensuring support for the sessions was prioritised and they were well attended as a result. These sessions will be repeated over February and March. During January 2020 there are four planned “bite size” education sessions across the 3 acute sites. The equipment and “Heels Up” sessions will be provided by the Community React to Red Team. Community 42 pressure ulcers were acquired on community caseloads in November across the three Community Networks. Of the 42 pressure ulcers identified and reported, 22 (52%) were identified in Care / Residential Homes whilst under the care of the Community Nursing Teams. Graph 5 Pressure ulcers acquired on community nurse caseload
One category 4 pressure ulcer was reported in December in the West Network. 10 Category 3 Pressure Ulcers were identified and reported in December which is an increase from the 5 in November (Table 11). 3 unstageable pressure ulcers were identified.
37
Table 11 Community acquired pressure ulcers by category
Thematic review of recent pressure ulcers declared as Serious Incidents where lapses of care were identified will be undertaken on 04/02/2020 to identify any additional themes and trends at Network level to support further improvement work.
6.4 Patient Experience
During December 2019, 27 new formal complaints were received and 79 new PALs concerns.
This data, along with the split across divisions, can be seen below, with a notable decrease in formal complaints raised across all divisions during quarter three.
The Patient Experience team has seen a slight increase in communication reported complaints during December which may coincide with increased activity across the Trust. Graph 6
0
20
40
60
80
100
120
140
160
180
Formal Complaints
Pals
Linear (FormalComplaints)
Linear (Pals)
38
Graph 7
Graph 8
The headline themes within the formal complaints for December remains as highlighted in November as Care, Treatment and Delays. A planned triangulation meeting to review all data relating to delays is to take place in January and will encompass complaints, concerns, serious incidents, claims and other intelligence. This deep dive will provide valuable insight into specific areas where focus can be applied. The Friends and Family Test implementation of revised guidance has commenced with redesign of existing FFT feedback cards, which have had patient involvement. Additional demographic data has been included to enable gaps in capturing feedback to be explored.
Divisional Split for Formal Complaints
Med
Surg
CSS
CTS
W&C
Themes Treatment
Care
Delays
Attitude & Behaviours
Communication
Access to Services
Discharge
39
Implementation of a new monthly Insight Survey will commence in the New Year, across the medicine division, which will provide patient feedback data centered on National Inpatient Survey questions. Patient Experience Officers will collate this data for ward areas providing timely local feedback. This methodology is recognised as improving staff engagement in patient experience data and utilized by several high performing Trust across the country. 6.5 15 Steps Throughout December six areas were visited; (see table 12) One area received outstanding, four areas received good ratings, these were all previously visited and received Requires Improvement in their first assessment had shown some real improvement and implementation of action plans. One area received Required Improvement, which was Maternity. The areas for improvement have been shared with Maternity. Table 12
03 December 2019 C5- revisit Good 04 December 2019 Ward 26 SGH Outstanding 11 December 2019 Maternity DPOW Requires Improvement 12 December 2019 Ward 24 Good 17 December 2019 C6 Good 18 December 2019 NRC Good
6.6 Infection Prevention and Control There have been no detected Trust acquired MRSA bacteraemia cases as such we remain on 1 case for the year so far. C.difficile infections The Trust reporting criteria changed in April and this has been previously mentioned it would result in additional cases being allocated to the Trust. There have been 32 cases attributed to the Trust with 5 lapses in practice / care identified. The main findings from the Post Infection Review are the antibiotic course lengths and choices. The use of coamoxiclav is high compared to most of our peers in Yorkshire & Humber so the PathLincs Consultant microbiologists are looking at ways to help reduce the reliance on this broad spectrum antibiotic which is known to increase risks of developing CDI. To further help prescribers a new antimicrobial app/website was developed http://www.antimicrobial.yolasite.com/ Gram negative blood stream infections There are a number of workstreams being undertaken by our CCG partners to help support the 50% reduction ambition by 2024. This requires collaboration with the acute IPC team to help support education and system change practice especially
the diagnosis and treatment of urinary tract infections. The number of Gram negative E.coli bacteraemia cases detected so far show similar numbers to last year. Influenza As predicted based on the Australian epidemiology the UK experienced an earlier influx of Influenza cases detected. This had a severe impact at SGH with record level of cases detected before Christmas. There was close working with Clinical Site Manager and laboratory staff to ensure minimal disruption to patient flow and ward activity.
7.0 Divisional summaries and oversight provided by Heads of Nursing 7.1 Medicine division The posts created by Phase one of the Chief Nurse establishment review continue to be recruited to. There continues to be recruitment challenges for both sites with Medicine having 69.1 wte RN vacancies in December 2019, (29.03wte at DPoW and 40.07wte at SGH). There are 28.8wte HCA vacancies with plans in place to recruit to these posts. This has meant continued use of Bank or Agency staff. The new model of an Acute Assessment Unit on both sites including Same Day Emergency Care (SDEC) continues to be an area of focus. Further escalation beds were opened at the DPoW and GDH sites which create challenges with staffing, resulting in additional duties and significant redeployment of substantive staff in order to maintain safety. The ED’s at both sites have seen an increase in activity of 9% through December 2019 in comparison to December 2018. To support the delivery of safe care
41
additional staffing resource has been added to the ED rosters. Medicine NEWS on time current Compliance is 85.37% which is a slight decrease on the previous month. There were three areas below 80%, Amethyst / C5 / Ward 17, which are monitored through the Head of Nursing Ward Performance reviews. One area scored below 90% on the Safety Thermometer in relation to New Harm Free Care in December which was Ward 18. During December there were 2 falls that resulted in harm, both patients suffering fractures, investigations are underway to understand if there was any learning, one of these falls occurred despite all possible risk reduction actions being undertaken. A baseline of 5% of patients age 65 and above having a lying/standing blood pressure recorded was shared with the Divisional teams and practice has being slowly improving. Communication regarding CQUIN and clinical reasons for performing lying/standing blood pressure and correct method for completing this was shared with the ward teams and a snap-shot audit revealed an improvement in compliance to 13.88%. A further audit is planned for February. To support the ongoing work in relation to pressure ulcers, the Ward Leadership teams are commencing attendance at the TVN training to ensure a consistent approach to grading and validation. 7.2 Surgery and Critical Care division Within the S&CC division the Registered Nurse vacancy position is offset by an ODP over establishment of 24.22 WTE within the theatre environment leaving an actual Registered Nurse vacancy of 14.96 WTE. This over establishment of ODPs meets the required standard needed within the theatre setting as most are dual trained and able to work flexibly between anaesthetics, scrub and recovery areas. We have seen an unprecedented level of sickness across S&CC within December and January averaging between 32-47 WTE in week, which has stretched out acute areas. Falls across the division remain static, with all falls being categorised as ‘no’ or ‘low’ harm. B7 at the DPOW site has the highest number of falls for the division at 8 in month up 2 from 6 last month. A deep dive is being undertaken by DHoN and Associate Chief Nurse. Bedside Multidisciplinary huddles for repeat fallers and B7 have actively participated in these with positive outcomes, all staff have been engaged within this new process National Early Warning Scores are available live via the Power BI system. The results for December are trending at 85%-92% at DPOW with B3 dropping to 79% in month which has been picked up by the ward manager in her monthly challenge meeting and working with the team to improve the position. SGH are all maintaining 90% or above with the exception of ward 25 who have slightly dropped to 88% which again has been highlighted and is working with the team to improve in month. Ward 6 at Goole have dropped to 86%, the matrons and DHoN are working with the team to understand the drop and improve position.
42
Headline Results for S&CC sepsis audit - There were 32 observations (12 pts) involved for surgery, much smaller than medicine but this is expected. 78% of their observations were escalated, the carrying out of sepsis screens in response to an observation was 31% (7pts) either within the last 24hrs or within an hour of the trigger observations). However, 13% of the observations (3 pts) where they were not screened did not have a clinical reason why not. For the 87% who did have a reason the most common reason supplied was the patient was already on intravenous antibiotics for an infection. Work is on-going regarding lying and standing Blood pressure to assist in the falls and also oxygen prescribing. Weekly audits are being undertaken and work is in progress to add this to the Ward assurance tool. We are in the process of setting up a sickness summit due to the high numbers of sickness and supporting the staff where possible through the policy and through flexible working. 7.3 Community and Therapies Division The number of Registered Nurse vacancies across the Division has reduced to 12.81 WTE in December 2019 compared to 15.29 WTE in November and there are a number of appointments in the pipeline therefore this position is expected to improve across community teams. NRC Goole (Ward 4) remains an area of concern for Registered Nurse staffing with 3.38 WTE vacancies, however reliance on agency staff has reduced with the majority of shifts being covered by regular bank staff. NRC has recently received a 15 steps assurance visit and has received a ‘good’ rating. Sickness levels across the community network teams remain above the Trust target and are resulting in a number of visits being prioritised and rescheduled on a daily basis. Harm free care remains a priority for the Division as lapses in care are still contributing to pressure ulcer development. A detailed thematic review of RCA investigation findings is planned for early February to gain a better understanding of ongoing issues in specific Networks to inform improvement work. 5 serious incidents was declared in November and related to pressure ulcer incidents where lapses in care were identified on initial review. FFT responses are positive with 99% of responders indicating that they are likely or extremely likely to recommend services, work is ongoing to improve response rates. The C & T dashboard is not available for this month’s report due to data quality issues. 7.4 Women’s and Children’s The Children’s arm of the Division remain consistently in a position of having limited vacancies in November for any specialty – RN/RSCN and HCA’s. All approved vacancies are at various stages of the recruitment process, with the expectation that all substantive vacancies will be filled by the end of January 2020. All substantive vacancies now recruited to with start dates, remaining vacancies coming up over next few months relate to maternity leave.
43
All areas continue to risk assess acuity and activity routinely twice daily and when the situation changes and staffing resource is allocated across the specialties and sites to ensure safety is maintained in all areas. The Division are trialing a model of ‘unit coordination’ which will enable there to be a much more co-ordinated and in-depth understanding across the clinical areas as to where there are issues and risks, which will in turn allow a more effective utilisation of our total staff base and support patient safety and flow. There is an increased level of sickness in month which is currently standing at 5.75%, the majority of which (29%) is attributed to stress/anxiety. This is being managed according to Trust Policy in conjunction with our HR Business Partner. A sustained level of Maternity Leave continues, which is being managed appropriately and backfilled utilising bank/substantive staff when needed. Agency spend is negligible and considered as a ‘last resort’, however there has been an increase in Agency use in month due to the high activity and acuity of paediatric attendances to the Trust and the need to open 4 escalation beds on the SGH site. Bank Staff are utilised as needed to keep the areas safe and usage/spend is being analysed at the weekly Divisional Quadumvirate Meetings in order to understand and manage our Bank spend more robustly. There were a total of six open PALS in December 2019, with three new PALS concerns received in month. The oldest open PALS dates from October 2019. The three new PALS relate to clinical care delivery concerns on the DPOW Site and one on the SGH site relates to clinical diagnosis. This is a slight deterioration on last month’s position and there has been little progress with the oldest outstanding PALS due to the complexity of the case. With respect to formal complaints, there were no new complaint received in month with two outstanding complaints being investigated. This is no change on last month’s position. There continues to be a weekly divisional complaints meeting with the complaints facilitator to ensure that all complaints are investigated and managed succinctly.
Review of all outstanding Datix being undertaken in conjunction with the W&C Governance Lead as deterioration in finally approved position noted over last 3 months. Steady progress and improvement in number of outstanding incidents being seen in month. There has been improvement on reporting for Paediatrics in month however still work to do around promotion of importance of reporting red flag incidents accurately.
Maternity Midwife: Birth Ratio The ratio of midwives per site and by Trust is as follows, as per Midwifery Safe Staffing Review2019 based on December 2019 calculations.
44
45
Table 13 Site Ratio
DPOW 1:28 SGH 1:24 Total Midwife : Birth Ratio
1:26
Continuity of Carer – December 2019 There is to be 35% of pregnant women at 28/29 weeks on a Continuity of Carer pathway by the end of March 2020. There are robust plans for 8 Continuity case loading teams to be in operation by the end of March 2020 and we have a trajectory at that time of 24.5% of women. It is envisaged that the trajectory will reach the 35% of women on a pathway by the end of May 2020. The teams at Grimsby and Louth will be made up of a geographical area at Louth and Teenagers, Perinatal Mental Health at Grimsby for the first team. Scunthorpe will initially be for women who live in the town, followed by further teams at Goole & Isle and then Brigg & Barton. Following the successful bid for monies from the LMS, we have advertised and appointed a project team that are currently coming into post. This is for a band 3 administrator, Band 7 lead midwife and a Band 8a project lead. Additional monies is being utilised for equipment which has been ordered and received in preparation for the inception of the teams. We have had fantastic support from the Improvement Team and everyone is eager to commence the teams. Data is being collected in readiness of the teams commencing as many women are already being booked on a pathway as their midwife will remain caring for them throughout their pregnancy. Diverts / Closures During December 2019, there were no diverts to the opposite site or full maternity closures. The Maternity Escalation Policy is used at times of high acuity and the process followed and documented as necessary but does not always convert to needing to divert or close. Maternity Red Flags – December 2019
Site Red Flags DPOW 3 (9) SGH 14 (11)
Community 0 (0) Total Red Flags 17 (20)
46
Identification of Red Flags
All Red Flags are monitored on a weekly basis and escalation processes are escalated at the time of the issue. The figures for December 2019 show a decrease on November.
8.0 Area’s identified with triggers this month
• Ward C6 supports highly acute patients , they have experienced a greater incidence of falls and pressure ulcers in December.
• Wards 28 and B4 pressure ulcer reporting has increased, both these wards have had high vacancy rates and are being supported by newly qualified staff and bank and agency nursing.
• ECC red flags have increased in December. • B4 and ECC SGH have not improved their 15 steps rating on a repeat visit.
9.0 Actions
• Establishment reviews are underway once again following collation of further SNCT data.
• Falls huddles pilot will be evaluated in January and the Falls pathway reviewed to align with feedback
• Plans are in place to roll out the supportive care policy and tool on six pilot sites in February to provide a framework for understanding dependency needs for high risk patients.
• B7 is undergoing a deep dive due to increased incidence of falls and pressure ulcers over the last two months
• Safe care roll out continues at SGH. 10.0 Conclusion
• All inpatient divisions have had reduced fill rates and increased staffing incidents throughout December. There was increased demand during December which was compounded with high sickness rates.
• Need to continue to support high falls incidence areas with MDT falls huddles
• Recruitment days have been planned throughout 2020 to support the filling
Reason for Red Flag Number Unit / department acuity – Escalation Tool
commenced 1 (4)
Delay in Induction of Labour 5 (5) Delay in Administering Medication due to
acuity 0 (0)
Community midwife / Specialist Midwife
working clinically 3 (0)
Staffing issue due to acuity 6 (6) Delay in care 3 (3)
Delay in Anaesthetist 0 (2)
47
of vacancies and the trust has signed up to the Health Education England Global Learners Programme where 50 international nurses will be recruited to the trust in early 2020.
Appendix 1 NHS Digital safer staffing return December 2019
Copy of Safer Staffing Return - December 20
49
Appendix 2 staffing fill rates December 2019
50
Appendix 3
51
NLG(20)023
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Peter Reading, Chief Executive
CONTACT OFFICER Kathryn Helley, Improvement Programme Director
SUBJECT CQC Stocktake Report as at 31 December 2019
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The CQC undertook a comprehensive inspection at the Trust during September 2019. At the time of submitting this update, the visit report for this inspection is expected to be published shortly. In the meantime, the Trust continues to report on actions identified from the visit undertaken in May 2018. The report attached provides an update on the actions identified from this visit.
TRUST BOARD ACTION REQUIRED The Board is asked to note the content of the report and identify any further actions required at this stage.
Page 1
UPDATE AS AT 31 December
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
1 The Trust must ensure they have evidence to show that complete employment checks for executive and non-executive staff have been taken in line with the Fit and Proper Persons Requirement (FPPR) (Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014.
Must Well Led Peter Reading Wendy Booth
G
Internal audit review of the Trust’s arrangements (including testing of the checks undertaken) is complete and a rating of ‘significant assurance’ has been provided with minor improvement recommendations including the need for an overarching policy which captures the Trust’s arrangements
Policy approved and in place.
Review of all Director files is being completed to identify gaps following CQC feedback. Re-audit of files by Internal Audit undertaken October 2019. Policy is also being updated.
Completed
2 The Trust must ensure that effective and robust systems are in place to support the management of governance, risk and performance.
Must Well Led Peter Reading Angie Legge
G
Following the retirement of the previous Director of Governance & Assurance, changes have been made to the configuration of the Trust’s clinical governance arrangements which are now included within the portfolio of the Medical Director. Following a review by KPMG, work is underway to strengthen the clinical governance arrangements at Divisional level. The action plan from the review is monitored on a bi-monthly basis at the Quality and Safety Committee.
A new Associate Director of Clinical Governance has been appointed and will support the above work.
A revised performance management framework and arrangements have been implemented. Monitoring of performance occurs through monthly performance review meetings with escalation of issues and mitigations to the Trust Board through the strengthened Integrated Performance Report and the relevant Board sub-committees.
Changes have also been made to strengthen the SI process. The Board Assurance Framework has been revised and the Risk Strategy published. The Risk Register Confirm and Challenge process which considers risks over 15 has been reviewed, and high level risks are now being taken to TMB with the highlight paper.
Completed
3 The Trust must establish accountability and effective clinical leadership throughout the organisation.
Must Well Led Peter Reading Shaun Stacey
G
Clinical leads all appointed and induction process has been commenced. Clinical Leads in place by
31/07/2019
4 The Trust must develop a clinical and financial strategy that addresses the delivery of safe and sustainable services.
Must Well Led Peter Reading Sue Barnett/ Kerry Carroll/ Jim Hayburn
A
Clinical Strategy is in development through the Humber Acute Service Review (HASR) Four Specialties plans are being taken forward and the next stage of development will be assisted by the appointed of consultants in July. This will include a base case model, and changes that can be made form improving efficiencies, the links to place based improvements and transfers to the community and options for reconfiguration where appropriate. This will be complete by September and December respectively. The attached update was provided to the Trust Board on 18 Dec 19 and currently being realigned to the HASR confirming priority specialities and refreshed timeline. This will also contain a financial model to align with the Trust financial strategy. The Trust will have some options for change at the end of Q2. The Trust has approved a strategic framework in May 2019.
01/12/2019Revised date TBA
CQC Requirement
WELL LED
Senior Management
Team Meetings
NORTHERN LINCOLNSHIRE AND GOOLE NHS FOUNDATION TRUST - MAPPING THE CQC ACTIONS TO IMPROVING TOGETHER/BUSINESS AS USUAL
NOTE: Not all CQC actions map to a project within Improving Together.
Page 2
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
5 The Trust must ensure complaints are addressed in line with the Trust Policy Must Well Led Ellie Monkhouse
Dawn Harper/ Jo Loughborough
A
In May 2018 the complaints team was realigned to be managed by the chief nurse directorate they have been carrying out work to create a patient centred and divisionally owned service. The volume of complaints and the complexity has resulted in each facilitator handling in excess of 50 complaints which continues to add a pressure to the service. Focussed work around the backlog of complaints continues with impact being seen via a weekly report. Deep Dive work has also been undertaken to address those waiting longest for responses, with clear actions for each one. Divisional engagement has improved. A complaints action plan is in place too add focus and oversight on a monthly basis, creating clear timescales for improvement.
01/12/2019Revised date TBA
6 The Trust must ensure they are able to evidence 1:1 care in labour. Must Maternity (DPOW/SGH)
G
Monthly report produced. From April 2018 to December 2018 the Trust has achieved overall compliance rate of 98.8% for 1:1 care for women giving birth who do not have a caesarean being recorded. It varies over this period from 97.1% to 98.8%.Midwives record this on CMIS and the data is collated each shift by the co-ordinator and audited daily.
Completed
7 The Trust should ensure staff incident report when there are delays in a consultant attending a patient.
Should Maternity (DPOW)
G
Divisional Clinical Lead has revised the algorithm/guidelines (DCM187), (urgent = response within 10 mins prioritising with other demands if clinically engaged, on-call consultant response in 30 mins from call). These have been sent round to all co-ordinators for action and this now is being monitored through datix reporting. Escalation audit will also provide a check of datix process.
Completed
8 The Trust should explore and address reasons for the low use of the birthing suite, and develop and implement a robust vision and strategy to improve utilisation.
Should Maternity (GDH)
A
Community Midwives and Head of Communications working on a project to advertise the service more robustly to increase usage. Review of information available to Women carried out and refreshed. LMS workstream will also support the issues as part of their work around choice of birth for women within the Humber, Coast and Vale region. Further work will be done as part of the service redesign in relation to the Community Model of Care to support the implementation of Continuity of Carer.
01/10/2019 extended date
01/04/2020
9 The Trust should consider developing a local teenage pregnancy midwife role and expanding the provision of smoking cessation services.
Should Maternity (GDH)
G
NLAG have a Consultant Midwife leading for public health which includes teenage pregnancies. Due to relatively small numbers and geography, we have adopted the link midwifery approach (we have 10) with a specialist interest in teenage pregnancy. Pregnant teenagers will be booked into the Continuity of Care pathway and be able to have greater input from the expert team. Consultant Midwife also oversees smoking cessation service whereby all women who smoke are referred to stop smoking services which is managed outside the Trust. There is a number of projects being undertaken along with Public Health England including - NRT being available for women on the maternity wards and N E Lincolnshire piloting 'Vaping' provision for women.
Completed
10 The Trust must ensure consultant staffing on labour ward is in line with the Royal College of Gynaecologist (RCOG) guidelines
Must Maternity (DPOW)
G
60 Hour Labour Ward Cover Job Descriptions approved through RCOG. Recruitment in progress for 2 consultants. This still remains a pressure on the service and is on the risk register. Roles have been advertised and the interviews are booked for 09/08/19. The 60 hour labour ward will be implemented Q3 once the new consultants commence their post.Update September - 2 x consultants posts have been recruited to starting 1st November and December.The new rotas have been discussed and changes that will be required to support this has been agreed. The 60 hour labour ward will be implemented from Monday 6th January following the Christmas leave.
Completed
IMPROVING TOGETHER - QUALITY AND SAFETY - SRO Kate Wood, Medical Director
Ellie Monkhouse
Dr Manohar/ Jane Warner
Maternity
Page 3
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
11 The Trust must ensure that community midwifery staffing caseloads are in line with national and professional guidance (a ratio of 96 cases per wte midwife)
Must Maternity (TW)
A
6 monthly Midwifery staffing review business case and risk register signed off at Divisional meeting on 13th May 2019. Establishment review completed with NHSi/E support, and business case has been drafted outlining basic establishment, the difference between that and birth rate plus methodology, the current outcome performance, and the risk mitigation, with a suggestion for a phased approach to recruitment pending the maternity 5 years strategy.
28/06/2019Revised to
28/02/2020
12 The Trust should ensure all staff have an annual appraisal in line with their policy Should Maternity (TW)
R
PADR Womens and Children's as at December 2019. 31/12/2019 extended date
01/04/2020
13 The trust must ensure all staff are up to date with mandatory training, including Mental Capacity Act (MCA) and Deprivation of Liberty Safeguarding (DoLs) training and safe guarding training.
Must Maternity(TW)
A
Womens and Children's mandatory training as at December 2019. 31/12/2019 extended date
01/04/2020
14 The Trust must ensure emergency medicines and equipment are in date. Must Community Dental
B
Dental Services - Significant Improvement since the new weekly checking system in place.Spot checks collated by the operational lead.During December and January collating evidence to demonstrate compliance.Community Services – This methodology to be replicated within community services.Sign off Documentation completed, first sign off completed at Community and Therapies Governance Meeting in February 2019. For Quality and Safety Oversight Sign off in March 2019.
Completed
15 The Trust must ensure that medicines are prescribed and administered in line with national guidance.
Must Community DentalB
Community Services - Sign off Documentation completed, first sign off completed at Community and Therapies Governance Meeting in February 2019. For Quality and Safety Oversight Sign off in March 2019.
Completed
16 The Trust must ensure that all non-medical prescribers receive regular supervision from a Designated Medical Practitioner (DMP) as per Trust policy Supervision must include regular monitoring, review and discussion of their prescribing history to ensure this is safe and effective.
Must Community Adults
A
Division to fund so no business case required.New guidance Nursing and Midwifery Council– DMP not required for training however requirement by UoH. Palliative Care nurse prescribers have supervision from Consultant.Currently on the risk register (Risk 2349) this is reviewed monthly.Review of Trust policy being led by Deputy Chief Nurse.Prescribing governance pathway approved at C&TS Governance meeting June 2019.
30/04/2019 date extended 31/10/19
revised date TBA
17 The Trust must ensure that prescription pad usage and storage is audited for all non-medical prescribers.
Must Community Adults
B
Audit undertaken in July 2018 Build in annual audit to ensure compliance – next audit for July 2019.Robust process for signing out new prescription pads, ongoing reminders to number beginning and end of day.Sign off Documentation completed, first sign off completed at Community and Therapies Governance Meeting in February 2019. For Quality and Safety Oversight Sign off in March 2019.
Completed
18 The Trust must ensure that community nurses are using a recognised and effective risk assessment tool to assess the risk of pressure damage to patients.
Must Community Adults
B
Community Services - Risk assessment tool to be amended to be used within the community settingAll clinical staff to be trained in assessing pressure areas AHP’s and support staff and nurses are to be re trained Trajectories are being developed for when staff will be trained.
Completed
Community Ellie Monkhouse
Jenny Hinchliffe/ Michael Stanfield/ Liz Houchin
Page 4
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
19 The Trust must ensure an effective system is in place to check when equipment used in the provision of the service requires servicing.
Must Community Dental
B
New form devised and implemented, Operational Lead to ensure that all aspects are checked. Issues with equipment that is maintained and serviced by medical engineering. Met with Medical Engineering and discussed a way forward working together. Medical Engineering to send list of inventory to operational Lead, and send a monthly report to division so they are aware of all equipment.
Completed
20 The Trust must ensure emergency equipment is available in line with nationally recognised guidance.
Must Community DentalB
Dental Services - All equipment checked against national guidance. Completed
21 The Trust must ensure that equipment used in the provision of the service is maintained appropriately.
Must Community Dental
B
New form devised and implemented. Operational Lead to ensure that all aspects are checked. Issues with equipment that is maintained and serviced by medical engineering. Met with Medical Engineering and discussed a way forward working together. Medical Engineering to send list of inventory to operational Lead, and send a monthly report to division so they are aware of all equipment.
Completed
22 The Trust should ensure that when staff transport used sharps bins in vehicles they secure the temporary closure and store the bins in a rigid container as per Trust policy.
Should Community Adults
B
Infection Prevention Control bins/transport boxes in use and placed in “black boot boxes”. Ad hoc audits conducted by IPC and Team Leads not available yet go to Governance in June.July 2019 – Boot check audits undertaken however robust evidence from South Network only. Additional evidence to go to Governance meeting on 22 July 2019.
Completed
23 The Trust must ensure the storage infection control procedures follow nationally recognised guidance.
Must Community Dental
B
Dental Services - Monthly audit to check compliance.BURs – undertaken clinical risk assessment for repeat use vs disposable, risk assessment to be sent to acting Medical Director
Completed
24 The Trust should continue to monitor the date of medicines stored in the community hubs and consider implementing a more robust way for all staff to carry medicines to ensure that it is usable in an emergency.
Should Community End of Life
B
Standardised process developed across network and teams. Evidence approved at C&TS Governance meeting in June 2019.
Completed
25 The service should implement a robust system to regularly check the dates of equipment such as blood sampling bottles.
Should Community End of Life
B
Standardised process developed across network and teams. Evidence approved at C&TS Governance meeting in June 2019.
Completed
26 The Trust must ensure that patients are able to access services in a timely way, especially in the continence service, the unscheduled care team and therapy services.
Must Community Adults
A
Productivity work underway. Continence service review planned, currently using bank to support capacity however waiting lists remain a concern and is on the risk register. Waiting list monitored – currently static , no additional resources available, need to look at review that has been done, specialist work is being done.
Unscheduled Care Team 24/7 service reinstated and currently meeting KPI’s.
Capacity and demand work and job planning ongoing in therapies. Capacity to provide a same day response created in community therapies.
Concerns remain regarding continence and community physio. Continence work to be represented at PRIM in July. Additional physio rotational posts being considered.
Risk stratification of waiting list underway. PTL and Capacity & Demand tool requested. Network staff picking up continence assessments as appropriate.
31/05/2019 extended date
31/10/19extended date to
31/03/2020
Page 5
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
27 The Trust must ensure that all staff receive an annual appraisal and regular supervision in line the trust policy to provide then with support and enable staff access to the training and development they need to improve services to patients.
Must Community Adults
G
PADR as at December PRIM meeting (03/12/19)Monitor for next 3 months if continue to achieve can sign off.
Completed
28 The Trusts must ensure their audit processes remain effective Must Community Dental
B
Audit calendar in place. Business as usual process is that Clinical Lead and Operational Manager meet to discuss audit results on a weekly basis with any issues escalated to governance meeting. Sign off Documentation completed, first sign off completed at Community and Therapies Governance Meeting in February 2019. For Quality and Safety Oversight Sign off in March 2019.
Completed
29 The Trust should ensure that patient outcomes are monitored, audited and where possible benchmarked to provide guidance of effectiveness and to drive service improvement.
Should Community Adults
B
Quality and Audit Group developed with Community and Therapy Services.
Evidence signed off at C&TS governance meeting June 2019
Completed
30 The Trust must ensure that system and processes are implemented to identify risks and take action to mitigate these risks.
Must Community Dental
B
New form devised and implemented. Operational Lead ensures that all aspects are checked.Issues with equipment that is maintained and serviced by medical engineering.Met with Medical Engineering and discussed a way forward working together with medical engineering.Medical Engineering to send list of inventory to Operational Lead, and send a monthly report.
Completed
31 The Trust must ensure that there are sufficient qualified, competent, skilled and experienced persons to meet the needs of people using the services.
Must Community AdultsA
Currently going through Business Planning Process. Ongoing
32 The Trust should ensure that all staff are aware of and use the template to record the information and communication needs of people with a disability or sensory loss in order to meet the accessible information standard.
Should Community Adults
B
Template designed for System one and in place.Report produced from Systmone to demonstrate compliance,.Accessibility reports available. Evidence reviewed at governance meeting in June – accessibility reports will continue to be reviewed quarterly until embedded.
Completed
Page 6
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
33 The Trust should ensure that pressure relieving mattresses are available for patients in HDU when required.
Should Critical Care (DPOW)
G
All beds now have red mattress within HDU (April 2019) Completed
34 The Trust must ensure assessment of mental capacity is formally recorded particularly when restraint is used and that all staff have received training.
Must Critical Care (SGH)
G
Online mental capacity act training is available until December 2019.
Work continues with the Clinical Leads to ensure Drs increase compliance on both sites.Have focussed on as department to ensure all patient receive mental capacity assessment when appropriate not just those requiring restraint.
Mental Capacity Act Training – December 2019.HDU DPOW Nursing 92%ITU DPOW Nursing 90%Outreach DPOW Nursing 100%DPOW Anaesthetic Medical Staff 74%ITU SGH Nursing 95%Outreach SGH Nursing 67% SGH Anaesthetic Medical Staff 96%
Total for the critical care staffing group = 89%DPOW = 86%SGH= 93%
Completed
35 The Trust should encourage and embed the use of patient diaries for patients on ICU Should Critical Care (DPOW)
G
Training undertaken in the departments with staff training sessions.Good compliance is seen within the Ward Assurance Tool results at both sites.Working group being pulled back together to re visit the CG83 NICE guidelines and consider the usage and training once patients leave Critical Care units.
Completed
36 The Trust should ensure screening for delirium is undertaken in the HDU. Should Critical Care (DPOW) G
Both Critical Care units are achieving the trust target of 85% in relation to delirium training.Clinical educators undertook bespoke training with both units and is monitoring.
Completed
37 The trust should review access to mental health support for patients on intensive care Should Critical Care (SGH)
G
Mental Health Services agreed to deliver training on the Use of the Mental Health Act 1983(2007) and the Mental Capacity Act (2005) in General Hospital Settings this will be delivered by a Consultant Psychiatrist and Hospital Liaison Practitioner.First training session in July 2019 and undertaken, further training dates agreed until the end of the year.Mental Health Lead nurse now in post within the organisation.
Completed
Kate Wood Helen DavisCritical Care
Page 7
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
38 The Trust must ensure there are plans to enable medical staffing to meet Guidelines for the Provision of Intensive Care Services (GPICS) 2015 recommendations
Must Critical Care (TW)
A
Critical Care Peer review completed in June 2019. GPICSv2 and the D05( replaced the D16) makes provisions for “ small and remote units”. It is envisaged that there are 16 such providers nationally. The Trust is looking at the requirements of a 'small and remote unit. The “small and remote” unit strategy does require access to Intensivists via options such as telemedicine and dedicated Intensivist cover during the day (and freed up from other duties). Telemedicine options are being explored. Considering options to increase responsiveness and maximise efficient use of both units.Monitored and standing agenda item on Critical Care Delivery Group.Continue to look at on going mitigation with the critical care network, Quality data would suggest that this hasn't impacted on quality within the service.
30/09/2019Extended
31/12/2020
39 The Trust must ensure nursing and medical staff are fully compliant with mandatory training requirements
Must Critical Care (DPOW)
G
Critical Care as at 31st DecemberDPOWHDU Nursing- 91%ITU Nursing- 91%ITU Outreach Nursing - 96%Medical Staff - 80%SGHITU Nursing- 97%ITU Outreach nursing- 91%Medical Staff - 86%
Total for Critical care services = 90%DPOW = 88%SGH = 92%
Completed
40 The Trust must ensure all nursing and medical staff have undergone an annual appraisal
Must Critical Care (DPOW)
G
Critical Care as at 31st DecemberDPOWHDU Nursing - 100%ITU Nursing - 94%ITU Outreach - 100%Medical Staff - 76%SGHITU Nursing - 100%ITU Outreach - 33%Medical Staff - 82%
Critical Care service = 90%DPOW= 91%SGH= 89%
Completed
41 The Trust must ensure all staff are aware of the fire evacuation procedure on the intensive care unit (ICU)
Must Critical Care (SGH)
G
On both sites all exits are kept clear. All staff aware of policy and have read and signed to agree they understand, this is saved within the division. Additional to the staff being aware of the evacuation policy, we are looking at fire training compliance being monitored, also stimulation training of the fire evacuation policy and going to be undertaking a live scenario, initially at SGH and then DPOW to follow Agreed at group.All 3 units have fire strategy in place.
Completed
42 The Trust should consider increasing the level of domestic input n the high dependency unit (HDU)
Should Critical Care (DPOW)
GUnit has daily domestic input. Completed
43 The Trust should ensure the most current versions of paper documents are use in patient records
Should Critical Care (SGH)A
Working with all leads to ensure paper work up to date. Discussed at Surgery Governance Meeting 30/09/2019Extended
31/03/202044 The Trust should ensure Trust policies and best practice guidelines are followed with
regards to the management of waste and used linen.Should Critical Care
(DPOW)G
Waste Management Policy re-issued on 14 November 2018. Staff to read and sign they understand their roles and responsibilities.
Completed
Page 8
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
45 The Trust should consider administrative support for staff on ICU. Should Critical Care (SGH)G
2 Data collections post and Ward clerks at each site as of February 2019. Completed
46 The Trust must ensure they are confident that nursing staff within critical care are competent and have the required training and skills, whilst working towards the GPIS recommendation of 50% of staff having a post registration award om critical care nursing.
Must Critical Care (DPOW)
A
55% of SGH nursing staff currently have post registration, however staff are leaving and therefore this will affect this figure.32% of DPOW nursing staff currently have post registration; will be funded by division if no external sources can be found ,once a suitable course that meets the GPICS standard has been identified.The Critical Care network are looking at potentially running a 60 credit course in September – they are awaiting a quote from Coventry university for providing a faculty to teach the course and have advised as a network staff are not to source their own education. This will not be run in affiliation with Hull University but definitely Coventry. As an interim the Critical Care Educators are working with staff on all 3 units on to achieve the Step competencies s for Critical Care, this will mitigate the risk of not having adequately trained and skilled staff on the units until the GPICS standard can be met. Trajectory of training has been requested for sharing.Course going ahead hosted at hull accredited to Coventry commencing January 2020 committed 2 from each unitMonitored and standing agenda item on Critical Care Delivery Group.6 out of 3 area commencing post grad education rolling programme
30/09/2019Extended
On going due to rolling programme
of training
47 The Trust should ensure that staff are aware of the transfer bag and are assured that is contains the necessary equipment to support a patient transfer.
Should Critical Care (SGH)G
Check list implemented.Checklist checked twice weekly and after every use.
Completed
48 The Trust should display information to staff, relatives and patient on current safety performance.
Should Critical Care (DPOW)
GInformation displayed on the Unit display board. Completed
49 The Trust must ensure that staff are appropriately trained in caring for children and young people with mental health conditions.
Must Children and Young People (TW)
A
Commitment from RDASH and Young Minds Matters to undertake training. E Learning package being looked into and exploring options for more consistent training package. Discussions within division to mandate mental health training for nursing staff. Education and awareness sessions planned for both SGH and DPOW sites in relation to CAMHS. This will extend to ED Teams. CAMHS updates to become part of Paediatric Mandatory Training Days - work in progress. Navigo and RDaSH supporting. Both DPOW and SGH Sites are on target for full implementation by 2020. Agreement from RDaSH in relation to Risk Assessment tool for use in North Lincolnshire - training to be agreed and rolled out. Matron for Childrens Services leading on forward work plan. On line module gone live at DPOW Still problems at SGH with go live
31/06/2019 - revised date 30/04/2020
50 The Trust must ensure that children and young people with a mental health condition are risk assessed for their mental health needs self-harm or suicide and are cared for in a safe environment that has been appropriately risk assessed.
Must Children and Young People (TW)
G
Individual Risk Assessment tool has been revised in conjunction with Young Mind Matters and Children and Adolescent Mental Health Services. Roll out plan developed. Mental health practitioner based between ED and Disney ward at Scunthorpe hospital.
Update as at 30 September 2019 : RDaSH withdrawn this staff member and working on a solution.
Completed
51 The Trust must ensure that the paediatric assessment unit has access to its own resuscitation trolley.
Must Children and Young People (DPOW)
BResus trolley for the paediatric assessment unit in place. Completed
Children's Services
Ellie Monkhouse
Debbie Bray
Page 9
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
52 The Trust must ensure that staffing in the paediatric assessment unit meets national guidance.
Must Children and Young People (TW)
R
Staffing levels still do not meet national guidance. A review of service direction is being undertaken to develop a strategy to help to mitigate.
Current mitigation:Pathway updated to reflect escalation of resus calls.
Added to paediatric ward safety huddles:
Resus/2222 Calls Response:Are we able to support ECC yes/noNurse allocated for 2222 response yes/noECC & site informed for non response yes/no
Update as at 30 September 2019: Business case submitted to Business Case Review Group and progressing onto Trust Management Board for decision on investment required.Lying squad model approved ECC and ED - in place by AprilEstablishment review with chief Nurse - agreed to take to trust board for approval
31/05/2019 extended date
30/04/2020
53 The Trust must ensure staff are up to date with mandatory training. Must Children and Young People (TW)
A
As at Women's and Children's PRIM DecemberMandatory Training
30/09/2019 extended
31/03/2020
54 The Trust must ensure that medical staff are up to date with safe guarding level three training.
Must Children and Young People (TW) B
Both medical teams at either site have been compliant for 3 consecutive months.Current compliance June = trust wide 93%
Completed
55 The Trust must ensure that access to the paediatric assessment is secure. Must Children and Young People (DPOW) G
Swipe access in place either end of assessment unit in ECC at DPOW. Restricted access to unit now in place. Reiterated to staff that not a thoroughfare into the Emergency Department and is a secure unit. Emergency Department at DPOW now has own waiting area for Children.
Completed
56 The Trust should ensure that they meet the Accessible Information Standards concerning the communication needs of patients/carers.
Should Children and Young People (DPOW) G
Posters displayed around clinical areas to make staff aware of accessible information and discussed at safety huddles.Moving forward looking at updating clerking collaborative documentation to ensure that we are actively asking the question.
Completed
57 The Trust must ensure that they are meeting national standards for medical staffing. Must Children and Young People (TW) G
Fixed term medical post now in place and FY1 no longer part of the on call rota. NICU consultant of the week in place from September 2018 so again this is also resolved.
Completed
Page 10
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
58 The Trust must ensure that staff are up to date with appraisals. Must Children and Young People (TW)
R
As Women's and Children's PRIM in December 30/09/2019 extended
31/03/2020
59 The Trust must ensure that all patients records are completed in line with professional and Trust standards.
Must Surgery (GDH)
A
This is will need to be picked up through Health records meeting reporting to Quality Governance Group.
TBC
60 The Trust must ensure that all patient records are completed fully. Must End of Life (SGH) A As above. TBC61 The Trust must ensure patient records are completed in line with professional
standards and Trust policy.Must Outpatients
(DPOW/SGH)A
As above. TBC
62 The Trust must ensure records are stored securely in out-patients. Must Outpatients (DPOW/SGH)
G
All notes are stored in a room with a key-pad access code or locked before and after each clinic, in readiness for SAT teams to collect. In clinic notes are stored in the trolley in a separate room accessed by staff only. Clinic lists are covered with a plain piece of card to protect patient ID information. Notes are kept face down behind reception. Education will continue.
Completed
63 The Trust must ensure safe medicines management; that there is adequate pharmacy support to all areas, that staff practice in line with policy and ensure staff are clear about what are reportable medicine incidents and are encouraged to report them.
Must Safe Use and Storage of Medicines
Medicine (TW) Kate Wood Simon Preistley
A
All divisions are represented in the Terms of Reference for the Safer Medication Group to provide assurance that medication incidents have been reviewed at the relevant speciality governance meetings and staff receive feedback and are encouraged to report all medicine incidents. A new report has been developed for sharing across the Trust to identify trends, highlight areas of concern and where actions are required to ensure safe medicines management. The Trust has 2 medicines management nurses who monitor and support investigation of medicine related incidents. The Safer Medication Group monitor compliance with relevant mandatory training. The pharmacy workforce is under review.
30/04/2020
64 The Trust must ensure that medicines are prescribed and administered in line with national guidance.
Must Surgery (DPOW/SGH)
AThe safer medication now reviews themes and trends for all incidents and good representation from all divisions and engagement, however this is an ongoing issue. Improvements will occur with the EPMA roll out.
30/04/2020
65 The Trust should ensure doctors complete prescription charts and records in line with the hospital and professional guidance.
Should Maternity (DPOW)
G
Womens and Children's division have developed a session during induction on prescribing and also sessions for junior doctors. Medication report developed at divisional level, lead identified through governance meetings for attendance at Safer Medication meeting. To be monitored through PIMS on week 1 safety week.
Completed
66 The Trust should make sure all portable electrical equipment is safety tested in line with the manufacturers guidance.
Should Maternity (DPOW/SGH)
G
Medical engineering hold a database of all other equipment within the organisation to ensure that PAT testing is completed in line with manufacturers guidance.
Completed
67 The Trust should continue to ensure that resuscitation equipment is regularly checked and tested consistently and in line with Trust policy.
Should Surgery (SGH)G
Daily checks are in place with weekly ward mangers walkabout tool for compliance. Completed
Equipment (including training)
Melanie Sharp/ Simon Tighe
Ellie Monkhouse/
Jug Johal
Record Keeping Kate Wood TBC
Page 11
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
68 The Trust must ensure that policies and guidelines in use within clinical areas are compliant with National Institute for Health and Care Excellence (NICE) or other clinical bodies.
Must Surgery (DPOW/SGH)
A
Update as at 30 September 2019: Policy on Guidelines amended to require the completion of a checklist which will prompt the question on evidence based practice. Draft new divisional governance agenda will prompt the checklist to be presented for each guideline.Check list for review and approval of a procedural document approved
31/12/2019 extended
30/04/2020
69 The Trust must ensure that policies are reviewed and updated in a timely manner. Must End of Life (DPOW)G
All end of life policies have been reviewed and updated. Completed
70 The Trust should ensure all policies and procedures are in date and reflect national guidance.
Should Maternity (DPOW/SGH) G
All policies in place for Maternity Services. Guideline update in progress. Fully established monthly clinical guideline group – reporting to O & G governance for ratification.
Completed
71 The Trust must continue to ensure that a patient's capacity is clearly documented and where a patient is deemed to lack capacity this is assessed and managed appropriately in line with the Mental Capacity Act (2015).
Must Mental Capacity and Vulnerability including dementia and LD
Surgery (DPOW/SGH)
Ellie Monkhouse
Craig Ferris
A
A new full day Safeguarding Adult level 3 study day has been now rolled out, which puts Consent, Capacity and the MCA at the heart of it. In April we launched, in partnership with WEBV, the ability to document capacity assessments on the WEBV system. In the two months since its introduction we have seen over 300 capacity assessments completed in this way and from the data we are seeing an increase in nursing staff completing assessments. MCA training figures are showing steady improvement. We have in partnership with Grimsby Institute arranged to have some role played capacity assessments filmed, which are to be used for training purposes. The North Lincolnshire CCG have agreed to fund this.
December 2019- We have now seen well over a thousand mental capacity assessments now completed on the electronic Two stage Capacity Assessment template we put on WeBV in May this year. The recent Audit in October this year showed an increase in the documenting of mental capacity assessments across Trust with DPOW now at 75% from 60% and SGH 70% up from 55%. (we are increasingly seeing more capacity assessments completed by Nursing Staff than we have seen previously) A repeat audit is planned for January 2020.
MCA/DoLs training figures were at 84% up 3% and DoLs 89% up 4%.
Plans are in place for work to be done around the quality of best interest meetings/discussions to commence January 2020.
31/12/2019Extended
28/02/2020
72 The Trust should ensure that patients mental capacity is assessed. Should Urgent and Emergency Care (DPOW) A
As above 31/12/2019Extended
28/02/2020
73 The Trust should continue to ensure that patients are assessed for delirium in line with national guidance.
Should Surgery (DPOW/SGH) A
As above 31/12/2019Extended
28/02/2020
74 The Trust must ensure staff apply Trust policy and guidance to care effectively patients with ongoing need for enteral nutrition (naso-gastric(NG) or percutaneous endoscopic gastrostomy (PEG) feeding)
Must Medicine (GDH)
A
Currently working on enteral policy and provide assurance against standard of care for patients with NG tubes. NG policy to be approved in October 2019 with final sign off at Nursing and Midwifery Board in Nov 2019. Paediatric Policy has also been updated. x2 Nutritional Nurses established in post and clinical lead now in postDecember - Enteral policy is finalised going to Adult Nutrition Group for final sign off.
31/07/2019Revised date30/04/2020
Ellie Monkhouse
Melanie Sharp
Evidence Based Practice
Angie LeggeKate Wood
Nutrition and Hydration
Page 12
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
75 The Trust must ensure that patients are fasted pre-operatively in line with best practice recommendations.
Must Surgery (DPOW/SGH)
G
Patient letters regarding fasting instructions have been updated following a review and co-engagement with the patient experience representatives.
Education has commenced with all in-patient wards and day surgery units to ensure patients are proactively encouraged to take clear fluids up to 2 hours pre-procedure to enable them to remain as hydrated as possible whilst they are awaiting their theatre time slot.
Emergency and trauma patients are treated in the same way unless the risks of delaying surgery out-way the clinical risks associated with not being fasted for the necessary time. In order to monitor this an audit of trauma patients fasting times to assess the current benchmark following the reinforcement of the NICE fasting guidelines with ward managers and their teams is being undertaken.
Completed
76 The Trust must implement a programme of nursing audits, monitoring and equipment checks at GDH to provide assurance that appropriate care and safety standards are being met.
Must Medicine (GDH)
G
The 15 Step Challenge is part of ‘The Future 5’- Nursing and Midwifery priorities- identified by our Chief Nurse for 2019/2020. The 15 step challenge is designed to provide insight /assurance and oversight on the quality of care and professional standards across our clinical team.The 15 Step Challenge is based on identified best practice and our process takes guidance from recommendations from The NHS Institute of Innovations and Improvement along with staff and service users to support patient and carer involvement for Maternity, Community and Children’s services. This focuses on seeing care through a patient or carer’s eyes and their first impressions, representing a snap shot of care on the date of the visit. This is an assurance approach to service/quality improvement that focuses on ward or department ‘walkarounds’ using a ’15 steps challenge’ team that will include patient reps, staff and board members. The team members consider their first impressions of the ward/department from the perspective of a patient or carer, recording how it appears in terms of how it looks, sounds, smells etc. The outcomes should inform improvement actions at a ward/department and organisational level. The ultimate outcome is to improve the quality of patient outcomes. The 15 steps challenge process has also been devised to meet the needs of an ongoing Care Quality Commission (CQC) mock type inspection.The 15 steps tool is based on the CQC Key Lines of Enquiry (KLOE), (CQC Oct 2017.60 areas have been assessed.• X7 received Outstanding• X26 received Good• X24 received Requires Improvement• X3 Intensive Support
Completed with on going monitoring
77 The Trust should continue to ensure the proper and safe management of medicines including: checking that fridge temperatures used for the storage of medicines are checked on a daily basis in line with the Trust's policy.
Should Surgery (SGH)
G
As above Completed with on going monitoring
78 The Trust should ensure that medicines and fridge temperatures are monitored and escalated when they are not within normal parameters.
Should Urgent and Emergency Care (DPOW)
GAs above Completed with on
going monitoring
79 The Trust must ensure that an effective system is in place to monitor equipment in the mortuary.
Must MortuaryG
Mortuary Manager for Path Links NHS Pathology Services has picked up outstanding actions collating evidence for sign off next month.
Completed
Ellie Monkhouse
Melanie Sharp
Ward Assurance Tool
Page 13
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
80 The Trust must provide services over seven days. Must End of Life (DPOW/SGH)
A
Ongoing discussions with commissioners about service provision. Currently reviewing resources across the NL and NEL patch to maximise capacity however no funding forthcoming for increase in medical support and 2 key members of the nursing team left in May.
No formal Specialist Palliative Care service at Goole hospital or in-reach from community Macmillan service. To encourage Goole staff to ring Hospital Macmillan service at SGH. Proposing 3 month trial of symptom control advice line to be offered by Community specialist palliative care team for acute wards at the weekend and looking at providing face to face cover on Bank Holidays by hospital team in the hospital at SGH.
Really important to gather data while these are being trialled. How many calls/patients seen, what was the benefit to the patient, what was the outcome and would consultant support have been beneficial.
TBC
81 The Trust must monitor the effectiveness of care and treatment provided. Must End of Life (DPOW/SGH)
G
The service undertakes a regular audits. This includes : Anticipatory Drugs prescribed, last days of live document used, achievement of preferred place of death, bereavement survey both in hospital and community, End of Life Audit and specialist palliative care report, currently 58%. Promotion through PIM and Head of Nursing. To review data from bereavement survey.
Completed
82 The Trust must ensure that all incidents are identified for the service, recorded and managed appropriately.
Must End of Life (DPOW/SGH)
GDatix has been updated and box added to identify End of Life incidents. All End of Life incidents discussed at NLAG end of life meeting.
Completed
83 The Trust must ensure that all patient records are completed full, particularly regarding MCA and do not attempt cardiopulmonary resuscitation (DNACPR)
Must End of Life (DPOW)
A
To be linked into the Medical Record Keeping lead by deputy medical directorFunding has been approved for a project manager for the roll out for respect document.
01/10/2019 extended
30/04/2020
84 The Trust must ensure that sufficient numbers of palliative care staff are employed to provide care and treatment.
Must End of Life (SGH/DPOW)
A
Discussion Paper with the Chief Executive looking at current model of care and also the local CCG's.This is an on going issue additional resource has been added to the business planning process for 2020.
30/06/2019Revised date30/06/2020
85 The Trust must ensure that all staff receive an annual appraisal. Must End of Life (Community)
GAll staff had a annual appraisal by the end of May 2019. Completed
86 The Trust must ensure that all staff complete mandatory training, including safe guarding training
Must End Of Life (DPOW/SGH)
GEnd of life staff mandatory training is compliant. Completed
87 The Trust must ensure complaints are identified for the service and managed appropriately.
Must End Of Life (SGH)
G
Jo Loughborough reviews all the complaints that have an EoL component and the triage tool that is used. Want to ensure that any EoL complaints are given a quick response and offer of face to face conversation. All complaints discussed at NLAG EoL meeting.
Completed
88 The Trust should ensure that patient information is available in formats other than English.
Should End of Life (SGH)G
All staff are aware of how to access information through the end of life mandatory training Completed
89 The Trust must review the training requirements needed for registered nurses and emergency nurse practitioners in relation to children.
Must Emergency Department
Urgent and Emergency Services (SGH/DPOW)
Kate Wood Simon Buckley
A
2 x Nurses from the Emergency Department are attending Lincoln University competency course. (Paediatric competencies for Adult Nursing). Paediatric Educators have undertaken 8 week training programme for Emergency Department.2 Nurse Practitioners to attend minor illness training course at DPOW.3 further ED RN’s attended Lincoln Uni course in Oct 2019Funding given for additional x4 ED RN’s to attend Lincoln Unit course in March 2020Plan for all Band 6 RN’s to complete EPLS by October 2020Ongoing education and training provided by Paediatric Team
01/10/2020
90 The Trust should review the environment provided for children to ensure they have waiting and treatment areas that are separated from adult patients.
Should Urgent and Emergency Services (DPOW)
GWork completed to create a area for Paediatrics. Completed
91 The Trust should review the designated mental health room and complete regular risk assessments of the room.
Should Urgent and Emergency Services (DPOW) G
Agreed with Mental Health Services at SGH to undertake yearly risk assessments.Training and Support provided from RDASH.NLaG Risk Assessment based on RCP Guidance used to assess MH rooms with MH providers
Completed
End of Life Kate Wood Dr Adcock
Page 14
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
92 The Trust must ensure that all patient's records contain relevant safeguarding information and referred to the safeguarding team as appropriate where there is evidence of risk.
Must Urgent and Emergency Services (SGH)
GReferral process is robust and guide to safeguarding referral in place.Continue to work closely together with the safe guarding team.Spot audit of referrals against ED records undertaken for assurance
Completed
93 The Trust should review the pathways and patient group directions that require updating.
Should Urgent and Emergency Services (TW)
GCurrently all updated.Both departments have files where staff have signed up to administer under the PGD
Completed
94 The Trust must continue to recruit medical staff to ensure that there are sufficiently suitably qualified, competent and experienced staff on duty to meet the needs of patients. The department was not in line with the Royal College of Emergency Medicine (RCEM) guidance of providing 16 hour consultant cover.
Must Urgent and Emergency Services (TW) G
Proposals are being fed into the annual Business Planning process.Moving Forward this action is going to be picked up via Business as Usual and managed through the Improvement Performance Meeting (Medicine)
Completed
95 The Trust must continue to appropriately recruit staff (specifically registered sick children's nurses (RSCN)) and ensure that there are sufficiently suitably qualified, competent and experienced staff on duty to meet the needs of patients.
Must Urgent and Emergency Services (SGH)
A
Proposals are being fed into the annual Business Planning process.Moving Forward this action is going to be picked up via Business as Usual and managed through the Improvement Performance Meeting (Medicine and Women’s and Children’s)Flying squad model approved by trust board, W&C's division currently on with recruitment proposed to be up and running by end of April 2020need to consult with current ED RSCN’s for transfer into ‘Flying Squad’.
01/10/2019 extended
30/04/2020
96 The Trust must continue to appropriately recruit staff (specifically registered sick children's nursing (RSCN) and ensure that there are sufficiently suitably qualified, competent and experienced staff in duty to meet the needs of patients. The emergency department was not meeting the intercollegiate Emergency Standard to have sufficient RSCNs to provide one per shift.
Must Urgent and Emergency Services (DPOW)
A
Proposals are being fed into the annual Business Planning process.Moving Forward this action is going to be picked up via Business as Usual and managed through the Improvement Performance Meeting (Medicine and Women’s and Children’s)Flying squad model approved by trust board, W&C's division currently on wit recruitment proposed to be up and running by end of April 2020need to consult with current ED RSCN’s for transfer into ‘Flying Squad’.
01/10/2019 extended
30/04/2020
97 The Trust should continue to increase compliance to 100% within the ED nursing dashboard.
Should Urgent and Emergency Services (SGH)
GNew dashboard devised and ready for implementation.Dashboard results shared at Emergency Care B&G meetingto be reviewed as part of the Unit Performance Reviews
Completed
98 The Trust should ensure that they are meeting the required complaint timescales. Should Urgent and Emergency Services (TW)
G
All open complaints now are closed, including the back log. Completed
99 The Trust must ensure that all staff complete mandatory training to meet the Trusts set Standard of 85%
Must Urgent and Emergency Services (TW)
A
Medicine as of 31.12.19 Ongoing
100 The Trust must ensure that all staff have an up to date appraisal completed. Must Urgent and Emergency Services (TW)
R
Medicine as of 31.12.19 On going
101 The Trust should ensure that strategies are implemented to allow medical staff in ED to work with other specialties to they can manage the flow in the department.
Should Urgent and Emergency Services (TW)
A
A review of internal professional standards and response times to ED from other specialties has been identified. The trust are currently working through plans to establish a Medical and Surgical Joint Assessment Unit (JAU) where on call teams will be focussed on pulling through referrals for assessment. a remit of the JAU Board is to review and agree the referral and response pathways between the ED and JAU capturing the work around internal professional standards.This work is ongoing through the Acute Assessment Unit and SDEC development groups
31/12/2019 extended date
30/09/2020
102 The Trust should continue to improve RCEM audits to achieve the required standard. Should Urgent and Emergency Services (TW)
AGoing to focus on clinical standards as a department 31/12/2019
extended date30/04/2020
Page 15
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
103 The Trust must review the risks within the department and increase compliance with paediatric training and risk associated with no registered sick children's nurses.
Must Urgent and Emergency Services (SGH)
A
2 x Nurses from the Emergency Department have attended Lincoln University to undertake a course designed for General RN's in Paediatric competencies and skills, this will continue to be rolled out to other staff members. Paediatric Educators have provided an 8 week training programme for Emergency Department staff with a focus on RCN Paediatric competencies. A review of the supportive pathways for Paediatric care within the ED's has taken place to ensure they are robust. SIM training has been completed within the ED's by the Paediatric Educators and has included all relevant specialties (anaesthetics / surgery etc). RN Child nurses have been appointed in the ED's, (2 at DPoW & 1 at SGH) a review of the model for paediatric nursing provision in the ED's has been undertaken and agreement for a team to sit with W&C and work within the ED's has been agreed, a Business case to support this is being written by W&C supported by medicine.Flying squad been approved at trust board - W&C's division currently going through recruitment process.3 further ED RN’s attended Lincoln Uni course in Oct 2019Funding given for additional x4 ED RN’s to attend Lincoln Unit course in March 2020Plan for all Band 6 RN’s to complete EPLS by October 2020Ongoing education and training provided by Paediatric Team
31/12/2019 extended
30/04/2020
104 The Trust should encourage staff in the department to participate in initiatives across the hospital and department.
Should Urgent and Emergency Services (SGH)
GPride and Respect training for all staffStaff Health and Wellbeing Ambassador training going ahead in July 2019 with staff from both departments attending.
Completed
105 The Trust must ensure learning from serious incidents is shared with staff and that learning is embedded to prevent similar incidents occurring in the future.
Must Medicine (DPOW/SGH)
Kate Wood Angie Legge
A
There are regular 'Learning on a Page' issued from each serious incident and a Trust newsletter, which had been paused during the changeover of staff, is being revived. New Serious Incident Review Group has met twice, actions monitored via QGG. Learning Strategy / Framework to be developed Jan to March 2020.
Ongoing
106 The Trust should consider how themes and trends from lower harm incidents can be shared to improve practice.
Should Medicine (DPOW/SGH)
Kate Wood Angie Legge
A
Themes and trends across all levels of harm, predominantly lower harm, are reported as part of the quarterly incident report to QSC, and in divisions, the monthly Governance reports. Work is currently underway to amend those divisional reports to include actions being taken to address the key themes. This will be aided by the new Governance Lead in Medicine.
Ongoing
107 The Trust must ensure that staff receive feedback on incidents and lessons learnt are shared across the wider teams.
Must Community Adults Kate Wood Angie Legge
A
Datix has been amended to enable an automatic email feedback and updates when the manager responds. This will continue to be reviewed as part of the longer term plan.
TBC
108 The Trust must ensure that lessons learnt from complaints are shared with all staff. Must Community Adults Ellie Monkhouse
Dawn Harper/ Jo Loughborough
A
Monthly governance reports are being shared with the divisions directly via their assigned complaints facilitators. It is through this route that learning will be shared as a headline, with the action plans running parallel to some of these, for more in-depth discussion from the Complaints Manager. There is opportunity for other learning outside of the action plans and this will be part of this report. Working towards meaningful action planning is a key element of the new complaints , concerns and FFT action plan. This will develop a shift in ensuring co design of action plans from lessons learnt as engagement in divisions continues to improve.
30/11/2019revised date 30/04/2020
109 The Trust must improve the Trust's referral to treatment time (RTT) for admitted pathways for medical patients.
Must RTT/ Waiting Lists
Medicine (SGH/DPOW)
A
An enhanced outpatient data collection form has been fully rolled out across the trust. Capacity and Demand and Waiting list forecasts have been modelled for each specialty. Recovery and sustainability plans have been completed and are currently being refreshed. Assurance on process for monitoring delivery for sign off at Performance Standards & Waiting List Project
Ongoing
110 The Trust must improve on national treatment performance standards. Must Surgery (DPOW/SGH)
AAs above. Ongoing
IMPROVING TOGETHER - ACCESS AND FLOW - SRO Shaun StaceyShaun Stacey Jackie France
Developing the Safety Culture
IMPROVING TOGETHER - LEADERSHIP AND CULTURE - SRO Jayne Adamson
Page 16
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
111 The Trust must put in place a robust and effective clinical validation system for the assessment of patients within the outpatient backlog that is prioritised based on clinical risk and covers all specialties.
Must Out-patients (TW)
G
Patients that were identified in the 2016 and 2017 cohort have all been clinically validated. A risk stratification document and framework have been developed and is currently agreed in principle and undergoing the sign off process. Speciality trigger points have been incorporated into the overall framework. Ongoing development through the Performance Standards and Waiting List project.
Completed
112 The Trust must ensure that the patients from the 2016 backlog have had an appropriate follow-up appointment.
Must Out-patients (TW)G
Patients from 2016 cohort have all been clinically validated, appointed and seen if appropriate. Completed
113 The Trust must put in place a clear plan for recovery with milestones and trajectory to address the backlog of patients waiting for follow up appointments in outpatients.
Must Out-patients (TW)
A
Capacity and Demand and Waiting list forecasts have been modelled for each specialty. Recovery and sustainability plans have been completed and are currently being refreshed.Risk Stratification and Trigger points agreed. Ability to clinical prioritise on PTL is being trialled in ophthalmology.
Dates agreed - monitored via
performance report
114 The Trust must put in place clear plan for recovery with milestones and trajectory to improve the referral to treatment performance.
Must Out-patients (TW)
A
As above. Dates agreed - monitored via
performance report
115 The Trust must put in place a clear plan for recovery with milestones and trajectory to improve the 62 day cancer pathway performance.
Must Out-patients (TW)
G
62 day improvement plan has been updated with divisional clinical and management teams.Progress against the plan is discussed weekly at operational and strategic level meetings.
Completed
116 The Trust must put in place a clear plan for recovery with milestones and trajectory to improve the 52 week wait performance.
Must Out-patients (TW)
G
Trajectory has been set for reduction in over 52 week patients and documented trust wide policy for undertaking quality reviews on all 52 week reported breaches.
Completed
117 The Trust must complete a formal review of the deaths of 181 patients who died whilst on the waiting list to consider if the delay in appointments or treatment delay contributed to their death.
Must Out-patients (TW)
G
As part of the COBRA Clinical Harm Review (CHR) process, a methodology was designed to effectively and efficiently review in detail the subset of deceased patients identified that had died whilst awaiting review at the time of the 8th August 2017 snapshot, in order to identify any cases in which the respective delays in review may have contributed to their death. This process was overseen initially by Louise Glover, and then subsequently Colin Farquharson (Deputy Medical Director, NLAG) and Ashy Shanker (Associate Chief Operating Officer, Operations Directorate, NLAG).
Completed
118 The Trust must carry out further work to improve reporting times for x-rays and scans. Must Diagnostic Imaging (TW)
G
Tenders have been received for outsourcing radiology reporting and a full business case has been requested regarding sustainability of turnaround times. NLAG radiologists undertake additional sessions to increase reporting capacity. Waiting times for unreported images are presented and challenged at the weekly PTL meeting. An escalation process is in the process of being put in place to support management of turnaround times. December - The contract with the external reporting company to address the backlog had been put in place in August 2019. This delay increased the potential risk of harm to patients
Completed
119 The Trust must carry out further work to improve waiting times for patients to receive scans and x-rays, including routine scans.
Must Diagnostic Imaging (DPOW/SGH) G
Bids for Capital monies for further equipment has been successful and currently increasing capacity with the use of mobile scanners.Second static CT scanner went live at Scunthorpe April 2019. Continue to supplement with mobile vans.
Work is ongoing. Timescales for
capital funding TBC
120 The department must improve the robustness of its escalation of untoward x-ray and scan results to ensure no patients' experience delayed diagnosis or treatment.
Must Diagnostic Imaging (DPOW/SGH)
G
Clinical Support Services have worked with WEB V to develop an electronic alert for x-ray and scan results. The pilot was completed at end of May 2019 and a review is currently underway and expected roll out will commence following evaluation.
31/12/2019
Page 17
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
121 The Trust must ensure that effective processes are in place to reduce the number of cancelled operations.
Must Surgery (DPOW/SGH)
A
The overall Trust position for cancellations on the day and cancellations on the day for non-clinical reasons have reduced, supported by the management processes in place. Service manager appointed in October 2019 to support the process by RCA are completed on all cancellations on the day. Monthly report provided to senior tri for assurance purposes.On a downward trajectory but winter pressures have impacted throughout November and December
31/12/2019 extended date
31/03/2020
122 The Trust should consider ways to reduce the number of cancelled clinics across outpatients.
Should Out-patients (TW)
A
The trust currently has an ambitious outpatient transformation programme which is underway and includes review of ways to reduce cancelled clinics and maximising efficiencies. The impact is also discussed through the Performance Standards and Waiting List project. We are particularly focusing on those specialities who have high rates, to ensure their leave policies and booking 6 weeks procedures are consistently applied.
31/03/2020
123 The Trust should consider ways to reduce the length of time patients wait for appointments in clinic.
Should Out-patients (TW)
A
This work will be picked up through outpatient transformation programme. It will be a rolling programme across 7 key specialties but the learning will be rolled out to other specialties by the end of the programme.
31/03/2020
124 The Trust should continue to ensure that effective processes are in place to enable access to theatres out of hours, and that all cases are clinically prioritised appropriately.
Should Surgery (DPOW)G
Policy in place, currently undertaking audit to ensure that the policy is followed and patients are being clinically prioritised.
Completed
125 The Trust should develop further communication with the GP to allow patients to be managed in the most appropriate health care setting.
Should UTC Urgent and Emergency Services (DPOW)
Shaun Stacey Abolfazl Abdi
A
The implementation of the integrated urgent care model will see the trust working with all local health care providers to agree a local model of care which will include not just acute healthcare but also community & primary care healthcare. The trust are in pilot form of delivering a UTC model at both the SGH & DPOW sites, this commenced in December 18 and there is currently a vast amount of work being undertaken with our stakeholders including GP’s and other health professionals around agreeing a local model on both sites. The full Implementation of the Urgent Treatment Centres will commence in June. Work with local GP’s is taking place around the future model and pathways in and out of acute care and GP/Acute engagement sessions are taking place on a regular basis. The trust are currently working with the local commissioners and partners to explore the benefits of a community frailty model. As part of the Urgent Treatment centre implementation the frailty service is a key part of the service delivery and early identification of frail patients to reduce the amount of unnecessary admissions to hospital. GP’s across North & North East Lincolnshire are now involved in a wide range of work with the trust to ensure patients are in the future cared for in the most appropriate setting, commissioners, GP representatives and patient representatives are involved in transformational meetings and work across the trust.
31/03/2020
126 The Trust should continue to develop the frailty service at the hospital to support elderly and frail patients to be cared for in the most appropriate place.
Should Frailty Urgent and Emergency Services (DPOW)
Abolfazl Abdi
A
The trust are currently working with the local commissioners and partners to explore the benefits of a community frailty model.
As part of the Urgent Treatment centre implementation the frailty service is a key part of the service delivery and early identification of frail patients to reduce the amount of unnecessary admissions to hospital.
Ongoing
127 The Trust should continue its work to improve patient flow throughout the hospital to reduce the number of ward moves, moves at night and outlying patients and ensure patients are cared for in the right place by the right speciality team.
Should SAFER, red2green
Medical Care (DPOW/SGH)
Abolfazl Abdi
A
The trust have recently worked with the ECIST team and taken part in a SAFER collaborative. The trust have identified 4 exemplar wards across SGH & DPOW , work is currently ongoing to ensure all key principles of SAFER and red2green are implemented and embedded before then developing a roll out programme for the remainder of the trust. Clinical engagement is a key part in this project to ensure the principles are embedded
Ongoing
128 The Trust should continue to work with partners to reduce delayed transfers of care and consider reviewing non-urgent transport arrangements for patients needing to attend one of the other hospital sites for investigations.
Should Discharge to Access
Medical Care (GDH)
Karen Fanthorpe
G
The Trust have developed and implemented the virtual ward where patients no longer requiring acute medical attention and be discharged and cared for by the trust and can be supported to ensure their future care with other partners are identified.
Completed
Page 18
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
129 The Trust must define and complete the vision and strategy for the medical services in a timely manner.
Must Business as Usual
Medicine (TW) Sue Barnett/ Kerry Carroll
Sue Barnett/ Kerry Carroll
A
The refresh of the HASR programme will see models and variants for all medical services with a long list by the end of Q1 and these will be assessed with Surgery and W&C aligned to the workforce, estates and finance through Q2 with the short list explored via pre consultation with scenarios available at the end of Q2The draft Medicine Strategy will be complete by 1st September 2019.
28/10/19 update: Draft strategy complete. Further development of the Medicine Strategy will require alignment to the HASR programme. This will see models and variants for all medical services with a long list by the end of Q3 and these will be assessed with Surgery and W&C aligned to the workforce, estates and finance through Q4 with the short list explored via pre consultation with scenarios available at the end of 2020.The final medicine strategy is scheduled for completion and approval March 2020.
30/09/2019 Revised to 31/032020
130 The Trust must ensure that the five year vision and strategy are enacted and work towards getting back on schedule so as to impact on waiting and reporting times and ensure visions of the future of the department are action planned and put into practice.
Must Diagnostic Imaging (DPOW/SGH)
A
Waiting times for planned patients treatments are reducing as is the volume waiting and improving reporting times for Radiology and Pathology are in place at an STP and Trust level recognising this national issue. The Refresh of the imaging strategy is due September 2019. The reporting outsourcing solution was approved at TMB in June and is in mobilisation phase.The Trust has agreed the Strategic Framework for 2019-24, outlining the vision, values and behaviours and combing the Trust’s principles, objectives and priorities for the next 5 years.Communication and engagement plan is due to launch throughout July, August and September. The Trust Strategy 2019-24 will be in draft by 1st September 2019The Trust 5 year Strategic Plan 2019-24 will be finalised by 15/11/19 (In line with the national timeline for the final plan due 15th November set by NHSI/E.)Implementation of the previous Diagnostics strategy continues (refer to action 133)
01/09/2019Revised Date
31/032020
131 The Trust must ensure that there is a robust strategy for community health services for adults, developed with involvement from staff, patients and key groups representing the local community.
Must Community Adults
A
These requirements will be Integrated within above and further defined within the Community & Therapies Strategy. Patients and key groups will be involved in the development of what community services will look like. For North Lincolnshire the Out of Hospital Transformation group has been formed and been functioning for 6 months.The draft Community & Therapies Strategy will be complete by 1st September 201928/10/10 - draft strategy completed, details to be finalised by 1/11/19The final Community and Therapies strategy is scheduled for completion and approval March 20.
01/08/2019Revised date:
31/032020
132 The Trust must define and complete the vision and strategy for the surgical services in a timely manner.
Must Surgery (TW)
A
The refresh of the HASR programme will see models and variants for all surgical services with a long list by the end of Q1 and these will be assessed with Surgery and W&C aligned to the workforce, estates and finance through Q2 with the short list explored via pre consultation with scenarios available at the end of Q2
ENT, Urology and Critical Care will be developed by the end of Q1.These will need to be assessed against the remaining services during Q2.The draft Surgery Strategy will be complete by 1st September 2019
28/10/10 - draft strategy completed, details to be finalised by 1/11/19 to align to the Trust Strategy 2019-24. Further development of the Surgery & Critical Care Strategy will require alignment to the HASR programme in due course. This will see models and variants for all surgical services with a long list by the end of Q3 and these will be assessed with Medicine and W&C aligned to the workforce, estates and finance through Q3 with the short list explored via pre consultation with scenarios available at the end of Q3/early Q4.
The above will required alignment to the strategic capital programme for all investment.
The final Surgery & Critical Care strategy is scheduled for completion and approval March 20.
01/09/2019Revised Date:
31 /032020
IMPROVING TOGETHER - STRATEGY AND CAPITAL - SRO Sue Barnett/Kerry Carroll
Page 19
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
133 The Trust must address the scanning access, breakdown, reliability and quality issues faced by the radiology and diagnostics departments.
Must Diagnostics (DPOW/SGH)
A
The receipt of the remaining £8.1m for scanner capacity allows the completion of the next phase of upgrade. This will provide two new MRI’s (one replacement and one additional in a new build) and one new additional CT at Grimsby. The full business case for DPOW MRI in was approved in December 2019 by trust board, construction commences 10/02/2020.DPoW CT scheme is progressing in 2019/20 working through the implementation of a relocatable solution in Qtr3.The Strategic Capital bid has provided the Trust with a notional allocation of £29.26m for which planning has commenced to complete the 5 step business case process for Treasury approval. This will provide the remaining priorities of an additional MRI scanner in Scunthorpe. The STP capital funding will be received over a 3 year period.The current SGH CT scheme funded from the Trust capital programme backed by a loan, is due for completion beginning of April 19 which will achieve x 2 CT scanners on the Scunthorpe site. Complete and operational.23/1/20 update:Emergency Capital; • SGH CT Scheme – completed and operational on site • DPoW MRI Scheme - Full Business Case approved by Trust Board in December 2019, construction commences on 10th February 2020, completion scheduled for March 2021• DPoW CT scheme - First cut of the Business Justification Case approved in December 2019, second stage (detailed design stages) has commenced and aimed for approval in Q1 2020/21 by Trust Board. Aiming for modular unit to be onsite and operational by late Autumn 2020National STP Wave 4 (£29.26m, of which £4.4m aligned to SGH MRI); • Strategic Outline Case approved by Trust Board, CCGs and STP. Joint OBC/FBC commenced January 2020. Pending NHSI/E and DHSC approval processes (timing), scheme working to the following dates; o Final contracts – Sept 2020o Work starts onsite – Oct 2020o Completion – Late summer to Oct 2021
Timescales for capital funding TBC
134 The Trust should ensure that a strategy is developed for outpatients. Should Outpatients (TW)
A
Configuration of this would will be assessed in Q1 of 2019/20 alongside operational policies to address this issue.DPoW Integrated Cardiology Ward complete and CCU transferred providing increased single room occupancy on 16th May 2019. This provides male and female accommodation removing the need to mix. There is a potential risk based on pt numbers that needs to be managed clinically and alongside the MSA Policy.The outpatients transformation programme is focusing on the 7 priority specialities across the sub-system, phasing in • ENT, Ophthalmology, Colorectal, Urology, Cardiology, Gastroenterology and Respiratory. • This includes linkages to GIRFT and RightCare. The draft Outpatient Strategy will be complete by 1st September 2019 - achieved. Final strategy is due by 1/11/19 to align to Long term plan and sub-system outpatient transformation priorities.Final Outpatient strategy is scheduled for completion and approval March 20.
01/09/2019Revised Date:
31/032020
135 The Trust should continue its plans to develop the cardiology area which will facilitate single sex accommodation and reduction in the number of missed sex accommodation breaches.
Should Medical Care (DPOW)
G
Configuration of this would will be assessed in Q1 of 2019/20 alongside operational policies to address this issue.There has been a conversation with CCG & other colleagues re the Resp HOBS bay at SGH and CCU at DPoW. The outcome of these discussions was that they visited to review the areas and our processes and agreed that we should not be reporting occurrences of MSA as breaches in these areas for acute patients. This brought us in line with other trusts with similar environmental layouts. There is clearly the process for step down of those patients no longer requiring an escalated care area, which is managed in line with the MSA Policy. DPoW Integrated Cardiology Ward complete and CCU transferred providing increased single room occupancy on 16th May 2019. This provides male and female accommodation removing the need to mix. There is a potential risk based on pt numbers that needs to be managed clinically and alongside the MSA Policy
Completed
136 The Trust should continue its plans to develop the respiratory ward area which will facilitate single sex accommodation and reduction in the number of missed sex accommodation breaches.
Should Medical Care (SGH) G
Configuration of this would will be assessed in Q1 of 2019/20 alongside operational policies to address this issue.
Completed
BUSINESS AS USUALMedicine
Page 20
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
137 The Trust must ensure safe medical staffing levels are maintained and every effort is made to recruit to vacancies. This should include the viewing the current hospital at night arrangements and ensuring patients are reviewed daily.
Must Performance Improvement Meeting
Medicine (SGH,DPOW)
Shaun Stacey Simon Thackray/ Abolfazl Abdi
A
Medical Workforce Plan in place with focus on establishments and targeted recruitment. SAFER principles focus on daily senior review, work ongoing through SAFER Group and through Medical job planning to enable this.
Ongoing
138 The Trust must ensure medical and nursing staff comply with mandatory training requirements and are appraised annually.
Must Performance Improvement Meeting
Medicine (DPOW/SGH)
Shaun Stacey Simon Thackray/ Abolfazl Abdi/ Anne-Marie Hall
R
Mandatory training figures as December 2019.Medicine
PADR
30/12/2019 date extended to 30/03/2020
139 The Trust must improve areas of care identified as needing improvement from national and local audits.
Must Performance Improvement Meeting
Medicine (DPOW/SGH)
Shaun Stacey Simon Thackray/ Abolfazl Abdi/ Anne-Marie Hall
G
Report of medicine audit programme for 2018/19 compiled and reviewed 30th November 2018.45 Audits on the programme: 15 x A&E, 2 x Blood transfusion, 6 x cardiology, 5 x diabetes, 7 x Elderly, 6 x Respiratory, 1 x Rheumatology, 1 x Stroke, 2 x No Speciality. 32 active (20 in data collection, 7 at report/action plan stage, 5 x not yet at data collection stage). Audits on agenda of every speciality Business and Governance Meeting. Review of nursing audits to ensure included in Annual Audit Programme.
Completed
140 The Trust must provide assurance of risk registers being actively managed and overseen.
Must Performance Improvement Meeting
Medicine (TW) Shaun Stacey Simon Thackray/ Abolfazl Abdi/ Anne-Marie Hall
G
Risk Register is reviewed at Medicine Governance Meeting held monthly.Each Business Group within Medicine to undertake a review of the Risk Register for their Group of Specialties to ensure all identified risks are added to the risk register.A review of the risk register by the Medicine Triumvirate undertaken in March 2019 to confirm and challenge the risks as currently no risks are categorised as Strategic.
Completed
141 The Trust must ensure robust arrangements are in place to ensure sufficient, effective senior clinical oversight to manage patient risk and take appropriate action to respond to urgent or changing needs.
Must Performance Improvement Meeting
Medical Services (GDH)
Shaun Stacey Simon Thackray/ Abolfazl Abdi/ Anne-Marie Hall G
Senior consultant presence on site daily basis (Mon-Fri 9-5). Compliant rosters re junior/middle grades. Site management 24/7
Completed
142 The Trust must ensure nursing staff carrying the emergency bleep receive the training regarding expectations and actions to take a lead site-wide emergency response out of hours, as soon as possible.
Must Performance Improvement Meeting
Medical Services (GDH)
Shaun Stacey Simon Thackray/ Abolfazl Abdi/ Anne-Marie Hall G
Matron (Surgery) appointed as Site Lead. OOHs site cover band 6 and above. Responsible for emergency bleep. All ALS trained.
Completed
143 The Trust should consider reviewing its management and governance arrangements for the neuro rehabilitation centre to ensure effective governance monitoring, risk management and service delivery on the unit.
Should Performance Improvement Meeting
Medical Services (GDH)
Shaun Stacey Dave Broomhead/ Karen Fanthorpe/ Dawn Daly/ Jenny Hinchliffe
G
Interim Band 7 in place. Goole matron supports the neuro unit and there has been increased visibility of the Head of Nursing and Deputy Head of Nursing. Business Manager role in place. Ward Manager appointed, start date TBC. Unit dashboard developed. Monthly unit meeting feeds into Divisional Clinical Governance meeting. Capability on site to stabilise and manage airways on site pending transfer to SGH if required. Tracheostomy training undertaken. Risk register updated. Ongoing monitoring and oversight.
Completed
Page 21
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
144 The Trust should continue to promote a caring culture and engage staff to address any residual issues of bullying and intimidation and involve staff in ongoing service improvements.
Should Performance Improvement Meeting
Medicine (SGH/DPOW)
Shaun Stacey Simon Thackray/ Abolfazl Abdi/ Anne-Marie Hall
A
Medicine Division have a number of staff who are Pride & Respect champions and a member of the management team is on the Pride & Respect Steering Committee. Members of staff across medicine have participated in the 2 hour training sessions.Members of staff have attended the compassionate leadership conference. Health & Wellbeing work – HCA & RN from most Clinical Areas in Medicine working on how we can make improvements to working lives. Ambassadors appointed and having badges to identify them.The Division has in place a Staff Engagement Plan.A Health Care Assistant Focus Group has been set up – first session held in April 2019.
Ongoing
145 The Trust must ensure that mandatory training compliance for all staff meet their own target.
Must Performance Improvement Meeting
Surgery (TW) Shaun Stacey Kishore Sasapu/ Jenn Orton/ Paul Hinchliffe
A
Mandatory training figures as at December 2019.Surgery and Critical Care
01/12/2019 extended date
31/03/2020
146 The Trust must ensure that there are sufficient qualified, competent, skilled and experienced persons to meet the needs of patient using the service.
Must Performance Improvement Meeting
Surgery (DPOW/SGH)
Shaun Stacey Kishore Sasapu/ Jenn Orton/ Paul Hinchliffe
A
Robust process of block booking for our high vacancy areas to ensure safe staffing. 24 Newly Qualified Nurses and 8 oversees nurses have commenced in division during August - October this will reduce the RN vacancy to 14 WYE which is the lowest it has been in division for a significant length of time. Vacancy rates remains at the lowest however there are 2 wards ward 25/28 concern SGH vacancy position although reduced still a concern
01/12/2019 extended date
30/06/2020
147 The Trust must ensure that 95% of staff have an up to date appraisal in line with their own target.
Must Performance Improvement Meeting
Surgery (TW) Shaun Stacey Kishore Sasapu/ Jenn Orton/ Paul Hinchliffe
R
PADR figures as at December 2019Surgery and Critical Care
01/12/2019 extended date
31/03/2020
Surgery
Page 22
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
148 The Trust must ensure that performance in all national audits improves and that action plans address the correct issues to ensure performance improves.
Must Performance Improvement Meeting
Surgery (DPOW/SGH)
Shaun Stacey Kishore Sasapu/ Jenn Orton/ Paul Hinchliffe
A
Surgery and Critical Care Audits. Significant improvements improving position anticipation to continue on upward trajectory.
WHO Monthly audits continue.National Ophthalmology Database Ophthalmology YearlyNational Audit of Prostate Cancer Urology YearlyBAUS National Audit of Nephrectomy Urology YearlyBAUS – National Audit of PCNL Urology YearlyNational Joint Registry (NJR) Orthopaedics YearlyNational Bowel Cancer Audit Gen Surg Yearly - Action plan developed to be discussed at governance meeting in May.National Oesphago-Gastric Cancer Audit Gen Surg Yearly - Action plan being developedDocumentation & Consent Audit All Yearly - Action plan developed quarterly updates at governance groupNational Audit of Breast Cancer in Older Patients Breast Surgery YearlyGIRFT Surgical Site Infection Audit Multiple Yearly (?) - Action plan to be developed(Ran last year, due this year)Elective Surgery (National PROMS Programme) Orthopaedics Six-monthlyICNARC – Case Mix Programme Anaesthetics QuarterlyNational Cardiac Arrest Audit (NCAA) Anaesthetics QuarterlySurgical Site Infection Surveillance Registry (DPOW & Goole) Orthopaedics QuarterlyNational Emergency Laparotomy Audit (NELA) Gen Surg / Anaesthetics Quarterly Reporting & submission from April 2019 - NELA pathway now implementedNational Hip Fracture Database Audit (NHFD) Orthopaedics Monthly Data / Annual ReportNational Audit of Head and Neck Oncology HANA / Saving Faces ENT Not yet commenced reportingBreast & Cosmetic Implant Registry Breast Surgery Reports as and when - Action plan discussed at breast service governance meeting.
30/06/2020
149 The Trust must ensure that service risks are identified, reviewed, updated and senior management teams have oversight.
Must Performance Improvement Meeting
Surgery (TW) Shaun Stacey Kishore Sasapu/ Jenn Orton/ Paul Hinchliffe G
All risks have been realigned into the new risk register template and are due for discussion at the senior meeting to allow the formulation of a robust surgery and critical care risk register.
Complete
150 The Trust must ensure that effective processes are in place to enable improvement on the number of fractured neck of femur patients who have surgery within 48 hours.
Must Performance Improvement Meeting
Surgery (SGH) Shaun Stacey Kishore Sasapu/ Jenn Orton/ Paul Hinchliffe
G
*Significantly reduced hours to operation over the past year with patient numbers still remaining the same.*short times to surgery at both sites. *Two consecutive months of 0% 30 day mortality at SGH (significantly dropping the YTD mortality) and really low mortality at DPOW*Massive jump in BPT achievement to well above national average at SGH*85% BPT achievement at DPOW, despite high patient numbers
Complete
151 The Trust must ensure safe medical staffing levels are maintained and every effort is made to recruit to vacancies. This should include reviewing the current hospital at night arrangements and ensuring patients are reviewed daily.
Must Performance Improvement Meeting
Medicine (DPOW/SGH)
Shaun Stacey Kishore Sasapu/ Jenn Orton/ Paul Hinchliffe
G
Hospital at night and Critical Care Outreach have been merged together and the gaps in service provision / handover time have now been eradicated. It is now a 24 hour service, 7 days a week. Critical Care competencies for the Hospital at Night Team are required to enhance their skill set. DPOW site hospital at night team have relevant critical care competencies SGH are working towards a plan with a bespoke critical care competency framework to meet the needs of the service.
Complete
152 The Trust should ensure that staff complete Mental Capacity Act Training. Should Performance Improvement Meeting
Surgery (DPOW/SGH)
Shaun Stacey Kishore Sasapu/ Jenn Orton/ Paul Hinchliffe A
As at September 2019Surgery and Critical Care - Mental Capacity Act Compliance - 80% - 8% increase in last 3 months.
31/03/2020
153 The Trust should continue to ensure that actions are taken to enable staff to raise concerns without fear of negative repercussions.
Should Performance Improvement Meeting
Surgery (DPOW/SGH)
Shaun Stacey Kishore Sasapu/ Jenn Orton/ Paul Hinchliffe
G
Actively encourage all staff to undertake pride and respect training with an increase month on month in compliance. Ask Peter is a well used conduit for staff to be able to speak out and freedom to speak out guardian is a well utilised service.The division is committed to ensuring that any concerns escalated are acted upon so that staff have confidence that their concerns are listened too and dealt with appropriately giving feedback where appropriate to do so.
Complete
Clinical Support Services
Page 23
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
154 The Trust must ensure that medical staff are up to date with all of their mandatory training to meet the Trust target of 85%.
Must Performance Improvement Meeting
Diagnostics (TW) Shaun Stacey Steven Griffin/ Tracey Broom/ Ruth Kent/ Jackie France/ Simon Priestley/ Mick Chomyn G
Mandatory training figures as at December 2019.Clinical Support Services
Completed - ongoing monitoring
155 The Trust must ensure that all staff receive appraisals in a timely manner to meet the Trust target of 95%
Must Performance Improvement Meeting
Diagnostics (TW) Shaun Stacey Steven Griffin/ Tracey Broom/ Ruth Kent/ Jackie France/ Simon Priestley/ Mick Chomyn
R
PADR as at December 2019.Clinical Support Services
31/03/2019revised date
31/03/202
156 The Trust must continue to recruit radiologists and reporting radiographers to address staff shortages and reduce reporting times.
Must Performance Improvement Meeting
Diagnostic Imaging (DPOW/SGH)
Shaun Stacey Steven Griffin/ Tracey Broom/ Ruth Kent
A
Ongoing attempts to recruit Radiologists, both nationally and internationally, with some success.
Scope of practice for reporting radiographers has been increased to cover all plain film referral sources. Capacity is being increased with backfill of clinical radiographers. One additional reporting radiographer will qualify in September and one further training place secured for next year. Further plans to grow the team are ongoing.
Accepting we will still have a gap in reporting capacity, we are working towards a contract with an outsourcing provider, to ensure we have guaranteed capacity available to allow us to deliver reporting in line with our internal professional standards. See action 118 above.
Reporting radiographers
qualify Sept 2019. New outsourcing Business Case to TMB July 2019 -
approved July 2019
Ongoing
157 The Trust should encourage clinical audit across all modalities and all sites since clinical audit provides robust evidence of quality.
Should Performance Improvement Meeting
Diagnostic Imaging (TW)
Shaun Stacey Steven Griffin/ Tracey Broom/ Ruth Kent/ Jackie France/ Simon Priestley/ Mick Chomyn
G
Audits on availability of health records has commenced as of January 2019. These will be published monthly and presented at week 1 of the PRIM (quality meeting)
A number of Radiology and Endoscopy Audits are planned or underway. Full Clinical Sciences Audit calendar t be produced in conjunction with Audit Department. Audits are regularly presented at the Performance Meetings. Central record of the audit programme is being managed through Divisional Governance and Central Audit Team.
Completed
158 The Trust should engage further with staff to support recruitment and retention of staff.
Should Performance Improvement Meeting
Diagnostic Imaging (DPOW/SGH)
Shaun Stacey Steven Griffin/ Tracey Broom/ Ruth Kent/ Jackie France/ Simon Priestley/ Mick Chomyn
G
Suggestion boxes and thank you boards are in all departments, an example of this is the request by CT staff to move to a nightshift model as part of core hours instead of on call as extra duty, due to the increase in workload and the poor work-life balance which has now been implemented
Completed
Estates and Facilities
Page 24
Must/Should
Project/ Monitoring Route
Core Service Identified
Executive Lead
Project Lead RAG Rating
Progress Update Estimated Completion Date
CQC Requirement
159 The Trust must ensure timely repair and maintenance of estates and facilities issues within the operating theatre department.
Must Performance Improvement Meeting
Surgery (SGH) Jug Johal Simon Tighe
B
Works reported on helpdesk and intranet is completed within policy timescales.This is monitored through Estates & Facilities Finance and Performance meeting – PPM and reactive maintenance KPIs.Sign off forms signed off at Estates and Facilities governance meeting 28 March 2019.
Completed
160 The Trust must ensure timely repair and maintenance of estates and facilities issue at GDH.
Must Performance Improvement Meeting
Medicine (GDH) Jug Johal Simon Tighe
B
Works reported on helpdesk and intranet is completed within policy timescales.This is monitored through Estates & Facilities Finance and Performance meeting – PPM and reactive maintenance KPIs.Sign off forms signed off at Estates and Facilities governance meeting 28 March 2019.
Completed
161 The Trust should display information to staff, relatives and patients on current safety performance.
Should Performance Improvement Meeting
Surgery (GDH) Shaun Stacey Kishore Sasapu/ Jenn Orton/ Paul Hinchliffe G
Matron in post for GDH site (April 19) All of the performance data is produced and displayed in the ward environment in Goole this is updated by the matron on a regular basis.
Completed
162 The Trust should take steps to improve its staff and public engagement activities. Should Performance Improvement Meeting
Surgery (SGH/GDH)
Ade Beddow Lisa Webster/ Charlie Grinhaff
A
The Trust is working hard to improve engagement. Since the last inspect it has: - Public – run a number of public engagement events with CCG partners in all three towns (Grimsby, Scunthorpe and Goole); doing more work on social media to highlight work taking place at the Trust; working with partners to engage around the NHS Long Term Plan and the acute services review where a number of specialty-specific workshops have taken place.- Staff – looked to improve internal comms channels such as screensavers, intranet and newsletter; introduced new ways to celebrate staff – Team of the Week and ThumbsUpFriday – as well as held another Ours Stars staff award event in November 2018; revised the approach to brief staff through the Senior Leadership Community meetings; held leadership conferences with 100+ senior leaders to discuss ways they can engage with staff; introduced a new approach to corporate induction
Ongoing
163 The Trust should ensure up to date patient information is available and in accessible format where appropriate.
Should Performance Improvement Meeting
Diagnostic Imaging (TW)
Shaun Stacey Tracey BroomG
All patient information leaflets are up to date, divisional document control is managed through Divisional Governance meeting. Access to accessible information is available via the Trusts website using browsealoud.
Completed
Communication and Engagement
NLG(20)025
DATE OF MEETING 04 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Claire Low, Acting Director of People and Organisational Effectiveness
CONTACT OFFICER Claire Low, Acting Director of People and Organisational Effectiveness
SUBJECT Monthly Staffing Report – January 2020
BACKGROUND DOCUMENT (IF ANY) N/A
PURPOSE OF THE REPORT: To provide workforce information for December 2019
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The Monthly Staffing Report gives an update for December 2019 on turnover, vacancies, sickness and workforce developments. This should be read in conjunction with the Integrated Performance report.
TRUST BOARD ACTION REQUIRED
The Board is asked to receive the Monthly Staffing Report for information and assurance
EXECUTIVE SUMMARY
Turnover & Retention:
The 12 month Trustwide turnover rate (permanent staff only) stands at 8.41% in December 2019, within the annual target of <9.4%. This
time last year the annual turnover rate stood much higher at 9.72%, therefore the position is continuously improving.
The overall turnover rate for December 2019 stood at 0.71%, within the monthly target of 0.78%. This time last year the turnover rate
stood lower at 0.67%.
• The Medical & Dental Staff Group turnover rate in month remains static at 0.38%. When compared to this time last year the
turnover figure stood much higher at 0.77%.
• Nursing and Midwifery Staff Group turnover rate has remained relatively stable in month at 0.59% but still within the target of
0.78%. This is an in month increase of 0.03%. When compared to the previous year, the turnover rate stood at 1.06%.
• The AHP turnover rate increased in December 2019 to 1.44%, which is outside the monthly target. This is an in month increase of
0.16%. Last year the monthly turnover in December 2018 stood at 1.21%.
The Exit Questionnaire return rate for November 2019 stood at 23% against the target of 50%. The return rate is higher when compared
to the same time last year where the return rate stood at 18%.
Vacancy Summary:
The Trustwide vacancy position has increased slightly in month resulting in a vacancy position of 6.99% within the Trust target of <7%.
This is an in month increase of 0.23%. The whole time equivalent vacancies that the Trust has now stands at 424.58 which is largely made
up of clinical roles. When compared to the same time last year, the Trust's vacancy position stood at 6.93%.
The Registered Nursing vacancy position remains outside of target resulting in an increased vacancy factor of 7.99%, against the target of
6% which is an in month increase of 0.19%. When compared to the same time last year the Registered Nursing vacancy position remains
relatively unchanged. The vacancy position stood at 8.37% in December 2018. Ongoing plans to address vacancies are in place and can be
found in the recruitment update section of this report.
The Unregistered Nursing vacancy rate stood at 4.5%, which is an increase of 1.3%. To compare, the vacancy position stood higher in
December 2018 at 3.94%.
The Medical & Dental vacancy position decreased in month to 13.59%, within the Trust target of <15%. This is an in month decrease of
0.47%. Last year’s vacancy rate stood at 15.93%, therefore the position has improved. The vacancy position is equivalent to 88.55 whole
time equivalent vacancies. Ongoing plans to further address Medical and Dental vacancies are in place and can be found in the
recruitment update section of this report.
Sickness Rates:
The Trust’s Sickness Percentage in November 2019 stood higher than in previous months at 5.28% which is outside the Trust target of
<4.1%. This is an in month increase of 0.28%. The increase in sickness absence in month is largely due to a number of Directorates/
Divisions which saw a large percentage increase in sickness rates during November. These were Community & Therapy, Surgery & Critical
Care and People & Organisational Effectiveness.
When compared to November last year the overall sickness percentage is higher. Last year's figures for November stood at 4.07%.
Nursing and Midwifery sickness rates remain high overall. In November 2019, the sickness rate stood at 5.5%, which is slightly higher than
the previous month.
Additional Clinical Services sickness rates rose significantly in November 2019 from 7.02% to 8.13%.
The highest sickness reasons in month were ‘anxiety/stress/depression/other psychiatric illnesses’ (2,748 calendar days lost) and 'other
musculoskeletal problems' (1,270 calendar days lost).
1.0 INTRODUCTION
2.0 BOARD ACTION
The Board is asked to:
2.1 RECOMMENDATIONS
3.0 AT A GLANCE
4.0 MONTHY DASHBOARD BY DIRECTORATE
5.0 MONTHLY WORKFORCE UPDATE AND MONTHLY THEMED ANALYSIS
Monthly Staffing Report
January 2020
· Recommendations for the monthly feature are welcomed. Please send any
Strategy and Planning 157 3.02% 0.73% 0% 6.60% 97% 95%
* Exit questionnaire return rates and sickness rates are reported 1 month behind to ensure accuracy of data.
* On the exit questionnaire column, N/A will be shown were there have been no leavers in the directorate. Were there have been leavers and no exit questionnaires returned this will
result in a 0% return rate.
5.0 MONTHLY WORKFORCE UPDATE
Workforce Update:
Recruitment Update:
Nursing:
The Registered Nursing vacancy position has increased slightly in month by 0.19% and stands at 7.99% against the target of <6%.
Nurse Recruitment Open days for 2020 have been finalised, dates available on the Trust website. Registered Nurses, Return to
Practice and NQNs are encouraged to apply. A further 2 pre-registered nurses are planned to commence in January 2020, to hit the
agreed recruitment target of 20 nurses.
Planning is underway, as approval via TMB has been received to recruit 50 international nurses though Health Education England,
Global Learners programme. 3 cohorts are currently being planned, with the first cohort commencing in April 2020, these nurses will
arrive from Kerala in India.
Support is being given to Surgery to successfully recruit ODPS and Registered Nurses within Theatres across the Trust.
Medical & Dental:
The Medical & Dental vacancy position decreased in month to 13.59% within the Trust target of <15%. The vacancy position is
equivalent to 88.55 whole time equivalent vacancies. The fill rate for trainee doctor posts due to rotate in February is currently 75%.
Of the vacant February rotating trainee posts, over half are already filled with locally appointed doctors to backfill.
Ongoing activity has created a substantial pipeline of Doctors that the Trust is working hard on to convert into starters; this pipeline
currently stands at 44 doctors awaiting start dates between January 2020 and May 2020. Local backfill arrangements to cover
vacancies are taking place through advertising, utilising the existing pipeline, and interim agency locums. Work to further build up the
existing pipeline, maintain this pipeline and deliver divisional recruitment plans are ongoing. Further sourcing of candidates from
overseas posts under the medical training initiative is underway alongside other methods including headhunting. The forecast for SAS
and Consultant recruitment against turnover shows a position that remains relatively stable. The use of the talent acquisition team
will help to positively influence this to recruit more middle and Consultant grades.
Workforce Update:
The integration of the HR Business Partner role into the triumvirate business planning and decision-making discussions are beginning
to demonstrate that this approach is working well in some areas. As workforce is our most expensive resource, most decision-making
has an impact on this. Therefore, to enable effective workforce development and planning to support divisional operational plan
delivery, we would encourage all divisions to warmly welcome their HR Business Partner into all of their workforce-related meetings,
as business as usual, to enable the continuing progress of good practice and ensure divisions are sufficiently supported to deliver on
their current and future commitments.
ESR Manager Self Service Project:
The majority of Class Administrators have now been trained on the Learner dashboard. Guides have been created and uploaded to
the My ESR Hub Page. OLM is now Live on ESR and the Course Booking System will be decommissioned from 13/01/2020.
Work is still underway for the preparation and roll out of MSS. Divisional Leads are being contacted to touch base on the roll out of
MSS and Hierarchy’s are being built by the ESR Team.
Apprenticeships:
The Digital Apprenticeship Service Platform has not been updated by organisations over the Christmas period therefore no current
apprenticeship data is available.
5.1 MONTHLY THEME ANALYSIS
Monthly Theme/ Analysis - Sickness rates and Long Term Conditions
The Trust sickness rate reached 5.28% in November 2019. However, it must be noted that in the latest 12-month period 1,907
members of staff have never had a day off sick, which equates to 32% of the workforce (excluding new starters during this period).
The Trust’s sickness rate is impacted by a number of staff that have long-term conditions such as diabetes, arthritis and the
menopause which can be considered a long-term condition that affects women between the ages 45-60. New research indicates that
the menopause can last a further 10 years than expected. Further to this, some mental health conditions can also be classed as a long-
term condition.
The table below breaks down the Trust’s absence reasons, some of which pertain to long-term conditions. These conditions can
impact on absence rates and how staff feel at work. Long-term conditions are conditions for which there is no cure, which can be
managed with drugs and other treatment such as therapies. Long-term conditions can be emerging, recurring or permanent and
normally exist for more than one year. An individual can have more than one long-term condition at the same time which is often
referred to as ‘multimorbidity’. As the workforce continues to age, we are likely to see are likely to increase in staff managing long
term conditions within the workforce as it is well known that long-term conditions are more prevalent in older people.
The Trust is currently supporting staff who consider themselves as having a long-term condition or who have caring responsibilities by
creating a Long Term Conditions (LTC) and People with Caring Responsibilities Staff Equality Network. This is being led by the Trust’s
Equality, Diversity and Inclusion Lead. The network aims to provide peer support and share information to improve the experience of
staff that have a LTC or caring responsibility and assist in raising awareness of disability issues across the organisation. For further
Claire Low, Acting Director of People and Organisational Effectiveness and Kay Farquharson, Acting Freedom to Speak Up Guardian
CONTACT OFFICER Kay Farquharson, Acting Freedom to Speak Up Guardian (FTSUG)
SUBJECT FTSUG Quarterly Report
BACKGROUND DOCUMENT (IF ANY) N/A
PURPOSE OF THE REPORT: For Assurance
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
Quarter 3 (2019/20) report detailing FTSUG staff concerns, FTSUG activities, FTSUG latest developments and Trust FTSU priorities for the next six months.
TRUST BOARD ACTION REQUIRED
The Board is asked to:
Note numbers and any themes of staff concerns raised through the FTSUG.
Note activities of the FTSUG and Trust progress against FTSU Priorities.
1
Freedom to Speak Up (FTSU) Guardian Report Q3 (October – December) 2019-20
1.0 Update from last Board Report on Q2 November 2019.
FTSU – progress on priorities for Trust:
Appointment of the permanent FTSU Lead Guardian.
NHSI have agreed to continue to assist with FTSU at NLaG until September 2020 (next visit
planned for 15 January 2020).
2.0 Reactive- NLAG FTSU Concerns
During Q3 there were 14 concerns raised, 14 concerns have been closed and there are currently 9
open concerns up to 31 December 2019.
Q3. 2019-2020 (Oct – Dec 2019)
Concerns 14
Themes
Behaviour / relationships
5
Bullying & Harassment
3
Culture 1
Leadership 0
Patient Safety 3
Process/Systems 3
Personal Grievance 0
Staff Safety 3
How Raised Openly 5
Confidentially 9
Anonymously 0
Perceived detriment
0
Concerns raised may include several elements.
2.1 NLAG FTSUG NGO Report Breakdown by Division and Role.
Q3. 2019-2020 (Oct – Dec 2019)
Role Division Number
Doctor S&CC 1
Nurse Medicine 2
S&CC 3
W&C 1
CNO 1
HCA S&CC 1
Admin Medicine 1
Ops 1
Other CSS 2
Corporate Medicine 1
In Q3 the concerns are varied and include behaviour, patient safety, staff safety and process. These
issues are being addressed through the appropriate internal processes. The area with the highest
2
reporting of concerns is Surgery and Critical Care (S&CC). The FTSUG has responded to all concerns
and followed through according to each individual case.
In Q3 no concerns have been raised anonymously and concerns raised openly continue to increase
which indicates an improvement in the reporting of concerns culture. There have been no reports of
any detriment to staff raising concerns.
To date for 2019-20 Q1-3 there have been 47 concerns, in comparison to Q1-4 2018-19 were there
were 35 concerns for the whole year. This represents an increase so far for 2019-20 of >30%.
2.2 FTSUG Feedback /Evaluations received:
Q1-Q2 2019-20 (47 Concerns)
Quarter 2019-2020 Feedback received Would you speak up again? Yes
Q1 7 7 Yes
Q2 7 6 Yes
Q3 8 8 Yes
Q4 - -
The evaluations include the question: How did you find out about the Freedom to Speak Up
Guardian? Answers include: word of mouth; Pride and Respect training; staff intranet; staff
newsletters; posters; FTSU policy. This indicates that varying promotional /informative resources
have been accessed and should be continued to raise awareness of the FTSUG.
2.3 FTSUG Feedback comments for Q3 2019-20:
“I felt the FTSUG was very friendly, helpful and understanding. I was worried about raising issues that
is why it took me so long, but I now feel that I could have raised it sooner and had nothing to worry
about. Thank you for helping me with this issue”.
“I have recommended the FTSUG to other colleagues”.
“I feel a lot better for reporting the issue and was made to feel like I was actually being listened to.
All credit to the Guardian who assisted me with this. I feel so happy knowing there are people out
there like you, helping us have a voice”.
2.4 FTSUG Response times:
The acting FTSUG continues to monitor the response times and in Q3 2019-20 for the 14 concerns
the response times were: 10 concerns - same day; 2 concerns next day; 2 concerns within 2 days; No
concern was unanswered.
3
3.0 FTSUG Developments – past 3 months
National
The new NGO website has been launched and includes a new data platform to submit concerns data.
The acting FTSUG has successfully uploaded the Q1 and Q2 data for NLaG.
The publication of NGO Guardian Survey and Annual report has been impacted by the General
Election which prevents Government agencies circulating politically sensitive information. Reports
will be circulated as soon as possible.
New National Training Guidance recommends FTSU training should be provided at three levels of
training: core training; line and middle management; senior leaders. The NGO has announced a plan
to work with HEE to develop training packages which will be aligned to all three groups.
Regional
The acting FTSUG attended the Regional network meeting 10 December 2019.
Key Points to feedback from Regional FTSUG’s:
The first local FTSUG peer reviews have been completed and provided an independent
review of processes and identified good practice and learning to support ongoing
development.
Agreement was established regarding the creation of a Regional digital platform. Regional
email on NHS Net to be set up and shared so all of the regional guardians can have access to
it as a ‘drop box’ in a secure way.
Regional conferences will replace the annual National (London based) one of previous years.
The North East and Yorkshire region conference will be on 16 March 2020 at York. There will
now be one place per Trust.
4.0 FTSUG Developing relationships with NHSI / NGO
The acting FTSUG has been in regular contact with NHSI who have provided advice and guidance and
will support the incoming new permanent FTSUG lead. The acting FTSUG has now met with the new
NGO North East and Yorkshire liaison and is able to take forward suggestions for improvement.
5.0 Proactive - FTSUG Activity
Oct 2019
1:1 with CEO
Walk-rounds FTSUG information and display posters
P&R evaluation to assessing FTSUG awareness -reviewed.
‘Speaking Up Month’
Cultural Collaboration event
Pop-Up promotion in staff restaurant
Meeting HR case manager
Handling concerns for managers
CQC Interview
Calls with NHSI
NED and ED lead attended FTSU foundation regional training
4
booklet promotion
2019 Annual FTSU report to Audit, Risk and Governance
FTSU Quarter 2 report to TMB
Nov 2019 1:1 with CEO
Anti-bullying week promotion
1:1 Exec Director FTSU
Telephone update with HR case manager
Walk-round DPOW
FTSU Quarter 2 report Workforce sub-committee and to TB
Infographics –concerns in staff mag.
Calls with NHSI and review of FTSU Developments
Internal Audit (Audit Yorkshire)
Dec 2019 Promotion in E&F staff area DPOW
Telephone update with HR case manager
1:1 Exec Lead for FTSU
Ward based FTSU training (W&C)
1:1 NED
Raising Concerns /FTSUG presentation to Drs with GMC Regional Liaison
Regional FTSU network meeting
Internal Audit (Audit Yorkshire)
6.0 FTSU - next steps / priorities for Trust for next 6 months:
Commencement of the permanent FTSUG Lead and then subsequent recruitment of the permanent FTSUG deputy
Work with NHSI to look at the new NGO guidance to establish the focus of FTSU
work for 20/21 and produce a clear plan to address areas for improvement.
Leadership / Board development programmes to include FTSU.
NLG(20)026a
DATE OF MEETING 04 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM
Claire Low, Acting Director of People and Organisational Effectiveness and Kay Farquharson, Acting Freedom to Speak Up Guardian
CONTACT OFFICER Kay Farquharson, Acting Freedom to Speak Up Guardian (FTSUG)
SUBJECT FTSUG Internal Audit Report
BACKGROUND DOCUMENT (IF ANY) N/A
PURPOSE OF THE REPORT: For Assurance
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
Trust Board are asked to read and acknowledge the findings of the audit and confirm their assurance in relation to the ‘significant’ assurance recommendation.
TRUST BOARD ACTION REQUIRED
As above
Internal Audit Report For
Northern Lincolnshire and Goole NHS Foundation Trust
Section 3 – Schedule of Findings and Recommendations 15
Section 4 – Key to Internal Audit Reports 25
Report Author: David Noble
Report Version: Final Report Date: 28 January 2020
Section 1: Executive Summary
2
Objective
To provide assurance to management and the Board that the Trust has effective processes in place to enable staff to raise a concern in accordance with the Trust’s Speaking Up Policy.
Overall Opinion
Significant
This audit confirmed that there are generally effective systems in place to enable staff to raise a concern in accordance with the Trust’s Speaking Up Policy. The Trust has developed a Freedom to Speak Up (FTSU) Policy and Process, along with associated procedures, that are supportive of adherence to the Public Interest Disclosure Act 1998 (PIDA) and guidance issued by the National Guardian’s Office (NGO). An experienced senior manager has been acting in the FTSU Guardian role, and we saw evidence that this individual is actively championing the importance of speaking-up within the Trust. A FTSU Strategy is in place to help support the delivery of the Trusts strategic objectives. The Strategy, which has had input from NHS Improvement, includes the vision of enabling a transparent and open culture where all staff feel safe to speak up. The strategy includes roles and responsibilities, actions, desired outcomes and measures against which to gauge progress. The Strategy is supported by a FTSU Communications Plan. The Board are involved through regular meetings (as held between the FTSU Guardian and the Chief Executive; the Trust Chair; the Executive Director responsible for the provision of speak up arrangements, and, a Non-Executive director (NED) who has specific responsibility for independent oversight of FTSU arrangements) and the receipt of comprehensive quarterly FTSU Guardian update reports. Following a visit from the NGO in September 2017, 23 recommendations were accepted to improve support for workers who wish to speak up. The Trust advised the NGO in August 2019 that all recommendations had been completed. Our own fieldwork confirms that (for those NGO recommendations which related to our own areas of enquiry) that, with the exception of ensuring all staff members are aware of FTSU arrangements, robust action has been taken and the issue identified by the NGO has been addressed.
Section 1: Executive Summary
3
Overall we were impressed by the work that we could see had been undertaken during 2019 to develop and enhance the Trust’s FTSU arrangements. Recommendations have been included where we considered that these would further improve the Trust’s arrangements. These include: review, update and formal approval of the FTSU Policy and Procedure (it was last formally approved in October 2015); and improving staff awareness of the Trust’s FTSU arrangements.
Assurance on Key Control Objectives
Control Objective Review Highlights ( Positive Assurance, ! Action Required)
Assurance Level
Recommendations (Priority)
Major Moderate Minor
There are effective governance arrangements in place supported by a robust policy and procedures which are aligned to NHS Guidance on Speaking Up.
A FTSU Guardian is in post. This individual has completed the NGO foundation training for Guardians. FTSU Guardian contact details have been made available to members of staff.
The current FTSU Guardian has been acting on an interim basis since March 2019 following the departure of the previous incumbent. A proposal has been approved for the FTSU Guardian role to be covered moving forwards by two managers, (a FTSU Guardian and a Deputy FTSU Guardian) each working on a part time basis. This will help ensure vital cover and continuity.
! We consider it would be useful for these two individuals, once appointed, to complete not only the NGO foundation training for Guardians, but also the NGO FTSU Guardian Competency Framework and Self-Assessment Toolkit.
An up to date FTSU Policy and Procedure (the policy) is in place. The policy was approved by the Audit, Risk and Governance Committee in October 2015 and is due for review March 2022. The policy was last updated and approved by the policy owner on 13 November 2019. The updated policy is
Significant 0 2 2
Section 1: Executive Summary
4
Control Objective Review Highlights ( Positive Assurance, ! Action Required)
Assurance Level
Recommendations (Priority)
Major Moderate Minor
available to members of staff via the Trust Intranet. ! Our review of the policy, which was generally informative,
identified that it did not provide clarity as to the duties and responsibilities of key individuals, staff groups or committees (although we did note that these were detailed in the FTSU Strategy), nor did it satisfactorily explain how Board oversight was enabled.
The Policy makes reference to, and appears generally consistent with PIDA and guidance provided by the NGO and NHS Improvement.
! However, the policy does require update to reflect the re-naming of Public Concern at Work (PCAW) as "Protect" in September 2018. Additionally a decision needs to be made as to whether the reference in the policy to the fact that employees will not be penalised in any way for raising concerns in good faith should be amended to reflect the changes to employee protection that flowed from the enactment of the Enterprise and Regulatory Reform Act 2013 (which introduced changes to PIDA).
The Trust has set an internal target (referenced within the policy) for those raising a concern to receive an acknowledgement within two working days of the receipt of the concern by the FT. We verified that procedures are in place to monitor and report on achievement against this internal target.
! The policy also states that rather than setting specific timescales for investigation or reporting back to the individual, the individual will be informed of how long the investigation is expected to take and will then be kept up to date with its progress. However, the FTSU Guardian has identified that investigation timescales can be difficult to anticipate. Therefore, in order that the individual raising the concern is not wrongly informed of a timescale that is subsequently found to be unachievable, initial communications
Section 1: Executive Summary
5
Control Objective Review Highlights ( Positive Assurance, ! Action Required)
Assurance Level
Recommendations (Priority)
Major Moderate Minor
do not provide the individual with any estimated timeframes. Instead, the FTSU Guardian liaises with the individual to keep them informed of progress during the investigation. As such the policy requires update so that it accurately reflects the current process and does not misinform readers.
! Given the length of time that has elapsed since the policy was last formally reviewed and approved by the Audit Risk & Governance Committee on behalf of the Board, it would be advisable if the policy was now subject to a full review, with this followed by the updated policy being submitted to Board (or a nominated sub-committee) for their ratification.
! The FTSU Policy states at section "19.0 Monitoring Compliance and Effectiveness" that "We will review the effectiveness of this policy and local process at least annually, with the outcome published and changes made as appropriate”. However the FTSU Guardian is unaware of such a review taking place, although it was acknowledged that a formal review of the effectiveness of the policy and process would be beneficial; this would help ensure that the outcomes of the review can be taken into account in any update and re-ratification of the FTSU Policy.
The Trust has, following input from NHSI, developed a FTSU Strategy for 2019/20. The strategy was approved by the Board in August 2019. The strategy supports the Trust’s 2019/20 priorities of improving culture and morale, by changing the culture within the Trust so that individuals feel safe in raising concerns and thereby driving increased use of the FTSU arrangements to highlight any concerns. The strategy includes actions to support the achievement of these outcomes. Additionally key outcomes and measures are documented within the strategy, along with indicators of success. Many of the measures have specific measurable targets.
Control Objective Review Highlights ( Positive Assurance, ! Action Required)
Assurance Level
Recommendations (Priority)
Major Moderate Minor
The FTSU Strategy is supported by a 'Speaking-up Communications Plan 2019-20'. This sets out the key factors supporting staff at the Trust to speak-up and details the key objectives and messages from the strategy.
! A sufficiently detailed Action Plan to support the FTSU Strategy is not yet in place. It is however the FTSU Guardians stated intention that this will be addressed in early 2020. This will allow the Action Plan to be developed in a way that will support the FTSU Strategy, take account of the new National FTSU Guidance (issued August 2019) as well as any relevant issues identified through review of this report, the 2019 Employee Survey results, and the CQC Report that was awaited at the time fieldwork was concluded.
The Trust has developed a FTSU Guardian Job Description (JD) and associated Person Specification. Our review of the JD confirmed that it provided a comprehensive overview of the duties and responsibilities of the role.
The FTSU Guardian has completed the NGO Foundation Course in FTSU. Additionally the FTSU Guardian attends the regional FTSU Guardian Group meetings, which serve as a forum to review case studies and share intelligence and good practice.
The FTSU Guardian has confirmed that she has adequate time to discharge her FTSU duties, which involve not only managing the FTSU process itself, but also promoting FTSU within the Trust.
The FTSU Guardian was positive about the support she receives from other senior management including Board members. We were informed that monthly meetings are in place with the Chief Executive and the Acting Director of People and Organisational Effectiveness, whilst bi-monthly meetings are
Section 1: Executive Summary
7
Control Objective Review Highlights ( Positive Assurance, ! Action Required)
Assurance Level
Recommendations (Priority)
Major Moderate Minor
held with the Board Chair and with the NED with specific responsibility for FTSU. We held our own discussions with the NED who informed us that he was very happy with progress made in respect of FTSU within the Trust over the last year and that the significant efforts of the FTSU Guardian had been central to this progress.
The FTSU Guardian is also supported by over 150 Pride & Respect Champions who are in place in the various Divisions and central functions. These individuals do not themselves become involved in FTSU cases, but instead help to raise awareness of the FTSU process and the FTSU Guardian, and signpost individuals to the most appropriate process or member of management where they have a specific concern.
Our testing of five randomly chosen Trust policies (of those that might be expected to include reference to FTSU) confirmed that the FTSU arrangements and FTSU Guardian contact details were referenced in all cases.
The Trust are compliant with the NGO's stated requirements for Trusts and Foundation Trusts to report data relating to the number of concerns raised via the speak-up process within the organisation during each quarterly reporting period, and for provision of supporting data.
The FTSU Guardian provides, on a quarterly basis, a ‘FTSU Guardian Report’ to the Trust Management Board, the Workforce Sub-Committee and the Trust Board. Our review of this report confirmed that it appeared sufficiently comprehensive.
The number of concerns raised each quarter, along with a summary of the source of these concerns (in terms of the role of those raising them) and the key themes they cover (e.g. patient safety, bullying and harassment) are also made available to Trust employees via various routes, including the FTSU
Section 1: Executive Summary
8
Control Objective Review Highlights ( Positive Assurance, ! Action Required)
Assurance Level
Recommendations (Priority)
Major Moderate Minor
Guardian page of the ‘Hub’ (the staff intranet) and the staff magazine.
In September 2017 the National Guardian’s Office conducted a review of the speaking up policies, processes and culture at Northern Lincolnshire and Goole NHS Foundation Trust. A subsequent report provided 23 recommendations relating to how the Foundation Trust could improve their support for their workers to speak up. Progress against the Action Plan has been reported on a quarterly basis to the Trust Board, with assurance over completion of the Action Plan advised in the FTSU Guardian Quarterly Report as provided to the Board in November 2019. Additionally in October 2019 an update report was provided to the Foundation Trusts Audit & Governance Committee confirming that the Action Plan was completed in August 2019.
Staff are aware of how to ‘speak up’.
The FTSU Policy and Procedure is available to staff via the Staff Intranet (the 'Hub'). There is a link at the bottom of the Hub opening page which takes you to the FTSU Guardian Page.
Additionally the existence of the policy is shared with staff through regular communications, posters and flyers, and through being referenced in the Trust’s Pride & Respect Training. FTSU is also promoted by the Trust’s 150+ Pride & Respect Champions.
Management have explained how these actions to build awareness have been supplemented via such methods as 'pop-up events', senior manager walk-rounds, and use of FTSU screensavers.
Management have confirmed that all new Trust employees receive Pride and Respect Training as part of their standard induction, through attending the mandatory corporate induction
Control Objective Review Highlights ( Positive Assurance, ! Action Required)
Assurance Level
Recommendations (Priority)
Major Moderate Minor
day. This training includes reference to the Trust’s FTSU arrangements and provides attendees with the FTSU Guardian’s contact details.
Pride & Respect Training, is available to, but is not currently mandatory for, existing members of staff. The availability of training is communicated to staff members via various means such as poster displays, ‘pop-up events’ and the involvement of Pride and Respect Champions. Additionally, HR Business Partners work with the Divisional management teams to raise awareness and encourage attendance.
! We were informed that as of November 2019 some 3028 (out of circa 6000 employees) had attended the Pride & Respect Training. There is therefore a potential gap in that unless individuals seek out and attend this training they remain unaware of the importance that the Trust attaches to the ability of members of staff to speak-up where they have concerns. Our own limited testing confirmed that despite the communications performed to date there is still a sizable minority of employees who are unaware of the trusts FTSU arrangements or the existence of a FTSU Guardian. (N.B. This finding relates to recommendations 4 and 12 in the NGO report which requires the Trust to take steps, including the provision of training, to ensure all existing and new workers are aware of the FTSU Policy)..
Robust processes are in place to investigate and escalate concerns.
The FTSU Policy and Procedure, guidance on the intranet and posters displayed throughout the Trust provide staff with information on how concerns should be raised and how they might be escalated if required. This is detailed in the form of a 4 step process: Step 1- Raise the concern with line manager, lead clinician
High 0 0 0
Section 1: Executive Summary
10
Control Objective Review Highlights ( Positive Assurance, ! Action Required)
Assurance Level
Recommendations (Priority)
Major Moderate Minor
or tutor (for students) Step 2 - Raise the concern with the FTSU Guardian Step 3 - Raise the concern Chief Executive, Medical
Director or Chief Nurse Step 4 - Raise the concern with external bodies
The FTSU Policy and Procedure includes guidance that staff should raise concerns via internal routes in the first instance, but that if this is not deemed acceptable to the individual then concerns may be raised outside the organisation with the appropriate ‘Prescribed Person’.
Appropriate protocols are in place and adhered to, to allow for, where individuals wish their concern to be treated confidentially, their identity to be protected during the subsequent investigation and reporting process. Management have confirmed that there have been no known cases of the identity of an employee who has raised a concern being accidentally leaked.
Our discussions with the FTSU Guardian and our review of relevant documentation confirmed that there was good involvement with, and regular communication to, those raising concerns via the speaking up route.
Individuals who have raised a concern are invited to provide feedback via completion of a comprehensive questionnaire.
Learning from concerns is appropriately disseminated.
Our review confirmed that the process involves steps (e.g. changes to processes, involvement of Divisional Governance Leads, presentation of key learnings findings to senior level forums) to ensure that learnings are identified and acted upon.
! The FTSU Guardian has identified however that it would be useful to have a more structured / formalised approach to sharing lessons more widely, and has confirmed that work is planned to enable this.
Control Objective Review Highlights ( Positive Assurance, ! Action Required)
Assurance Level
Recommendations (Priority)
Major Moderate Minor
Details related to the protected characteristics of those raising concerns are gathered via completion by the individual on a (optional) questionnaire. Completed responses are analysed by the FTSU Guardian in order to identify any trends or commonalities.
Section 2: Audit Background, Objectives, Scope and Circulation
12
Background Information
Northern Lincolnshire and Goole NHS Foundation Trust is committed to delivering safe and high quality care to patients, tackling malpractice and wrongdoing and promoting a culture of constant improvement and self-awareness through effective risk management. The Trust is committed to promoting an open culture in which everyone can raise any concerns they may have and developing openness around safety incidents, discussing incidents promptly, fully and compassionately. Staff have a right and a duty to raise any matters of concern they may have about the care or services delivered to patients and their relatives or carers, the management of care or services and the health, safety and welfare of employees. Every manager has a duty to ensure that their staff are easily able to express their concerns and that any such concerns are dealt with promptly, thoroughly and fairly, including the submission of a response.
Key Risks
Key risks associated with this area included:
Failure to comply with NHS Guidance as a result of inadequate oversight, unclear roles and responsibilities and inconsistent practices.
Concerns are not raised.
Failure to respond to staff concerns.
Recurrence if required actions arising from concerns are not communicated.
Objectives & Scope
To provide assurance to management and the Board that the Trust has effective processes in place to enable staff to raise a concern in accordance with the Trust’s Speaking Up Policy.
Section 2: Audit Background, Objectives, Scope and Circulation
13
In order to meet this objective, the audit focussed on the following key control objectives:
There are effective governance arrangements in place supported by a robust policy and procedures which are aligned to NHS Guidance on Speaking Up.
Staff are aware of how to ‘speak up’.
Robust processes are in place to investigate and escalate concerns.
Learning from concerns is appropriately disseminated.
Methodology The objectives of this review were achieved by: :
Discussions with key staff to gain an understanding of systems and processes relating to speaking up.
Review of the policies and procedures in place.
Fieldwork was undertaken to ensure controls are operating as expected. This included discussions with a random sample of staff to ascertain whether they were aware of the Foundation Trust’s speaking up processes.
Limitations
The assurance given is based on the review work undertaken and is not necessarily a complete statement of all weaknesses that exist or potential improvements. Whilst every care has been taken to ensure that the information provided in this report is as accurate as possible, no complete guarantee or warranty can be given with regard to the advice and information contained. Our work does not provide absolute assurance that material errors, loss or fraud do not exist.
Section 2: Audit Background, Objectives, Scope and Circulation
14
Report Circulation
Draft Final Recipient Name Recipient Title
Kay Farquharson Assistant Director of People and Organisational Effectiveness & Freedom to Speak Up Guardian
Claire Low Acting Deputy Director of People & Organisational Effectiveness Lee Brown Deputy Director of People and Organisational Effectiveness Jeffrey Ramseyer Non-Executive Director
Wendy Booth Company Secretary
Sally Stevenson Assistant Director of Finance – Compliance and Counter Fraud Jim Hayburn Interim Director of Finance Dr Peter Reading Chief Executive
Acknowledgement
The auditor is grateful for the assistance received from management and staff during the course of this review. The following members of the Audit Yorkshire team were involved in the production of this report: Head of Internal Audit: Helen Kemp-Taylor Audit Manager: Tom Watson Senior Auditor: David Noble
Date: 28 January 2020
Section 3: Schedule of Findings and Recommendations
15
Finding Risk Recommendation Priority Management
Response
Responsible Officer
Target Date
Freedom to Speak Up Policy & Procedure
A FTSU Policy & Procedure is in place. The policy was approved by the Audit, Risk and Governance Committee in October 2015 and is shown as due for review March 2022. The policy was last updated and approved by the policy owner on 13 November 2019. The updated policy is available to members of staff via the Trust Intranet.
Board Review and Ratification
Given the length of time that has elapsed since the Policy was last formally reviewed and approved by the Audit, Risk and Governance Committee (more than four years), recent and planned changes in respect of individuals acting in the FTSU Guardian role, and changes to how FTSU is communicated and supported within the FT, it would be advisable if, following the appointment of a new FTSU Guardian in early 2020, the policy was subject to a full
Failure to comply with NHS Guidance as a result of inadequate oversight, unclear roles and responsibilities and inconsistent practices.
1. Management should, following the commencement of the new Freedom to Speak Up (FTSU) Guardian in early 2020, review and update the FTSU Policy and Procedure to ensure that it fully reflects current Trust arrangements for staff to raise concerns at work in a confidential or anonymous manner. Following this update the policy should then be ratified by the Foundation Trust Board or a nominated sub-committee. As part of the policy update we recommend that management: i) Incorporate clear
reference to duties and responsibilities (e.g. for key individuals, groups of staff, and formal groups or committees).
ii) Provide clarity as to
Moderate
Agreed.
Freedom to Speak Up Guardian
30 September 2020
Section 3: Schedule of Findings and Recommendations
16
Finding Risk Recommendation Priority Management
Response
Responsible Officer
Target Date
review, with this followed by the updated policy being submitted to Board (or a nominated sub-committee) for their review and ratification. We consider also that the policy should then be, on an ongoing basis, subject to future Board (or Board sub-committee) review and ratification on a frequency that does not exceed three years.
Reference to Duties and Responsibilities
Our review of the policy, which was generally informative, identified that it did not provide clarity as to the duties and responsibilities of key individuals, staff groups or committees. Management have highlighted how the duties and responsibilities are in fact instead referenced in the FTSU Strategy for 2019/20.
We consider however that given that staff members can be expected to reference the FTSU Policy rather than the FTSU Strategy, it would be preferable for the policy to be updated (as
how Board oversight is enabled.
iii) Update the guidance in the policy at relating to communicating with individuals so that it correctly references the fact that investigation timescales can be difficult to anticipate and for that reason no specific timescales for reporting back to the individual will normally be given.
iv) Update the current reference to Public Concern at Work (PCAW) in paragraph 21.0 to instead read “Protect (formerly PCAW)”
v) Consider whether the policy should be amended to more accurately reflect the protection afforded to individuals who make a disclosure (whether or not the disclosure was made in good faith).
Section 3: Schedule of Findings and Recommendations
17
Finding Risk Recommendation Priority Management
Response
Responsible Officer
Target Date
part of the recommended refresh referenced above) to make clear reference to duties and responsibilities.
Board Oversight
The policy did not satisfactorily explain how Board Oversight was enabled; instead it appeared that the previous section (which related to investigations) was duplicated under the 'Board Oversight’ section.
Reference to Investigation Timescales
The FTSU policy states that where a concern is raised there are no set specific timescales for investigation or reporting back to the individual. Instead the policy states (para 16.0) that the individual will be informed of how long the investigation is expected to take and will then kept up to date with progress.
However the FTSU Guardian has rightly identified that investigation timescales can be
vi) Include, on the face of the policy, a future review date that is no more than three years in the future.
Section 3: Schedule of Findings and Recommendations
18
Finding Risk Recommendation Priority Management
Response
Responsible Officer
Target Date
difficult to predict. Consequently, in order that the individual making the complaint is not wrongly informed of a timescale that is subsequently found to be unachievable, existing communications do not provide the individual with any estimate as to how long the investigation might take. As such the policy requires update so that it accurately reflects the current process and does not misinform readers.
Policy Reference to External Agencies and Relevant Legislation
The policy requires update to reflect the re-naming of PCAW as "Protect" in September 2018. Additionally a decision needs to be made as to whether the existing policy reference to the fact that employees will not be penalised in any way for raising concerns in good faith should be amended: We understand from our investigations that the Enterprise and Regulatory Reform Act 2013 amended PIDA so that it removed the
Section 3: Schedule of Findings and Recommendations
19
Finding Risk Recommendation Priority Management
Response
Responsible Officer
Target Date
requirement that a worker or employee must make a protected disclosure 'in good faith'. Instead tribunals will have the power to reduce compensation for detriment or dismissal in respect of a disclosure not made in good faith.
Review of Policy Compliance and Effectiveness
The FTSU Policy states (paragraph 19.0) that "We will review the effectiveness of this policy and local process at least annually, with the outcome published and changes made as appropriate."
The current FTSU Guardian is unaware of such reviews taking place in the past. It was agreed that a regular formal review of the effectiveness of the policy and process, with a formal output, would be beneficial. This audit serves to fulfil this requirement for 2019/20, but it was agreed that a peer assessment or self-assessment should be performed in future
2. As part of the planned
refresh of the Freedom to Speak Up (FTSU) Policy and Procedure, management should consider and then document within the updated policy how future reviews of the effectiveness of the FTSU arrangements will be performed.
Minor
Agreed.
Freedom to Speak Up Guardian
30 September 2020
Section 3: Schedule of Findings and Recommendations
20
Finding Risk Recommendation Priority Management
Response
Responsible Officer
Target Date
years, with results provided to senior executive management for information and review.
Delivery of the FTSU Strategy
The Trust has, following input from NHSI, developed a FTSU Strategy for 2019/20. The strategy includes objectives and the high level actions that are required to be completed to achieve them. Additionally key outcomes and measures are documented within the strategy, along with indicators of success.
Although not yet in place it is the FTSU Guardians intention that a detailed Action Plan will be developed in the early part of 2020. This will allow the Action Plan to be built to support the FTSU Strategy and also take account of the new National FTSU Guidance (issued August 2019) as well as any relevant issues identified through review of this report, the 2019 Employee Survey results, and the CQC Report that is currently awaited.
Delays in delivering, or non-achievement of, Trust strategic objectives.
3. Management should undertake planned activity to develop a detailed Action Plan that supports delivery of the Freedom to Speak Up (FTSU) Strategy, along with any other FTSU related requirements as identified through examination of: the recently published National FTSU Guidance; 2019 Employee Survey results; this Internal Audit Report; and, the forthcoming CQC Report.
Moderate
Agreed.
Freedom to Speak Up Guardian
30 June 2020
Section 3: Schedule of Findings and Recommendations
21
Finding Risk Recommendation Priority Management
Response
Responsible Officer
Target Date
Training and Awareness
FTSU Guardian Training
NGO foundation training for Guardians is a requirement which the current FTSU Guardian has completed.
The NGO have also developed a FTSU Competency Framework and Self-Assessment Toolkit. This provides links to associated resources for use in self-development. Many of the materials can also be downloaded for use in training sessions.
Staff FTSU Training
Management have confirmed that all new Trust employees receive ‘Pride and Respect Training' as part of their standard induction. This training includes reference to the FT’s FTSU arrangements and FTSU Guardian contact details.
Failure to comply with NHS Guidance as a result of inadequate oversight, unclear roles and responsibilities and inconsistent practices.
Concerns are not raised.
4. In addition to completing the National Guardian’s Office (NGO) Foundation Course in Freedom to Speak Up (FTSU) the new FTSU Guardian and FTSU Deputy Guardian should, once appointed, complete the NGO FTSU Guardian Competency and Self-Assessment Toolkit in order to help inform and develop their learning and development plans.
5. Management should
consider how they might build awareness of the Trust’s Freedom to Speak Up arrangements for those members of staff who do not voluntarily elect to attend a Pride & Respect training session.
Minor
Moderate
Agreed.
Agreed. Consideration will be given to how to continue to build awareness of FTSU arrangements amongst existing staff members as part of the action
Freedom to Speak Up Guardian Freedom to Speak Up Guardian
30 September 2020 30 June 2020
Section 3: Schedule of Findings and Recommendations
22
Finding Risk Recommendation Priority Management
Response
Responsible Officer
Target Date
Pride & Respect Training, is also available to, but is not currently mandatory for, existing members of staff. Management have confirmed that this was a deliberate decision given the nature of the training.
The availability of training, which has been in place for approximately one year, is communicated to staff members via various methods (e.g. posters displayed through the Trust, pop-up events and through the involvement of Pride and Respect Champions). We were informed that as of November 2019 some 3028 (out of circa 6000 employees) had attended the Pride & Respect Training.
Consequently there is a potential gap in that unless individuals attend Pride and Respect Training they remain unaware of the importance that the Trust attaches to the ability of members of staff to speak-up where they have concerns.
Our own limited testing, which
planning detailed in recommendation 3 above.
Section 3: Schedule of Findings and Recommendations
23
Finding Risk Recommendation Priority Management
Response
Responsible Officer
Target Date
involved discussions with 25 members of staff, indicated that that despite the communications performed to date there were a significant minority of seven individuals (28%) who indicated they were unaware of the existence of the Trusts FTSU arrangements.
87% of those individuals who recalled receiving Pride & Respect Training were aware of the FTSU arrangements as compared to 50% who stated they had not yet untaken this training. As such the delivery of Pride & Respect Training appears to us to be an effective method of building staff FTSU knowledge.
Learning Lessons
Our fieldwork confirmed that the FTSU investigation and reporting process involves steps to ensure that learnings are identified and shared with relevant management.
The FTSU Guardian has identified however that it would
Recurrence if required actions arising from concerns are not communicated.
6. Management should
complete planned activity to develop and commence additional communication routes for the wider dissemination of key learnings from Freedom to Speak Up cases.
Minor
Agreed.
Freedom to Speak Up Guardian
30 September 2020
Section 3: Schedule of Findings and Recommendations
24
Finding Risk Recommendation Priority Management
Response
Responsible Officer
Target Date
be useful to have a more structured / formalised approach to sharing lessons more widely, and has confirmed that work is planned to enable this.
Section 4: Key to Internal Audit Reports
25
Audit Opinion
The following opinions provide management assurance in line with the following definitions:
Opinion Level Opinion Definition Guidance on Consistency
HIGH (STRONG)
High assurance can be given that there is a strong system of internal control which is designed and operating effectively to ensure that the system’s objectives are met.
The system is well designed. The controls in the system are clear and the audit has been able to confirm that the system (if followed) would work effectively in practice. There are no significant flaws in the design of the system.
Controls are operating effectively and consistently across the whole system. There are likely to be core controls fundamental to the effective operation of the system. A High opinion can only be given when the controls are working well across all core areas of the system. For example with ‘Debtors’ the controls over identifying income, raising debt, recording debt, managing debt, receiving debt, etc. are all working effectively – there are no serious concerns. Note this does not mean 100% compliance. There could be some minor issues relating to either systems design or operation which need to be addressed (and hence the report may include some recommendations) – however these issues do not have an impact on the overall effectiveness of the control system and the delivery of the system’s objectives.
SIGNIFICANT (GOOD)
Significant assurance can be given that there is a good system of internal control which is designed and operating effectively to ensure that the system’s objectives are met and that this is operating in the majority of core areas
The system is generally well designed - but there may be weaknesses in the design of the system that need to be addressed.
In addition most core system controls are operating effectively – but some may not be. Whilst any weaknesses may be significant they are not thought likely to have a serious impact on the likelihood that the system’s overall objectives will be delivered.
LIMITED (IMPROVEMENT
REQUIRED)
Limited assurance can be given as whilst some elements of the system of internal control are operating, improvements are required in the system’s design
The system is operating in part but there are notable control weaknesses. There are weaknesses in either design or operation of the system that may mean that core system objectives are not achieved.
Section 4: Key to Internal Audit Reports
26
and/or operation in core areas to effectively meet the system's objectives
In terms of what differentiates a borderline Significant Opinion to a borderline Limited opinion – the main factors are the scale and potential impact of weaknesses found. Multiple weaknesses across a range of core areas would suggest a Limited Opinion level is applicable. However it also true that ONE weakness can suggest a Limited Opinion if it is fundamental enough to mean that a number of core system objectives will not be achieved.
LOW (WEAK)
Low assurance can be given as there is a weak system of internal control and significant improvement is required in its design and/or operation to effectively meet the system's objectives.
The audit has found that there are serious weaknesses in either design or operation that may mean that the overall system objectives will not be achieved and there are fundamental control weaknesses that need to be addressed.
It should be borne in mind that Low Assurance is not ‘No Assurance.’ The key point here is that there is a good chance that the system may not be capable of delivering what it has been set up to deliver – either through poor systems design or multiple control weaknesses. The report will clearly state if ‘No Assurance’ is actually more applicable than low assurance.
Where limited or no assurance is given the management of the Trust must consider the impact of this upon their overall assurance framework and their Annual Governance Statement.
Section 4: Key to Internal Audit Reports
27
Priorities assigned to individual recommendations
Individual recommendations are graded in accordance with the severity of the risk involved to the Trust. Audit Yorkshire has a standard definition for each level of recommendation priority. This is represented in the table below:
Grading Definition Guidance on Consistency
Major (High)
Recommendations which seek to address those findings which could present a significant risk to the organisation with respect to organisation objectives, legal obligations, significant financial loss, reputation/publicity, regulatory/statutory requirements or service/business interruption.
These are recommendations which aim to address issues which if not addressed could cause significant damage or loss to the organisation. The expectation is that these recommendations would need to be taken as a matter of urgency. These recommendations should have a high corporate
profile – with a clear implementation tracking process in place, overseen by
the Board or a Board level committee.
Moderate (Medium)
Recommendations which seek to address those findings which could present a risk to the effectiveness, efficiency or proper functioning of the system but do not present a significant risk in terms of corporate risk.
These are recommendations which if not addressed could cause problems with the safe or effective operation of the system being reviewed. The recommendations should have appropriate profile within the division or business area in which the system being considered sits and some profile at Board /Audit Committee level also. These recommendations should be carefully tracked to ensure that action reduces the risks found
Minor (Low)
Recommendations which relate to issues which should be addressed for completeness or for improvement purposes rather than to mitigate significant risks to the organisation. (This includes routine/housekeeping issues)
All other recommendations fall into this category. This includes recommendations which further improve an already robust system and housekeeping type issues.
28
NLG(20)027
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Tony Bramley, Chair of Audit, Risk & Governance Committee
CONTACT OFFICER Jim Hayburn, Interim Director of Finance
PURPOSE OF THE REPORT: Issues from the Audit, Risk & Governance Committee meeting requiring escalation by exception to the Trust Board.
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The attached highlight report summarises the key issues presented to, and discussed by the Audit, Risk & Governance Committee at its meeting on the 22 January 2020.
TRUST BOARD ACTION REQUIRED The Board is asked to note the report and consider the need for any further actions to address issues highlighted in the report
Northern Lincolnshire and Goole NHS Foundation Trust NLG(20)027 ____________________________________________________________________________________________________________
Highlight Report to the Trust Board Report for Trust Board Meeting on:
4 February 2020
Report From: Audit, Risk and Governance Committee held on 22 January 2020
Highlight Report: 1. Information Governance Mandatory Training – The Committee was concerned to hear that the
target of 95% compliance with IG training is not being achieved, and if the Trust does not achieve the necessary compliance it will result in a ‘Standards not Met’ rating with the Data Security and Protection Toolkit (DSPT) 2019/20. The highest recorded compliance rate was 87% in March 2019 but this has dropped to 81% at January 2020. The Committee was advised that there are lots of different ways for staff to undertake this training, and a work booklet is going to be printed off as a further method of completion – however printing booklets will come at a financial cost. Staff and their managers are receiving the appropriate reminders to undertake the training, but this is not always having the desired effect.
2. Overdue Controlled Documents – The latest routine quarterly report for controlled documents
shows that certain areas of the Trust (most notably POE/Medicine/Surgery) are still not moving forward with addressing the level and age (with some expiring in 2014) of their overdue controlled documents. The Committee was most concerned that sufficient progress is still not being made and questioned whether operating with certain out-of-date controlled documents was putting patients and/or staff at risk. This may also be a consideration for the Trust’s external auditors “adequacy of arrangements” judgement in their annual VFM assessment as part of their audit of the Trust’s financial statements, and that the Trust Board needed to be alert to this.
3. Free Hospital Car Parking – As part of the Internal Audit paper on latest developments within the
NHS, the Committee noted the issue of free hospital car parking for various patients and some staff (those working night shifts) as from April 2020. The Committee queried what was being done to put these plans in place so that we are ready for the April 2020 deadline.
4. Internal Audit Annual Programme 2019/20 – The Committee received an update on progress with
the 2019/20 plan and was concerned to hear that the Internal Auditors were struggling to get engagement with certain officers at a senior level. This is causing delays to agreeing the scope of certain pieces of audit work and commencement of the actual audit. If this issue persists there is a risk of non-delivery of the agreed internal audit plan for the year, which could impact on the preparation of the annual ‘Head of Internal Audit Opinion’ for the year (a key document for the Annual Governance Statement).
5. Annual Review of Policy for Engagement of External Auditors for Non-Audit Work – was re-
approved and is attached to this highlight report for information only. Confirm or Challenge of the Board Assurance Framework (BAF): The Committee received the BAF and noted key movements in the month. The Committee will maintain oversight that Board sub-committees are reviewing and challenging their areas of the BAF. Action Required by the Trust Board: The Trust Board is asked to note the key points raised by the Committee, and consider any further action needed. Tony Bramley Non-Executive Director and Chair of Audit, Risk and Governance Committee
_____________________________________________________________________________________________________________ Finance Directorate, February 2020 Page 2 of 2
Directorate of Finance
POLICY FOR THE ENGAGEMENT OF EXTERNAL AUDITORS FOR
NON-AUDIT WORK
Reference: DCP106 Version: 1.3 This version issued: 28/02/19 Result of last review: Minor changes Date approved by owner (if applicable):
N/A
Date approved: 31/01/19 Approving body: Trust Audit, Risk and Governance Committee Date for review: January, 2022 Owner: Marcus Hassall, Director of Finance Document type: Policy Number of pages: 14 (including front sheet) Author / Contact:
Sally Stevenson, Assistant Director of Finance – Compliance & Counter Fraud
Northern Lincolnshire and Goole NHS Foundation Trust actively seeks to promote equality of opportunity. The Trust seeks to ensure that no employee, service user, or member of the public is unlawfully discriminated against for any reason, including the “protected characteristics” as defined in the Equality Act 2010. These principles will be expected to be upheld by all who act on behalf of the Trust, with respect to all aspects of Equality.
Reference DCP106 Date of issue 28/02/19 Version 1.3
11.0 Freedom to Speak Up .................................................................................. 7
Appendices:
Appendix A - Examples of Work Types .................................................................. 8
Appendix B - Extract from NAO Guidance Note relating to the Application of the 70% Cap on Non-Audit Work .......................................................... 12
Printed copies valid only if separately controlled Page 2 of 14
Reference DCP106 Date of issue 28/02/19 Version 1.3
1.0 Introduction and Purpose
1.1 It is important that the independence of our External Auditors in reporting to Governors, Non-Executive Directors and Northern Lincolnshire and Goole NHS Foundation Trust (the Trust) is not, or does not appear to be, compromised in terms of the objectivity of their opinion on the financial statements of the Trust. Equally the Trust should not be deprived of expertise where it is needed, should the External Auditors be able to demonstrate higher quality and more cost effective service than other providers.
1.2 Auditors are required to comply with relevant ethical standards and guidance issued or adopted by their professional accountancy bodies. This includes the Ethical Standards issued by the Auditing Practices Board (APB). The ethical standards and guidance require that a member of a professional accountancy body should behave with integrity in all professional, business and financial relationships. Integrity implies not merely honesty but fair dealing and truthfulness.
1.3 Auditors must carry out their work with independence and objectivity. The Auditors’ opinions, conclusions and recommendations should both be, and be seen to be, impartial. Auditors and their staff should exercise their professional judgement and act independently of the NHS Foundation Trust. They should ensure they maintain an objective attitude at all times and that they do not act in any way that might give rise to, or be perceived to give rise to, a conflict of interest.
1.4 This policy therefore seeks to set out what threats to audit independence theoretically exist and thus provides a definition of non-audit work which can be shared by the Trust and its External Auditor. It then seeks to establish transparent approval processes and corporate reporting mechanisms that will be put in place for any non-audit work that the Trust’s External Auditor is asked to perform.
1.5 Guidance issued by NHS Improvement (NHSI) (formerly Monitor), the Independent Regulator of NHS Foundation Trust recommends (in both the Foundation Trust Code of Governance and its publication ‘Governance over audit, assurance and accountability: guidance for Foundation Trusts’) that Foundation Trusts implement a policy for approving any non-audit services that are to be provided by their External Auditor. The guidance publication states:
‘The Audit Committee should review and monitor the external auditor’s independence and objectivity and the effectiveness of the audit process, taking into consideration relevant UK professional and regulatory requirements.’
‘The Audit Committee should also develop and implement policy on the engagement of the external auditor to supply non-audit services, taking into account relevant ethical guidance regarding the provision of non-audit services by the external audit firm.’
‘The Council of Governors should receive a report at least annually of non-audit services that have been approved for the auditors to provide under the policy (on the basis of services approved, regardless of whether they have started or finished) and the expected fee for each service.’
Printed copies valid only if separately controlled Page 3 of 14
Reference DCP106 Date of issue 28/02/19 Version 1.3
1.6 The Institute of Chartered Accountants in England and Wales sets out threats to independence as the following:
• Self-interest – where an interest in the outcome of their work or in a depth of relationship with the Trust may conflict with the auditor’s objectivity
• Self-audit – where the auditors may be checking their own colleagues work and might feel constrained from identifying risks and shortcomings
• Advocacy – which may be present in engagement but could become a threat if an auditor becomes an advocate for an extreme position in an adversarial matter
• Familiarity or trust – where the level of constructive challenge provided by the auditor is diminished as a result of assumed knowledge or relationships that exist
1.7 The National Audit Office (NAO) issued an auditor guidance note in December 2016 (updated December 2017) outlining new requirements in relation to non-audit services provided by the External Auditor which were effective from 17th June 2017. The new requirements placed a cap on the value of non-audit services that can be provided to the public body. From 17th June 2017 the total fees for non-audit services cannot exceed 70% of the total fee for all audit work carried out under the Code in any one year. There are some exclusions for the purposes of applying the cap. The relevant extracts from the NAO guidance note are attached at Appendix B for ease of reference.
2.0 Area
This policy applies to all employees working for the Trust.
3.0 Duties
3.1 Trust Audit, Risk and Governance Committee is responsible for approving this policy and monitoring its effectiveness.
3.2 The Chief Executive is ultimately responsible for the effective implementation of this policy.
3.3 The Director of Finance has responsibility for ensuring this policy is adhered to and for ensuring that the policy remains up to date and appropriate.
3.4 All Directors/Managers are responsible for ensuring the implementation of and compliance with this policy within their respective areas.
3.5 All Staff who have delegated authority to make such an appointment must adhere to this policy.
Printed copies valid only if separately controlled Page 4 of 14
Reference DCP106 Date of issue 28/02/19 Version 1.3
4.0 Defining Types of Non-Audit Work and the Associated Approval Process
4.1 In order to provide a transparent mechanism by which non-audit work can be reviewed and progressed, the following categories of work are agreed as professional services available from the Trust’s External Auditors in line with Auditor Guidance Note 1 issued by the NAO (December 2016 – updated December 2017).
4.1.1 Statutory and audit related work not requiring Audit, Risk and Governance Committee approval:
• See table at Appendix A
• It is proposed that such assignments do not require Audit, Risk and Governance Committee approval. However, there shall be a fee limit of £25,000 above which prior Audit, Risk and Governance Committee approval should be sought for such work
4.1.2 Audit related and advisory services requiring prior Audit, Risk and Governance Committee approval:
• There are projects and engagements where the auditors are best placed to perform the work:
− Due to their network within and knowledge of the business Due to their previous experience
− See table at Appendix A
• It is proposed that prior Audit, Risk and Governance Committee approval is sought for projects of this nature
4.1.3 Projects that are not permitted
There are some projects that are not to be performed by the External Auditors. These projects represent a real threat to the independence of the audit team such as where the External Auditors would be in a position where paragraph 1.6 might apply, such as auditing their own work (for example, systems implementation).
4.2 More detail on each type of work is set out in the table at Appendix A.
4.3 The Audit, Risk and Governance Committee is responsible for approving all non-audit work undertaken by the External Auditors.
4.4 For the avoidance of doubt, the Audit, Risk and Governance Committee requires the business sponsor of the proposed work to obtain a proposed scope and fee estimate before the work commences. The business sponsor should also seek written confirmation that the Auditor will be able to safeguard their independence in relation to the proposed work.
Printed copies valid only if separately controlled Page 5 of 14
Reference DCP106 Date of issue 28/02/19 Version 1.3
4.5 If the proposed fee obtained as part of 4.4 exceeds the established limits or falls into a category of work that requires approval, details of the scope and fee proposal should be submitted to the Audit, Risk and Governance Committee Chairman and Director of Finance for consideration and approval. If approved the project should be logged by the Audit, Risk and Governance Committee secretary to be raised at the next Audit, Risk and Governance Committee meeting.
4.6 The Audit, Risk and Governance Committee shall report to the Council of Governors at least annually details of non-audit services that have been approved under this policy.
4.7 In cases where it is undecided which category services fall into they will default to the category that requires Audit, Risk and Governance Committee approval and be expected to take that route until such time as a this policy is reviewed and updated by the Audit, Risk and Governance Committee.
5.0 Monitoring Compliance and Effectiveness
The arrangements for monitoring compliance with and effectiveness of this policy/procedure will be as follows:
• The Audit, Risk and Governance Committee will formally agree on an annual basis that it is content with the structure, content and operation of this policy
• The Audit, Risk and Governance Committee will include within their Annual Report to the Trust Board and the Council of Governors all additional work performed by the Trust’s External Auditors
• The External Auditors will include within their annual ISA 260 (report to those charged with governance) an appendix that summarises any additional work that they have performed for the Trust and a review of the effectiveness of this policy
• Such engagements will also be reported in the Trust’s Annual Report in line with guidance issued by NHSI
6.0 Associated Documents
6.1 Governance over audit, assurance and accountability: guidance for Foundation Trusts (Monitor, 2015).
6.2 NHS Foundation Trust Code of Governance (Monitor, July 2014).
6.3 NHS Foundation Trust Annual Reporting Manual (Monitor).
6.4 Ethical Standard for Reporting Accountants (Auditing Practices Board, October 2006).
6.5 Auditor Guidance Note 1 (National Audit Office, December 2017).
7.0 References
There are no references.
Printed copies valid only if separately controlled Page 6 of 14
Reference DCP106 Date of issue 28/02/19 Version 1.3
8.0 Definitions
There are no definitions.
9.0 Consultation
Trust Audit, Risk and Governance Committee.
10.0 Equality Act (2010)
10.1 Northern Lincolnshire and Goole NHS Foundation Trust is committed to promoting a pro-active and inclusive approach to equality which supports and encourages an inclusive culture which values diversity.
10.2 The Trust is committed to building a workforce which is valued and whose diversity reflects the community it serves, allowing the Trust to deliver the best possible healthcare service to the community. In doing so, the Trust will enable all staff to achieve their full potential in an environment characterised by dignity and mutual respect.
10.3 The Trust aims to design and provide services, implement policies and make decisions that meet the diverse needs of our patients and their carers the general population we serve and our workforce, ensuring that none are placed at a disadvantage.
10.4 We therefore strive to ensure that in both employment and service provision no individual is discriminated against or treated less favourably by reason of age, disability, gender, pregnancy or maternity, marital status or civil partnership, race, religion or belief, sexual orientation or transgender (Equality Act 2010).
11.0 Freedom to Speak Up
Where a member of staff has a safety or other concern about any arrangements or practices undertaken in accordance with this policy, please speak in the first instance to your line manager. Guidance on raising concerns is also available by referring to the Trust’s ‘Speaking Out Policy’ (Freedom to Speak Up Policy and Procedure (DCP126)) or by contacting the Human Resources Department. Staff can raise concerns verbally, by letter, email or by completing an incident form. Staff can also contact the Trust’s Freedom to Speak Up Guardian in confidence by email to [email protected] or by phoning 304141. More details about how to raise concerns with the Trust’s Freedom to Speak Up Guardian or with one of the Associate Guardians can be found on the Trust’s intranet site.
Reference DCP106 Date of issue 28/02/19 Version 1.3
Appendix A EXAMPLES OF WORK TYPES
The table below sets out example of the different work types that could be requested from
the External Auditor and the associated approval process.
Statutory and Audit Related
(not requiring Audit, Risk and Governance Committee approval
unless over £25k)
Audit and Assurance Related and Non-Audit
Advisory Services (sensitive projects requiring referral without de minimis)
Projects that are not permitted.
Characteristics
• Reporting required by law or regulation to be provided by the auditor;
• Reviews of interim financial information;
• Reporting on regulatory returns;
• Reporting to a regulator on client assets;
• Reporting on government grants, where such reporting is not mandated by legislation or by a relevant national body or regulator and where the audited body is not required to obtain the report from its auditor;
• Reporting on internal financial controls when required by law or regulation; and
• Extended audit work that is authorised by those charged with governance performed on financial information and/or financial controls where this work is integrated with the audit work and is performed on the same principal terms and conditions.
• Audits or examinations of controlled entities, including charities, consolidated into the accounts of local public bodies
• Services to the parent undertaking of a local public body where the parent undertaking is a government department (for example the Department of Health) or a relevant national body (for example NHS England) and where such services are inconsequential to, and remote from, the decision –making of the local audited body
• Any other services required by EU or national legislation to be performed by the auditor
• Requiring independent objective assessment of information or proceduressee note 2 below
• Staff secondmentssee note 2
below • Other advisory servicessee
note 2 below
• Services that involve playing any part in the management or decision making of the audited body
Printed copies valid only if separately controlled Page 8 of 14
Reference DCP106 Date of issue 28/02/19 Version 1.3
• Other assurance (such as work on the quality accounts of local health bodies) where such assurance is mandated by legislation or by a relevant national body or regulator and where the audited body is required to obtain the assurance for its auditor acting as a reporting accountant
Acquisitions / Disposals
• Accountants reportssee note 2 below
• Reporting on financial assistancesee note 2
below • Audit of carve out
financial statementssee note 2
below
• Due diligence and related advicesee note 2 below
• Completion accounts auditsee note 2 below
• Agreement of adjustments as a result of completion accountssee note 2 below
• Advice on integration activitiessee note 2 below
• Preparation of forecast of investment proposalssee note
2 below
Internal Audit and risk management services
• None • Provision of specialistsee
note 2 below skills/training • Advice on methodology
and systemssee note 2 below • Co-sourcingsee note 2 below
• Designing and implementing internal control or risk management procedures related to the preparation and/or control of financial information or designing and implementing financial information technology systems
• Services relating to the audited body’s internal audit function
Taxation
• None • None – unless required by law
• Preparation of tax formssee note 1 below
• Payroll tax • Customs duties • Identification of
public subsidies and tax incentives unless support from the auditor in respect of such
Printed copies valid only if separately controlled Page 9 of 14
Reference DCP106 Date of issue 28/02/19 Version 1.3
services is required by lawsee
note 1 below • Support regarding
tax inspections by tax authorities unless support from the auditor in respect of such inspections is required by law
• Calculation of direct and indirect tax and deferred tax
• Provision of tax advicesee note 1 below
General Accounting
• None • Advice on accounts preparation and application of accounting standardssee note 2 below
• Training for accounting and risk management projectssee note 2 below
• Bookkeeping and preparing accounting records and financial statements
• Payroll services • Services linked to
the financing, capital structure and allocation, and investment strategy of the audited body except providing assurance services in relation to the financial statements, such as the issuing of comfort letters in connection with prospectuses issued by the audited body
Other
• Valuation services, including valuations performed in connection with actuarial services or litigation support servicessee note 1
below • Legal services,
with respect to the provision of general counsel; negotiating on behalf of the audited body;
Printed copies valid only if separately controlled Page 10 of 14
Reference DCP106 Date of issue 28/02/19 Version 1.3
acting in an advocacy role in the resolution of litigation
• Promoting, dealing in, or underwriting shares in an entity controlled by the audited body
• Human resources services, with respect to management in a position to exert significant influence over the preparation of accounting records or financial statements which are the subject of the statutory audit where such services involve searching for or seeking out candidates for such positions, or undertaking reference requests for such positions; structuring the organisation design; cost control.
Note 1: By way of a derogation this service may be provided (but would be included for the purposes of applying the 70% cap) if the following requirements are complied with:
a) they have no direct or, in the case of an objective, reasonable and informed third party, would have an inconsequential effect, separately or in the aggregate on the audited financial statements, or on the audited body’s arrangements to secure value for money; b) the estimation of the effect on the audited financial statements, or on the audited body’s arrangements to secure value for money, is comprehensively documented and explained to those charged with governance; c) the principles of independence laid down in section 1 of the FRC’s ethical standard are complied with; and d) for the purposes of giving an opinion on the financial statements and/or, where appropriate, reaching a conclusion on arrangements to secure value for money, the auditor would not place significant reliance on the work performed in carrying out these services.
Where there are doubts about whether a service would have an inconsequential effect on the financial statements, or arrangements to secure value for money, in the view of an objective, reasonable and informed third party, then the effect is not regarded as inconsequential. Note 2: These items have not been prohibited directly by AGN01 (December 2016), however given the potential sensitivities surrounding such services these would be considered on a case by case basis as to whether they would be allowable within the parameters of AGN01, independence and generally accepted procedures.
Printed copies valid only if separately controlled Page 11 of 14
Reference DCP106 Date of issue 28/02/19 Version 1.3
Appendix B Extract from NAO Guidance Note relating to the application of the 70%
cap on non-audit work When the auditor provides to the audited local public body, or its controlled undertakings, non-audit services (other than the services listed in paragraphs 1 and 2 below), the total fees for such services to the audited entity and its controlled entities in any one year should not exceed 70%1
of the total fee for all audit work carried out in respect of the audited entity under the Code for that year. Non-audit services that are excluded for the purposes of applying the 70% cap as defined above are: 1. the following prohibited non-audit services which cannot be provided to an audited local public body while the firm is, or is proposed to be, the auditor –
a) tax services relating to i. preparation of tax forms ii. payroll tax iii. customs duties iv. identification of public subsidies and tax incentives unless support from the auditor in respect of such services is required by law v. support regarding tax inspections by tax authorities unless support from the auditor in respect of such inspections is required by law vi. calculation of direct and indirect tax and deferred tax vii. provision of tax advice,
b) services that involve playing any part in the management or decision-making of the audited body, c) bookkeeping and preparing accounting records and financial statements, d) payroll services, e) designing and implementing internal control or risk management procedures related to the preparation and/or control of financial information or designing and implementing financial information technology systems, f) valuation services, including valuations performed in connection with actuarial services or litigation support services, g) legal services, with respect to
i. the provision of general counsel ii. negotiating on behalf of the audited body iii. acting in an advocacy role in the resolution of litigation,
h) services relating to the audited body’s internal audit function, i) services linked to the financing, capital structure and allocation, and investment strategy of the audited body, except providing assurance services in relation to the financial statements, such as the issuing of comfort letters in connection with prospectuses issued by the audited body, j) promoting, dealing in, or underwriting shares in an entity controlled by the audited body, k) human resources services, with respect to
1 Although the 70% cap is similar to the limit applicable to public interest entities of the FRC’s ethical standard, the definition used in this AGN is the one applicable to local public bodies which are not public interest entities. The definition of the nature and extent of services to take into account when applying the cap in this AGN has been tailored to the specific circumstances of local public bodies. Printed copies valid only if separately controlled Page 12 of 14
Reference DCP106 Date of issue 28/02/19 Version 1.3
i. management in a position to exert significant influence over the preparation of the accounting records or financial statements which are the subject of the statutory audit where such services involve searching for or seeking out candidates for such positions, or undertaking reference checks for such positions ii. structuring the organisation design iii. cost control; and
2. the following other services which can be provided by the auditor, which are explicitly excluded for the purposes of applying the 70% cap –
a) audits or examinations of controlled entities, including charities, consolidated into the accounts of local public bodies, b) services to the parent undertaking of a local public body where the parent undertaking is a government department (for example the Department of Health) or a relevant national body (for example NHS England) and where such services are inconsequential to, and remote from, the decision-making of the local audited body, c) other assurance (such as work on the quality accounts of local health bodies or work on grant claims and returns at local authorities) where such assurance is mandated by legislation or by a relevant national body or regulator, d) any other services required by European Union or national legislation to be performed by the auditor.
By way of a derogation from paragraph (1) above, the services referred to in points (a)(i), (a)(iv) to (a)(vii) and (f), may be provided (but would be included for the purposes of applying the 70% cap) if the following requirements are complied with:
a) they have no direct or, in the case of an objective, reasonable and informed third party, would have an inconsequential effect, separately or in the aggregate on the audited financial statements, or on the audited body’s arrangements to secure value for money; b) the estimation of the effect on the audited financial statements, or on the audited body’s arrangements to secure value for money, is comprehensively documented and explained to those charged with governance; c) the principles of independence laid down in section 1 of the FRC’s ethical standard are complied with; and d) for the purposes of giving an opinion on the financial statements and/or, where appropriate, reaching a conclusion on arrangements to secure value for money, the auditor would not place significant reliance on the work performed in carrying out these services.
Where there are doubts about whether a service would have an inconsequential effect on the financial statements, or arrangements to secure value for money, in the view of an objective, reasonable and informed third party, then the effect is not regarded as inconsequential. Audit-related services Non-audit work, for the purposes of applying the 70% cap referred to above, includes audit-related services (other than those services which are listed above and which are explicitly excluded from the calculation). Audit-related services are:
• reporting required by law or regulation to be provided by the auditor; • reviews of interim financial information; • reporting on regulatory returns; • reporting to a regulator on client assets;
Printed copies valid only if separately controlled Page 13 of 14
Reference DCP106 Date of issue 28/02/19 Version 1.3
• reporting on government grants, where such reporting is not mandated by legislation or by a relevant national body or regulator;
• reporting on internal financial controls when required by law or regulation; and
• extended audit work that is authorised by those charged with governance performed on financial information and/or financial controls where this work is integrated with the audit work and is performed on the same principal
Printed copies valid only if separately controlled Page 14 of 14
NLG(20)028
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Jim Hayburn – Interim Director of Finance
CONTACT OFFICER Jim Hayburn
SUBJECT Annual Accounts 2019/20 – Delegation of Authority
BACKGROUND DOCUMENT (IF ANY) NHSI Accounts and reporting timetable 2019/20 for NHS Provider Organisations
PURPOSE OF THE REPORT: For Approval
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
In order to ensure the timely sign off of the Trust’s audited accounts by the Chief Executive and the External Auditor, prior to submission to NHSI on the 29th May 2020, the Trust Board is requested to delegate formal authority to the Audit, Risk and Governance Committee at its meeting on the 18th May 2020 to sign off the accounts and reports on its behalf.
TRUST BOARD ACTION REQUIRED The Trust Board is asked to: • Note the key dates in the final accounts process • Delegate formal authority to the Audit, Risk & Governance
Committee to sign off the 2019/20 Audited Accounts on behalf of the Trust Board
Northern Lincolnshire & Goole NHS Foundation Trust NLG(20)028 ________________________________________________________________________________________________
Report to Trust Board – February 2020
ANNUAL ACCOUNTS 2019/20 - DELEGATION OF AUTHORITY
Introduction The Audit, Risk and Governance Committee, under its delegated powers, reviews the draft accounts and reports before they are submitted to NHSI and the Auditors on behalf of the Trust Board (SFI 3.1.3 b). The Audit, Risk and Governance Committee also reviews the audited accounts and reports before they are submitted to the Trust Board for approval before final submission. The key dates for the 2019/20 accounts are as follows:- Tuesday 5th May 2020 Trust Board meeting.
Monday 18th May 2020 Audit, Risk and Governance Committee meeting where the
final audited accounts and reports will be reviewed in detail. The Chief Executive is invited to attend this meeting.
Friday 22nd May 2020 Chief Executive sign off expected sign off date. Once signed will be passed to External Auditor for their formal sign off prior to return and submission to NHSI.
Friday 29th May 2020 Final audited accounts and reports to be formally submitted to NHSI by noon.
Given that the May 2020 Trust Board meeting falls so early in the month the Audited Accounts will not be ready for final review by that point. The Trust Board can therefore, as in previous years, delegate formal authority to the Audit, Risk and Governance Committee to approve the final accounts on its behalf before submission to the External Auditor and NHSI. Recommendation
The Trust Board is asked to note the key dates in the final accounts process and is requested to delegate formal authority to the Audit, Risk and Governance Committee at its meeting on the 18th May 2020 to sign off the 2019/20 audited accounts and reports on behalf of the Trust Board, prior to formal signing by the Chief Executive and the External Auditor. Jim Hayburn Interim Finance Director February 2020
___________________________________________________________________________________________________________ Directorate of Finance, February 2020
NLG(20)029
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Tony Bramley – Chair of Audit, Risk and Governance Committee
CONTACT OFFICER Jim Hayburn, Interim Director of Finance
SUBJECT Audit, Risk and Governance Committee Self-Assessment Exercise Results
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
Audit, Risk and Governance Committee members/regular attendees attended the annual workshop event on the 9th January 2020 to complete the latest HFMA Audit Committee self-assessment checklist. Those present during the session were:
1. Tony Bramley – NED / Chair of ARG Committee 2. Neil Gammon - NED 3. Jim Hayburn – Interim Director of Finance 4. Sally Stevenson – Assistant DoF – Compliance & Counter Fraud 5. Helen Kemp-Taylor – Head of Internal Audit, Audit Yorkshire 6. Tom Watson – Internal Audit Manager, Audit Yorkshire
Wendy Booth, Trust Secretary, was unable to attend the meeting but advised in advance that she had no adjustments to make to the draft self-assessment document. The results of the 2020 self-assessment exercise are recorded on the attached checklist with the latest comments added.
TRUST BOARD ACTION REQUIRED The Trust Board is asked to note the results of the self-assessment exercise performed by the Audit, Risk and Governance Committee in January 2020.
Area/ Question Yes No Comments/Action
Composition, establishment and duties
Does the audit committee have written terms of reference and have they been approved by the governing body?
√ Latest version freely available on the Trust intranet. Last approved by the Trust Board in July 2019.
Are the terms of reference reviewed annually? √ Part of the Committee’s annual work plan. Last updated by the Committee for minor amendments in May 2019.
Has the committee formally considered how it integrates with other committees that are reviewing risk?
√ Members also attend other Board sub-committee meetings on an ad-hoc basis even when not formal members. Minutes of other sub-committee meetings submitted to the ARG Committee for information.
Are committee members independent of the management team?
√ The Committee’s membership comprises 3 Non-Executive Directors.
Are the outcomes of each meeting and any internal control issues reported to the next governing body meeting?
√ Minutes and highlight reports submitted to Trust Board.
Chair of ARG Committee presents highlight report at TB (as do all other sub-committee Chairs).
Does the committee prepare an annual report on its work and performance for the governing body?
√ Annual report also submitted to the CoG for information.
Has the committee established a plan of matters to be dealt with across the year?
√ Formal work plan adopted in 2012, reviewed annually thereafter. Revised for minor changes in July 2019. Due for scheduled annual review at January 2019 ARG Committee meeting.
Are committee papers distributed in sufficient time for members to give them due consideration?
√ In line with ToR – 5 working days before each meeting.
Has the committee been quorate for each meeting this year?
√ There were 5 meetings during 2018/19 and all were quorate. There have been 4 meetings to date during 2019/20 and all have been quorate.
Internal control and risk management
Has the committee reviewed the effectiveness of the organisation’s assurance framework?
√ Through internal audit annual review. The Committee also routinely receives the BAF and Strategic Risk Register report at each meeting.
Page 2 of 7
Area/ Question Yes No Comments/Action
Does the committee receive and review the evidence required to demonstrate compliance with regulatory requirements - for example, as set by the Care Quality Commission?
√ Through minutes from other sub-committees. As from April 2017 the Committee has received a quarterly report on the Strategic Risk Register and BAF for oversight and scrutiny purposes.
Has the committee reviewed the accuracy of the draft annual governance statement?
√ ARG Committee minutes will evidence this.
Has the committee reviewed key data against the data quality dimensions?
√ New question in 2018 - The Trust’s Data Quality Strategy was refreshed and submitted to the July 2019 meeting of the ARG Committee for review/comment. External audit review performance indicators as directed by NHSI as part of their year end audit work, and report the results accordingly to the Committee. The Committee also receives reports from Internal Audit on the outcome of reviews of targeted KPI’s as part of the IA annual plan.
Annual report and accounts and disclosure statements
Does the committee receive and review a draft of the organisation’s annual report and accounts?
√ Annual Accounts.
Does the committee specifically review:
• The going concern assessment • Changes in accounting policies • Changes in accounting practice due to
changes in accounting standards • Changes in estimation techniques • Significant judgements made in preparing
the accounts • Significant adjustments resulting from the
audit • Explanations for any significant variances?
√
Facilitated as necessary through reports from Finance / External Auditor and discussion at Committee meetings.
Is a committee meeting scheduled to discuss any proposed adjustments to the accounts and audit issues?
√ Prior to submission to NHSI.
Does the committee ensure it receives explanations for any unadjusted errors in the accounts found by the external auditors?
√ Robust discussions involving annual accounts. Letter of Representation includes explanations for areas of non-adjustment.
Page 3 of 7
Area/ Question Yes No Comments/Action
Internal audit
Is there a formal ‘charter’ or terms of reference, defining internal audit’s objectives and responsibilities?
√ Formal Internal Audit Charter and Internal Audit Working Protocol with Internal Audit Provider (currently Audit Yorkshire.
Does the committee review and approve the internal audit plan, and any changes to the plan?
√ Annual and strategic plans are approved prior to the beginning of each financial year. Changes are documented and approved through IA progress reports to each ARG Committee meeting.
Is the committee confident that the audit plan is derived from a clear risk assessment process?
√ ARG Committee members and Executive Team participate in annual workshop event to identify risks and discuss inclusion in audit plan. Most recent workshop on 9 January 2020 (previously 17 January 2019).
Does the committee receive periodic progress reports from the head of internal audit?
√ At each meeting.
Does the committee effectively monitor the implementation of management actions arising from internal audit reports?
√ At each meeting.
Does the head of internal audit have a right of access to the committee and its chair at any time?
√ Specifically referred to in ToR.
Is the committee confident that internal audit is free of any scope restrictions, or operational responsibilities?
√ Could be raised at private meeting with Internal Audit before each Committee meeting or during Committee meetings if such an issue arose.
Has the committee evaluated whether internal audit complies with the Public Sector Internal Audit Standards?
√ Audit Yorkshire’s work is undertaken in accordance with their detailed Internal Audit Quality Assurance Manual which ensures a consistent approach and compliance with all relevant regulatory standards. In addition they use an Internal Audit Quality Assessment Framework biennially and an external review every five years to objectively assess the quality of our service.
Page 4 of 7
Area/ Question Yes No Comments/Action Audit Yorkshire agreed with their Board to perform a self-assessment in 2019/20 to confirm compliance for the organisation, with an external review planned for 2020.
Does the committee receive and review the head of internal audit’s annual opinion?
√ ARG Committee minutes will evidence this.
External audit
Do the external auditors present their audit plan to the committee for agreement and approval?
√ ARG Committee minutes will evidence this. Scheduled for January 2020 meeting.
Does the committee review the external auditor’s ISA 260 report (the report to those charged with governance)?
√ ARG Committee minutes will evidence this.
Does the committee review the external auditor’s value for money conclusion?
√ ARG Committee minutes will evidence this.
Does the committee review the external auditor’s opinion on the quality account when necessary? [Note: this question is not relevant for CCGs]
√ ARG Committee minutes will evidence this.
Does the committee hold periodic private discussions with the external auditors?
√ Prior to the start of each meeting (as for internal audit) until November 2018. Now only once a year or if requested in advance by the auditors.
Does the committee assess the performance of external audit?
√ On-going assessment by exception.
Does the committee require assurance from external audit about its policies for ensuring independence?
√ Formal confirmation in audit strategy/fee documentation.
Has the committee approved a policy to govern the value and nature of non-audit work carried out by the external auditors?
√ Policy for Engagement of External Auditors on Non-Audit Work devised and approved in February 2015 and subject to annual review thereafter. Revised in January 2019 to reflect new NAO guidance on this area and scheduled for review at January 2020 meeting. Details of non-audit work is included in the annual ISA260 report from the External Auditor. Value of non-audit work is also identified separately in the annual accounts.
Page 5 of 7
Area/ Question Yes No Comments/Action
Clinical audit [Note: this section is only relevant for providers] If the committee is NOT responsible for monitoring clinical audit, does it receive appropriate assurance from the relevant committee?
√ Q&S Committee are responsible for monitoring the delivery of clinical audit activity. Q&S Committee minutes received by the ARG Committee. The clinical audit annual plan for 2019/20 was received by the ARG Committee in July 2019 for information. The Chair of ARG Committee is Deputy Chair of Q&S Committee, and appropriate links will continue to be made.
If the committee is responsible for monitoring clinical audit has it:
• Reviewed an annual clinical audit plan? • Received regular progress reports? • Monitored the implementation of
management actions? • Received a report over the quality
assurance processes covered by clinical audit activity?
N/A N/A
Part of the formal terms of reference for the Q&S Committee.
Counter fraud
Does the committee review and approve the counter fraud work plans, and any changes to the plans?
√ Plan agreed with DoF and received by the ARG Committee for review.
Is the committee satisfied that the work plan is derived an appropriate risk assessment and that coverage is adequate?
√ Counter fraud work plan informed by register of fraud risks, internal audit, NFI, NHS Counter Fraud Authority (NHS CFA) intelligence reports, etc. Work plan areas based on national provider standards established by the NHS CFA.
Does the audit committee receive periodic reports about counter fraud activity?
√ Standing agenda item for written counter fraud progress reports from the LCFS.
Does the committee effectively monitor the implementation of management actions arising from counter fraud reports?
√ ARG Committee minutes will evidence this where appropriate.
Do those working on counter fraud activity have a right of direct access to the committee and its chair?
√ Contained within ToR in relation to the LCFS.
Page 6 of 7
Does the committee receive and review an annual report on counter fraud activity?
√ This has always been the case in relation to counter fraud work since 2000.
Does the committee receive and discuss reports arising from quality inspections by NHSCFA?
√ ARG Committee minutes will evidence this where appropriate.
Page 7 of 7
NLG(20)031
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Neil Gammon, Chair of Health Tree Foundation Trustees Committee
CONTACT OFFICER Ellie Monkhouse, Chief Nurse and Kate Wood, Medical Director
SUBJECT Health Tree Foundation Trustees’ Committee Highlight Report – January 2020
BACKGROUND DOCUMENT (IF ANY) -
PURPOSE OF THE REPORT: Issues from the Health Tree Foundation Trustees Committee meeting requiring escalation by exception to the Trust Board.
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The attached highlight report summarises the key issues presented to, and discussed by the Health Tree Foundation Trustees Committee at its meeting on the 16 January 2020.
TRUST BOARD ACTION REQUIRED The Board is asked to note the report and consider the need for any further actions to address issues highlighted in the report
Northern Lincolnshire and Goole NHS Foundation Trust NLG(20)031 ____________________________________________________________________________________________________________
Highlight Report to the Trust Board Report for Trust Board Meeting on:
4 February 2020
Report From: Health Tree Foundation Trustees’ Committee held on 16 January 2020
Highlight Report: • The Committee agreed that the Chair would write to Fund Guardians requesting any large
scale bids from their area to be considered for Charity funding or potentially the subject of an appeal. This letter would be sent after the conclusion of the current Trust Business Planning meetings.
• The Committee discussed the current governance and reporting arrangements for the Trust
staff lottery. It was agreed that the HTF Trustees’ Committee was perhaps not the most appropriate committee to monitor the staff lottery. The chair agreed to write to the Chief Executive with these concerns.
• The Laparoscopic Surgical equipment to be purchased from the Rear into Gear appeal has
now been agreed by the clinicians (£192,000). • The Committee considered an initial proposal for HTF to set-up a public charity lottery and
agreed for this to be investigated further, with a report back to the committee before any action is taken.
• The Committee agreed for a detailed proposal to be put together for a Clinical Scholarship
fund, for discussion at the next HTF committee. The Committee discussed again the appointment of a HTF Patron and agreed to search out further potential candidates. Confirm or Challenge of the Board Assurance Framework: N/A Action Required by the Trust Board: The Trust Board is asked to note the key points raised by the Committee, and consider any further action needed. In addition, the HTF Trustees’ Committee would gratefully receive any Trust Board suggestions for both further major charitable funding suggestions as well as nominations for appropriate individuals who could be approached as potential HTF Charity patrons. Neil Gammon Chair of Health Tree Foundation Trustees’ Committee _____________________________________________________________________________________________________________ Finance Directorate, February 2020 Page 2 of 2
NLG(20)032
DATE OF MEETING 04 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Claire Low, Acting Director of People and Organisational Effectiveness
CONTACT OFFICER Karl Portz, Equality and Diversity Lead
SUBJECT Gender Pay Gap Report
BACKGROUND DOCUMENT (IF ANY) N/A
PURPOSE OF THE REPORT: To meet the Trusts legal responsibility to report against the Gender Pay Gap
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
This report provides the Trust Board with a highlight report against the Gender Pay Gap reporting standard, which legally it must publish each year
TRUST BOARD ACTION REQUIRED
The Trust Board are asked to approve the content of the Gender Pay Gap report, which it is legally required to publish on the Government Website and the Trust Website. The Trust Board are asked to approve Appendix 1 which reflects the data and format that it must use to publish our Gender Pay Gap information on the Government Website. We are unable to include any other commentary at this stage on the Government Website this must be done by 30th March 2020.
Gender Pay Gap Report for
Trust Board / Workforce Committee
February 2020
1.0 1.1 1.2
PURPOSE OF THE REPORT The purpose of this report is to share the Trust’s Gender Pay Reporting data for the pay period including 31 March 2019. The report provides a brief analysis and comparison to last year’s Gender Pay Gap data.
2.0 2.1 2.2 2.3 2.4 2.5 2.6
BACKGROUND/CONTEXT New regulations that took effect on 31 March 2017 (The Equality Act 2010 - Specific Duties and Public Authorities - Regulations 2017) require all public sector organisations in England employing 250 or more staff to publish gender pay gap information annually. The gender pay gap shows the difference between the average (mean or median) earnings of all male and all female employees. It is expressed as a percentage of earnings and it is a measure of disadvantage. The gender pay gap is not the same as equal pay. Equal pay is about ensuring men and women doing similar work or work that is different but of equal value (in terms of skills, responsibility, effort) are paid the same. A gender pay gap could reflect a failure to provide equal pay but it usually reflects a range of factors, including a concentration of women in lower paid roles and women being less likely to reach senior management levels. Closing the gender pay gap is not just about achieving gender equality but also about boosting the economy given the cost of the under-utilisation of women’s skills to the UK economy, and the impact on productivity. The Government anticipates that reducing the gap at workforce level will help to narrow the gap at a national level. Additionally, nationally there is demand, by regulators and the public, for a move to greater pay transparency. The Government believes that increasing transparency around the differences in pay between men and women will make employers more accountable and encourage them to scrutinise their own recruitment, remuneration, reward and staff development practices and ensure that steps are being taken to close any gender pay gaps identified by the reporting process. Over time it is anticipated that reporting might be extended to race, disability or age. Gender pay gaps are the outcome of economic, cultural, societal and educational factors. Whilst also reflecting personal choice, the outcome of the choice is strongly influenced by matters outside individual control, and it is still the case that women’s choices are more constrained than those of men. The key influences, which are complex and feed into each other includes unpaid caring responsibilities, part-time working, differences in human capital, occupational segregation, undervaluing of women’s work and pay discrimination.
3.0 3.1 3.2 3.3 3.4
REPORTING REQUIREMENTS The Trust is required to publish annually six gender pay gap measures:
Mean pay gap – the difference between the mean hourly rate of pay (excluding overtime) of male and female employees
Median pay gap – the difference between the median hourly rate of pay (excluding overtime) of male and female employees
Mean bonus gap – the difference between the mean bonus paid to male and female employees who received a bonus in the relevant pay period
Median bonus gap – the difference in the median bonus pay for male and female employees who received a bonus
Bonus distribution by gender – the proportions of male and female employees who received bonus pay
Pay distribution by gender – the proportion of male and female employees in the lower, lower middle, upper middle and upper quartile pay bands.
The measures are calculated using a ‘snapshot date’. For public sector organisations this is the pay period which includes 31 March 2019. The figures must be calculated using the mechanisms set out in the gender pay gap reporting legislation. The dates used for our data was 31 March 2019 for the pay data. For the bonus pay data the period of 1 April 2018 to 31 March 2019 was used. The Trust is required to publish the information within one year of the snapshot date (i.e. by 30 March 2020) and by the same date every subsequent year. It must be published on the Trust’s website in a way that is accessible to staff and the public, and retained on this for a period of three years. The report must also be uploaded to the Gov.UK website in the prescribed format (see Appendix 1). There is no legal requirement to publish any accompanying narrative or commentary to explain what the figures mean, what the Trust believes are the factors behind the gender pay differences and what the Trust intends to do to close the gap. However guidance produced by ACAS and the Government Equalities Office emphasises the importance of employers producing a supporting narrative.
4.0 4.1 4.2 4.3
TRUST DATA and ANALYSIS The Trust’s Gender Pay Gap Data 2019/20 for mean hourly rates and median rates are set out below and compared to the 2017/18 and 2018/19 figures:
Gender Mean Hourly Rate Median Hourly Rate
2017/18 2018/19 2019/20 2017/18 2018/19 2019/20
Male £20.5751 £18.8682 19.2138 £14.8896 £14.0384 14.3449
Pay Gap % 32.5176 34.8954 34.1105 18.9534 27.6766 27.0976
This shows that this year male staff earn on average £6.55 per hour more than female staff, and as a percentage male staff earn 34.1% more than female staff. The median hourly rate for male staff is £3.89 per hour higher than female staff, and that the median hourly rate for male staff equates to 27.1% higher than that of female staff.
4.4 4.5 4.6 4.7 4.8
In comparison the figures compared to last year’s figures are very similar. The Trust’s workforce headcount stands at 6816 of which 5523 (81%) are female and 1293 (19%) are male. The distribution of pay by gender is broken down into quartiles as below. Quartile 1 reflects the lower pay bands and quartile 4 the higher bands. It can be seen below that in quartiles 1, 2 and 3 the percentage of female workforce is proportionately slightly higher the organisational percentage of female workforce (81%). However, in quartile 4 the high pay quartile is significantly male dominated. As a percentage of the whole female workforce quartile 4 shows 20.4% (1129) and as a percentage of the whole male workforce shows 44.5% (579). This disproportionality in quartile 4 accounts for both the average and median gender pay rates.
Quartile Female Male Female %
Male %
1 £3.70 - £9.10 1417.00 (1361.00)
230.00 (244.00)
86.04 (84.8)
13.96 (15.2)
2 £9.10 – £10.89 1537.00 (1402.00)
222.00 (204.00)
87.38 (87.3)
12.62 (12.7)
3 £10.89 – £15.46 1440.00 (1408.00)
265.00 (215.00)
84.46 (86.61)
15.54 (13.39)
4 £15.48 - £107.51 1129.00 (1047.00)
576.00 (559.00)
66.22 (65.19)
33.78 (31.7)
*As a comparator The figures shown in ( ) are last year’s figures. Bonus Payments The percentage of female and male staff who receive bonus payment, the average amount each group receives and the median each group receives can be seen below.
Gender Employees Who Receive Bonus Payments
Total Employees % Who Receive a Bonus
Female 108 (144) 6250 (5218) 1.73% (2.76%)
Male 97 (100) 1557 (1222) 6.23% (8.1%)
*As a comparator The figures shown in ( ) are last year’s figures. The total number of employees reflects the total number of staff who worked for the Trust in the whole year.
*As a comparator The figures shown in ( ) are last year’s figures.
Bonus payments include things that relate to profit sharing, productivity, performance, incentives and commission. These are generally received in the form of cash or have a monetary value. For example we have included Clinical Excellence Awards, theatre list incentives and some other adhoc payments.
4.9 5.0 5.1 5.2
It can be seen that the percentage of the workforce who receive bonus payments remains higher for males. However, bonus payments are only received by a small number within the workforce and some of the payments are for high amounts therefore, small changes can have a significant impact. The main outlier still appears to be the Clinical Excellent Awards. Clinical Excellence Awards Clinical Excellence Award (CEA) payments are awarded to Medical Consultants and are classified as a bonus payment. The chart below shows the bonus data but excludes the CEA payments. It can be seen if the CEA’s were removed from the bonus pay gap would be significantly reduced.
Gender Mean Pay Median Pay
Male 2,573.63 848.25
Female 1,087.83 478.00
Difference 1,485.80 370.25
Pay Gap % 57.73 43.65
Our Medical Consultants are 80.81% (160) male and 19.19% (38) female. Those Medical Consultants who currently receive Clinical Excellence Award Payments is 35% of male consultants (56 people) and 31.6% of female consultants (12 people).
6.0 6.1 6.2 6.3
KEY AREAS OF FOCUS Collecting this data meets our legal requirements however, to be of real benefit it will be necessary to develop a long term action plan and an approach to tackling the gender pay gap. Best practice suggests we focus on pay, progression, recruitment and flexibility.
Pay – Continue to conduct a review of our locally determined pay and bonus pay frameworks and to consider these in line with the principles of the gender pay gap. This in part can be achieved by equality impact assessing our local pay and bonus frameworks.
Progression and Recruitment – To continue annually analysing the equality data we hold on our staff in relation to all protected groups (Equality Act 2010) and to explore if there are any other existing or potential inequalities which effect different equality groups.
Flexibility – Ensure our policies/working practices are equality impacted assessed to ensure we don’t discriminate against any protected groups including gender and people with caring responsibilities.
These actions will form part of the wider Trust’s Equality and Diversity action plan and link to the Equality and Diversity Strategy, and Equality Objectives. Progress against these actions will be monitored by the Trust’s Equality, Diversity and Inclusion Lead and progress reported as part of the agreed Equality and Diversity Strategy reporting system. In addition, going forward each year we will publish our data on the Government Equality Website and our own Website.
Appendix 1 Northern Lincolnshire and Goole NHS FT – Gender Pay Gap Data
HOURLY RATE
Female Hourly Rate is 34.11% Lower (Mean)
Female Hourly Rate is 27.09% Lower (Median)
PAY QUARTILES
Female Male
Top 66.22 33.78
Upper Middle 84.46 15.54
Lower Middle 87.38 12.62
Lower 86.04 13.96
BONUS PAYMENTS
Female Bonus Pay is 71.44% Lower (Mean)
Female Bonus Pay is 75.75% Lower (Median)
1.73% of Females Receive a Bonus Payment
6.23% of Males Receive a Bonus Payment
NLG(20)033
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Jim Hayburn – Interim Director of Finance
CONTACT OFFICER Jim Hayburn
SUBJECT Trust Scheme of Delegation and Standing Financial Instructions – Revised Drafts
BACKGROUND DOCUMENT (IF ANY) -
PURPOSE OF THE REPORT: Revised draft documents for review and approval.
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The paper contains two documents (which have been PDF’d separately to preserve the integrity of the numbering/referencing within each document) namely: 1. Trust Scheme of Delegation (SoD) – including Appendix A (delegated
authority levels in table format); and
2. Standing Financial Instructions (SFIs). The draft SoD and SFI’s have been revisited and updated to reflect comments and changes since they were presented to the September 2019 Trust Board. Changes since September 2019 have been tracked for ease of reference at the request of the CEO. Changes to the table at Appendix A of the SoD are shown in red narrative for a job title change/introduction of new post. Items where the cell is highlighted in green or red are amendments since September 2019 (green adding / red removing). The documents have been amended to reflect the change in job title of the Director of Strategy and Planning to Director of Strategic Development, and the new Executive post of Chief Information Officer. The relevant areas of the documents have also been adjusted to take account of the introduction of the Chief Information Officer post and their associated responsibilities (i.e. the transfer if IM&T functions to their portfolio). The structure chart at section 5.1 of the SoD has been updated at the request of the Wendy Booth, Trust Secretary, to reflect the structure chart supplied by Wendy following the September 2019 Board meeting. As a result of the proposed changes to the delegated authority levels within the SoD (in respect of expanding authority levels of certain personnel/pay transactions and authorisation of requisitions), individual Divisional and Directorate SoD’s will need to be revisited and updated and the necessary changes made within the Finance team. As a result of the work that will be necessary for this exercise to be completed it is proposed that the new Divisional and Directorate SoD’s will be implemented with effect from 1st April 2020. A minor amendment is also required to the stand alone ‘Waiver Procedure’ to reflect the updated procedure in the SFI’s. This will be made once the Board has approved the SFIs. Please note that page numbers on the contents pages will be adjusted once all changes have been agreed and the document is final.
TRUST BOARD ACTION REQUIRED The Trust Board is asked to: 1. Consider and approve the revised draft Scheme of Delegation;
2. Consider and approve the revised draft Standing Financial
Instructions.
Chief Executive’s Office
TRUST SCHEME OF DELEGATION AND POWERS RESERVED FOR THE TRUST
BOARD
Reference XXX Date of issue XXX Version XX
Contents
Section Item Page
1.0 Introduction 3
2.0 Underpinning Principles of Empowerment 4
3.0 The Council of Governors and the Trust Board 6
4.0 Trust Board Committees 8
5.0 Management Decision Making and Organisational Structure 10
6.0 Management Structures and Performance Management 13
7.0 Powers Retained by the Board 16
8.0 Scheme of Delegation of Powers from the Board 19
9.0 Levels of Delegated Authority within the Scheme of Delegation 20
10.0 Agreeing Contracts for the Trust’s Services 21
11.0 Managing Pay Expenditure and Staffing Costs 22
12.0 Managing Non-Pay Expenditure and Commitments 24
13.0 Managing Tenders, Quotations and Contracts 26
14.0 Managing Capital Expenditure 28
Appendix A Summary of Scheme of Delegation 29
2 | P a g e
Reference XXX Date of issue XXX Version XX
1.0 Introduction:
1.1 This document is designed to describe how the Trust operates i.e. how it is structured, how it takes decisions, and where authority and accountability is held.
1.2 For effective governance the Trust Board must have in place arrangements to ensure that there is clarity about how and where decisions are made, and who makes them. The NHS Foundation Trust Code of Governance requires that the Trust Board:
• Clearly identifies the types of decision which are to be reserved for the Council of Governors and the Trust Board, and;
• Ensures that arrangements are in place to enable responsibility for other decisions to be clearly delegated to executive management.
1.3 The Trust Board has a responsibility to ensure that staff at all levels of the organisation confidently understand what delegated authority they have to make decisions, and are clear what to do when they do not have authority. The Scheme of Delegation sets out who has the authority to make decisions within the Trust.
1.4 This document cannot be read in isolation, it sits alongside other documents to create a governance framework for the Trust. Critical documents linked to the Scheme of Delegation are the Trust Constitution, Standing Financial Instructions (SFI’s), the Performance Management Framework, and the Standards of Business Conduct policy. All such documents are freely available to all staff on the Trust’s intranet site.
1.5 The Trust’s Directorates and Divisions are not independent, they are part of the Trust. They are granted powers through the Scheme of Delegation to allow them to manage themselves effectively to organise and deliver high quality services. However, they will be expected to use the authority delegated to them in the best interests of the organisation and patients.
3 | P a g e
Reference XXX Date of issue XXX Version XX
2.0 Underpinning Principles of Empowerment
2.1 The Scheme of Delegation has been designed to be a tool to empower Directors, and those managers who have been given authority to act on their Directors’ behalf through the respective Directorate or Divisional Scheme of Delegation, to take appropriate action within a robust corporate framework.
2.2 Directorates and Divisions will have defined freedoms under the Scheme of Delegation, but will remain bound to Trust’s Vision and Values, strategies, policies and procedures. Any Directorate or Divisional decision taken under the freedoms set out in the Scheme of Delegation remains subordinate to Trust Board decisions. Responsibility for appropriate implementation, and ensuring appropriate compliance, rests with the Directorates and Divisions which make up the Trust.
2.3 Directorates and Divisions are not legal entities in their own right, but are part of the corporate whole that is the NHS Foundation Trust. Participation in and compliance with the Trust’s strategies, policies and procedures is mandatory.
2.4 Whilst the Scheme of Delegation provides the power to commit resources to individual Directorates and Divisions, Directorates and Divisions must recognise the decisions of the Trust Board in the allocation of resources.
2.5 The Trust Board’s strategies, policies and procedures also shape the expectation of the employer regarding the behaviour of employees. Employees will comply with instructions issued by the Trust Board, or set out the Scheme of Delegation, or in other corporate governance or policy documents.
2.6 Where the Trust is subject to independent review and inspection (e.g. CQC, NHSI, External Audit, HSE, etc.) the Trust will co-ordinate the organisation’s preparation for assessment and the action plan following assessment. Directorates and Divisions must support and co-operate with these initiatives as they apply to their areas of responsibility.
2.7 Corporate Directorates will manage a range of services where it is judged by the Trust Board that this represents the most appropriate course of action. Other Directorates and Divisions do not have the prerogative to establish their own services in these areas, and must make use of corporate services. Where required, Directorates and Divisions will identify staff who will co-ordinate these arrangements at local level, and work with the central teams to ensure that the Trust discharges its responsibilities effectively.
2.8 The Scheme of Delegation is also based on a key principle that all leases and buildings are owned by the Trust, and any users of that space, do so as a “tenant” of the Trust. The Director of Estates and Facilities acts as the “landlord” on behalf of the Trust, and has control over which users occupy which space.
2.9 The Trust Board will retain the option to authorise corporate intervention to support a Directorate or Division. In certain circumstances, it may also be necessary to set aside the usual devolution arrangements, using this authority, in order to manage specific issues and problems. This will be agreed by the Trust Chairman on behalf of the Trust Board.
2.10 Any decision to suspend the agreed devolution arrangements will be reported to the Trust Board by the Trust Chairman, along with an explanation of the rationale for doing so. The Performance Management Framework provides the rules and processes for such action. The Chief Executive may choose to intervene outside the formal Performance Management Framework, according to individual circumstances, subject to the oversight of the Trust Board.
4 | P a g e
Reference XXX Date of issue XXX Version XX 2.11 In order to ensure that responsibility is clearly delegated within individual Directorates and
Divisions, individual Directorate and Divisional Schemes of Delegation will be adopted which are appropriate to their particular circumstances and management structures.
2.12 Each Director remains accountable for compliance with all strategies, policies and procedures in their Directorate or Division, and must take all appropriate steps to ensure that their staff are aware of the necessary details to carry out their duties.
2.13 Each Director must take corrective action when issues of non-compliance occur in their Directorate or Division, including escalation of the issue where this is necessary.
5 | P a g e
Reference XXX Date of issue XXX Version XX
3.0 The Council of Governors and the Trust Board 3.1 The Trust is constituted with two principal bodies charged with overseeing the running of the
organisation:
3.2 The Council of Governors: The Council of Governors represent the interests of local communities, partners and staff in the development of our organisation, and forms the link between the Directors of the organisation (the Trust Board), and the members – the staff, patients and public of the organisation who have formally become members. The Council of Governors hold the Trust Board to account on behalf of the members.
3.3 The Governors: The Council of Governors is composed of a mix of elected and appointed members, and includes a Lead Governor, representing the following groups:
• The public in the various localities served by the Trust; • The staff of the Trust; • Stakeholder organisations. The detailed composition of the Council of Governors is set out in the Trust Constitution. The Chair of the Trust is also the Chair of the Council of Governors.
3.4 Purpose of the Council of Governors: The primary role of the Council of Governors is to hold the Trust Board to account for its effectiveness in leading the organisation, and in ensuring effective governance and management. In this task they protect the interests of the groups they represent. This is designed to ensure that the Trust Board will always act in the interests of the local communities they serve.
3.5 Powers of the Governors: The Council of Governors have specific powers reserved for them in the Constitution by which they exercise their control over the Trust Board. The key powers are:
• Appointing both the Chair and Non-Executive Directors to the Trust Board; • Appointing the Trust’s External Auditors (with the advice of the Audit, Risk and Governance
Committee); • Agreeing to refer the Trust Board to the Regulator (currently NHS Improvement) where they
believe that the Trust Board is failing to exercise its duties effectively. 3.6 The Council of Governors therefore has restricted but important powers – by the control over
critical oversight and governance functions, and through the power of referral to the Regulator, the Council of Governors forms a crucial part of the Trust’s governance system. Further details of the operation and structure of the Council of Governors can be found in the Trust Constitution.
Council of Governors
Overseeing the Trust Board’s management of the organisation
Trust Board
Leading and overseeing the effective management of the organisation
6 | P a g e
Reference XXX Date of issue XXX Version XX 3.7 The Trust Board: The Trust Board is the principal accountable body within the Trust. It is
responsible for ensuring that the Trust has clear and coherent strategic objectives, to benefit the public and other stakeholders, is effectively managed in pursuit of those strategic objectives, and that appropriate governance safeguards are in place to protect the interests of patients, staff and the taxpayer. Board membership is shown below:
3.8 Trust Chairman: Also appointed by the Council of Governors, the Trust Chairman, in addition to performing the duties of a Non-Executive Director, is responsible for the effective running of the Board, and ensuring that the Board is able to properly coordinate the activities of the Trust.
3.9 Deputy Chairman: One of the Non-Executive Directors will also be nominated as Deputy Chairman, primarily to perform the duties of the Chairman in his or her absence.
3.10 Senior Independent Director: One of the Non-Executive Directors will be appointed as Senior Independent Director. This role is established primarily to take an independent view where there are significant disagreements within the Trust Board.
3.11 Non-Executive Directors: Non-Executive Directors are appointed by the Council of Governors Non-Executive Directors are selected to bring a range of differing skills and experience to the Trust Board, and effectively scrutinise the work of the Trust Executive Directors in performing their duties, through the various assurance Committees of the Trust Board (see section 4), and through more general review of the activities of the Trust.
3.12 Chief Executive: The Chief Executive is the Accountable Officer and Accounting Officer of the Trust, ultimately responsible for the economical, efficient and effective running of the organisation. This includes overall responsibility for management of resources across the organisation.
3.13 Executive Directors: The Board also includes the Executive Directors of the Trust. Executive Directors do not all have voting rights within the Trust Board, and those who do not vote are marked with an asterisk (*) on the list below:
• Medical Director • Chief Nurse • Director of Finance • Chief Operating Officer • Director of Estates and Facilities* • Director of People and Organisational Effectiveness* • Director of Strategic DevelopmentStrategy and Planning* • Chief Information Officer*
3.14 Trust Secretary: The Trust Secretary has a dual reporting line to both the Trust Chairman and the
Chief Executive and is responsible for corporate governance, managing the Foundation Trust office and is the lead for legal services.
3.15 The Unitary Board: The Trust Board is designed as a Unitary Board with decisions to be reached by discussion and consensus, with all Executive and Non-Executive Directors permitted to
Non-Executive Directors
(5 - voting)
Trust Chairman
(voting)
Chief Executive (voting) Executive
Directors (78: 4
voting) Trust Secretary
(Non-voting)
Associate Director of Communications
& Engagement (Non-voting)
7 | P a g e
Reference XXX Date of issue XXX Version XX
participate in all discussions. All members of the Trust Board are bound collectively to the decisions taken by the Board. Further details of the working of the Trust Board can be found in the Trust Constitution.
4.0 Trust Board Committees:
4.1 The Trust Board has established a number of Committees of the Board to control manage and oversee the activities of the organisation:
4.2 Executive Committees: Executive Committees of the Trust Board have delegated authority from the Board to make management decisions – committing resources and determining priorities within their Terms of Reference:
Trust Management Board: The purpose, remit and supporting structure of Trust Management Board is set out in section 5. This is the key management committee for the Trust, ensuring that the organisation is clinically led.
Remuneration Committee: This Committee is responsible for reviewing and setting Executive Director pay, and reviewing Executive Director performance. In addition, this Committee reviews and approves any engagements of interim or temporary staff above certain financial limits set by the Regulator.
4.3 Assurance Committees: These committees are designed to provide appropriate Non-Executive Director scrutiny of the Executive and management team in running the Trust. They have no direct decision making authority, but have the power to escalate to the full Trust Board any concerns they have, and require the Trust Board to develop appropriate response actions. As such, assurance committees are a critical element of the Trust’s risk management and performance management arrangements. These committees are as follows:
Quality and Safety Committee: Established to ensure that the Trust delivers safe, effective and personalised patient care, consistent with best practice and appropriate standards.
Finance and Performance Committee: Established to ensure that the Trust is able to effectively deliver its operational performance and financial objectives, as set out in the plans agreed with Regulators.
Trust Board
Trust Management
Board
Remuneration Committee
Health Tree Foundation
Trustees Committee
Quality and Safety
Committee
Finance and Performance Committee
Workforce Committee
Audit, Risk and
Governance Committee
Executive Committees Assurance Committees
8 | P a g e
Reference XXX Date of issue XXX Version XX
Workforce Committee: Established to review theat Trusts plans and progress in delivering an appropriately structured, skilled and motivated workforce to carry out its operations, and to meet future requirements.
Audit, Risk and Governance Committee: Established to oversee the management of risk within the organisation, and to ensure that the Trust has in place appropriate governance arrangements to ensure efficient, economic and effective care. Reports from Internal Audit and the Trust’s External Auditor are received by this Committee. It also has oversight of the Trusts’ counter fraud arrangements.
Health Tree Foundation Trustees Committee: This Committee manages the Trust’s Charitable Funds, the Health Tree Foundation. As an ‘arm’s length’ management body, chaired by an independent Trustee, this Committee is designed to ensure that Charitable Funds operate with appropriate independence from the Trust.
4.44.2 Trust Board committees are configured to carry out the duties of the Trust Board in ensuring the effective management of the Trust. They are established based on formal membership and terms of reference approved by the Trust Board, which set out their purpose and delegated authority. Membership and terms of reference documents for these committees are freely available to all staff on the Trust’s intranet site.
9 | P a g e
Reference XXX Date of issue XXX Version XX
5.0 Management Decision Making and Organisational Structure
5.1 The Trust Board has established a range of bodies to carry out management decision making, and ensure that the Trust can deliver its plans and objectives, and is running efficiently and effectively. The summary structure of these bodies is set out below:
5.2 Trust Management Board: The Trust Board has delegated management decision making authority to the Trust Management Board, an Executive Committee of the Board. This delegation of authority does not include the powers the Trust Board has reserved for itself (which are set out in section 7).
5.3 Purpose of Trust Management Board: The Trust Management Board brings together the Executive and Clinical leaders of the Trust to run the Trust and maintain robust efficient operational management. It is tasked by the Trust Board with ensuring delivery of the operational, service, and financial plans agreed by the Trust Board, considering:
• Service changes • Business plans and business cases • Revenue and Capital resource prioritisation and allocation • Delivery of operational performance objectives • Policy ratification • Resolution of inter-Divisional or inter-Directorate issues, as required.
Trust Board
Executive Team
Trust Management
Board
Digital Strategy Board
Decision making bodies Problem solving bodies TMB sub-groups
Quality Governance
Group
Workforce Oversight
Group
Access and Flow
Group
Finance Recovery
Board
Business Planning
Group
Capital Investment
Board
Business Case
Review Group
Nursing and Midwifery
Board
Risk Register
‘Confirm & Challenge’
Group
10 | P a g e
Reference XXX Date of issue XXX Version XX 5.4 Membership of Trust Management Board: The Trust Management Board is chaired by the Chief
Executive, and membership includes the Executive Team and the Trust’s Clinical Directors.
5.5 Trust Management Board Sub-Groups: The Trust Management Board has established a number of sub-groups to develop work in critical areas. These sub-groups do not have decision making authority, but are established to work up proposals, plans and policies for Trust Management Board approval. The sub-groups are:
• Quality Governance Group: This group is responsible for ensuring that appropriate arrangements are in place in relation to patient safety, quality and clinical governance.
• Workforce Oversight Group: responsible for rebuilding the clinical workforce of the Trust, developing appropriate career structures within professional groups, and improving the Trust’s systems and controls relating to deployment of clinical staff. It is also responsible for supporting redesign and development of the organisation’s leadership and management structures, and developing plans to improve the culture of the organisation.
• Access and Flow Group: responsible for improving the productivity and effectiveness of the
Trust’s clinical services, and improving performance against NHS Constitutional standards. • Finance Recovery Board: responsible for improving the financial performance of the Trust,
and overseeing delivery of the financial recovery plan and financial strategy.
• Business Planning Group: responsible for coordinating the development of capital and revenue resource allocation plans, and advising in terms of high level oversight on the development of service change, business plans and business cases.
• Capital Investment Board: responsible for providing strategic and operational advice on the
Trust’s capital investment programme to TMB and the Trust Board. • Business Case Review Group: responsible for considering all business cases and proposals
to ensure that good business decisions are made by the organisation which ensure quality, safety and value for money regarding the use of Trust resources.
• Digital Strategy Board: responsible for developing appropriate IM&T strategies to support
effective management, the removal of paper records, the development of IT infrastructure and cyber security.
• Nursing & Midwifery Board: responsible for enhancing senior staff participation in strategic
decision making, directing the future of professional practice and shaping the Trust’s nursing and midwifery agenda to improve clinical standards and the patient’s experience.
Additional groups may be created by TMB as it considers necessary.
5.6 Executive Team: The Trust’s Executive Team meet weekly to discuss key issues, to share opinions, and to agree actions. However, the Executive Team are not a decision making body as authority remains with the Trust Board, delegated to the Trust Management Board as appropriate. The Executive Team is a problem solving group, working to foresee risks, identify opportunities, and discuss how best to support Trust Management Board.
5.7 Staff Side Liaison: The Trust recognises the importance of appropriate communication and collaboration with ‘staff side’, as representatives of the Trust’s workforce. Two groups exist to enable this process:
11 | P a g e
Reference XXX Date of issue XXX Version XX
• Joint Local Negotiation Committee (JLNC): This provides a forum to discuss, consult and negotiate with staff representatives on issues affecting Medical and Dental staff;
• Joint Negotiation and Consultative Committee (JNCC): This provides the equivalent channel for the representatives of all other staff groups.
Though not part of the decision making structure of the Trust, they are important in that they provide the opportunity for the Trust’s leadership and management to engage constructively with the representatives of staff. The Trust’s workforce are critical stakeholders in the organisation, and collaborative relationships are essential.
12 | P a g e
Reference XXX Date of issue XXX Version XX
6.0 Management Structures and Performance Management:
6.1 The Trust is currently organised into Directorates and Clinical Divisions, which form the basic operating units of the Trust, and the foundation for the Scheme of Delegation. Whilst there may be some minor movement of responsibility between divisions and between directorates, the overall functions remain as per this structure. If there is a fundamental change however this document will be reviewed.
6.2 Directorates: Each Directorate is accountable to the Chief Executive, and through him/her to the Board, for:
• Delivering agreed plans and objectives;
• Managing a delegated budget within the terms of the Scheme of Delegation and the SFIs, and;
• Complying with the Trust’s vision and values, strategies, policies and procedures established and approved by the Trust Board.
6.3 Directors: Directors are ultimately responsible for ensuring that their Directorates remain compliant and deliver against their plans and budget.
6.4 Corporate Directorates: Corporate Directorates are responsible for delivering support services to the Trust and front line services:
• Chief Executive’s Office: This includes the Trust Board and central functions including Trust Secretary, Membership, Legal Services and Communications.
Chief Executive’s
Office
Operations Directorate
Estates and Facilities
Directorate
Medical Directors
Office
Chief Nurse’s Office
Finance Directorate
People and Organisational Effectiveness
Directorate
Strategic Development Directorate
Central Operations
Division of Medicine
Division of Surgery and Critical Care
Division of Women & Children’s Services
Division of Clinical Support Services
Division of Community & Therapy Services
Corporate Directorates Front Line Directorates Divisions within Operations Directorate
Trust Secretary
Trust Chairman
Chief Information
Officers Office
13 | P a g e
Reference XXX Date of issue XXX Version XX
• Medical Director’s Office: This is responsible for supporting clinical services and teams in maintaining appropriate clinical Quality governance complianceexpertise including risk, incidents, claims, clinical audit, best practice and assurance, and developing best clinical practice.
• Chief Nurse’s Office: This is responsible for supporting clinical services and teams in delivering safe and caring services to patients, and for supporting development of the Nursing, Midwifery and Allied Health Professionals within the Trust. This office also has responsibility for Safeguarding matters and infection, prevention and control.
• Directorate of Finance: This is responsible for providing the Trust’s leadership and management teams with appropriate financial management information and advice, and for providing financial services including procurement, payments, payroll and pensions, contracts, costing and income and audit and counter fraud services.
• Directorate of People and Organisational Effectiveness: This is responsible for supporting and developing the Trust’s workforce, supporting the Trust’s management teams with human resources advice and workforce information, recruitment and staff records, and organisational development.
• Directorate of Strategic Development Strategy and Planning: This supports the Trust Board and clinical services in developing service plans and strategy, coordinates capital programme projects and develops major capital business cases for the Trust, in addition to leading on the Humber Acute Services Review (HASR) on behalf of the organisation., operates the Trust’s Information Technology infrastructure and information systems, collects and reports clinical data and provides performance and management information to the Trust’s leadership teams.
• Chief Information Officer’s Office: This will lead on digital transformation across the Trust and the wider local health and social care economy. This office will have responsibility of all IM&T/Digital services including IT Operations, Switchboard, Reprographics, Telecoms, Networking, Information Systems (including WebV EPR), Information Services, Information Governance and Clinical Coding. It will collect and report clinical data and provide accurate and timely performance management information to the Trust’s leadership teams.
6.5 Front Line Directorates: These Directorates deliver patient facing services, and associated support services:
• Directorate of Estates and Facilities: This provides non clinical staff to support clinical services, including Hospital Support Assistants and porters. In addition, the Directorate operates and maintains the Trust’s estate and buildings, and manages linked commercial services.
• Operations: This includes the Trust’s clinical services, and associated management and support services.
6.66.5 The Directorate of Operations: This is led by the Chief Operating Officer, and includes five clinical divisions providing direct patient care, and a central operations function providing associated management and support services which are cross-divisional.
6.76.6 Clinical Divisions: Clinical divisions are based on coherent groupings of clinical services, on a cross-site basis. The clinical divisions are:
• Division of Medicine;
14 | P a g e
Reference XXX Date of issue XXX Version XX
• Division of Surgery and Critical Care;
• Division of Women and Children’s Services;
• Division of Clinical Support Services;
• Division of Community and Therapy Services.
Details of services within each Division can be found on the Trust’s intranet.
6.86.7 Divisional Clinical Directors: Each clinical division is led by a Divisional Clinical Director, supported by a management team. The Divisional Clinical Director is central to ensuring that the organisation is appropriately clinically led. The Divisional Clinical Director (though not a member of the Trust Board and accountable to the Chief Operating Officer rather than directly to the Chief Executive) is ultimately responsible for ensuring that their Division remains compliant with Trust visons, strategies, policies and procedures, and delivers against plans and budget.
6.96.8 Divisional Schemes of Delegation: Each Divisional Clinical Director is responsible for ensuring that their Division has in place an appropriate Scheme of Delegation which is in line with the levels of authority set out in this document, making clear who has the authority to make decisions and commit resources. This Scheme of Delegation must be compliant with corporate policies, and must be kept up to date. This is a key control document for each Division, and the organisation.
6.106.9 Central Operations Functions: Some elements of the Directorate of Operations are not allocated to divisions, but are operated centrally to support all divisions. These functions currently include Directorate senior management and site management. The Chief Operating Officer is also responsible for ensuring that an appropriate Scheme of Delegation, which is in line with the levels of authority set out in this document, is in place for central operations functions.
6.116.10 Performance Management Framework: The Trust sets out in its Performance Management Framework the principles to be used in scrutinising Directorates and Divisions concerning their operational, quality and financial performance. This includes the measures available to the Trust Board in withdrawing delegated authority from a Director, in whole or in part, and the grounds on which such action might be taken.
6.126.11 Performance Management Arrangements within Operations: Clinical Directorates have their performance reviewed through the Chief Operating Officer’s review process, with regular performance improvement meetings.
15 | P a g e
Reference XXX Date of issue XXX Version XX
7. Powers Retained by the Board
7.1 Code of Accountability of the Trust Board
The Code of Accountability, which has been adopted by the Trust, requires the Board to determine which decision making powers it retains at Trust Board level, and does not delegate. These reserved matters are set out in paragraphs 7.2 to 7.10 below, and in effect constitute the core duties of the Trust Board.
7.2 General Enabling Provisions
7.2.1 The Board may determine any matter it wishes in full session within its statutory powers and conditions of the Foundation Trust Provider Licence.
7.2.2 Equally, the Board may choose, in full session within its statutory powers and conditions of the Foundation Trust Provider Licence, to specifically delegate responsibility for any of its reserved powers, having fully defined the terms of such delegation.
7.3 Regulation and Control:
7.3.1 Approval of the Trust Constitution and Standing Orders (SOs), a schedule of matters reserved to the Board, and Standing Financial Instructions (SFIs) for the regulation of its proceedings and business.
7.3.2 Approval of a Scheme of Delegation of powers from the Board to officers.
7.3.3 Requiring and receiving the declaration of Directors’ interests which may conflict with those of the Foundation Trust, and determining the extent to which that Director may remain involved with the matter under consideration.
7.3.4 Disciplining Directors who are in breach of statutory requirements of SOs or SFIs.
7.3.5 Approval of the disciplinary procedure for employees of the Trust.
7.3.6 Approval of arrangements for dealing with complaints.
7.3.7 Adoption of or substantial modification to the structures and procedures used by the Trust to carry out its operations.
7.3.8 Receiving reports from its sub-committees, and to take appropriate action in response to issues raised by those committees.
7.3.9 Confirming the recommendations of any of the Trust’s committees, where the committee does not have delegated executive powers.
7.3.10 Establishing terms of reference and reporting arrangements of the formal sub-committees of the Trust Board.
7.3.11 Noting of any urgent business decisions taken by the Chairman and/or Chief Executive.
7.3.12 Approval of arrangements relating to the discharge of the Trust’s responsibilities as a corporate trustee for Charitable Funds.
16 | P a g e
Reference XXX Date of issue XXX Version XX
7.4 Appointments:
7.4.1 The creation and dissolution of formal sub-committees of the Trust Board.
7.4.2 The appointment of members of any sub-committee of the Trust Board.
7.5 Arrangements for Discharging Statutory Responsibilities:
7.5.1 Approving management responsibilities, arrangements and policies which relate to the fulfilment of a statutory function.
7.6 Business Plans and Budgets:
7.6.1 Defining the strategic and operational aims and objectives of the Trust.
7.6.2 Each year, approving a Trust Plan which is submitted to the Independent Regulator which includes:
• assumptions on service delivery and requirements;
• contract and associated income assumptions;
• expenditure plans and associated assumptions;
• savings plans on revenue;
• capital expenditure programmes;
• plans for managing working capital and cash; and
• any non-revenue financing arrangements, such as loans.
7.6.3 Overall approval of programmes of investment.
7.7 Direct Operational Decisions:
7.7.1 Acquisition and disposal of land and/or buildings.
7.7.2 The introduction or discontinuance of any significant activity or operation. An activity or operation shall be regarded as significant in line with the financial limit set out in the Scheme of Delegation at Appendix A.
7.7.3 Approval of individual contracts (other than NHS contracts) of a capital or revenue nature in line with the financial limits set out in the Scheme of Delegation at Appendix A.
7.7.4 Approval of individual losses, write offs and compensation payments in line with SFI 13.2.8.
7.7.5 Agreeing action on litigation not covered by CNST or RPST against or on behalf of the Trust.
7.7.6 Approval of acquiring or granting new leases in line with SFI 9.6.1(a).
7.8 Financial and Performance Reporting Arrangements:
7.8.1 Continuous appraisal of the affairs of the Trust by means of receipt of reports, as specified by the Trust Board, from Directors, Committees and officers of the Trust. All monitoring returns
17 | P a g e
Reference XXX Date of issue XXX Version XX
required by the Independent Regulator and the Charity Commission shall be reported, at least in summary, to the Trust Board.
7.8.2 Approval of the opening or closing of any bank or investment account.
7.8.3 Consideration and approval of the Foundation Trust’s annual report, including the annual financial accounts and quality accounts.
7.8.4 As Corporate Trustee, receipt and approval of the annual report for Charitable Funds.
7.8.5 Receipt of the minutes of the Finance and Performance Committee meetings, taking appropriate action in the light of recommendations emanating from it.
7.9 Audit Arrangements:
7.9.1 Approval of internal audit arrangements (including arrangements for the separate audit of Charitable Funds).
7.9.2 Receipt of the minutes of the Audit, Risk and Governance Committee meetings, and take appropriate action.
7.9.3 Receipt of the annual management letter received from the external auditor, and agreement of action on any recommendations, where appropriate, from the Audit, Risk and Governance Committee.
7.9.4 Receipt of the annual report including the Annual Governance Statement and Head of Internal Audit Opinion received from the internal auditor, and the agreement of action on the any recommendations, where appropriate, from the Audit, Risk and Governance Committee.
7.9.5 Ensuring appropriate support arrangements are in place to enable the Council of Governors to carry out its duties in appointing and continued engagement of the External Auditor.
7.10 Risk Monitoring and Management:
7.10.1 Approval and monitoring of the Trust’s policies and procedures for the management of risk.
18 | P a g e
Reference XXX Date of issue XXX Version XX
8. Scheme of Delegation of Powers from the Board
8.1 Role of the Chief Executive
8.1.1 All powers of the Trust which have not been retained as reserved by the Board or delegated to an Executive Committee or Trust Board sub-committee shall be exercised on behalf of the Board by the Chief Executive. The Chief Executive shall prepare a Scheme of Delegation identifying which functions they shall perform personally and which functions have been delegated to other Directors and officers.
8.1.2 All powers delegated by the Chief Executive can be re-assumed should the need arise. The Chief Executive is the Accountable Officer.
8.2 Caution over the Use of Delegated Powers
8.2.1 Powers are delegated to Directors and officers on the understanding that they will not exercise delegated powers in a manner which is likely to be a cause for public concern, or that are not in the best interests of the Trust overall.
8.3 Directors’ Ability to Delegate their own Delegated Powers
8.3.1 The Scheme of Delegation shows only the overview of delegation within the Trust. The Scheme of Delegation is to be used in conjunction with the systems of budgetary control and other established procedures within the Directorates and Divisions of the Trust. The Scheme of Delegation (Appendix A) sets out the limits applicable to Directors in delegating their authority.
8.4 Absence of Director or Officer to Whom Powers have been Delegated
8.4.1 In the absence of a Director or officer to whom powers have been delegated, those powers shall be exercised by that Director or officer’s superior, unless there is a designated deputy or interim post holder, or appropriate alternative arrangements have been approved by the Chief Executive.
8.5 Executive Committees and Trust Board Sub-Committees
8.5.1 The Board may determine that certain of its powers shall be exercised by Executive Committees or Board sub-committees. The composition and terms of reference of such committees shall be that determined and approved by the Board from time to time, taking into account where necessary the requirements of the Independent Regulator and/or the Charity Commissioners (including the need to appoint an Audit Committee and a Remuneration Committee).
8.5.2 The Board shall determine the responsibility, scope and reporting requirements in respect of all Executive Committees or Trust Board sub-committees. Committees may not delegate executive powers to other subsidiary committees unless expressly authorised by the Board.
8.6 Delegation from Directors to Officers
8.6.1 Each Director is responsible for the delegation within their Directorate or Division, and should produce a Scheme of Delegation to this effect which is in line with the levels of authority set out in this document.
8.6.2 Divisional and Directorate Schemes of Delegation must include clear accountability and delegation arrangements for budget management, and procedures for approval of expenditure.
19 | P a g e
Reference XXX Date of issue XXX Version XX
9. Levels of Delegated Authority within the Scheme of Delegation
9.1 Authority Levels: The Trust operates a simplified range of authority levels (Appendix A), which are used to construct Directorate and Divisional Schemes of Delegation. The aims of the levels are to provide clarity of authority, and to enable effective management decision making at the most appropriate level, supporting the smooth running of the organisation.
9.2 Effective Controls: The authorisation levels are also designed to limit the numbers of staff able to unilaterally commit resources, in line with NHS Improvement’s best practice requirements. This has to be balanced against allowing the organisation to effectively carry out its operations.
9.3 Compliance with SOs and SFIs: Authorisation levels do not exempt any officer of the Trust from maintaining compliance with the Trust’s Constitution, Standing Orders, or Standing Financial Instructions.
9.4 Levels of Authority:
9.5 Specific authority and powers at each level are set out in the following sections, which look at
principal areas of management decision making and control.
Chief Executive:
Accountable Officer and Prime Budget
Holder
Directors:
Directorate and Divisional Budget
Holders
Senior Managers:
Budget Managers
Managers and Supervisors:
Authorised Signatories
The Trust Board delegates budgetary responsibility to the Chief Executive, as
the Prime Budget Holder.
The Chief Executive in turn delegates to Directors.
Directorate and Divisional Budget Holders are accountable for the budget and use of resources delegated to them.
They must also ensure that an appropriate scheme of delegation is in place to cover their area of delegated
authority which is in line with the levels of authority set out in this document.
Budget Managers have delegated powers in line with the Directorate or
Divisional scheme of delegation, and are accountable for management decision
making and use of resources in the area over which they have delegated authority.
Authorised Signatories are managers and supervisors authorised to sign off expenditure within budgets in line with
agreed polices and procedures.
20 | P a g e
Reference XXX Date of issue XXX Version XX 10. Agreeing Contracts for Trust Services
10.1 Delegation to Lead Director: The Chief Executive, on behalf of the Trust Board, delegates to the Director of Finance and the Chief Operating Officer (with advice from the Medical Director and Chief Nurse on issues of quality and safety as necessary) responsibility for negotiating contracts for its services with commissioners. The Director of Finance is responsible for reporting regularly to the Trust Board on progress in negotiating contracts, and on monitoring and delivery against contracts in year. Such contracts will be formally signed by the Chief Executive on behalf of the Trust Board, based on the recommendation of the Director of Finance and Chief Operating Officer.
10.2 Contracting Objectives: Contracts should be agreed in accordance with prevailing NHS rules and guidelines, and should be constructed to support service development plans agreed by the wider community.
10.3 Performance and Quality Parameters within Contracts: Contracts should reflect the service objectives agreed and signed off by the Trust Board as part of the business planning process, subject to the constraints arising from contract negotiation with Commissioners.
10.4 Financial Parameters within Contracts: Contracts should align with the financial parameters agreed by the Trust Board as part of its annual business planning process, subject to the constraints of negotiations with Commissioners.
10.5 Powers and Duties:
Trust Board:
Governing Body
The Trust Board oversees the business planning process, and signs off the financial plan within
which contracts should be set.
Chief Executive:
Accountable Officer
Director of Finance and Chief Operating Officer:
Lead Directors
Directors:
Directorate and Divisional Budget
Holders
The Chief Executive delegates the Director of Finance and Chief Operating Officer to negotiate contracts for Trust services with Commissioners.
The Chief Executive will formally sign off such contracts on behalf of the Trust Board, based on the recommendation of the Director of Finance
and Chief Operating Officer.
The Director of Finance and Chief Operating Officer are responsible for negotiating contracts
with Commissioners on behalf of the Trust, in line with agreed service plans and financial plans, and making recommendations to the
Chief Executive.
Directors are responsible for supporting the contracting process, and delivery of contracting and income objectives through their Directorate
and Divisional plans.
21 | P a g e
Reference XXX Date of issue XXX Version XX
11. Managing Pay Expenditure and Staffing Costs
11.1 Delegation of Budget to Divisional/Directorate Budget Holders: The Trust Board agrees the financial plan and budget for each planning period, usually the coming financial year, before the commencement of the period. This budget will include a proposed allocation for the Chief Executive to delegate to the Directorate and Divisional Budget Holders (Directors).
11.2 Budgeting for Pay: Divisional and Directorate Budget Holders will decide the allocation of their budget between pay and non-pay. They may change this in year through virements. Divisional and Directorate Budget Holders remain accountable for overall budget management, and delivery against other service and performance objectives.
11.3 Delegation: Directors may delegate budgets as they deem appropriate to best empower their team and deliver effective control.
11.4 Powers: Powers available to each level of delegated authority, and powers held by the Trust Board’s Executive Committees, are set out below:
Remuneration Committee:
Executive Committee
The Remuneration Committee is delegated with: • Setting Director and other VSM remuneration; • Approving Interim engagements above financial thresholds set
by the Regulator; • Approving Interim engagements where pay rates exceed
Regulator guidance; • Approving any redundancy or early retirement payments; • Approving arrangements for additional payments for
performance or excellence; • Approving arrangements for additional payments for
recruitment or retention. • Approve pay or other terms and conditions outside nationally
set contracts;
Trust Management
Board:
Executive Committee
The Trust Management Board will:
• Make recommendations to the Remuneration Committee on pay or other terms and conditions outside nationally set contracts;
• Make recommendations to the Remuneration Committee on pay rates for non-substantive engagements, including bank rates and extra contractual duty rates.
Chief Executive:
Accountable Officer and Prime Budget
Holder
The Chief Executive as Accountable Officer delegates the pay budget, and:
• Approves any control measures which limit the powers of
Director/Divisional Budget Holders, or their Budget Managers.
22 | P a g e
Reference XXX Date of issue XXX Version XX 11.5 All staff are bound to all Trust policies and procedures when exercising any of these powers.
11.6 Where Directors delegate budgetary control, financial delegation will be subject to confirmation that those staff have the necessary skills and competencies relevant to the scale and complexity of the budget responsibility delegated to them. Financial training and support will be arranged where necessary and compliance with this training is required.
Directors:
Directorate and Divisional Budget
Holders
Directorate and Divisional Budget Holders have the power to: • Agree establishments and changes to establishments within
their funded budget allocation with the approval of the Director of Finance and the Director of People and Organisational Effectiveness, in line with Appendix A of the Scheme of Delegation;
• Agree upgrades or incremental progression within their budget, in line with Corporate policies and with the approval of the Director of People and Organisational Effectiveness, in line with Appendix A of the Scheme of Delegation;
• In addition, they may exercise any powers available to their delegated budget managers and authorised signatories.
Senior Managers:
Budget Managers
Budget Managers have delegated powers to: • Adjust establishments within their existing delegated budget; • Recruit to posts within their budgeted establishment; • Authorise payroll data forms affecting pay, new starters,
change forms and termination forms, for staff working within their delegated area of responsibility (in line with their Directorate/Divisional SoD);
• In addition, budget managers may exercise any powers held by authorised signatories for the budgets within their area of responsibility.
Managers and Supervisors:
Authorised Signatories
Authorised Signatories are empowered to: • Authorise timesheets and electronic shift records (in line with
their Directorate/Divisional SoD); • Authorise travel claims and subsistence expenses within agreed
policies and procedures (in line with their Directorate/Divisional SoD).
23 | P a g e
Reference XXX Date of issue XXX Version XX 12. Managing Non-Pay Expenditure and Commitments
12.1 Delegation of Budget to Divisional/Directorate Budget Holders: The Trust Board agrees the financial plan and budget for each planning period, usually the coming financial year, before the commencement of the period. This budget will include a proposed allocation for the Chief Executive to delegate to the Directorate and Divisional Budget Holders (Directors).
12.2 Budgeting for Non-Pay: Divisional and Directorate Budget Holders will decide the allocation of their budget between pay and non-pay. They may change this in year through virements. Divisional and Directorate Budget Holders remain accountable for overall budget management, and delivery against other service and performance objectives.
12.3 Delegation: Directors may delegate budgets as they deem appropriate to best empower their team and deliver effective control.
12.4 Powers: Powers available to each level of delegated authority, and powers held by the Trust Board’s Executive Committees, are set out below:
Trust Board:
Governing Body
The Trust Board retains authority to: • Agree contracts in line with financial limits set out in the Scheme
of Delegation at Appendix A; • Agree instigation of legal action in contract disputes outside
standard procedures.
Chief Executive or Director of Finance:
Authorising Executives
The Authorising Executives may authorise expenditure commitments above Director limits, to ensure appropriate compliance: • Approve expenditure in line with financial limits set out in the
Scheme of Delegation at Appendix A.
Directors:
Directorate and Divisional Budget
Holders
Directorate and Divisional Budget Holders have the power to: • Approve expenditure in line with financial limits set out in the
Scheme of Delegation at Appendix A; • In addition, they may exercise any powers available to their
delegated budget managers and authorised signatories.
Senior Managers:
Budget Managers
Budget Managers have delegated powers to: • Approve expenditure in line with financial limits set out in the
Scheme of Delegation at Appendix A ; • In addition, budget managers may exercise any powers held by
authorised signatories for the budgets within their area of responsibility.
Managers and Supervisors:
Authorised Signatories
Authorised Signatories are empowered to: • Authorise orders through standard contract systems with agreed
frameworks and prices, in line with financial limits set out in the Scheme of Delegation at Appendix A;
24 | P a g e
Reference XXX Date of issue XXX Version XX
12.5 All staff are bound to all Trust policies and procedures when exercising any of these powers. Refer
also to sections 2.9 and 2.10 of this document.
12.6 Where Directors delegate budgetary control, financial delegation will be subject to confirmation that those staff have the necessary skills and competencies relevant to the scale and complexity of the budget responsibility delegated to them. Financial training and support will be arranged where necessary and compliance with this training is required.
25 | P a g e
Reference XXX Date of issue XXX Version XX
13. Managing Tenders, Quotations and Contracts
13.1 Regulatory Framework Governing Tendering and Awarding Contracts for Services and Supplies: The Trust is required and detailed by law to ensure that such competition for the use of public funds is open, fair and free from bribery and nepotism. Therefore before any commitment is made to incur expenditure, the appropriate procurement procedure must be followed, in line with the requirements relating to tendering and contracting procedures contained within the SFIs.
13.2 Powers: Powers available to each level of delegated authority, and powers held by the Trust Board’s Executive Committees, are set out below:
13.3 Waiving SFI Requirements: In exceptional circumstances it may be impractical to follow the above process. If so a request for Waiver of Standing Financial Instructions (relating to quotations and tenders) must be completed and signed by the relevant Director, before being submitted to the Head of Procurement for review and recommendation to the Director of Finance and Chief Executive, who must both authorise the waiver in line with the Trust’s Waiver Procedure. In the absence of either the Director of Finance or the Chief Executive refer to the Waiver Procedure for instructions on how to proceed. Expenditure should only be committed once a waiver of SFIs has been approved.
13.4 All staff are bound to all applicable Trust policies and procedures when exercising any of these powers. Refer also to sections 2.9 and 2.10 of this document.
Trust Board:
Governing Body
The Trust Board retains authority to: • Set SFIs relating to contracts, procurement and tendering; • Approve individual contracts in line with financial limits set out in
the Scheme of Delegation at Appendix A.
Chief Executive and Director of
Finance:
Authorising Executives
The Authorising Executives must both: • Authorise contract commitments above Director limits, to ensure
appropriate compliance, in line with financial limits set out in the Scheme of Delegation at Appendix A;
• Approve all waivers of SFIs.
Directors:
Directorate and Divisional Budget
Holders
Directorate and Divisional Budget Holders have the power to: • Ensure that all tenders and contract awards are compliant with
OJEU and other regulatory requirements, in liaison with the Procurement Department;
• Ensure that tenders and quotations are obtained in line with the requirements / financial limits set out in the Scheme of Delegation at Appendix A.
• Ensure that Waivers are submitted and approved for all instances where the above SFI requirements cannot be met.
26 | P a g e
Reference XXX Date of issue XXX Version XX 13.5 Each Division and Directorate is bound to maintain appropriate input to the Trust Contract
Register, which maintains a comprehensive listing of the Trust’s contractual commitments. This will allow appropriate Procurement support to contract renewal or re-tendering processes.
13.6 Responsibility for compliance with the Trust’s SFIs resides solely with the relevant Director for their area. However, every member of staff has a responsibility to comply with the SFIs.
27 | P a g e
Reference XXX Date of issue XXX Version XX
14. Managing Capital Expenditure
14.1 Regulatory Framework Capital Expenditure: The Trust Board is responsible for agreeing the capital programme as part of the financial plan. The responsibility for managing the capital programme is delegated to the Trust Management Board.
14.2 Powers: Powers held by the Trust Board’s Executive Committees, are set out below:
14.3 Capital Programme Governance: The Trust Management Board is responsible for ensuring that the
Trust Board remains appropriately informed on progress in delivering the capital programme, and any changes made to the programme within its delegated limits. This extends to ensuring that appropriate project management groups and monitoring arrangements are in place for the whole capital programme.
14.4 All staff are bound to all applicable Trust policies and procedures when exercising any of these powers. Refer also to sections 2.9 and 2.10 of this document.
Trust Board:
Governing Body
The Trust Board will: • Approve an annual capital programme as part of the annual
budget; • Ensure that the capital programme is in line with the Trust’s
strategic priorities; • Ensure that the capital programme is within the Trust’s capital
limits set by Regulators; • Agree variation to the total capital allocation, or variation to
individual elements of the capital programme exceeding in line with financial limits set out in the Scheme of Delegation at Appendix A.
Trust Management
Board:
Executive Committee
The Trust Management Board is empowered to: • Review and manage the capital programme in line with the
limits delegated by the Trust Board, as set out in the Scheme of Delegation at Appendix A;
• Agree capital programme changes within the scope of the overall programme limits, and in line with financial limits set out in the Scheme of Delegation at Appendix A.
• Ensure regular reporting to the Trust Board on delivery progress on the capital programme.
Capital Investment
Board:
TMB Working Group
The Capital Investment Board is empowered to: • Prepare, prioritise, monitor and implement the Trust’s capital
investment programme. • Authorise variations to schemes up to a certain financial value,
as set out in the Scheme of Delegation at Appendix A; • Recommend schemes over a certain financial value to TMB /
Trust Board.
28 | P a g e
AUTHORITY DELEGATED TO: (Note: a tick followed by an asterisk indicates that both delegated officers are required to give authority)
Trust BoardTrust
Management Board
Remuneration Committee
Capital Investment
Board
Chief Executive
Trust Secretary
Medical Director
Chief Nurse
Chief Operating
Officer
Director of Finance
Director of Estates & Facilities
Director of People &
Organisational Effectiveness
Director of Strategic
Development
Chief Information
Officer
Divisional Clinical
Directors
Delegated Budget
Manager
Authorised Signatory
1 BUSINESS PLANNING, BUDGET SETTING, AND MONITORING2 Agreeing Annual Financial Plan (including budgetary allocations, savings and efficiency targets) - - - - - - - - - - - - - - - -
30 Approving redundancy or early retirement payments - all staff - - - - - - - - - - - - - - - -
31 Approving arrangements for additional payments for performance or excellence - - - - - - - - - - - - - - - -
32 Approving arrangements for additional payments for recruitment and retention - - - - - - - - - - - - - - - -
33 Approving pay or other terms and conditions outside nationally set contracts - - - - - - - - - - - - - - - -
34 Approving pay rates for non substantive engagements including bank and extra contractual duty rates - - - - - - - - - - - - - - - -
35 Authority to book clinical / non-clinical agency staff (in line with area's SoD) - - - - -
36 Authority to alter funded establishments within their area of delegated control - - - - - - - - - * - * - - - - -
37 Authority to agree upgrades or incremental progression (via AFC Banding Panel process) - - - - - - - - - - - - - - - -
38 Authority to authorise overtime, time off in lieu, or other exceptional items - - - - 39 Authority to complete payroll data forms affecting pay, new starters, variations & leavers (in line with area's SoD) - - - - -
40 Authority to authorise time sheets and electronic shift records - - - - 41 Authority to authorise travel and subsistence expenditure - - - -
AUTHORITY DELEGATED TO: (Note: a tick followed by an asterisk indicates that both delegated officers are required to give authority)
Trust BoardTrust
Management Board
Remuneration Committee
Capital Investment
Board
Chief Executive
Trust Secretary
Medical Director
Chief Nurse
Chief Operating
Officer
Director of Finance
Director of Estates & Facilities
Director of People &
Organisational Effectiveness
Director of Strategic
Development
Chief Information
Officer
Divisional Clinical
Directors
Delegated Budget
Manager
Authorised Signatory
42 AUTHORITY TO OBTAIN QUOTATIONS, AND TENDERS / WAIVING SFIs FOR QUOTATIONS AND TENDERS43 £0 to £25,000 total value (excl. VAT) - obtain informal quotes ensuring value for money - - - - -
44 £25,001 to £50,000 total value (excl. VAT) - obtain min. of 3 formal quotes via Procurement dept (or waiver req'd) - - - - -
45 £50,001 to OJEU limit total value (excl. VAT) - obtain 4 written competitive tenders via Procurement (or waiver req'd) - - - - - - - -
46 Above OJEU limit total value (excl. VAT) - in line with OJEU tendering requirement via Procurement (or waiver req'd) - - - - - - - -
47 Approval for waiving SFIs for quotations and tenders - - - - * - - - - * - - - - - - -
48 AUTHORITY TO AWARD AND SIGN CONTRACTS (SEE ALSO NHS SERVICE CONTRACTS ABOVE)49 Authorisation of single contracts for longer than 5 years duration (including any option to extend years ) - - - - - - - - - - - - - - - -
50 Authorisation of single contracts for revenue or capital over £2.5m total value (excl. VAT) - - - - - - - - - - - - - - - -
51 Authorisation of single contracts for revenue or capital £500k to £2.5m total value (excl. VAT) - - - - - - - - - - - - - - - -
52 Authorisation of single contracts for revenue or capital up to £500k total value (excl. VAT) - - - - - - - -
53 Authorising extension options contained with contracts - over £250k total value of extension (excl.VAT) - - - - - - - - - - - - - - - -
54 Authorising extension options contained with contracts - £50k to £250k total value of extension (excl.VAT) - - - - * - - - - * - - - - - - -
55 Authorising extension options contained with contracts - up to £50k total value of extension (excl.VAT) - - - - - - -
56 Authorising variations to contract - over £250k total value of variation (excl. VAT) (subject to procurement regs) - - - - - - - - - - - - - - - -
57 Authorising variations to contract - £50k to £250k total value of variation(excl. VAT) (subject to procurement regs) - - - - * - - - - * - - - - - - -
58 Authorising variations to contract - below £50k total value of variation (excl. VAT) (subject to procurement regs) - - - - - - -
59 AUTHORISATION LIMITS - REQUISITIONS AND PURCHASE ORDERS
60 Authorisation of supply chain requisitions up to £5k (excl. VAT) - Ward Managers - - - - 61 Authorisation of requisitions up to £25k (excl. VAT) - Matrons/AGMs/Assistant Directors - - - - -
62 Authorisation of requisitions up to £100k (excl. VAT) - HoN's/GM's/Deputy Directors - - - - - -
63 Authorisation of requisitions up to £500k (excl. VAT) - - - - - - -
67 Carbon Trading with values up to £100k - - - - - - - - - * * - - - - - -
68 Authorisation of extraordinary non-pay expenditure items for which no budget exists. - - - - * - - - - * - - - - - - -
69 Instigating legal action in any contractual dispute with a supplier - - - - - - - - - - - - - - - -
70 BUSINESS CASES WITH MATERIAL STRATEGIC IMPACT - THRESHOLDS71 Capital and non-recurrent spend - in excess of £2.5m total cost - - - - - - - - - - - - - - - -
72 Recurrent revenue commitment - in excess of £1m per year - - - - - - - - - - - - - - - -
73 CAPITAL SCHEMES74 Approving the annual capital programme - - - - - - - - - - - - - - - -
75 Approving variations to the total agreed annual capital programme - - - - - - - - - - - - - - - -
78 Approving variations on scheme cost up to £50k - - - - - - - - - - - - - - - -
79 Selection of architects, quantity surveyors, consultant engineers, and other professional advisors within EU regs - - - - - - - - - - - - - - -
80 AGREEMENTS AND LICENCES81 Establishing, extending or terminating leases with annual rental over £500k - - - - - - - - - - - - - - - -
82 Establishing, extending or terminating leases with annual value £100k to £500k - - - - - - - - - - - - - - - -
83 Establishing, extending or terminating leases with annual rental up to £100k - - - - - - - - - * * - - - - - -
84 Prep / signature of all tenancy agreements/licences for all staff subject to Trust policy on accommodation for staff - - - - - - - - - - - - - - - -
85 Granting of use of Trust property under licence - - - - - - - - - - - - - - - -
120 BANK ACCOUNTS / INVESTMENT OF FUNDS / BORROWING121 Approval of the opening or closing of any bank or investment account (based on recommendation from DoF) - - - - - - - - - - - - - - - -
123 Investment of Exchequer funds - in line with Treasury Management Policy - - - - - - - - - - - - - - - -
124 Investment of funds held on Trust (charitable funds) - Charitable Trustees - - - - - - - - - - - - - - - - -125 Use of borrowing as financing mechanism - normal revenue requirements - - - - * - - - - * - - - - - -
126 Use of borrowing as financing mechanism - special requirements (e.g. capital developments, add'l working capital) - - - - - - - - - - - - - - - -
127 PETTY CASH DISBURSEMENTS (other than through central cashiers offices at each site)
128 Expenditure up to £15 per item - petty cash holder - - - - - - - - - - - - - - - - -129 Expenditure over £15 per item - - - - -
AUTHORITY DELEGATED TO: (Note: a tick followed by an asterisk indicates that both delegated officers are required to give authority)
Trust BoardTrust
Management Board
Remuneration Committee
Capital Investment
Board
Chief Executive
Trust Secretary
Medical Director
Chief Nurse
Chief Operating
Officer
Director of Finance
Director of Estates & Facilities
Director of People &
Organisational Effectiveness
Director of Strategic
Development
Chief Information
Officer
Divisional Clinical
Directors
Delegated Budget
Manager
Authorised Signatory
130 APPROVAL OF INTRODUCTION OR DISCONTINUANCE OF SIGNFICANT ACTIVITY OR OPERATION131 Activity or operation shall be regarded as significant if gross annual income or expenditure is in excess of £2.5m - - - - - - - - - - - - - - - -
132 AUTHORISATION OF INVESTMENT OF NEW EQUITY IN A SPIN OUT COMPANY133 Approval of creation of/participation in spin out companies and collaborative ventures - - - - - - - - - - - - - - - -
134 Approval of Trust withdrawal/cessation of spin out company, joint venture and collaborative venture - - - - - - - - - - - - - - - -
135 Approval of sale of spin out company, joint venture and collaborative venture - - - - - - - - - - - - - - - -
136 Investment in joint venture or other external structure - - - - - - - - - - - - - - - -
137 Delegated power to act as representative in collaborative venture once approved by the Trust Board - - - - - - - - - - - - - - - -
147 Approval of Material changes to IP policy - - - - - - - - - - - - - - - -
148 Departure from inventor reward in IP policy - - - - - - - - - - - - - - - -
149 REPORTING OF INCIDENTS TO THE POLICE150 Fraud - - - - - - - - - - - - - - - -
151 Other - - - - - - - -
152 GOVERNANCE / RISK MANAGEMENT153 Responsible for ensuring effective governance / risk management arrangements in place - - - - - - - - - - - - - -
154 Responsible for ensuring policies / procedures & meeting structures are in place & provision of advice - - - - - - - - - - - - - - -
155 Responsible for ensuring governance is 'owned by all' - - 156 MANAGEMENT OF INCIDENTS / SIs, COMPLAINTS / CONCERNS AND CLAIMS157 Overall responsibility for sufficient systems and processes to report and respond to incidents / SIs - - - - - - - - - - - - - - - -
158 Responsibility for ensuring incidents/SIs are investigated thoroughly and in a timely manner - - - - - -
159 Responsibility to ensure appropriate remedial action is taken / lessons learnt are shared for incidents/Si's - - - - - -
160 Overall responsibility for ensuring that all complaints and concerns are dealt with effectively - - - - - - - - - - - - - - - -
161 Responsibility for ensuring complaints are investigated thoroughly and within agreed timescales - - - - - -
162 Responsibility for ensuring appropriate remedial action is taken / lessons learnt are shared for complaints - - - - - -
163 Responsibility for ensuring that claims are dealt in accordance with agreed procedures and timescales - - - - - - - - - - - - - - - -
164 Responsibility for ensuring provision of timely information to enable the Trust to respond effectively to claims - - - - - -
165 Responsibility for ensuring appropriate remedial action is taken / lessons learnt are shared for claims - - - - - -
167 COMPLIANCE WITH ALL STATUTORY LEGISLATION AND HEALTH AND SAFETY REQUIREMENTS 168 Review of Fire Precautions (Nominated Fire Officer) - - - - - - - - - - - - - - - -
169 Responsible for ensuring adequate processes are in place to ensure compliance - - - - - - - - - - - - - - - -
170 Responsible for ensuring staff awareness and compliance with H&S policies and procedures - - - - - -
171 Responsible for identification of designated leads to co-ordinate health & safety arrangements at local level - - - - - -
172 Review of compliance with environmental regulations, for example those relating to clean air and waste disposal - - - - - - - - - - - - - - - -
187Approval to permanently delete IT systems (on the rec of Director of Strategy & Planning Chief Information Officer and Digital Strategy Board) - - - - - - - - - - - - - - - -
188 IMPLEMENTATION OF NICE GUIDANCE 189 Overall responsibility for ensuring arrangements are in place for the Trust to implement NICE guidance - - - - - - - - - - - - - - - -
190 Ensuring operational arrangements are in place to ensure implementation of NICE guidance - - - - - - - - - - -
191 Responsible for escalating proposed deviations in accordance with NICE Implementation Policy to TMB - - - - - - - - - - - -
192 Responsible for escalating proposed deviations in accordance with NICE Implementation Policy to Trust Board - - - - - - - - - - - - - - - -
196 Relationships with Press - within hours - Associate Director of Communications - - - - - - - - - - - - - - - - -
197 Relationships with Press - outside hours - On-Call Director / Associate Director of Communications - - - - - - - - - - - - - - - - -198 The keeping of Registers for Declarations of Interest, Hospitality, Sponsorship and Gifts - all staff - - - - - - - - - - - - - - -
199 Attestation of sealings in accordance with Standing Orders - - - - - - - - - - - - - - - -
200 The keeping of a register of sealings - - - - - - - - - - - - - - -
201 Compliance with requirements of the Civil Contingencies Act - - - - - - - - - - - - - - - -
Directorate of Finance
STANDING FINANCIAL INSTRUCTIONS
INCORPORATING STANDING ORDERS RELATING TO TENDERING AND CONTRACTING PROCEDURES
Reference: DCM076 Version: This version issued: Result of last review: Minor changes Date approved by owner (if applicable):
Date approved: Approving body: Trust Audit, Risk and Governance Committee / Trust
Board Date for review: Owner: Marcus Hassall, Director of Finance Document type: Miscellaneous Number of pages: 65 (including front sheet) Author / Contact:
Marcus Hassall, Director of Finance and Sally Stevenson, Assistant Director of Finance – Compliance and Counter Fraud
Northern Lincolnshire and Goole NHS Foundation Trust actively seeks to promote equality of opportunity. The Trust seeks to ensure that no employee, service user, or member of the public is unlawfully discriminated against for any reason, including the “protected characteristics” as defined in the Equality Act 2010. These principles will be expected to be upheld by all who act on behalf of the Trust, with respect to all aspects of Equality.
Reference DCM076 Date of issue Version
Contents
Section Item Page
1.0 Introduction 3
2.0 Annual Accounts and Reports 8
3.0 Audit and Counter Fraud 9
4.0 Business Planning, Budgets, Budgetary Control and Monitoring 15
5.0 Agreements for Provision of Services 19
6.0 Bank Accounts 21
7.0 Income, Fees and Charges & Security of Cash, Cheques and Other Negotiable Instruments
23
8.0 Terms of Service and Payments of Directors and Officers 26
9.0 Non-Pay Expenditure 29
10.0 Stores and Receipt of Goods 34
11.0 External Borrowing and Investments 35
12.0 Capital Investment, Fixed Asset Registers and Security of Assets 36
13.0 Disposals and Condemnations, Losses and Special Payments 40
14.0 Computerised Financial Data Storage and Security 42
15.0 Patients’ Property 44
16.0 Funds Held on Trust 45
17.0 Risk Management and Insurance 46
18.0 Standards of Business Conduct 48
19.0 Retention of Documents 50
Appendix A Standing Orders in Relation to Tendering and Contract Procedures 51
Appendix B Waiver Procedure 61
Printed copies valid only if separately controlled Page 2 of 65
Reference DCM076 Date of issue Version
1.0 Introduction
1.1 General
1.1.1 Northern Lincolnshire and Goole NHS Foundation Trust (hereafter referred to as ‘the Trust’) achieved Foundation Trust status on 1st May 2007 following approval by the Independent Regulator at that time (Monitor).
1.1.2 These Standing Financial Instructions (SFIs), incorporating the Trust’s Standing Orders (SOs) relating to Tendering and Contracting Procedures, provide a comprehensive business and financial framework within which all executive directors, non-executive directors and officers of the Trust are expected to work. All executive and non-executive directors and all officers should be aware of the existence of these financial governance documents and, where necessary, be familiar with the detailed provisions contained therein.
1.1.3 These Standing Financial Instructions (SFIs) shall have effect as if incorporated in the Constitution and Standing Orders (SOs) of the Trust.
1.1.4 These documents fulfil the dual role of protecting the Trust’s interests and protecting officers from any possible accusation that they have acted less than properly in the conduct of their duties.
1.1.5 These SFIs detail the financial responsibilities, policies and procedures to be adopted by the Trust. They are designed to ensure that its financial transactions are carried out in accordance with the law and the requirements of the Independent Regulator in order to achieve probity, accuracy, economy, efficiency and effectiveness. They should be used in conjunction with the ‘Trust Scheme of Delegation and Powers Reserved for the Trust Board’ formally adopted by the Trust (collectively called the Scheme of Delegation).
1.1.6 These SFIs identify the financial responsibilities which apply to everyone working for the Trust and its constituent organisations. They do not provide detailed procedural advice. These statements should therefore be read in conjunction with the relevant detailed departmental and financial policies and procedure notes. All financial policies and procedures must be approved by the Director of Finance and the appropriate committee of the Trust Board (e.g. the Audit, Risk and Governance Committee or Trust Management Board).
1.1.7 Should any difficulties arise regarding the interpretation or application of any of the SFIs, then the advice of the Director of Finance 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 (contained within the Trust Constitution), particularly in relation to tending and contracting procedures, which were previously contained within the Trust Constitution but are now reproduced within this document at Appendix A for ease of reference.
1.1.8 Failure to comply with SFIs and SOs is a disciplinary matter that could result in dismissal.
1.1.9 Overriding Standing Financial Instructions - if for any reason these SFIs are not complied with, full details of the non-compliance and justification for non-compliance shall be reported to the Director of Finance and escalated to the Audit. Risk and Governance Committee as appropriate for referring action or ratification. All
Printed copies valid only if separately controlled Page 3 of 65
Reference DCM076 Date of issue Version
members of the Trust Board and officers have a duty to disclose any non-compliance with these SFIs to the Director of Finance as soon as possible.
1.2 Interpretation
1.2.1 Any expression to which a meaning is given in the 2006 National Health Service Act and other Acts relating to the NHS, or in financial directions and guidance issued by the Independent Regulator made under such Acts or regulations made under such Acts, shall have the same meaning in these SFIs. The following terms shall, where the context permits, have the meanings set out below:
“Accounting Officer” means the person who is responsible and accountable for the funds entrusted to the Trust. They shall be responsible for ensuring the proper stewardship of public funds and assets. For this Trust, it shall be the Chief Executive
“Audit, Risk and Governance Committee” means the committee established in accordance with the Constitution (section 39) and SFI 3.1
“Authorisation” means the Trust’s terms of authorisation as authorised by the Independent Regulator (NHSI)
“Board of Directors” and (unless the context otherwise requires) “Board” means the executive and non-executive directors of the Trust, including the Chairman, collectively as a body
“Budget” means a resource, expressed in financial terms, 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 officer with delegated authority to manage finances (income and expenditure) for a specific area of the organisation
“Chairman of the Board (or Trust)” is the person appointed by the Council of Governors to lead the Board of Directors and to ensure that it successfully discharges its overall responsibility for the Trust as a whole. The expression “the Chairman” shall be deemed to include the vice Chairman or such other person so appointed if the Chairman is absent from the meeting or is otherwise unavailable
“Chief Executive” means the Chief Executive Officer (and Accounting Officer) of the Trust appointed in accordance with the Constitution
“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 of the Board of Directors, appointed by the Board and which reports to the Board
“Committee member” means a person appointed by the Board to sit on or to chair a specific committee
“Constitution” means the Constitution of the Trust as authorised by the Independent Regulator
“Council of Governors” means the Council of Governors of the Trust, as constituted by the Constitution
Printed copies valid only if separately controlled Page 4 of 65
Reference DCM076 Date of issue Version
“Director of Finance” means the chief financial officer of the Trust appointed in accordance with the Constitution
“Employee” means a person paid via the payroll of the Trust, or for whom the Trust has responsibility for making payroll arrangements, but excluding Non-Executive Directors
“Executive Director” means a Member of the Board of Directors who holds an executive office of the Trust appointed in accordance with the Constitution
"External Auditor" means the external auditor appointed by the Council of Governors in accordance with the Constitution
“Funds Held on Trust” means those funds which the Trust holds at its date of incorporation or chooses subsequently to accept. Such funds may or may not be charitable
"Independent Regulator" means NHS Improvement (NHSI), the regulator of NHS Trusts and Foundation Trusts
"Internal Audit" means the function described in SFI 3.4
“Legal Advisor” means the properly qualified person appointed by the Trust to provide legal advice
“Licence” means the NHS Provider Licence issued by the Independent Regulator (NHSI)
“Local Counter Fraud Specialist” means the officer who has daily operational responsibility for implementing the requirements of the relevant service conditions of the NHS Standard Contract in relation to counter fraud arrangements
"Member of the Board" means an Executive or Non-Executive Director. (Member of the Board in relation to the Board of Directors includes its Chairman)
“Nominated Officer” means an officer charged with the responsibility for discharging specific tasks within Standing Orders and Standing Financial Instructions
“Non-Executive Director” means a Member of the Board of Directors who does not hold an executive office of the Trust and is appointed in accordance with the Constitution. This includes the Chairman of the Trust.
“Officer” means an employee of the Trust or any other person holding a paid appointment or office with the Trust and employee shall be deemed to include employees of third parties contracted to the Trust when acting on behalf of the Trust
“Remuneration Committee” means a committee carrying out the functions described in SFI 8.1
“Scheme of Delegation and Trust Devolution Policy” means the formal Trust document containing the Reservation of Powers to the Board and the Scheme of Delegation for the Trust
“SFIs” means these Standing Financial Instructions of the Trust
Printed copies valid only if separately controlled Page 5 of 65
Reference DCM076 Date of issue Version
“SOs” means the Standing Orders of the Trust (as contained within the Trust Constitution)
“the 2006 Act” means the National Health Service Act 2006
“Trust” means Northern Lincolnshire and Goole NHS Foundation Trust.
1.2.2 Wherever the title Chief Executive, Director of Finance or other nominated officer is used in these instructions, it shall be deemed to include such other director or officers who have been duly authorised to represent them.
1.3 Responsibilities and Delegation
1.3.1 The Board of Directors has resolved that certain powers and decisions may only be exercised by the Board of Directors in formal session. These are set out in the ’Powers Retained by the Board’ contained within the Trust Scheme of Delegation document.
1.3.2 The Board of Directors will delegate responsibility for the performance of its functions to executive directors or committees of the Board in accordance with the Scheme of Delegation document formally adopted by the Trust. The Board must approve the membership and terms of reference of all committees reporting directly to the Board. The extent of delegation will be kept under review by the Board.
1.3.3 The Board of Directors exercises financial supervision and control by:
(a) formulating the financial strategy;
(b) requiring the submission and approval of budgets within an approved financial plan;
(c) defining and approving essential features in respect of important procedures and financial systems (including the need to obtain value for money); and
(d) defining specific delegated responsibilities placed on directors and employees as indicated in the Scheme of Delegation document containing the powers of delegation and reservations as the Trust has established.
1.3.4 The Chief Executive has overall executive responsibility for the Trust's activities, is responsible to the Board of Directors for ensuring that its financial obligations and targets are met and has overall responsibility for the Trust’s system of internal control. Within these SFIs, it is acknowledged that the Chief Executive is ultimately accountable to the Board of Directors and as Accounting Officer, to the Independent Regulator and to Parliament for ensuring that the Board of Directors meets its obligation to perform its functions within the available financial resources. The Chief Executive will at all times comply with the NHS Foundation Trust Accounting Officer Memorandum (August 2015).
1.3.5 The Chief Executive and Director of Finance will, as far as is appropriate, delegate their detailed responsibilities but they remain accountable for financial control.
1.3.6 It is a duty of the Chief Executive to ensure that existing directors and officers and all new appointees are notified of and put in a position to understand their responsibilities within these SFIs.
Printed copies valid only if separately controlled Page 6 of 65
Reference DCM076 Date of issue Version
1.3.7 The Director of Finance is responsible for:
(a) Ensuring that these SFIs and ensuring that they are appropriate and up to date;
(b) implementing the Trust's financial policies and for co-ordinating any corrective action necessary to further these policies;
(c) 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 SFIs;
(d) 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
(e) without prejudice to any other functions of directors and employees to the Trust:
i. the provision of financial advice to the Trust and its directors and employees;
ii. the design, implementation and supervision of systems of internal financial control; and
iii. 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.
1.3.8 All Directors and Officers, 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; and
(d) conforming to the requirements of the Independent Regulator, the Provider Licence, the Trust Constitution, Standing Orders, Standing Financial Instructions, financial policies and procedures and the Scheme of Delegation.
1.3.9 Any contractor, or officer 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 SFIs. It is the responsibility of the Chief Executive to ensure that such persons are made aware of this.
1.3.10 For any and all directors and officers who carry out a financial function, the form in which financial records are kept and the manner in which directors and officers discharge their duties must be to the satisfaction of the Director of Finance.
1.3.11 It shall be the duty of any officer having evidence of, or reason to suspect, financial or other irregularities or impropriety in relation to these SFIs to report these suspicions without delay to the Director of Finance and/or the Trust’s Local Counter Fraud Specialist for further investigation and action as appropriate, in line with the Trust’s ‘Local Counter Fraud, Bribery and Corruption Policy and Response Plan’.
Printed copies valid only if separately controlled Page 7 of 65
Reference DCM076 Date of issue Version
2.0 Annual Accounts and Reports
2.1 The Director of Finance, on behalf of the Trust, will:
(a) keep accounts and in respect of each financial year must prepare annual financial accounts, in such form as the Independent Regulator may, with the approval of HM Treasury, direct
(b) ensure that, in preparing annual accounts, the Trust complies with any directions given by the Independent Regulator with the approval of HM Treasury as to:
i. the methods and principles according to which the accounts are to be prepared; and
ii. the information to be given in the accounts;
(c) ensure that a copy of the annual accounts and any report of the External Auditor on them are laid before Parliament and that copies of these documents are sent to the Independent Regulator in accordance with the timescales prescribed.
2.2 The Trust’s annual accounts, financial returns and annual report must be audited by the External Auditor in accordance with appropriate auditing standards.
2.3 The Trust's Audited Annual Accounts (including the Auditor’s report) must be presented to the Board of Directors for approval or the Audit, Risk and Governance Committee (when specifically delegated the power to do so, under the authority of the Board of Directors) and received by the Council of Governors at a public meeting by 30th September each year. The Trust’s audited accounts must be made available to the public.
2.4 The Associate Director of Communications and Engagement, supported by the Trust Secretary, on behalf of the Trust, will prepare an annual report in accordance with the requirements of NHSI’s NHS Foundation Trust Annual Reporting Manual. This annual report will be presented to the Board of Directors for approval and received by the Council of Governors at a public meeting. A copy will be forwarded to the Independent Regulator in line with the prescribed timescales.
Printed copies valid only if separately controlled Page 8 of 65
Reference DCM076 Date of issue Version
3.0 Audit and Counter Fraud
3.1 Audit, Risk and Governance Committee
3.1.1 In accordance with the Trust Constitution and SOs (and as set out in The NHS Foundation Trust Code of Governance and guidance document for Foundation Trusts – Governance over Audit, Assurance and Accountability, issued by the Independent Regulator), the Board of Directors shall establish a committee of non-executive directors as an Audit, Risk and Governance Committee with formal terms of reference, approved by the Board, to perform such monitoring, reviewing and other functions as are appropriate to provide an independent and objective view of internal control.
3.1.2 The Board of Directors shall satisfy itself that at least one member of the Audit, Risk and Governance Committee has recent and relevant financial experience.
3.1.3 The Audit, Risk and Governance Committee will provide an independent and objective view of internal control by:
(a) overseeing audit arrangements, including strategic and annual audit plans for Internal and External Audit services on behalf of the Trust Board;
(b) reviewing financial information and systems and monitoring the integrity of the financial statements and reviewing significant reporting judgements, including the draft Annual Accounts;
(c) reviewing the establishment and maintenance of an effective system of governance, risk management and internal control across the whole of the Trust’s activities (both clinical and non-clinical);
(d) reviewing schedules of write-offs and Losses and Compensations on behalf of the Board and reviewing all occasions on which the Trust Board waiver standing orders;
(e) ensuring that agreed actions and recommendations arising out of internal and external audit reports are appropriately progressed;
(f) monitoring compliance with SOs and SFIs;
(g) reviewing the work of other committees and other significant assurance providers, where relevant and appropriate;
(h) overseeing counter fraud arrangements provided by the Local Counter Fraud Specialist within the Trust; and
(i) ensuring that the function of the Audit, Risk and Governance Committee complies, as appropriate, with the latest Healthcare Financial Management Association (HFMA) NHS Audit Committee Handbook recommendations.
3.1.4 The Audit, Risk and Governance Committee shall make a recommendation to the Council of Governors with respect to the re-appointment of the Trust’s external auditors. The Council of Governors is responsible for the appointment of the Trust’s external auditors. If their work has been satisfactory and the charges reasonable, the Council of Governors may re-appoint the auditors for the following year without the
Printed copies valid only if separately controlled Page 9 of 65
Reference DCM076 Date of issue Version
need for a formal selection process. However, the Trust will undertake a market-testing exercise for the appointment of the external auditor at least once every five years.
3.1.5 The Audit, Risk and Governance Committee shall appoint the Trust’s internal auditor and will be involved in the selection process when an internal audit service provider is changed. The Trust will undertake a market-testing exercise for the appointment of the internal auditor at least once every five years.
3.1.6 Where the Audit, Risk and Governance Committee feel 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, Risk and Governance Committee should raise the matter at a full meeting of the Board of Directors. Exceptionally, the matter may need to be referred to the Independent Regulator via the Director of Finance in the first instance.
3.2 Director of Finance
3.2.1 The Director of Finance is responsible for:
(a) ensuring that 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 internal audit is adequate and effective and meets the standards of the Independent Regulator;
(c) deciding at what stage to involve the police and liaising with the Independent Regulator as appropriate in cases of misappropriation and other irregularities not involving fraud and corruption;
(d) ensuring that an annual internal audit report is provided by the Head of Internal Audit for consideration by the Audit, Risk and Governance Committee on a timely basis. The annual report must cover:
i. a clear opinion on the effectiveness of internal control in accordance with current assurance guidance issued by the Independent Regulator, including for example compliance with control criteria and standards;
ii. progress against plan over the previous year;
iii. major internal financial control weaknesses discovered; and
iv. progress on the implementation of Internal Audit recommendations.
(e) ensuring that a risk based internal audit plan for the coming year is produced and approved by the Audit, Risk and Governance Committee.
3.2.2 The Director of Finance or designated internal/external auditor is 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
Printed copies valid only if separately controlled Page 10 of 65
Reference DCM076 Date of issue Version
(b) access at all reasonable times to any land, premises, Trust Board member or officer of the Trust;
(c) the production of any cash, stores or other property of the Trust under an officer's control; and
(d) explanations concerning any matter under investigation.
3.3 External Audit
3.3.1 It is for the Council of Governors, with advice from the Audit, Risk and Governance Committee, to appoint or remove the External Auditor at a general meeting of the Council of Governors in accordance with section 38 of the Constitution.
3.3.2 The initial appointment of the External Auditor must be made as soon as possible and no later than the end of the first period for which the Trust will be preparing accounts.
3.3.3 The Trust must ensure that the External Auditor appointed by the Council of Governors meets the criteria included by the Independent Regulator within The NHS Foundation Trust Code of Governance and guidance document for Foundation Trusts – Governance over Audit, Assurance and Accountability, at the date of appointment and on an on-going basis throughout the term of their appointment.
3.3.4 The External Auditor must ensure that a cost-efficient service is provided, agree work plans (except for statutory requirements) and comply with the audit code issued by the National Audit Office (NAO).
3.3.5 Prior approval must be sought from the Audit, Risk and Governance Committee (the Council of Governors may also be notified for information) for each discrete piece of additional external audit work (i.e. over and above the audit plan approved at the start of the year) awarded to the external auditors. Competitive tendering is not required and the Director of Finance is required to authorise expenditure associated with such additional work. See also 3.3.9 in relation to non-audit work permitted to be undertaken by the Trust’s External Auditor.
3.3.6 In the case of an emergency, external audit shall be permitted to carry out additional discrete pieces of work if authorised to do so by the Chief Executive, the Director of Finance and the Chair of the Audit, Risk and Governance Committee; this shall be reported to the next meeting of the Audit, Risk and Governance Committee.
3.3.7 The Trust will provide the external auditor with every facility and all information which he/she may reasonably require for the purposes of his/her functions under Schedule 10 of the 2006 Act.
3.3.8 Where the External Auditor issues a public interest report the Trust shall forward a report to the Independent Regulator either at once if it is an immediate report or otherwise not later than fourteen days after conclusion of the audit (as per the NHS Act 2006 Schedule 10). The report shall include details of the Trust’s response to the issues raised within the public interest report.
3.3.9 In line with guidance issued by the Independent Regulator, the Trust shall implement a policy for approving any non-audit services that are to be provided by the Trust’s
Printed copies valid only if separately controlled Page 11 of 65
Reference DCM076 Date of issue Version
External Auditor. It is important that the independence of the External Auditor is not, or does not appear to be, compromised in terms of the objectivity of their opinion on the financial statements of the Trust. The Trust’s policy document ‘Policy for the Engagement of External Auditors for Non-Audit Work’ refers.
3.4 Role of Internal Audit
3.4.1 Internal Audit provides an independent and objective opinion to the Chief Executive, the Audit, Risk and Governance Committee and the Board on the degree to which risk management, control and governance arrangements support the effective operation of the Trust and the achievement of the Trust’s agreed objectives. Internal Audit will, in accordance with recognised professional best practice, review, evaluate and report upon:
(a) the effectiveness of the Trust’s operations and the management of the risks associated with those operations;
(b) the extent of compliance with, and the financial effect of or risk associated with, relevant established policies, plans, procedures, laws and regulations;
(c) the adequacy and application of financial and other related management controls;
(d) the suitability and effective usage of financial and other related management information and data, including internal and external reporting and accountability processes;
(e) 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 and inefficient administration;
iii. poor value for money;
iv. any form of risk, especially business and financial risk but not exclusively so.
(f) The adequacy of follow-up actions by the Trust to internal audit reports;
3.4.2 The Head of Internal Audit will produce an annual audit opinion on the effectiveness of the system of internal control.
3.4.3 The Head of Internal Audit will make suitable provision to form an opinion on key systems operated on behalf of other organisations, and key systems being operated by other organisations, either by deriving the opinions themselves or by relying on the opinions provided by other auditors/review bodies.
3.4.4 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 must be notified immediately (see also SFI 13 – Disposals and Condemnations, Losses and Special Payments) and in the case of alleged or suspected fraud, the Local Counter Fraud Specialist must be notified.
Printed copies valid only if separately controlled Page 12 of 65
Reference DCM076 Date of issue Version
3.4.5 The Head of Internal Audit and/or the Internal Audit Manager for the Trust will normally attend Audit, Risk and Governance Committee meetings and has a right of access to all Audit, Risk and Governance Committee members, the Chairman and Chief Executive of the Trust.
3.4.6 The Head of Internal Audit shall be accountable to the Director of Finance.
3.4.7 The reporting system for internal audit shall be agreed between the Director of Finance, the Audit, Risk and Governance Committee and the Head of Internal Audit. The agreement shall be in writing and shall comply with appropriate guidance. The reporting system shall be reviewed at least every three years. Where, in exceptional circumstances, the use of normal reporting channels could be seen as a possible limitation on the objectivity of the audit, the Head of Internal Audit shall have access to report directly to the Chief Executive, Chairman or any non-executive Director of the Trust.
3.4.8 The Head of Internal Audit shall co-ordinate internal audit plans and activities with line managers, external audit and other review agencies to ensure that the most effective audit coverage is achieved and duplication of effort is minimised.
3.4.9 The Trust will provide the Head of Internal Audit with every facility and all information which he/she may reasonably require for the purposes of his/her functions under the terms of reference.
3.5 Fraud, Bribery and Corruption
3.5.1 The Director of Finance, as the executive board member responsible for countering fraud, bribery and corruption in the Trust, shall monitor and ensure compliance with the NHS Standard Contract Service Condition 24 to put in place and maintain appropriate anti-fraud, bribery and corruption arrangements, having regard to the NHS Counter Fraud Authority (NHS CFA) provider standards.
3.5.2 The Trust shall nominate a suitable person to carry out the duties of the professionally accredited Local Counter Fraud Specialist (LCFS) in accordance with NHS CFA’s' provider standards.
3.5.3 The LCFS shall report directly to the Trust's Director of Finance. The LCFS shall work with staff in the NHS CFA as necessary.
3.5.4 The LCFS will provide a written report, at least annually, on counter fraud work within the Trust to the Audit, Risk and Governance Committee and the Board.
3.5.5 The Director of Finance shall review and sign off the annual self-review tool (SRT) assessment of the organisations arrangements for meeting the NHS provider standards in relation to anti-fraud, bribery and corruption measures and ensure its submission to the NHS CFA is in line with the required deadline.
3.5.6 The Director of Finance is responsible for providing detailed procedures to enable the Trust to minimise and, where possible, to eliminate fraud and corruption. The Trust’s ’Local Counter Fraud, Bribery and Corruption Policy and Response Plan’ sets out action to be taken by persons detecting a suspected fraud and persons responsible for investigating it.
3.5.7 It is expected that all officers shall act with the utmost integrity, ensuring adherence to all relevant regulations and procedures. It is the responsibility of the Director of
Printed copies valid only if separately controlled Page 13 of 65
Reference DCM076 Date of issue Version
Finance to produce and issue these regulations and procedures to the appropriate Directors and Managers who should ensure that all staff have access to these.
3.5.8 Both Internal and External Audit shall be informed of all suspected, alleged or detected fraud so that they can consider the adequacy of the relevant controls and evaluate the implication of fraud for their opinion on the system of risk management, control and governance.
3.5.9 Any officer discovering or suspecting fraud and/or corruption must inform the Trust’s LCFS or Director of Finance without delay. Details of how to report a fraud are shown in the Trust’s ’Local Counter Fraud, Bribery and Corruption Policy and Response Plan’.
3.5.10 The Director of Finance is responsible for ensuring that action is taken to investigate any allegations of fraud or corruption through the LCFS.
Printed copies valid only if separately controlled Page 14 of 65
Reference DCM076 Date of issue Version
4.0 Business Planning, Budgets, Budgetary Control and Monitoring
4.1 Preparation and Approval of Business Plans and Budgets
4.1.1 The Chief Executive shall prepare at least every five years or more regularly as required, a statement of strategic direction for approval by the Board of Directors.
4.1.2 The Chief Executive will compile and submit to the Board of Directors a Business Plan. The Business Plan will contain:
(a) a statement of the significant assumptions on which the plan is based; and
(b) details of any major changes in workload, delivery of services or resources required to achieve the plan.
4.1.3 All budget holders must provide information as required by the Director of Finance to enable budgets to be compiled.
4.1.4 The Trust will provide its Business Plan to the Independent Regulator on an annual basis. This information will be prepared by the directors, who must have regard to the views of the Council of Governors.
4.1.5 Prior to the start of the financial year, the Director of Finance will, on behalf of the Chief Executive, prepare and submit annual budgets for approval by the Board of Directors. Such budgets will:
(a) be in accordance with the aims and objectives set out in the Business Plan;
(b) accord with workload and manpower plans;
(c) be produced following discussion with appropriate budget holders;
(d) be prepared within the limits of available funds as per the Prudential Borrowing limit;
(e) identify potential risks;
(f) be based on reasonable and realistic assumptions; and
(g) enable the Trust to comply with the Regulatory Framework for Foundation Trusts (in particular the Prudential Borrowing Code).
4.1.6 The Director of Finance shall monitor financial performance against financial, activity and other performance targets. Performance reports shall be presented to the Board of Directors not less frequently than quarterly.
4.1.7 Officers shall provide the Director of Finance with all financial, statistical and other relevant information necessary for the compilation of such budgets, plans, estimates and forecasts.
4.1.8 The Director of Finance has a responsibility to ensure that adequate financial training is delivered on an on-going basis to budget holders to help them manage successfully.
Printed copies valid only if separately controlled Page 15 of 65
Reference DCM076 Date of issue Version
4.1.9 Operating surpluses may be used to:
(a) spend on revenue;
(b) meet locally determined health needs;
(c) build up cash reserves for future investments;
(d) finance an investment or purchase; or
(e) make payments on a loan.
4.1.10 Operating surpluses may not be distributed to members.
4.1.11 The Chief Executive shall monitor and review performance against Business Cases and report to the Board. Business Cases will be reported to the Board by ‘exception’ where benefits have not been delivered as originally approved. All major business cases must be subject to a benefits realisation process, which will be monitored by the Finance and Performance Committee.
4.2 Budgetary Delegation
4.2.1 The Chief Executive and all delegated budget holders must not exceed the budgetary totals or virement limits set by the Board of Directors.
4.2.2 The Chief Executive, on the advice of the Director of Finance, 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; and
(f) the provision of regular reports.
4.2.3 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.
4.2.4 Non-recurring budgets should not be used to finance recurring expenditure without the authority in writing of the Chief Executive.
Printed copies valid only if separately controlled Page 16 of 65
Reference DCM076 Date of issue Version
4.3 Budgetary Control and Financial Reporting
4.3.1 The Director of Finance will devise and maintain systems of budgetary control and financial reporting. These will include:
(a) monthly financial reports to the Board of Directors, in a form approved by the Board of Directors, containing sufficient information to allow the Directors of the Board to ascertain the financial performance of the Trust. This may include the following:
i. income and expenditure to date, showing trends and forecast year-end position;
ii. summary statement of cash flow and forecast year-end position;
iii. summary statement of financial position;
iv. movements in working capital;
v. capital project spend and projected outturn against plan;
vi. explanations of any material variances that explain any movement from the planned retained surplus/deficit at the end of the current month position;
vii. performance against the Prudential Borrowing Limit covenants; and
viii. details of any corrective action required and the Chief Executive's and/or Director of Finance's view of whether such action is 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;
(c) investigation and reporting of variances from financial, workload and manpower budgets;
(d) monitoring of management action to correct variances; and
(e) arrangements for the authorisation of budget transfers.
4.3.2 The Director of Finance shall keep the Chief Executive and the Board informed of the financial consequences of changes in policy, pay awards and other events and trends affecting budgets and shall advise on the financial and economic aspects of future plans and projects.
4.3.3 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 written consent of the Director of Finance;
(b) the amount provided in the approved budget is not used in whole or in part for any purpose other than that specifically authorised in writing subject to the rules of virement;
Printed copies valid only if separately controlled Page 17 of 65
Reference DCM076 Date of issue Version
(c) no permanent officers are appointed without the approval of the Chief Executive other than those provided for by the pay budget as approved by the Board of Directors; and
(d) the systems of budgetary control established by the Director of Finance are complied with fully.
4.3.4 The Chief Executive is responsible for identifying and implementing cost improvements and income generation initiatives in accordance with the requirements of the Business Plan and a balanced budget.
4.4 Capital Expenditure
4.4.1 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).
4.5 Performance Monitoring Returns
4.5.1 The Chief Executive is responsible for ensuring that the appropriate monitoring forms are submitted to the Independent Regulator and any other requisite monitoring organisation within the prescribed timescales; and also that:
(a) financial performance measures have been defined and are routinely monitored;
(b) reasonable targets have been identified for these measures;
(c) a robust system is in place for managing performance against the targets;
(d) reporting lines are in place to ensure that overall performance is managed effectively; and
(e) arrangements are in place to manage/respond to adverse performance.
Printed copies valid only if separately controlled Page 18 of 65
Reference DCM076 Date of issue Version
5.0 Agreements for Provision of Services
5.1 Contracts with Commissioners
5.1.1 The Board of Directors shall regularly review and shall at all times maintain and ensure the capacity of the Trust to provide the commissioner requested services referred to in the Provider Licence and other related schedules.
5.1.2 The Chief Executive, as Accounting Officer, supported by the Director of Finance, is responsible for ensuring that contracts are in place with commissioners for the provision of services to patients in accordance with the Business Plan.
5.1.3 Contracts with commissioners shall comply with best costing practice and shall be so devised as to minimise contractual risk whilst maximising the Trust’s opportunity to generate income. Contracts with commissioners are legally binding and appropriate legal advice, identifying the organisation’s liabilities under the terms of the contract, should be considered.
5.1.4 Contracts with commissioners will be signed by both parties in accordance with the Scheme of Delegation.
5.1.5 In carrying out these functions, the Chief Executive should take into account the advice of the Director of Finance regarding:
(a) costing and pricing of services (in accordance with PbR) and the activity/volume of services planned;
(b) payment terms and conditions;
(c) billing systems and cash flow management;
(d) any other matters of a financial nature;
(e) the contract negotiation process and timetable;
(f) the provision of contract data;
(g) contract monitoring arrangements;
(h) amendments to contracts; and
(i) any other matters of a legal or non-financial nature.
5.1.6 Prices should match national tariff under PbR, where appropriate, but the Trust can negotiate locally agreed prices where services are not covered by the national tariff.
5.1.7 The Director of Finance shall produce regular reports (in the form of service line reports) detailing actual and forecast service activity income with a detailed assessment of the impact of the variable elements of income. These reports will be submitted to the Finance and Performance Committee and the Trust Board.
5.1.8 The Trust will maintain a public and up-to-date schedule of the authorised goods and services which are being currently provided, including non-mandatory health services, as set out in the Trust Licence.
Printed copies valid only if separately controlled Page 19 of 65
Reference DCM076 Date of issue Version
5.2 Other Contracts
5.2.1 Where the Trust enters into a relationship with another organisation for the supply or receipt of services – clinical or non-clinical – the responsible officer should ensure that an appropriate contract is in place and signed by both parties.
5.2.2 No officer shall enter into any form of contract on behalf of the Trust unless they have specific authority to do so, in line with the Scheme of Delegation and relevant Trust policies and procedures. This applies even if the contract has no obvious financial value attached to it, e.g. agreements to advertise on Trust premises or documentation. Refer also to the Trust’s ‘Advertising Policy’ for such agreements.
5.2.3 Contracts should incorporate:
(a) a description of the service and indicative activity levels;
(b) the term of the agreement;
(c) the value of the agreement;
(d) lead officers;
(e) performance and dispute resolution procedures; and
(f) risk management and governance arrangements.
5.2.4 Contracts should be reviewed and agreed on an annual basis or as determined by the term of the agreement so as to ensure value for money and to minimise any potential loss of income.
5.3 Involving Partners and Jointly Managing Risk
5.3.1 A good contract will result from a dialogue of clinicians, users, carers, public, health professionals and managers. It will reflect knowledge of local needs and inequalities. This will require the Chief Executive to ensure that the Trust works with all partner agencies involved in both the delivery and the commissioning of the service required. The contract will apportion responsibility for handling a particular risk to the party or parties in the best position to influence the risk in question and financial arrangements should reflect this. In this way the Trust can jointly manage risk with all interested parties.
5.3.2 The Trust has a duty to work together collaboratively with all other local stakeholders. The interests of the Trust will not be pursued where this will adversely impact upon the interests of the local health and care system as a whole.
Printed copies valid only if separately controlled Page 20 of 65
Reference DCM076 Date of issue Version
6.0 Bank Accounts
6.1 General
6.1.1 The Director of Finance 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 the Independent Regulator’s guidance and directions as issued from time to time.
6.1.2 The Board of Directors shall approve the banking arrangements.
6.2 Bank and Government Banking Service (GBS) Accounts
6.2.1 The Director of Finance is responsible for:
(a) all bank accounts (including GBS accounts);
(b) establishing separate bank accounts for the Trust’s non-exchequer funds;
(c) ensuring that payments made from bank or GBS 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 (together with remedial action taken); and
(e) monitoring compliance with HM Treasury guidance and any guidance issued by the Independent Regulator or any other relevant guidance on the level of cleared funds.
6.3 Banking Procedures
6.3.1 The Director of Finance will prepare detailed instructions on the operation of bank and GBS accounts which must include:
(a) the conditions under which each bank account is to be operated;
(b) the limit to be applied to any overdraft; and
(c) those authorised to sign cheques or other orders drawn on the Trust's accounts and the limitation on single signatory payments.
6.3.2 The Director of Finance must advise the Trust's bankers in writing of the conditions under which each account will be operated.
6.3.3 The Director of Finance must prepare detailed instructions on the investment policy in relation to the Trust’s bank accounts.
6.3.4 All funds shall be held in accounts in the name of the Trust. No officer other than the Director of Finance shall open or close any bank account in the name of the Trust, following approval by the Trust Board in line with the Scheme of Delegation.
6.4 Tendering and Review
6.4.1 The Director of Finance will review the commercial banking arrangements of the Trust at regular intervals not exceeding five years, to ensure that they reflect best
Printed copies valid only if separately controlled Page 21 of 65
Reference DCM076 Date of issue Version
practice and represent value for money by periodically reviewing competitive bank rates. Following such reviews, the Director of Finance shall determine whether or not to seek competitive tenders for the Trust's commercial banking business.
6.4.2 The results of such reviews will be reported to the Audit, Risk and Governance Committee and the Board.
6.4.3 This review is not necessary for Government Banking Service accounts.
Printed copies valid only if separately controlled Page 22 of 65
Reference DCM076 Date of issue Version
7.0 Income, Fees and Charges and Security of Cash, Cheques and Other Negotiable Instruments
7.1 Income Systems
7.1.1 The Director of Finance is responsible for designing, maintaining and ensuring compliance with systems for the proper recording, invoicing, collection and coding of all income due to the Trust.
7.1.2 All such systems shall incorporate, where practicable, the principles of internal check and separation of duties.
7.1.3 The Director of Finance is responsible for the prompt banking of all monies received by the Trust.
7.1.4 The Trust will carry on activities for the purpose of making additional income available in order to better carry out the Trust’s principal purpose, subject to any restrictions in the Independent Regulator’s authorisation and as stated in the Constitution.
7.2 Fees and Charges
7.2.1 The Trust shall follow the Department of Health Payment by Results (PbR) guidelines and any other applicable guidance in setting prices for contracts with NHS commissioners for all services falling within the PbR framework.
7.2.2 The Director of Finance 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.
7.2.3 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.
7.2.4 In receiving cash payments, it should be noted that the maximum value of any single cash transaction is limited to the equivalent of 10,000 euros (regardless of currency). This is in line with the Money Laundering, Terrorist Financing and Transfer of Funds Regulations 2017.
7.2.5 All officers must inform the Director of Finance promptly of income due arising from transactions which they initiate/deal with, including all contracts, leases, tenancy agreements, private patient undertakings and other transactions.
7.3 Debt Recovery
7.3.1 The Director of Finance is responsible for the appropriate recovery action on all outstanding debts.
7.3.2 Outstanding debts will be reviewed periodically and follow up action taken, dependent upon the value of the debt and length of time outstanding.
Printed copies valid only if separately controlled Page 23 of 65
Reference DCM076 Date of issue Version
7.3.3 Income and salary overpayments not received after all attempts at recovery have failed should be dealt with in accordance with losses procedures (see also SFI 13 – Disposals and Condemnations, Losses and Special Payments).
7.3.4 Overpayments should be detected (or preferably prevented) and recovery initiated.
7.4 Security of Cash, Cheques and Other Negotiable Instruments
7.4.1 All officers have a responsibility to ensure that any Trust monies in their possession or under their responsibility are properly safeguarded and are held securely when not in use.
7.4.2 The Director of Finance 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 officers whose duties include collecting and holding cash, including the provision of safes or lockable cash boxes, the procedures for keys and for the opening of coin operated machines and subsequent counting and recording of takings from coin operated machines; and
(d) prescribing systems and procedures for handling cash and negotiable securities on behalf of the Trust.
7.4.3 An official receipt will be made out for all cash receipts when requested, showing the type of remittance and the reasons for payment.
7.4.4 A special receipt will be issued for all charitable fund donations, which will enable the donor to express their wishes as to the purpose of the donation.
7.4.5 Trust monies shall not under any circumstances be used for the encashment of private cheques or loans or IOUs.
7.4.6 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.
7.4.7 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 shall not be held liable for any loss and written and signed indemnities must be obtained from the organisation or individuals absolving the Trust from responsibility for any loss.
7.4.8 All unused cheques and other orders shall be subject to the same security precautions as are applied to cash.
7.4.9 Where cash collection is undertaken by an external organisation, this shall be subject to such security and other conditions as required by the Director of Finance.
7.4.10 Any loss or shortfall of cash, cheques or other negotiable instruments, however occasioned, shall be reported immediately in accordance with the agreed procedure
Printed copies valid only if separately controlled Page 24 of 65
Reference DCM076 Date of issue Version
for reporting losses (see also SFI 13 – Disposals and Condemnations, Losses and Special Payments). Any loss or surplus of cash should be immediately reported to the Director of Finance.
7.4.11 All payments made on behalf of the Trust to third parties should normally be made using the Bankers Automated Clearing System (BACS), or by crossed cheque and drawn in accordance with these instructions, except with the agreement of the Director of Finance, as appropriate, who shall be satisfied about security arrangements.
7.4.12 Staff shall be informed on their appointment of their responsibilities and duties for the collection, handling or disbursement of cash, cheques, etc.
Printed copies valid only if separately controlled Page 25 of 65
Reference DCM076 Date of issue Version
8.0 Terms of Service and Payment of Directors and Officers
8.1 Remuneration and Terms of Service
8.1.1 In accordance with SOs, the Board shall establish a Remuneration Committee, with clearly defined terms of reference, specifying which posts that fall within its area of responsibility, its composition and the arrangements for reporting. The operation of this committee will comply with all current regulatory and best practice requirements.
8.2 Funded Establishment
8.2.1 The workforce plans incorporated within the annual budget will form the funded establishment.
8.2.2 The funded establishment of any department may not be varied without the approval of the Chief Executive or nominated officer authorised by them, as referred to in the Scheme of Delegation.
8.2.3 Each Director must ensure that all of their budget holders operate within the agreed staffing establishment.
8.3 Staff Appointments
8.3.1 No director or officer may engage, re-engage or re-grade officers, 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 or person with delegated authority, in line with the Scheme of Delegation; and
(b) such engagement, re-engagement or re-grade is within the limit of his/her approved pay budget and funded establishment.
8.3.2 The Board of Directors will approve procedures presented by the Chief Executive for the determination of commencing pay rates and conditions of service for officers.
8.3.3 All staff engagements must comply with the latest regulations on staff appointments issued by the Independent Regulator and HM Revenue and Customs (HMRC).
8.4 Processing of Payroll
8.4.1 The Director of Finance 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; and
(d) agreeing methods of payment.
Printed copies valid only if separately controlled Page 26 of 65
Reference DCM076 Date of issue Version
8.4.2 The Director of Finance will issue instructions regarding:
(a) verification and documentation of payroll data;
(b) the timetable for receipt and preparation of payroll data and the payment of officers;
(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 Acts;
(g) methods of payment available to various categories of officers;
(h) procedures for payment by bank credit, or other method when agreed, to officers;
(i) procedures for the recall of bank credits and other methods of payment;
(j) pay advances and their recovery;
(k) the establishment of suitable arrangements for the collection of payroll deductions and payment of these to appropriate bodies;
(l) maintenance of regular and independent reconciliation of pay control accounts;
(m) a system for the effective and timely recovery of payroll overpayments from existing members of staff; and
(n) a system to ensure the effective and timely recovery from leavers of sums of money and property due by them to the Trust.
8.4.3 Appropriately nominated managers have delegated responsibility for:
(a) Submitting accurate time records (whether paper or electronic) and other notifications in accordance with agreed timetables;
(b) completing time records (whether paper or electronic) and other notifications in accordance with the Director of Finance's instructions and in the form prescribed by the Director of Finance; and
(c) submitting termination forms in the prescribed form immediately upon knowing the effective date of an officer's resignation, termination or retirement, to ensure that overpayments to leavers do not occur. Where an officer fails to report for duty in circumstances that suggest they have left without notice, the Director of Finance must be informed immediately to consider appropriate action to prevent or recover any overpayment.
Printed copies valid only if separately controlled Page 27 of 65
Reference DCM076 Date of issue Version
8.4.4 Regardless of the arrangements for providing the payroll service, the Director of Finance shall ensure that the chosen method is supported by appropriate (contracted) terms and conditions, robust internal controls and suitable audit review procedures.
8.4.5 Managers and employees are jointly responsible and accountable for ensuring that claims for pay and expenses are timely and correct.
8.4.6 All employees have a responsibility to check their own payslips each month and bring any under or overpayments to the attention of the Trust’s Payroll and Pensions department as soon as discovered so that appropriate corrective action can be taken. The Trust has specific policies in relation to the recovery of salary overpayments and also the correcting of salary underpayments.
8.5 Contracts of Employment
8.5.1 It is the responsibility of the Director of People and Organisational Effectiveness for:
(a) ensuring that all employees are issued with a contract of employment in a form approved by the Board of Directors and which complies with employment legislation; and
(b) dealing with variations to, or termination of, contracts of employment.
Printed copies valid only if separately controlled Page 28 of 65
Reference DCM076 Date of issue Version
9.0 Non-Pay Expenditure
9.1 Delegation of Authority
9.1.1 The Board of Directors will approve the level of non-pay expenditure as part of the annual budget and the Chief Executive will determine the level of delegation to budget managers. prior to the start of the financial year to which the budget relates.
9.1.2 The Chief Executive will set out in the Scheme of Delegation:
(a) the list of managers who are authorised to place requisitions for the supply of goods and services; and
(b) the maximum level of each requisition and the system for authorisation above that level.
9.1.3 The Chief Executive shall set out procedures on the seeking of professional advice regarding the supply of goods and services.
9.1.4 The Council of Governors will be consulted on ‘significant transactions’ as defined in section 46 of the Trust’s Constitution.
9.2 Tendering and Quotations
9.2.1 Wherever appropriate, the supply of goods and services shall be covered by a contract following a tender or quotation exercise. Trust policy and procedures in relation to the requirement to conduct a tender or quotation exercise are contained within these SFIs at Appendix A and delegated limits are set out in the Scheme of Delegation at Appendix A
9.2.2 The Director of Finance, in conjunction with the Head of Procurement where appropriate, will:
(a) advise the Board of Directors regarding the setting of thresholds above which quotations (competitive or otherwise) or formal tenders must be obtained. Once approved, the thresholds will be incorporated into SOs and the Scheme of Delegation (Appendix A) and regularly reviewed. These thresholds shall have effect as if incorporated into these SFIs; and
(b) prepare procedural instructions on the obtaining of goods, works and services incorporating the approved thresholds; and
(c) Prepare procedural instructions regarding the waiving of SO’s and SFI’s in relation to the procurement of goods and services. The Trust’s Waiver Procedure can be found at Appendix B of these SFI’s.
9.2.3 Approved thresholds will be applied to leases or recurring service contracts to the total costs over the term of the lease or contract.
9.3 Choice, Requisitioning, Ordering, Receipt and Payment for Goods and Services
9.3.1 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 Head of Procurement shall be sought. Where this advice is not
Printed copies valid only if separately controlled Page 29 of 65
Reference DCM076 Date of issue Version
acceptable to the requisitioner, the Director of Finance (and/or the Chief Executive) shall be consulted.
9.3.2 The Trust’s Head of Procurement shall be responsible for ensuring that the Trust complies with all applicable laws in relation to choice, requisitioning, ordering and receipt for goods and services.
9.3.3 Once the item to be supplied (or service to be performed) has been identified the requisitioner should raise an official Trust requisition which will in turn generate an official Trust order to be raised. Only for agreed goods and services (e.g. utilities) should goods or services be obtained without an official requisition being raised and an official Trust order being generated. A list of approved items not requiring an official order will be maintained by the Finance Directorate and made available to staff on the Trust intranet. Raising a requisition at the time an invoice is received is not acceptable.
9.3.4 The Director of Finance shall be responsible for the prompt payment of all properly authorised accounts and claims. Payment of contract invoices shall be in accordance with contract terms or otherwise in accordance with national guidance.
9.3.5 In relation to supplies to and disposals by the Trust, the Director of Finance will:
(a) 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 directors/officers (including specimens of their signatures) authorised to approve invoices for payment;
ii. Certification that:
• Goods and services ordered have been duly received, examined and are in accordance with specification and the prices are correct;
• work done or services rendered 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 and are reasonable;
• where appropriate, the expenditure is in accordance with regulations and all necessary authorisations have been obtained;
• the account is arithmetically correct; and
• the account is in order for payment.
Printed copies valid only if separately controlled Page 30 of 65
Reference DCM076 Date of issue Version
• Where an officer certifying accounts relies upon other officers to do preliminary checking he/she shall, wherever possible, ensure that those who check delivery or execution of work act independently of those who have placed orders and negotiated prices and terms and that such checks are evidenced;
iii. A timetable and system for submission to the Director of Finance 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 officers regarding the handling and payment of accounts within the Finance Directorate.
(b) be responsible for ensuring that payment for goods and services is only made once the goods and services are received (except as per section 9.4 - Prepayments below);
(c) prepare and issue procedures regarding the treatment of Value Added Tax (VAT).
9.3.6 Purchasing cards may be operated in line with robust purchasing card procedures, as set out by the Director of Finance.
9.4 Prepayments
9.4.1 Prepayments, other than those which are a legal contractual obligation or are standard practice such as certain utilities and software licences, are only permitted where exceptional circumstances apply. In such instances:
(a) prepayments are only permitted where the financial advantages outweigh the disadvantages;
(b) The supplier is of sufficient financial status or able to offer a suitable financial instrument to protect against the risk of insolvency;
(c) the appropriate Director must provide, in the form of a written report, 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 their commitments;
(d) the Director of Finance will need to be satisfied with the proposed arrangements before contractual arrangements proceed; and
(e) the budget holder is responsible for ensuring that all items due under a prepayment contract are received and he/she must immediately inform the appropriate Director or Chief Executive if problems are encountered.
9.5 Official Orders and Requisitions
9.5.1 Official Orders and requisitions must:
(a) be in a form approved by the Director of Finance;
(b) be consecutively numbered;
Printed copies valid only if separately controlled Page 31 of 65
Reference DCM076 Date of issue Version
(c) state the Trust's terms and conditions of trade; and
(d) only be raised by those duly authorised by the Chief Executive through the scheme of delegation.
9.6 Duties of Officers
9.6.1 All officers must ensure that they comply fully with the guidance and limits specified in Appendix A of the Scheme of Delegation and that:
(a) all contracts, leases, tenancy agreements and other commitments which may result in a liability, whether relating to land, buildings, vehicles or equipment shall be subject to authorisation by the Director of Finance or by an officer so delegated by him/her, in advance of any commitment being made;
(b) contracts above specified thresholds are advertised and awarded in accordance with EU rules on public procurement;
(c) where consultancy advice is being obtained, the procurement of such advice must be in accordance with guidance issued by the Independent Regulator;
(d) no order shall be issued for any item or items to any supplier/contractor that has made an offer of gifts, reward or benefit to any officer of the Trust, other than (and in line with the Trust’s Standards of Business Conduct Policy):
i. low cost branded promotional aids such as pens or post it notes less than £6 in value; and
ii. conventional hospitality, such as lunches in the course of working visits.
(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 on behalf of the Chief Executive;
(f) all goods, services or works are ordered on an official order except those approved items not requiring an order as referred to in section 9.3.3 , purchases from Trust petty cash and purchases using an official Trust purchasing card;
(g) verbal orders must only be issued very exceptionally by an officer 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 relevant financial thresholds, as outlined in the Scheme of Delegation;
(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 directors/officers authorised to approve invoices for payment are notified to the Director of Finance;
Printed copies valid only if separately controlled Page 32 of 65
Reference DCM076 Date of issue Version
(k) purchases from petty cash are restricted in value and by type of purchase in accordance with instructions issued by the Director of Finance (as set out in Appendix A of the Scheme of Delegation); and
(l) petty cash records are maintained in a form as determined by the Director of Finance.
9.6.2 The technical audit of building and engineering contracts shall be the responsibility of the relevant Executive Director. The Director of Finance shall ensure that the arrangements for financial control and financial audit of building and engineering contracts and property transactions comply with best practice.
9.6.3 Under no circumstances should goods be ordered through the Trust for personal or private use (other than approved schemes such as lease cars or mobile phones).
Printed copies valid only if separately controlled Page 33 of 65
Reference DCM076 Date of issue Version
10.0 Stores and Receipt of Goods
10.1 Stores, defined in terms of controlled stores and departmental stores (for immediate use), should be:
(a) the asset replacement policy;
(b) kept to a minimum;
(c) subjected to annual stock takes; and
(d) valued at the lower of cost and net realisable value.
10.2 Subject to the responsibility of the Director of Finance for the systems of control, the day-to-day responsibility may be delegated to departmental officers and stores managers/keepers, subject to such delegation being entered in a record available to the Director of Finance.
10.3 The control of pharmaceutical stocks shall be the responsibility of a designated Pharmaceutical Officer; the control of fuel oil shall be the responsibility of a designated Estates manager.
10.4 The responsibility for security arrangements and the custody of keys for all stores and locations shall be clearly defined in writing by the designated manager/Pharmaceutical Officer. Wherever practicable, stocks should be marked as property of the Trust.
10.5 The Director of Finance shall set out procedures and systems to regulate stores including:
(a) records for receipt of goods, issues and returns to stores;
(b) stocktaking arrangements (to include the requirement for a physical check covering all items in store at least once a year);
(c) stock valuation; and
(d) the review of slow moving and obsolete items and for condemnation, disposal and replacement of all unserviceable articles.
10.6 All goods shall be receipted by an appropriate officer in a timely manner once they are satisfied that the goods have been received by the Trust.
10.7 Officers shall report to the Director of Finance any evidence of significant overstocking, negligence or malpractice in relation to the management of stocks and stores (see also SFI 13 – Disposals and Condemnations, Losses and Special Payments).
Printed copies valid only if separately controlled Page 34 of 65
Reference DCM076 Date of issue Version
11.0 External Borrowing and Investments
The Director of Finance will be responsible for the management of the Trust's cash flow.
11.1 External Borrowing
11.1.1 The Foundation Trust must ensure compliance with the Prudential Borrowing Code set by the Independent Regulator.
11.1.2 The maximum borrowing limit will be calculated using the Prudential Borrowing Code formula based on projected cash flows.
11.1.3 The Trust will secure the most preferential interest rates for borrowing.
11.1.4 The Director of Finance will advise the Board of Directors concerning the Trust’s ability to pay interest on, and repay, both the originating capital debt and any proposed new borrowing. The Director of Finance is also responsible for reporting periodically to the Board of Directors concerning the originating debt and all loans, overdrafts and associated interest.
11.1.5 Any application for new borrowing will only be made by the Director of Finance or by an officer so delegated by him/her. All such applications must be formally approved in advance in line with Appendix A of the Scheme of Delegation.
11.1.6 Assets protected under the authorisation agreement with the Independent Regulator shall not be used as collateral for borrowing. Non-protected assets will be eligible as security for a loan.
11.2 Investments
11.2.1 The Audit, Risk and Governance Committee will review and approve the Trust’s Treasury Management Policy.
11.2.2 Temporary cash surpluses must be held only in such investments as approved by the Board of Directors and within the terms of guidance as may be issued by the Independent Regulator.
11.2.3 The Director of Finance is responsible for advising the Board of Directors on investment strategy and shall report periodically to the Board of Directors concerning the performance of investments held.
11.2.4 The Director of Finance will prepare detailed procedural instructions on the operation of investment accounts and on the records to be maintained.
Printed copies valid only if separately controlled Page 35 of 65
Reference DCM076 Date of issue Version
12.0 Capital Investment, Fixed Asset Registers and Security of Assets
12.1 Capital Investment
12.1.1 The Chief Executive, supported by the Director of Finance and Director of Strategicy Development and Planning:
(a) Shall ensure that the Trust maintains a robust plan for capital investments which is subject to regular update to reflect both operational priorities for investment and the availability of resources;
(b) Shall ensure that this capital programme is subject to regular oversight and approval by the Finance and Performance Committee on behalf of the Trust Board, and that the Trust Board has formally approved the programme and any mechanism to vary that programme at least annually as part of its approval of the wider Trust Business Plan;
(c) All items on the investment programme must be supported by either:
i. an agreed schedule of spend with explicitly stated governance arrangements; or
ii. a full business case setting out the parameters of the investment concerned.
These supporting schedules and business cases which will manage the investment programme must be reviewed and approved by the Business Case Review Group on behalf of the Trust Board. These must be approved in line with Appendix A of the Scheme of Delegation. Queries relating to the Business Case process should be directed in the first instance to the Assistant Director of Finance – Financial Management.
(d) shall ensure that there is an robust appraisal and approval process in place for determining capital expenditure priorities and the effect of each proposal upon business plans; and that these are in line with guidance published by the Independent Regulator;
(e) shall ensure that robust arrangements are in place to effectively manage all stages of capital schemes and ensuring that schemes are delivered on time and to cost; and
(f) shall ensure that the capital investment is not undertaken without the availability of resources to finance all revenue consequences, including capital charges.
12.1.2 For business cases on a significant enough scale to be considered major strategic decisions is required that these be formally approved by the full Trust Board. This would take place after discussion at the Finance and Performance Committee which would be expected to make a recommendation to the Trust Board. The thresholds above which a business case should be considered to have material strategic impact are shown in Appendix A of the Scheme of Delegation.
12.1.3 Day to day management and decision making in relation to the capital programme remains the responsibility of the Chief Executive. The Chief Executive will establish
Printed copies valid only if separately controlled Page 36 of 65
Reference DCM076 Date of issue Version
within the Scheme of Delegation appropriate arrangements for the management of in year changes to the capital programme and the provision of appropriate reporting to the Trust Board to support the oversight role. This will include the setting of any value thresholds or other parameters to govern the day to day management of the programme.
12.1.4 For capital schemes where the contracts stipulate stage payments, the Director of Finance will issue procedures for their management, incorporating relevant Estates guidance (where appropriate and to the extent that this is not inconsistent with any directions or guidance from the Independent Regulator).
12.1.5 The Director of Finance shall issue procedures for the regular reporting of expenditure and commitment against authorised expenditure.
12.1.6 The approval of a capital programme shall not constitute approval for the initiation of expenditure on any scheme. The right to commit expenditure is subject to the clause at 12.1.7.
12.1.7 The Chief Executive, or the Director of Finance on their behalf, shall issue to the manager responsible for any scheme:
(a) specific authority to commit expenditure;
(b) authority to proceed to tender; and
(c) approval to accept a successful tender.
12.1.8 The Chief Executive will issue a Scheme of Delegation for capital investment management in accordance with relevant Estates guidance (where appropriate and to the extent that this is not inconsistent with any directions or guidance from the Independent Regulator) and the Trust's Standing Orders (contained within the Trust Constitution).
12.2 Private Finance
12.2.1 When the Trust proposes to use private finance, the following procedures shall apply:
(a) the Director of Finance shall demonstrate that the use of private finance represents value for money and genuinely transfers significant risk to the private sector;
(b) where the sum exceeds the delegated limits set out in the Scheme of Delegation, a business case must be prepared and the Trust shall comply with any relevant guidance and/or best practice advice issued by the Independent Regulator; and
(c) the proposal must be specifically agreed by the Board of Directors in the light of such professional advice as should reasonably be sought.
Printed copies valid only if separately controlled Page 37 of 65
Reference DCM076 Date of issue Version
12.3 Asset Registers 12.3.1 The Director of Finance is responsible for the maintenance of registers of assets and
for establishing clear procedures 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 a publicly available asset register recording protected property, in accordance with the guidance issued by the Independent Regulator.
12.3.3 The Trust may not dispose of any protected property without the approval of the Independent Regulator. This includes the disposal of part of the property or granting an interest in it. Where protected property is lost or disposed of, the value must be removed from the accounting records and each disposal must be validated by reference to authorisation documents and invoices (where appropriate).
12.3.4 The Director of Finance shall approve procedures for reconciling balances on protected property accounts in ledgers against balances on protected property asset registers.
12.4 Security of Assets
12.4.1 The overall control of all assets is the responsibility of the Chief Executive, advised by the Director of Finance for the accounting and physical management and control aspects of asset management.
12.4.2 The Trust has a Security Management Director, who is the Director of Estates and Facilities, and a Non-Executive Director with overall responsibility for security management at Board level. The operational level officer is the Local Security Management Specialist (LSMS).
12.4.3 Asset control procedures (including protected property, non-protected assets, cash, cheques and negotiable instruments and also including donated assets) must be approved by the Director of Finance. These procedures shall make provision for: (a) recording managerial responsibility for each asset;
(b) identification of additions and disposals;
(c) identification of all repair 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) the asset replacement policy.
12.4.4 All discrepancies revealed by verification of physical assets to the asset register shall be notified to the Director of Finance who shall decide what further action shall be taken.
12.4.5 Whilst each officer has a responsibility for the security of property of the Trust, it is the responsibility of Directors and all employees to apply appropriate security practices in relation to property of the Trust as may be determined by the Board of
Printed copies valid only if separately controlled Page 38 of 65
Reference DCM076 Date of issue Version
Directors. Any breach of agreed security practices must be reported in accordance with Trust policy.
12.4.6 Any damage to the Trust's premises, vehicles and equipment, or any loss of equipment, stores or supplies must be reported by Directors and officers in accordance with the procedure for reporting losses (See SFI 13 - Disposals and Condemnations, Losses and Special Payments).
12.4.7 Where practical, assets should be marked as Trust property.
Printed copies valid only if separately controlled Page 39 of 65
Reference DCM076 Date of issue Version
13.0 Disposals and Condemnations, Losses and Special Payments
13.1 Disposals and Condemnations
13.1.1 The Director of Finance must prepare detailed procedures, in accordance with the regulatory framework and guidance issued by the Independent Regulator, for the disposal of assets including condemnations, scrap materials and items surplus to requirements and ensure that these are notified to managers. The Trust may not dispose of any protected property without the approval of the Independent Regulator. These procedures shall comply with all appropriate SOs and SFIs.
13.1.2 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 of the estimated market value of the item, taking account of professional advice where appropriate and the recommended disposal mechanism to adopt (including whether competitive bids should be sought) in order to ensure that best value is achieved. The disposal method will take into account potential risks and reputational impacts.
13.1.3 No officer shall transfer any equipment to a consumer without the prior written authority of the Director of Finance.
13.1.4 All unserviceable articles shall be:
(a) condemned or otherwise disposed of by an officer (the condemning officer) authorised for that purpose by the Director of Finance; and
(b) recorded by the condemning officer in a form approved by the Director of Finance, 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 officer authorised for the purpose by the Director of Finance.
13.1.5 The condemning officer shall satisfy him/herself as to whether or not there is evidence of negligence in use and shall report any such evidence to the Director of Finance, who will take the appropriate action.
13.1.6 Authority to condemn plant and equipment shall be in line with the delegated limits set out in Appendix A of the Scheme of Delegation.
13.2 Losses and Special Payments
13.2.1 The Director of Finance must prepare procedural instructions on the recording of and accounting for condemnations, losses and special payments.
13.2.2 Any officer discovering or suspecting a loss of any kind must immediately inform their Head of Department, who must immediately, or without undue delay depending on the seriousness of the loss, inform the Director of Finance. The Director of Finance will inform the Chief Executive where this demonstrates the potential for further loss or where there is a material impact on the financial performance of the organisation.
13.2.3 For incidents of theft, arson, minor break-ins, etc. the appropriate Site Manager or Security Officer is responsible for informing the LSMS / police (as appropriate) and thereafter the Director of Estates and Facilities. The Director of Finance must be duly notified regarding losses incurred from such acts of criminality. In cases of fraud or
Printed copies valid only if separately controlled Page 40 of 65
Reference DCM076 Date of issue Version
corruption or of anomalies that may indicate fraud or corruption, the Director of Finance must immediately inform the LCFS.
13.2.4 The Director of Finance must notify the Trust’s External Auditor of all actual frauds against the Trust (this is normally through the Audit, Risk and Governance Committee).
13.2.5 For losses apparently caused by theft, fraud, arson, neglect of duty or gross carelessness, except if trivial, the Director of Finance must immediately notify:
(a) the Board of Directors; and
(b) the LCFS (issues of fraud) or LSMS (issues of theft).
13.2.6 For all losses, the Director of Finance shall review the reasons for the loss and take action to address any weaknesses in Trust systems identified as a result.
13.2.7 For any loss, the Director of Finance, as appropriate, should consider whether any insurance claim can be made.
13.2.8 Within limits delegated to it by the Independent Regulator and HM Treasury, the Board of Directors shall approve the writing-off of losses above the level delegated to nominated Executive Directors or other senior officers, as contained in the Scheme of Delegation.
13.2.9 The Director of Finance shall maintain a Losses and Special Payments Register in which write-off action is recorded.
13.2.10 Reports of requests for write-off of losses and special payments shall be made routinely to the Audit, Risk and Governance Committee. The minutes of the Audit, Risk and Governance Committee will be reported to the Board of Directors.
13.2.11 No special payments exceeding delegated limits shall be made without prior approval of the Independent regulator/HM Treasury.
13.2.12 The Director of Finance shall take any necessary steps to safeguard the Trust's interests in bankruptcies and company liquidations.
Printed copies valid only if separately controlled Page 41 of 65
Reference DCM076 Date of issue Version
14.0 Computerised Financial Data Storage and Security
14.1 The Director of Finance, 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 protection of the Trust's data, programs and computer hardware for which he/she is responsible from accidental or intentional disclosure to unauthorised persons, deletion or modification, theft or damage, having due regard for the Data Protection Acts and NHS Information Governance requirements;
(b) ensure that adequate 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; and
(d) ensure that an adequate management audit trail exists through the computerised systems (including those obtained by external agency arrangements) and that such computer audit reviews as he/she may consider necessary are being carried out.
14.2 The Director of Finance shall satisfy him/herself 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, written assurances of adequacy will be obtained from them prior to implementation.
14.3 The Director of Finance 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 shall also ensure rights of access for audit purposes.
14.4 Where another health organisation or any other agency provides a computer service for financial applications, the Director of Finance shall periodically seek written assurances that adequate controls are in operation.
14.5 Where computer systems have an impact on corporate financial systems, the Director of Finance, in conjunction with the Director of Strategy and PlanningChief Information Officer, shall satisfy him/herself that:
(a) systems acquisition, development and maintenance are in line with relevant Trust strategies and 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) Finance staff have access to such data;
(d) such computer audit reviews as are considered necessary are being carried out; and
Printed copies valid only if separately controlled Page 42 of 65
Reference DCM076 Date of issue Version
(e) any changes to such systems are notified to and approved by the Director of Finance.
14.6 The Director of Strategy and PlanningChief Information Officer shall ensure that all computer software held by the Trust is properly licensed and operated in accordance with the terms of the licence.
14.7 The Director of Strategy and PlanningChief Information Officer shall ensure that risks to the Trust arising from the use of IT are effectively identified and considered and appropriate action is taken to mitigate or control risk. This shall include the preparation and testing of disaster recovery plans.
14.8 The Director of Strategy and Planning Chief Information Officer will devise procedures which ensure that orders for the acquisition of computer hardware, software and services (other than consumables) are placed in accordance with relevant Trust strategies and policies, such as an Information Technology Strategy.
14.9 The Director of Strategy and Planning Chief Information Officer will ensure that appropriate control procedures are put in place for computer systems. These procedures will include the arrangements for the acquisition and disposal of IT systems and equipment and the decommissioning of systems containing confidential data. Such procedures will comply with all relevant guidance issued by regulatory bodies. The permanent deletion of IT systems will be approved in line with Appendix A of the Scheme of Delegation.
Printed copies valid only if separately controlled Page 43 of 65
Reference DCM076 Date of issue Version
15.0 Patients' Property
15.1 The Trust has a responsibility to provide safe custody for money and other personal property (hereafter referred to as "property") handed in by patients, in the possession of unconscious or confused patients, or found in the possession of patients dying in hospital or dead on arrival. Staff have a duty of care to make every effort to take care of patient’s possessions which are not handed in for safe keeping, particularly if the patient does not have the capacity to look after their own possessions. This includes items of daily living such as glasses, false teeth, hearing aids, etc.
15.2 The Chief Executive is responsible for ensuring that patients or their guardians, as appropriate, are informed before or at admission of the arrangements for safeguarding property by:
(a) notices and information booklets;
(b) hospital admission documentation and property records; and
(c) the oral advice of administrative and nursing staff responsible for admissions.
This will include the requirement to inform them that the Trust will not accept responsibility or liability for patients' property brought into Trust premises unless it is handed in for safe custody and a copy of an official patients' property record is obtained as a receipt.
15.3 The Director of Finance must provide detailed written instructions on the collection, custody, investment, recording, safekeeping and disposal of patients' property (including instructions on the disposal of the property of deceased patients and of patients transferred to other premises) for all officers whose duty is to administer, in any way, the property of patients. Due care should be exercised in the management of a patient's money.
15.4 Where necessary and appropriate, the Director of Finance shall establish suitable arrangements for opening and managing individual bank accounts for money deposited with the Trust for safekeeping by patients, in line with any relevant national guidance.
15.5 Staff should be informed, on appointment, by the appropriate departmental or senior manager of their responsibilities and duties for the administration of patients’ property and income.
Printed copies valid only if separately controlled Page 44 of 65
Reference DCM076 Date of issue Version
16.0 Funds Held on Trust (Charitable Funds)
16.1 The Trust has defined financial responsibilities as a corporate trustee for the management of funds held on trust. The discharge of these responsibilities is distinct from the management arrangements for the Trust’s exchequer funding but must adhere to the overriding principles of financial regularity, prudence and propriety.
16.2 The Trust has a Charitable Funds Committee, known as the Health Tree Foundation Trustees Committee, with approved Membership and Terms of Reference, which is responsible for overseeing the management of the affairs of the Trust’s Charitable Funds. The Committee reports directly to the Trust Board., but is designed to be independent in its decision making. The working name of the Trust’s Charitable Funds is The Health Tree Foundation.
16.3 The Director of Finance shall establish procedures to manage all funds held on trust. This will include ensuring compliance with Charity Commission and other relevant best practice guidance. Procedure notes for fund managers can be found on the Trust intranet.
16.4 Unless specific regulatory requirements to the contrary exist, these SFIs will fully apply to the management of funds held on trust.
16.5 The Trust’s Charitable Funds accounts will be subject to annual external audit.
Printed copies valid only if separately controlled Page 45 of 65
Reference DCM076 Date of issue Version
17.0 Risk Management and Insurance
17.1 The Chief Executive shall ensure that the Trust has a programme of risk management in accordance with the current directions and guidance in relation to assurance frameworks as issued by the Independent Regulator, which must be approved and monitored by the Board of Directors.
17.2 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 that 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 and health and safety review;
(f) arrangements to review the risk management programme; and
(g) decisions on which risks shall be insured through arrangements with either the NHS Resolution Pooling Schemes or commercial insurers, in line with the Scheme of Delegation;
17.3 The existence, integration and evaluation of the above elements will provide a basis to make a statement on the effectiveness of internal control within the annual report and accounts, as required by the Independent Regulator’s guidance.
17.4 The Chief Executive, in consultation with the Trust Secretary, Director of Finance and Medical Director, shall be responsible for ensuring that adequate insurance cover is effected in accordance with the risk management policy approved by the Board of Directors.
17.5 Each officer shall promptly notify the designated officer of all new risks or property under his/her control which require insurance and of any alterations affecting existing risks or insurances. The information held on the Trust’s Risk Register will be used to inform the Trust of any changes needed to existing insurance policies.
17.6 The designated officer shall ascertain the amount of cover required and shall effect such insurances as are necessary to protect the interests of the Trust.
17.7 The Chief Executive or his/her designated officer shall make all claims arising out of policies of insurance and each officer shall furnish the Director of Finance immediately with full particulars of any occurrence involving actual or potential loss to the Trust and an estimate of the probable cost involved.
17.8 The Director of Estates and Facilities shall ensure that all engineering plant under his/her control is inspected by the relevant insurance companies within the periods prescribed by legislation.
Printed copies valid only if separately controlled Page 46 of 65
Reference DCM076 Date of issue Version
17.9 The value of all assets and risks insured shall be reviewed or index-linked on an annual basis by the designated officer.
17.10 Where the NHS Resolution Risk Pooling Schemes are used, the Trust Secretary, Director of Finance and Medical Director shall ensure that the arrangements entered into are appropriate and complementary to the risk management programme.
17.11 The Director of Finance shall ensure that documented procedures cover the management of claims and payments in respect of all insurance arrangements, including the management of excesses payable by the Trust.
17.12 If an 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 NHS Resolution. In any case of doubt concerning a Trust’s powers to enter into commercial insurance arrangements, the Director of Finance should consult NHS Resolution.
Printed copies valid only if separately controlled Page 47 of 65
Reference DCM076 Date of issue Version
18.0 Standards of Business Conduct
18.1 General
18.1.1 A policy on Standards of Business Conduct shall be approved by the Audit, Risk and Governance Committee and made available to staff. The Trust’s Standards of Business Conduct Policy, and its associated procedures/declaration forms, is designed to ensure that Trust staff maintain the highest standard of public accountability and are open and honest in their NHS business conduct.
18.1.2 The Standards of Business Conduct Policy deals with accepting gifts, hospitality and sponsorship; employee’s declarations of interest and secondary employment.
18.2 Acceptance of Gifts and Hospitality
18.2.1 The Bribery Act 2010, which came into effect on 1 July 2011, makes it a criminal offence to give, promise or offer a bribe and to request, agree to receive or accept a bribe, either at home or abroad. The Bribery Act 2010 shall have effect as if incorporated into these SFIs.
18.2.2 All officers shall declare any offer of hospitality or gifts, whether accepted or declined, in line with the Standards of Business Conduct Policy. The Trust Secretary will maintain a register of hospitality and gifts, as notified to him/her and this will be reported routinely to the Audit, Risk and Governance Committee for review.
18.2.3 The Trust Secretary shall ensure that all officers are made aware of the Trust policy on acceptance of gifts, hospitality and other benefits in kind.
18.3 Private Transactions
18.3.1 Officers having official dealings with contractors or other suppliers of goods or services should avoid transacting any kind of private business with them by means other than normal commercial channels. No favour or preference with regard to price or otherwise which is not generally available should be sought or accepted. Refer also to section 18.2.1 above regarding the requirements of the Bribery Act 2010.
18.4 Declaration of Interests
18.4.1 The Trust Constitution refers to the regulatory framework requirement for Board Directors and Governors to formally declare interests that are relevant and material to the NHS Foundation Trust Board or Council of Governors of which they are a member. It also gives examples of ‘relevant and material’ interests.
18.4.2 In accordance with the Trust Constitution, the Trust Secretary shall be advised of declared pecuniary interests of members of the Board of Directors and Governors for recording in the relevant Register of Interests, which the Trust Secretary will maintain for that purpose. The declaration form contained within the Trust’s Standards of Business Conduct Policy shall be used for the Board of Directors and Governors to make such declarations.
18.4.3 For all other employees any such interests shall be declared to the Trust Secretary in line with the Standards of Business Conduct Policy and the associated declaration form.
Printed copies valid only if separately controlled Page 48 of 65
Reference DCM076 Date of issue Version
18.4.4 Declarations of interest will be reported routinely to the Audit, Risk and Governance Committee for review. Additionally, registers of such interests will be submitted to public meetings of the Trust Board (for Board members and all other Trust employees) and the Council of Governors (for Governors interests).
Printed copies valid only if separately controlled Page 49 of 65
Reference DCM076 Date of issue Version
19.0 Retention of Documents
19.1 The Chief Executive shall be responsible for defining retention periods and maintaining archives for all documents required to be retained, in accordance with guidance from the Independent Regulator and/or the Department of Health.
19.2 The documents held in archives shall be capable of retrieval by authorised persons.
19.3 All documents shall be held for the required retention periods in line with guidance from the Independent Regulator, the Department of Health and local policies on the preservation, retention and destruction of documents.
19.4 Documents held in accordance with the latest Independent Regulator (and where applicable Department of Health) guidance shall only be destroyed in accordance with procedures specified by the Chief Executive. Records shall be maintained of documents so destroyed.
_________________________________________________________________________ The electronic master copy of this document is held by Document Control,
Trust Secretary, NL&G NHS Foundation Trust.
Printed copies valid only if separately controlled Page 50 of 65
Reference DCM076 Date of issue Version
Appendix A
Standing Orders in relation to Tendering and Contracting Procedures 1. Duty to Comply with Standing Orders
The procedure for making all contracts by or on behalf of the Trust shall comply with these Standing Orders (except where SO 28.0 (Suspension of SOs) contained within the Trust Constitution is applied). Failure to comply will be treated as a disciplinary matter.
2. EU Directives Governing Public Procurement
Directives by the Council of the European Union on public sector purchasing as brought into effect in England by Act of Parliament and statutory instrument shall have effect as if incorporated in these Standing Orders (subject to any revisions made following withdrawal from the European Union).
3. Compliance with Guidance
The Trust shall comply as far as is practicable and relevant with the requirements of “Estatecode” in respect of capital investment and estate and property transactions and with the Department of Health guidance. In the case of management and consultancy contracts the trust shall comply as far as is practicable with relevant DoH and Independent Regulator guidance.
4. Formal Competitive Tendering
4.1 The Chief Executive shall be responsible for ensuring that best value for money can be demonstrated for all services provided under contract or in-house. The Board may determine from time to time that in-house services should be market tested by competitive tendering (section 15 refers).
4.2 The Trust shall ensure that competitive tenders are invited for the following, in line with the authority levels for obtaining tenders (and quotations) as set out in Appendix A of the Scheme of Delegation:
(a) the supply of goods, materials and manufactured articles;
(b) the rendering of any services including all forms of management consultancy;
(c) the design, construction and maintenance of building and engineering works (including construction and maintenance of grounds and gardens); and
(d) disposals.
4.3 It is a breach of regulations to split contracts to avoid appropriate tendering / quotation thresholds. The value used should be the overall contract value for the life of the equipment or service not annual costs, and excluding VAT.
4.4 For waiving of formal tendering requirements refer to section 12.
4.5 The Trust shall ensure that requirements are tendered openly in a clear and transparent manner or procured via approved framework agreements. Use of approved frameworks must be in line with the requirements of the framework. Any
Printed copies valid only if separately controlled Page 51 of 65
Reference DCM076 Date of issue Version
use of frameworks which is not through a mini competition exercise, for example a direct award, should be justified with a waiver.
4.6 For details of when quotations should be obtained refer to section 13.
5. Invitation to Tender (E-Tendering) – For Manual Tendering Rules see section 8
5.1 Electronic Tendering - All invitations to tender will be on a formal competitive basis applying the principles set out below using the Trust’s e-tendering Portal.
5.2 All tendering carried out through e-tendering will be compliant with the Trust policies and procedures relating to tendering as set out below. The issue of all tender documentation will be undertaken electronically through a secure website with controlled access using secure login, authentication and viewing rules. All tenders will be received into a secure electronic location so that they cannot be accessed until an agreed opening time. Where the electronic tendering package is used the details of the officer opening the electronic documents will be recorded in an audit trail together with the date and time of the document opening. All actions and communication by both Procurement staff and suppliers are recorded with the system audit reports.
5.3 Every tender for goods, materials, manufactured articles supplied as part of a works contract and services shall embody such of the main contract conditions as may be appropriate in accordance with the contract forms described in section 5.5 and 5.6 below.
5.4 Every tender for building and engineering works, shall embody or be in the terms of the current edition of the appropriate Joint Contracts Tribunal (JCT) or NEC 3 form of contract amended to comply with Concode. When the content of the works is primarily engineering, tenders shall embody or be in the terms of the General Conditions of Contract recommended by the Institutions of Mechanical 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 Institution of Civil Engineers. The standard documents should be amended to comply with Concode and, in minor respects, to cover special features of individual projects.
5.5 Every tender for goods, materials, services (including consultancy services) or disposals shall embody the NHS Standard Contract Terms and Conditions as are applicable. Every tenderer must have given a written undertaking not to engage in collusive tendering or other restrictive practice.
5.6 For every invitation to tender for services the Director of Finance must be satisfied as to the financial standing, and the relevant Executive Director satisfied as to the technical/clinical competence of the provider.
6. Receipt, Safe Custody and Record of Formal Tenders (E-Tendering)
6.1 Formal competitive tenders shall be submitted via the Trust’s e-tendering portal. .
6.2 The Director of Finance shall ensure that appropriate security arrangements are in place to receive tenders electronically, and that the system will register the tenders with the date and time received, but will not allow opening until the tender close date and time.
6.3 The date and time of receipt of each tender shall be logged on the e-tendering system.
Printed copies valid only if separately controlled Page 52 of 65
Reference DCM076 Date of issue Version
6.4 Tenders shall be opened by the Procurement lead for the project using the appropriate system access logins.
7. Opening Formal Tenders (E-Tendering)
7.1 As soon as practicable after the date and time stated as being the latest time for the receipt of tenders they shall be opened by the Procurement lead in accordance with the agreed policy.
7.2 Every tender received shall be recorded electronically within the e-tendering system.
7.3 A permanent record shall be maintained to show for each set of competitive tender invitations despatched:
(a) the names of firms/individuals invited;
(b) the names of and the number of firms/individuals from which tenders have been received;
(c) the total price(s) tendered;
(d) closing date and time;
(e) date and time of opening; and the persons present at the opening shall sign the record.
7.4 Except as in section 7.5 below, a record shall be maintained of all price alterations on tenders, i.e. where a price has apparently been altered, and the final price shown shall be recorded. Every price alteration appearing on a tender and the record should be recorded through the e-tendering system.
7.5 A report shall be made in the record if, on any one tender, price alterations are so numerous as to render the procedure at section 7.4 unreasonable.
7.6 The tender documents will then be shown to the director or their nominated officer of the originating department for confirmation.
8. Manual Tendering – General Rules
8.1 Where the Trust’s electronic tendering procedure is not used for any reason, the following general rules should be applied to the invitation, receipt and opening of manual tenders:
8.2 Invitation to Tender - All invitations to tender on a formal competitive basis shall state that no tender will be considered for acceptance unless submitted in either:
(a) a plain, sealed package bearing a pre-printed label supplied by the trust (or bearing the word `Tender' followed by the subject to which it relates and the latest date and time for the receipt of such tender); or
(b) in a special envelope supplied by the Trust to prospective tenderers and the tender envelopes/packages shall not bear any names or marks indicating the sender.
Printed copies valid only if separately controlled Page 53 of 65
Reference DCM076 Date of issue Version
8.3 Every tender for goods, materials, services (including consultancy services) or disposals shall embody such terms and conditions as are applicable. Every tenderer must have given or give a written undertaking not to engage in collusive tendering or other restrictive practice.
8.4 For every invitation to tender for services the Director of Finance must be satisfied as to the Financial Standing, and the relevant Executive Director satisfied as to the technical/clinical competence of the provider.
8.5 Receipt, Safe Custody and Record of Formal Tenders - Formal competitive tenders shall be addressed to the Chief Executive.
8.6 The date and time of receipt of each tender shall be endorsed on the unopened tender envelope/package.
8.7 The Chief Executive shall designate an officer or officers, not from the originating department, to receive tenders on his/her behalf and to be responsible for their endorsement and safe custody until the time appointed for their opening and for the records maintained in accordance with sections 8.8 to 8.12.
8.8 Opening Formal Tenders - As soon as practicable after the date and time stated as being the latest time for the receipt of tenders they shall be opened in the presence of two senior officers designated by the Chief Executive, and not from the originating department.
8.9 Every tender received shall be stamped with the date of opening and initialled by two of those present at the opening.
8.10 A permanent record shall be maintained to show for each set of competitive tender invitations despatched:
(a) the names of firms/individuals invited;
(b) the names of and the number of firms/individuals from which tenders have been received;
(c) the total price(s) tendered;
(d) closing date and time;
(e) date and time of opening; and the persons present at the opening shall sign the record.
8.11 Except as in section 8.12 below, a record shall be maintained of all price alterations on tenders, i.e. where a price has apparently been altered, and the final price shown shall be recorded. Every price alteration appearing on a tender and the record should be initialled by two of those present at the opening.
8.12 A report shall be made in the record if, on any one tender, price alterations are so numerous as to render the procedure at section 8.11 unreasonable.
9. Admissibility and Acceptance of Formal Tenders
9.1 In considering which tender to accept, if any, the designated officers shall have regard to whether value for money will be obtained by the trust, taking into account
Printed copies valid only if separately controlled Page 54 of 65
Reference DCM076 Date of issue Version
whole lifetime costs, and whether the number of tenders received provides adequate competition. In cases of doubt they shall consult the Chief Executive.
9.2 Tenders received after the due time and date may be considered only if the Chief Executive or nominated officer decides that there are exceptional circumstances, (e.g. where significant financial, technical or delivery advantages would accrue), and is satisfied that there is no reason to doubt the bona fides of the tenders concerned. The Chief Executive or nominated officer shall decide whether such tenders are admissible and whether re-tendering is desirable. Re-tendering may be limited to those tenders reasonably in the field of consideration in the original competition. If the tender is accepted the late arrival of the tender should be reported to the Board at its next meeting.
9.3 Materially 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/her own initiative either orally or in writing after the due time for receipt) should be dealt with in the same way as late tenders under section 9.2.
9.4 Where examination of tenders reveals errors or a need for clarification that would affect the tender figure, the tenderer is to be given details of such errors/clarifications and afforded the opportunity of confirming or withdrawing his/her offer.
9.5 Necessary discussions with a tenderer of the contents of his/her tender, in order to elucidate technical points etc., before the award of a contract, need not disqualify the tender.
9.6 While decisions as to the admissibility of late, incomplete, or amended tenders are under consideration and while re-tenders are being obtained, the tender documents shall remain strictly confidential and kept in safekeeping by an officer designated by the Chief Executive.
9.7 Where only one tender/quotation is received the Trust shall, as far as practicable, ensure that the price to be paid is fair and reasonable.
9.8 All tenders shall be evaluated on the basis of MEAT (Most Economically Advantageous Tender) and in conjunction with the published award criteria and weightings.
9.9 A tender other than the most economically advantageous tender (MEAT) shall not be accepted unless there are good and sufficient reasons permanently recorded and approved by the Head of Procurement, Director of Finance, and the Chief Executive.
9.10 Where the form of contract includes 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.
9.11 All tenders should be treated as confidential and should be retained for inspection.
10. Delegated Limits for Award
Formal tenders/quotations may be awarded as detailed in Appendix A of the Trust Scheme of Delegation.
Printed copies valid only if separately controlled Page 55 of 65
Reference DCM076 Date of issue Version
11. Lists of Approved Firms
11.1 Where relevant and applicable, the Trust shall compile and maintain lists of approved firms and individuals from whom tenders may be invited, as provided for in section 4.4 and shall keep these under review. The lists shall be selected from all firms that have applied for permission to tender provided that:
(a) in the case of building, engineering and maintenance works, the Chief Executive or his/her nominated officer is satisfied on their capacity, conditions of labour, etc., and that the Director of Finance is satisfied that their financial standing is adequate
(b) in the case of the supply of goods, materials and related services, and consultancy services the Chief Executive or the nominated officer is satisfied as to their technical competence etc., and that the Director of Finance is satisfied that their financial standing is adequate.
(c) in the case of the provision of healthcare services to the Trust by a private sector provider, the Director of Finance is satisfied that their financial standing is adequate, and the Medical Director is satisfied as to their technical/clinical competence.
11.2 If in the opinion of the Chief Executive or the Director of Finance it is impractical to use a list of approved firms/individuals (for example where specialist services or skills are required and there are insufficient suitable potential contractors on the list), the Chief Executive should ensure that appropriate checks are carried out as to the technical and financial capability of firms invited to tender or quote.
11.3 A permanent record should be made of the reasons for inviting a tender other than from an approved list.
12. Waiving of Formal Tendering Procedures
12.1 In exceptional circumstances it may be impractical to follow the tendering process. If so a request for waiver of Standing Financial Instructions (SFIs) (relating to quotations and tenders) must be completed.
12.2 The reason for waiving competitive tendering procedures under this Standing Order shall be documented in a permanent record and approved, before any order may be placed or any financial commitment entered into, by the Director of Finance and the Chief Executive (in the absence of either the Chief Executive or the Director of Finance, and the need for urgency, their designated deputies shall perform the authorisation function. In cases where the Chief Executive is on annual leave this would be the Acting Chief Executive. In cases where the Chief Executive is off site and there is a need for urgency in signing the waiver, the Chief Executive will formally nominate in writing via email a Deputy to act on his/her behalf for that specific purpose);
12.3 All waivers must be completed prospectively.
12.4 All officers must comply with the waiver procedure where necessary. The waiver procedure can be found on the Trust intranet (and a main extract is reproduced at Appendix B of these SFIs).
Printed copies valid only if separately controlled Page 56 of 65
Reference DCM076 Date of issue Version
12.5 If any officer is uncertain about the Trust’s tendering and quotation requirements or the waiver procedure they must contact the Trust’s Procurement team for advice and guidance.
12.6 Failure to plan the work properly and as a result be time restricted is not a justification for waiver. Such instances will be recorded as non-compliant and reported to the Audit, Risk and Governance Committee.
12.7 All waivers will be reported to the Audit, Risk and Governance Committee for oversight and scrutiny purposes.
12.8 Formal tendering procedures may be waived where:
(a) where the supply is proposed under special arrangements negotiated by the Department of Health, NHS Supply Chain, NHS Improvement, NHS Business Services Authority, or Commercial Procurement Collaborative, in which event the said special arrangements must be complied with; or
(b) where the requirement is ordered under existing contracts. However, where the goods and services are capable of being provided by a number of firms under contract arrangements, as specified in (a) above, a value for money assessment shall take place to demonstrate that the Trust receives best value; or
(c) where it is an extension to an existing (or very recently expired) contract which was sourced by competitive selection or via a framework either by the Trust or by agencies such as the Crown Commercial Service, NHS Supply Chain or another commercial procurement collaborative acting on behalf of a NHS organisation; or
(d) where so provided in Concode or Estatecode for building, engineering and grounds maintenance; or
(e) where, in the opinion of the Head of Procurement, Director of Finance and the Chief Executive, the nature of the requirement is such that the invitation of competitive tenders is demonstrably not practicable; or,
(f) where a decision as to the particular item(s) to be purchased has already been taken for reasons of standardisation of equipment across the Trust.
(g) the timescale genuinely precludes competitive tendering. Failure to plan the work properly is not a justification for a waiver; or
(h) the task is essential to complete the project, AND arises as a consequence of a recently completed assignment and engaging different consultants for the new task would be inappropriate.
13. Quotations
13.1 The Trust shall ensure that quotations are obtained in line with the authority levels for obtaining quotations as set out in Appendix A of the Scheme of Delegation. It is a breach of regulations to split contracts to avoid appropriate tendering / quotation thresholds. The value used should be the overall contract value for the life of the equipment or service not annual costs, and excluding VAT
Printed copies valid only if separately controlled Page 57 of 65
Reference DCM076 Date of issue Version
13.2 Where formal quotations are not obtained in line with Appendix A of the Scheme of Delegation, a waiver recording the reason(s) for this shall be required.
13.3 All quotations should be treated as confidential and should be retained for inspection or audit scrutiny in line with the Trust’s retention and destruction of records policy.
13.4 The nominated officer should evaluate the formal quotations and select the one that gives the best value for money. If this is not the lowest then this fact and the reasons why the lowest formal quotation was not chosen should be documented in a permanent record (i.e. a waiver).
13.5 The Director of Finance and Chief Executive may waive formal quotation procedures, following advice from the Trust’s Procurement department. A waiver must be completed. In these circumstances non-competitive quotations may be obtained for the following purposes:
(a) the supply of goods and services of a special character for which it is not, in the opinion of the Chief Executive and the Director of Finance, possible or desirable to obtain competitive quotations; or
(b) the goods/services are required urgently and was not foreseeable.
13.6 The Audit, Risk and Governance Committee shall review all occasions where the Chief Executive has waived competitive quotations.
13.7 For estimated expenditure or income below the limits set in Appendix A of the Scheme of Delegation in relation to informal quotations, the Trust shall procure goods and services through the NHS Supply Chain, or alternatives, as appropriate. Officers should at all times demonstrate value for money by:
(a) obtaining quotations; or
(b) documenting in a departmental record how value for money has been secured if quotations are not appropriate; or
(c) justification for not obtaining quotations.
Such records should be retained in the department and be available for audit scrutiny.
14. Procurement of Consultancy Services
14.1 The Regulators have issued specific guidance setting out expenditure delegation limits for individual organisations and requiring central Regulator approval for all consultancy engagements above a certain value. All Trust budget holders must follow the latest iteration of this guidance whenever procuring consultancy services.
14.2 For consultancy engagements below the latest Regulator guidance the rules in these SFI’s apply.
15. In-House Services
15.1 In all cases where the Trust determines that in-house services should be subject to competitive tendering the following groups shall be set up:
Printed copies valid only if separately controlled Page 58 of 65
Reference DCM076 Date of issue Version
(a) Specification group, comprising the Chief Executive or nominated officer(s) and specialist(s).
(b) In-house tender group, comprising representatives of the in-house team, a nominee of the Chief Executive and technical support;.
(c) Evaluation group, comprising normally a specialist officer, a supplies officer and a Director of Finance representative. For services having a likely annual expenditure exceeding £500,000, a non-executive director will be a member of the evaluation team.
15.2 All groups should work independently of each other but individual officers may be members of more than one group. No member of the in-house tender group may, however, participate in the evaluation of tenders.
15.3 The evaluation group shall make recommendations to the board.
15.4 The Chief Executive shall nominate an officer to oversee and manage the contract.
16. Contracts
16.1 The Trust may only enter into contracts within its statutory powers and shall comply with:
• these Standing Orders;
• the Trust's SFIs;
• EU Directives and Public Contract Regulations 2015 (as appropriate following withdrawal from the European Union) and other statutory provisions;
• any relevant NHSI guidance on the Procurement and Management of Consultants.
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.
In all contracts made by the Trust, the Board shall endeavour to obtain best value for money. The Chief Executive shall nominate an officer who shall oversee and manage each contract on behalf of the Trust. Contracts shall be signed in line with Appendix A of the Scheme of Delegation.
17. Personnel and Agency or Temporary Staff Contracts
The Chief Executive shall nominate officers with delegated authority to enter into contracts for the employment of other officers, to authorise the regrading of staff, and enter into contracts for the employment of agency staff or temporary staff. Refer to Appendix A of the Scheme of Delegation.
18. Cancellation of Contracts
Every written contract shall include standard clauses empowering the Trust to cancel the contract and to recover from the contractor the amount of any loss resulting from such cancellation under the circumstances stated in the standard NHS contract or relevant framework contract documentation.
Printed copies valid only if separately controlled Page 59 of 65
Reference DCM076 Date of issue Version
19. Contracts Involving Funds Held on Trust
Such contracts involving charitable funds shall comply with the requirements of the Charities Acts.
20. 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 pre-determined in a reserve) by the Chief Executive or his/her nominated officer;
(b) obsolete or condemned articles and stores, which may be disposed of in accordance with the supplies policy of the Trust;
(c) items to be disposed of with an estimated sale value of less than £5,000, this figure to be reviewed annually;
(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 guidance has been issued by the independent regulator, but subject to compliance with such guidance
Condemning and disposal of plant and equipment shall however be authorised in line with Appendix A of the Scheme of Delegation.
Printed copies valid only if separately controlled Page 60 of 65
Reference DCM076 Date of issue Version
Appendix B
WAIVER PROCEDURE 1.0 Purpose
1.1 In exceptional circumstances it may be impractical to follow the tendering process. If so a request for waiver of Standing Financial Instructions (SFIs) (relating to quotations and tenders) must be completed and authorised by the relevant Director, before being submitted to the Head of Procurement for review and recommendation to the Director of Finance and Chief Executive, who must both approve all waivers of SFIs.
1.2 The purpose of this document is to outline the process required to complete a waiver for the justification for non-compliance with the Trust’s SFIs and Standing Orders (SOs) during the procurement of goods and services.
2.0 Area
Trustwide for any staff involved in the selection and procurement of goods and services on behalf of the Trust.
3.0 Duties
Any requests for goods/services which do not comply with Standing Orders/SFIs must be accompanied by an appropriately completed Waiver Form (see below) which is available as a standalone document for completion on the Trust intranet titled Waiver Form.
4.0 Actions
4.1 Any requisition received which does not comply with Standing Orders/SFIs should be returned to the Requestor by the Procurement Officer concerned. When returning a requisition to the Requestor an appropriate explanation for its return should always be provided.
4.2 Standing Financial Instruction Thresholds (SFIs) for Ordering of Goods & Services:
Value of Expenditure
Authority Delegated to / Quotation & Tendering requirements
For details of the quotation and tendering requirements and associated financial limits refer to Appendix A of the Trust’s Scheme of Delegation.
Printed copies valid only if separately controlled Page 61 of 65
Reference DCM076 Date of issue Version
4.3 Step by Step Guide to completing a Waiver Form:
• Step 1: Sections 2 and 3 must be completed by the Requestor, stating the nature of the procurement and clearly detailing the justification for non-compliance with SFI’s/SOs. To facilitate faster processing the completed waiver should be accompanied by the official Trust purchase requisition and copies of any relevant supporting paperwork such as quotes, clinical justifications, business cases, committee reports, etc
• Step 2: The requestor or authorised officer responsible must also sign section 3 and obtain an approval signature from the appropriate Director. It should be noted that the official Trust purchase requisition still requires the correct authorisation/signatures according to value and cost centre, regardless of the signatures that appear on the waiver form itself
• Step 3: Once authorised by the appropriate Director the original waiver form, purchase requisition and supporting documentation must be sent to the Head of Procurement for completion of section 4
• The Strategic Procurement Team will, if appropriate, check the requirement against any local contract arrangements, National or Regional Contracts/Framework Agreements (NHS Supply Chain/Crown Commercial Service (CCS)/North of England Commercial Procurement Collaborative (NOECPC) to ensure there are no conflicts of interest with existing contracts or supply arrangements. This will include any category towers (see definitions below) which result from the Department of Health’s Future Operating Model programme
• The Head of Procurement will provide the justification for waiving the Standing Orders as one of the following categories, based on the information received and subject to further clarification (where necessary):
− Non-compliance with Standing Orders and Standing Financial Instructions/Adverse impact on Trust Operations (if not approved)
− Standardisation
− Insufficient Suppliers
− Maintenance Agreement
− Rejection of Lowest Tender
• Where a waiver is signed with the ‘Non-compliance with Standing Orders/Adverse impact on Trust Operations (if not approved)’ justification the Head of Procurement will be responsible for conducting an investigation into the background behind the requisition
• The Head of Procurement will be responsible for reporting the findings of this investigation and suggested improvements to the Audit, Risk and Governance Committee
Printed copies valid only if separately controlled Page 62 of 65
Reference DCM076 Date of issue Version
• Step 4: If the Head of Procurement is satisfied that the request for a waiver is justified on procurement grounds the waiver form will be signed as evidence of this by the Head of Procurement
• Step 5: All waivers must then be forwarded to and authorised by both the Director of Finance and the Chief Executive before an order may be placed or financial commitment entered into
(In the absence of either the Chief Executive or the Director of Finance, and the need for urgency, their designated deputies shall perform the authorisation function. In cases where the Chief Executive is on annual leave this would be the Acting Chief Executive. In cases where the Chief Executive is off site and there is a need for urgency in signing the waiver, the Chief Executive will formally nominate in writing via email a Deputy to act on his/her behalf for that specific purpose)
• Step 7: Once the relevant authorisation has been provided the Waiver form is returned to the Procurement Team for order processing and completion of section 5
• Step 8: A report detailing the waivered transactions shall also be compiled on behalf of the Director of Finance for submission to each meeting of the Trust's Audit, Risk and Governance Committee for oversight and scrutiny
• Original Waiver forms shall be retained on file for a minimum period of 6 years
5.0 Monitoring Compliance and Effectiveness
A schedule of all authorised requests for waivers shall be maintained within the Strategic Procurement Department to facilitate compilation of a report detailing the waivered transactions for submission to each meeting of the Trust's Audit, Risk and Governance Committee. Instances of non-compliance with the waiver procedure shall be brought to the attention of the Audit, Risk and Governance Committee (at the next available meeting) as and when they arise.
Definitions
Category Towers – The category towers will be procurement hubs, who will replace the procurement operations of NHS Supply Chain as part of the Department of Health’s Future Operating Model.
Future Operating Model – The Future Operating Model is a programme initiated and run by the Department of Health to replace the current NHS Supply Chain solution. This model includes the replacement of IT systems, procurement solutions and account management activities.
Non-compliance with Standing Orders/Adverse impact on Trust Operations (if not approved) – This occurs where a department has not followed the correct procurement processes, but it is not within the Trust’s operational interests to block the procurement process.
Printed copies valid only if separately controlled Page 63 of 65
Reference DCM076 Date of issue Version
Standardisation – This occurs where a strategic decision is made to choose a supplier’s products or services which are already in use within the Trust, creating a consistent approach across all Trust areas. This may occur where there are clear clinical benefits to using the same equipment, for example where cross-site staffing is in place.
Insufficient Suppliers – This occurs when the Trust’s SFIs cannot be met, for example where there are only two capable suppliers who can meet a specification but the Trust requirements dictate three or four quotes/tenders.
Maintenance Agreement – This covers the on-going maintenance of equipment which will have been procured via a capital procurement process. In these situations it is often the original equipment manufacturer who provides the maintenance service.
Rejection of Lowest Tender – This occurs where a procurement process has been followed, but the lowest priced offer is not the favoured solution. The procurement methodology of most economically advantageous tender (MEAT) will have been followed to identify the most suitable solution.
Printed copies valid only if separately controlled Page 64 of 65
Reference DCM076 Date of issue Version
Printed copies valid only if separately controlled Page 65 of 65
NLG(20)034
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Tony Bramley – Chair of Audit, Risk and Governance Committee
CONTACT OFFICER Jim Hayburn, Interim Director of Finance
SUBJECT Audit, Risk and Governance Committee Membership and Terms of Reference
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
In line with its agreed annual work programnme, the Committee performed its annual review of its formal Membership and Terms of Reference at its meeting on 22nd January 2020. The document was last updated following discussions at the May 2019 meeting of the Committee. No further changes were considered necessary at this time, and the Board are asked to re-approve the Membership and Terms of Reference for a further year.
TRUST BOARD ACTION REQUIRED The Trust Board is asked to re-approve the Audit, Risk and Governance Committee’s Membership and Terms of Reference for a further year.
Reference: DCT122 Version: 1.4 This version issued: 07/10/19 Result of last review: Minor changes Date approved by owner (if applicable):
N/A
Date approved: 16/05/19 / 02/07/19 Approving body: Trust Board Audit, Risk & Governance / Trust Board Date for review: July, 2020 Owner: Marcus Hassall, Director of Finance Document type: Terms of Reference Number of pages: 14 (including front sheet) Author / Contact:
Marcus Hassall, Director of Finance / Sally Stevenson, Assistant Director of Finance – Compliance & Counter Fraud
Northern Lincolnshire and Goole NHS Foundation Trust actively seeks to promote equality of opportunity. The Trust seeks to ensure that no employee, service user, or member of the public is unlawfully discriminated against for any reason, including the “protected characteristics” as defined in the Equality Act 2010. These principles will be expected to be upheld by all who act on behalf of the Trust, with respect to all aspects of Equality.
Directorate of Finance
TRUST BOARD AUDIT, RISK AND GOVERNANCE COMMITTEE
Membership and Terms of Reference
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 2 of 14
1.0 Constitution
1.1 The Audit, Risk and Governance Committee (the Committee) is a standing committee formally established by the Trust Board (the Board).
1.2 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.
1.3 These terms of reference have been produced in line with the guidance contained within the Healthcare Financial Management Association (HFMA) NHS Audit Committee Handbook (2018).
2.0 Membership and Quorum
2.1 The Committee shall be appointed by the Board from among the Non-Executive Directors of the Trust and shall consist of not less than three members. One of the members shall have recent relevant financial experience.
2.2 A quorum shall be two of the three members.
2.3 One of the members will be appointed Chair of the Committee by the Board.
2.4 The Chair of the Trust shall not be a member of the Committee.
3.0 Attendance at Meetings
3.1 The Director of Finance and internal and external audit representatives shall normally attend meetings.
3.2 The Trust Secretary shall normally attend meetings.
3.3 The Chair of the Trust and the Chief Executive should be invited to attend and should discuss at least annually with the Audit, Risk and Governance Committee the process for assurance that supports the Annual Governance Statement. The Chief Executive should also attend when the Committee considers the draft annual governance statement and the annual report and accounts.
3.4 Other Executive Directors/managers should be invited to attend, normally for their items(s) only, particularly when the Committee is discussing areas of risk or operation that are the responsibility of that Director/manager.
3.5 The Local Counter Fraud Specialist will attend to report upon and discuss counter fraud matters.
3.6 Representatives from other organisations (e.g. NHS Counter Fraud Authority (NHS CFA)) and other individuals (e.g. Local Security Management Specialist) may be invited to attend on occasion.
3.7 The Secretary to the Committee shall attend to take minutes of the meeting and provide appropriate support to the Chair and Committee members.
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 3 of 14
3.8 At least once a year, usually at its May meeting, members of the Committee shall meet privately with the External and Internal Auditors. Other meetings will take place at the request of members or auditors.
4.0 Access
The Head of Internal Audit, representatives of External Audit and the Local Counter Fraud Specialist have a right of direct access to the Chair of the Committee.
5.0 Frequency of Meetings
5.1 The Committee should meet at least five times per year at appropriate times in the audit cycle to allow it to discharge all of its responsibilities in line with its annual workplan. Additional meetings, including any focus working group, may be called as required. The Committee will review this annually.
5.2 The Accountable Officer, External Auditors and/or Head of Internal Audit may request a meeting if they consider that one is necessary.
6.0 Authority
6.1 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 co-operate with any request made by the Committee.
6.2 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.
7.0 Responsibilities
7.1 The Committee supports the Board by:
Assessing the Trust’s overarching framework of governance, risk and control
Obtaining assurances about the design and operation of internal controls
Seeking assurances about the underlying data (upon which assurances are based) to assess their reliability and accuracy
Challenging poor and/or unreliable sources of assurance
Challenging relevant managers when controls are not working or data are unreliable
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 4 of 14
The duties/responsibilities of the Committee are categorised as the follows:
7.2 Integrated Governance, Risk Management and Internal Control
7.2.1 The Committee shall 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.
7.2.2 In particular, the Committee will review the adequacy and effectiveness of:
All risk and control related disclosure statements (in particular the Annual Governance Statement), together with any accompanying Head of Internal Audit Opinion, external audit opinion or other appropriate independent assurances, prior to submission to the Board
The underlying assurance processes that indicate the degree of 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 and related reporting and self-certifications
The policies and procedures for all work related to counter fraud and corruption as required by the NHS Counter Fraud Authority
7.2.3 In carrying out this work the Committee use the work of Internal Audit, External Audit and other assurance functions, but will not be limited to these sources. It will also seek reports and assurances from directors and managers.
7.2.4 This will be evidenced through the Committee’s use of an effective Assurance Framework to guide its work and that of the audit and assurance functions that report to it.
7.2.5 As part of its integrated approach, the Committee will have effective relationships with other Trust Board Sub Committees (which may include reciprocal membership) to provide an understanding of processes and linkages. This will include the exchange of Chair’s action logs and .highlight reports to the Trust Board.
7.3 Internal Audit
The Committee shall assure itself that there is an effective internal audit function that meets Public Sector Internal Audit Standards (PSIAS) and provides independent assurance to the Committee, Chief Executive and Board. This will be achieved by:
Considering the provision of the internal audit service and the costs involved
Reviewing and approving the internal audit strategy, the annual internal audit plan and more detailed programme of work, that is consistent with the audit needs of the Trust as identified in the Assurance Framework
Considering the major findings of internal audit work (and management’s response), and ensuring co-ordination between the internal and external auditors to optimise the use of audit resources
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 5 of 14
Monitoring the implementation of agreed internal audit recommendations in line with agreed timescales, and where concerns exist in relation to the lack of implementation in a particular area the Committee can request the relevant operational manager to attend a meeting and give explanation
Ensuring that the internal audit function is adequately resourced and has appropriate standing within the organisation
Reviewing the Internal Auditor’s annual report before its submission to the Board
Monitoring the effectiveness of internal audit and carrying out an annual review and obtaining independent assurance that Internal Audit complies with PSIAS
7.4 External Audit
The Committee shall review and monitor the External Auditor’s independence and objectivity and the effectiveness of the audit process. In particular, the Committee will review the work and findings of the External Auditors and consider the implications and management’s responses to their work. This will be achieved by:
Assisting and advising the Council of Governors in their appointment of the External Auditors (and make recommendations to the Board when appropriate)
Discussing and agreeing with the External Auditors, before the audit commences, the nature and scope of the audit as set out in the annual plan
Discussing with the External Auditors their evaluation of audit risks and assessment of the organisation and the impact on the audit fee
Reviewing 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 responses
Establishing a clear policy for the engagement of external auditors to supply non-audit services
7.5 Financial Reporting
7.5.1 The Committee shall monitor the integrity of the financial statements of the Trust and any formal announcements relating to its financial performance.
7.5.2 The Committee should 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.
7.5.3 The Committee shall review the annual report and financial statements before submission to the Board, focusing particularly on:
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
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 6 of 14
Unadjusted mis-statements in the financial statements
Significant judgements in preparation of the financial statements
Significant adjustments resulting from the audit
Letters of representation
Explanations for significant variances
7.6 Risk Management
7.6.1 The Committee shall request and review reports and assurance from directors and managers as to the effectiveness of arrangements to identify and monitor risk. This will include:
Inviting the Trust’s IT team to explain the organisation’s cyber security arrangements, in order to provide assurance to the Board that the organisation is properly managing its cyber risk and has appropriate risk mitigation strategies
Reviewing arrangements for new mergers and acquisitions, in order to seek assurance on processes in place to identify significant risks, risk owners and subsequent management of such risks
Overseeing actions plans relating to regulatory requirements in terms of the Single Oversight Framework and Use of Resources
Providing the Board with assurance over developing partnership arrangements (e.g. accountable care organisations) and mitigation of risks which may arise at the borders between such organisations
7.6.2 The Board will however retain the responsibility for routinely reviewing specific risks.
7.7 Counter Fraud and Security
7.7.1 The Committee shall satisfy itself that the organisation has adequate arrangements in place for counter fraud that meet the NHS CFA’s standards and shall review the outcomes of work in these areas. The Committee shall receive the annual report and annual work plan from the Local Counter Fraud Specialist, and shall also receive regular progress reports on counter fraud activities.
7.7.2 The Committee shall also receive and review the annual report and the annual work plan from the Local Security Management Specialist. It shall receive other security activity reports as appropriate.
7.8 Management
7.8.1 The Committee shall request and review reports, evidence and assurances from Directors and managers on the overall arrangements for governance, risk management and internal control.
7.8.2 The Committee may also request specific reports from individual functions within the organisation (e.g. clinical audit).
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 7 of 14
7.9 Other Assurance Functions
7.9.1 The Committee shall review the findings of other significant assurance functions, both internal and external to the organisation, and consider the implications for the governance of the organisation.
7.9.2 These will include, but not be limited to, any reviews by Department of Health arm’s length bodies or regulators/inspectors (e.g. the Care Quality Commission, NHS Improvement, NHS Resolution, etc) and professional bodies with responsibility for the performance of staff or functions (e.g. Royal Colleges, accreditation bodies, etc).
7.9.3 In addition, the Committee will review the work of other committees within the Trust, whose work can provide relevant assurance to the Committee’s own areas of responsibility. In particular this will include any clinical governance, risk management or quality committees that are established. The Committee shall receive the action logs and highlight reports to the Trust Board of the following Board sub-committees for information:
Finance and Performance Committee
Quality and Safety Committee
Workforce Committee
7.9.4 In reviewing the work of the Quality & Safety Committee, and issues around clinical risk management, the Committee will wish to satisfy itself on the assurance that can be gained from the clinical audit function.
7.9.5 The Committee will review Standing Financial Instructions, Scheme of Delegation and those elements of the Trust Constitution (Standing Orders) that provide assurances on the internal management of procurement and financial matters. It will also review the Trust’s Standards of Business Conduct Policy.
8.0 Reporting
8.1 Minutes of each meeting shall be submitted to the next meeting for formal approval and signature by the Chair as a true record of that meeting. A Chair’s log and the minutes will be submitted to the next meeting of the Board.
8.2 The Chair shall draw to the attention of the Board (via a highlight report) any issues that require disclosure to the Board, or require executive action.
8.3 The Committee shall report to the Board annually on its work in support of the Annual Governance Statement specifically commenting on the fitness for purpose of the Assurance Framework, the completeness and 'embeddedness' of risk management in the organisation, the integration of governance arrangements, the appropriateness of the evidence that shows the organisations is fulfilling regulatory requirements relating to its existence as a functioning business and the robustness of the processes behind the quality accounts.
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 8 of 14
8.4 The annual report should also describe how the Committee has fulfilled its terms of reference and give details of any significant issues that the Committee considered in relation to the financial statements and how they were addressed. The report will also outline its workplan for the coming year.
8.5 The Committee’s annual report and workplan will also be submitted to the Council of Governors for information.
9.0 Whistleblowing / Freedom to Speak Up Guardian
9.1 The Committee shall review the effectiveness of the arrangements in place for allowing staff to raise (in confidence) concerns about possible improprieties in financial, clinical or safety matters and ensures that any such concerns are investigated proportionately and independently.
9.2 The Trust’s Freedom to Speak Up Guardian, or his or her nominated deputy, shall attend the Committee at least annually to provide assurance on the design and operation of the function.
10.0 Administrative Support
10.1 The agenda for the Committee shall be approved by the Chair of the committee (or his or her nominated deputy).
10.2 Secretarial support (including distribution of agenda and papers to the Committee and noting of apologies) will be arranged by the Director of Finance (or his or her nominated deputy).
10.3 Agenda papers will be circulated to all members of the Committee no less than five working days prior to each meeting. Late papers may only be circulated, or tabled at the meeting, with the prior approval of the Chair.
11.0 Review
11.1 The Committee will review its Terms of Reference annually, or as necessary in the intervening period, to ensure that they remain fit for purpose and best facilitate the discharge of its duties. It shall recommend any changes to the Trust Board for approval.
11.2 The Committee will carry out an annual self-assessment (Appendix A) that is based on the good practice guide found in the HFMA’s NHS Audit Committee Handbook.
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 9 of 14
12.0 Equality Act (2010)
12.1 Northern Lincolnshire and Goole NHS Foundation Trust is committed to promoting a pro-active and inclusive approach to equality which supports and encourages an inclusive culture which values diversity.
12.2 The Trust is committed to building a workforce which is valued and whose diversity reflects the community it serves, allowing the Trust to deliver the best possible healthcare service to the community. In doing so, the Trust will enable all staff to achieve their full potential in an environment characterised by dignity and mutual respect.
12.3 The Trust aims to design and provide services, implement policies and make decisions that meet the diverse needs of our patients and their carers the general population we serve and our workforce, ensuring that none are placed at a disadvantage.
12.4 We therefore strive to ensure that in both employment and service provision no individual is discriminated against or treated less favourably by reason of age, disability, gender, pregnancy or maternity, marital status or civil partnership, race, religion or belief, sexual orientation or transgender (Equality Act 2010).
The electronic master copy of this document is held by Document Control, Trust Secretary, NL&G NHS Foundation Trust.
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 10 of 14
Appendix A
HFMA NHS Audit Committee Handbook, 2018 – Extract
This checklist is designed to elicit a simple yes or no answer to each question. Where ‘no’ answers have been given, the issues should be debated to determine if any further action is needed.
Area/Question Yes No Comments/Action
Composition, establishment and duties
Does the audit committee have written terms of reference and have they been approved by the governing body?
Are the terms of reference reviewed annually?
Has the committee formally considered how it integrates with other committees that are reviewing risk?
Are committee members independent of the management team?
Are the outcomes of each meeting and any internal control issues reported to the next governing body meeting?
Does the committee prepare an annual report on its work and performance for the governing body?
Has the committee established a plan of matters to be dealt with across the year?
Are committee papers distributed in sufficient time for members to give them due consideration?
Has the committee been quorate for each meeting this year?
Internal control and risk management
Has the committee reviewed the effectiveness of the organisation’s assurance framework?
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 11 of 14
Area/Question Yes No Comments/Action
Does the committee receive and review the evidence required to demonstrate compliance with regulatory requirements - for example, as set by the Care Quality Commission?
Has the committee reviewed the accuracy of the draft annual governance statement?
Has the committee reviewed key data against the data quality dimensions?
Annual report and accounts and disclosure statements
Does the committee receive and review a draft of the organisation’s annual report and accounts?
Does the committee specifically review:
The going concern assessment
Changes in accounting policies
Changes in accounting practice due to changes in accounting standards
Changes in estimation techniques
Significant judgements made in preparing the accounts
Significant adjustments resulting
from the audit
Explanations for any significant
variances?
Is a committee meeting scheduled to discuss any proposed adjustments to the accounts and audit issues?
Does the committee ensure it receives explanations for any unadjusted errors in the accounts found by the external auditors?
Internal audit
Is there a formal ‘charter’ or terms of reference, defining internal audit’s objectives and responsibilities?
Does the committee review and approve the internal audit plan, and any changes to the plan?
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 12 of 14
Area/Question Yes No Comments/Action
Is the committee confident that the audit plan is derived from a clear risk assessment process?
Does the committee receive periodic progress reports from the head of internal audit?
Does the committee effectively monitor the implementation of management actions arising from internal audit reports?
Does the head of internal audit have a right of access to the committee and its chair at any time?
Is the committee confident that internal audit is free of any scope restrictions, or operational responsibilities?
Has the committee evaluated whether internal audit complies with the Public Sector Internal Audit Standards?
Does the committee receive and review the head of internal audit’s annual opinion?
External audit
Do the external auditors present their audit plan to the committee for agreement and approval?
Does the committee review the external auditor’s ISA 260 report (the report to those charged with governance)?
Does the committee review the external auditor’s value for money conclusion?
Does the committee review the external auditor’s opinion on the quality account when necessary?
[Note: this question is not relevant for CCGs]
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 13 of 14
Area/Question Yes No Comments/Action
Does the committee hold periodic private discussions with the external auditors?
Does the committee assess the performance of external audit?
Does the committee require assurance from external audit about its policies for ensuring independence?
Has the committee approved a policy to govern the value and nature of non-audit work carried out by the external auditors?
Clinical audit [Note: this section is only relevant for providers]
If the committee is NOT responsible for monitoring clinical audit, does it receive appropriate assurance from the relevant committee?
If the committee is responsible for monitoring clinical audit has it:
Reviewed an annual clinical audit plan?
Received regular progress reports?
Monitored the implementation of
management actions?
Received a report over the quality
assurance processes covered by
clinical audit activity?
Counter fraud
Does the committee review and approve the counter fraud work plans, and any changes to the plans?
Is the committee satisfied that the work plan is derived an appropriate risk assessment and that coverage is adequate?
Does the audit committee receive periodic reports about counter fraud activity?
Reference DCT122 Date of issue 07/10/19 Version 1.4
Printed copies valid only if separately controlled Page 14 of 14
Area/Question Yes No Comments/Action
Does the committee effectively monitor the implementation of management actions arising from counter fraud reports?
Do those working on counter fraud activity have a right of direct access to the committee and its chair?
Does the committee receive and review an annual report on counter fraud activity?
Does the committee receive and discuss reports arising from quality inspections by NHSCFA?
NLG(19)035
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM
Dr Kate Wood, Medical Director / Tony Bramley, Vice-Chair of Quality & Safety Committee
CONTACT OFFICER Dr Kate Wood, Medical Director / Tony Bramley, Vice-Chair of Quality & Safety Committee
SUBJECT Quality & Safety Committee minutes from October, November & December meetings
BACKGROUND DOCUMENT (IF ANY)
PURPOSE OF THE REPORT: For information
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
These are the minutes from the Quality and Safety Committee meetings held in October, November and December 2019.
TRUST BOARD ACTION REQUIRED
The Board is asked to note the minutes
1
Meeting: QUALITY & SAFETY COMMITTEE Date: Thursday 17 October 2019 Time: 1.30pm – 4:00pm Venue: Main Boardroom, Diana Princess of Wales Hospital, Grimsby
MINUTES
MINUTES OF THE MEETING
Sandra Hills Non-Executive Director (Chair of the meeting) Tony Bramley Non-Executive Director Kate Wood Medical Director Angie Legge Associate Director for Quality Governance Jan Haxby Director of Quality & Nursing N E Lincs CCG Dawn Harper Deputy Chief Nurse In attendance Ian Reekie Governor Steve Griffin (item 216/19) Divisional Clinical Director, Clinical Support Services Jason Baker (item 223/19) Quality and Audit Manager Hayli Garrod (item 222/19) Quality and Audit Manager Jane Warner (item 224/19) Head of Midwifery Sarah Smyth (item 224/19) Divisional General Manager, Women and Children’s Mahadeva Manohar (item 224/19) Divisional Clinical Director, Women and Children’s Jeremy Daws (item 225/19) Head of Quality Assurance Laura Coo PA to the Medical Director (for the minutes)
210/19 Apologies for Absence; Peter Reading, Ellie Monkhouse (Dawn Harper to represent), Tracey Broom, Julie Taylor
211/19 Declaration of interest
There were no declarations of interest to note.
212/19 Minutes of the Previous Meeting, 20 September 2019
Sandra Hill noted for accuracy that under item 206/19 that she was the NED lead for SAFER not insulin management.
The minutes were otherwise accepted as a true and accurate reflection of the previous meeting.
Matters Arising
Sandra Hills noted that there had been a number of late papers for this meeting which on this occasion due to the CQC visit had been approved to be late.
Tony Bramley would be having his CQC interview tomorrow in relation to this committee. Jan Haxby asked for any feedback in terms of the unannounced CQC visit. In response Kate Wood
noted that for both visits nothing was brought to our attention for immediate action.
213/19 CQC update
The CQC planned visit to NLaG was 24th September for 4 days and were back on site for an
unannounced visit last week. Feedback so far was that there were a number of improvements listed particular for oversight and waiting lists. Morale remained mixed across the organisation. The introduction of the future 5 was a welcome addition to the organisation. The official report is expected in December.
214/19 Mortality update
Kate Wood reported that the SHMI had worsened again and was now at 118. Work was on-going as per the highlight report, need to refresh that the actions. The organisation was now in a place where we have a single point of contact from a community perspective for End of Life, Caroline Briggs, and from a Trust perspective, Pooja Balchandra was the End of Life Clinical Lead. Ian Reekie asked who was responsible for reviewing deaths within 30 days of discharge; it was noted that feedback so far had been that some of the patents should never had been admitted to hospital. It was confirmed that this cohort were reviewed by a group within the CCG. Jan Haxby queried if she was right in thinking that there were lots of other things that were coming out of those reviews other than what Kate Wood had had mentioned. Jan Haxby was keen for conversations to be had with North Lincs CCG.
215/19 Review of Action Log
June 2019 meeting
140/19 – CNST update was on today’s agenda.
April 2019 meeting
88/19 – an update to be provided at the January 2020 meeting. Action closed to be added to the forward plan.
Items for discussion
216/19 Clinical Sciences update – Steve Griffin
Steve Griffin referred to the documents distributed and summarised the key points;
Pharmacy - The positive progress highlights were already taken to the PRIM meetings, which were found to be helpful. EPMA had been signed off; the first prescriptions would be going live today at GDH. This had been actioned on time and in budget but had been quite tight on both. Training has been delivered, including for super users. Although the full Trust roll out date had not been set it was hoped that by the end of quarter 4 the system would be fully up and running once any issues had been ironed out.
Endoscopy – Achieved JAG accreditation at SGH. The service has employed two Consultant
Endoscopists to support the 5 year plan. Jan Haxby asked whether the two consultants were additional capacity. In response Steve Griffin advised that this was about the whole of the endoscopy provision and about making better use of what was already there.
Pathology – A successful recruitment programme had been undertaken in Pathology, and the service
was now on one site, so all Pathologists were in one place on one site. 5 Pathologists were recruited, four Consultants and one Specialist grade, they had not all started in post yet but it was good news. The turnaround time (the green line on the graph) showed the routine reporting, which they had managed to reduce. The new staff would be starting in the New Year, a slight deterioration was likely to be seen before things started to improve. This meant that whilst we were able to get rid of the ‘swim lanes’ for a while we have had to revert back to that, streamlining the urgency of the cases to ensure all urgent cases were turned round in requisite timescales. The digital programme continued and was being used as an exemplar.
Radiology – Issues continued linked to not being able to recruit Radiologists, which was a national issue. The new CT scanner was up and running at SGH on time and in budget but had not yet led to an increase in capacity as the existing machine had gone down. This has since been resolved. The
scanner at DPoW will be going where the modular building is. Radiology had been asked to support ECC, to get round that had increased the mobile scanner at a cost but it seemed to have helped.
The outsourcing had finally been sorted, the team were on a trajectory which hopefully by the end of November would give a three week turn around. The outsourcing was sent to consultants outside of the Trust who unfortunately are having the same pension problems as everybody in the NHS so they may not be keen to continue.
Radiologists – have managed to get the support for the radiographer and managed to get the DR
room installed. The waiting lists, RTT and follow-ups presentation from Jackie France was taken as read. Across the Division there had been a lot of conversation making sure that the General Managers and
Steve Griffin had got into every corner of the department to encourage staff engagement. What Steve Griffin was reading in the staff survey was not reflective of what staff were saying when he has spoken to them. They were generally proud to work here and proud of their jobs.
PADR and mandatory training were well over trust target, sickness levels were below trust target but
the division was anticipating achieving their CIP target. Areas of concern; Medicine safety and insulin errors - There had been a number of incidents since January; over half
had been on the Grimsby site. A safer Medication dashboard was in place for divisions and for the Safer Medication Group, and the team had put on extra training. Jo Goode was pulling together an overarching action plan in relation to insulin errors to show the work underway.
Kate Wood commented that medication storage had been a risk identified in the short term and
addressed rapidly. The CQC had only found one swab right at the back of a cupboard, despite considerable scrutiny.
Scoping would be reviewed in terms of demand. Jan Haxby asked if it was appropriate demand,
Steve Griffin felt that most of the referrals were inappropriate and would escalate this as it was the same conversation this committee had with colorectal last month.
Action: Steve Griffin to follow up on inappropriate referrals
Hull had agreed to take up some of the fit testing from the closure of the Endoscopy unit at GDH. It was commented that this was included in Peter Readings PowerPoint presentation which was presented at the Overview and Scrutiny Committee.
The capacity and demand modelling for CT and MRI came down to the number of scanners. Steve
Griffin had a personal worry about the lack of audit in Radiology reporting. There was no audit for the Radiographers, but their work was checked via their MDT. Kate Wood suggested if that was the case for them it needed to be put in writing from the Clinical Lead and it would need to be included in their job plan.
Clinical Harm - linked to delayed Radiology reporting. Anne Spalding and Steve Griffin had reviewed
the cases where the patient’s radiological report had been abnormal, to ascertain if this had been linked to the delay. As the reporting times come down this would not be an issue, but 100 days was not acceptable.
A 7 day working programme had been introduced for Pathology to try to improve work through the
lab; that business plan was turned down but was currently being revisited because the team could not physically expand.
The digital pathology had run into some problems where the software did not provide anything as
planned. Estates – there was one room at Lincoln which had a leaking ceiling so that has to be replaced at a
cost.
Patient access were running out of space and putting a business case together for more space. Kate
Wood asked about EPR and why they were looking for places to store paper. Steve Griffin added that they were not allowed to destroy the paperwork and needed to retain papers for a certain amount of time, and there was insufficient capacity to cope with the storage requirements prior to the introduction of EPR.
In summary the Division had done a huge amount of work but there were still a number of worries that
Steve Griffin had highlighted above. The committee thanked Steve Griffin for the update.
217/19 Cancer update – Kate Wood
Kate Wood informed members that this Committee had been expressing concerns about cancer across the organisation for many months. There had been a proposal that cancer may be put into performance framework special measures, this has not yet been made formal. If this was made formal, Kate Wood would like to bring it here next month to explain what that meant. Kate Wood was just waiting for feedback from Shaun Stacey to pull that together but would expect to know timescales, KPI’s etc.
218/19 Nutritional Strategy update – Mel Sharp
Mel Sharp referred to the document distributed and summarised the key points. This week was Malnutrition awareness week, 18
th – 20
th October. Educational awareness stands including pop up
BMI service were providing support and information as well as on-going educational sessions in communal areas in Grimsby and Scunthorpe. Nutrition and hydration was a key component to the recovery of our patients and complements the care given within each area. The document identified the positive work completed for Nutrition and Hydration within the Trust.
Martin Gough was appointed as the official Clinical Lead for Nutrition and would be taking over the
chair of the Adult Nutrition Group. Two Nutrition Support Nurses, Charlie and Hannah, had commenced, who were challenging on the TPN usage and were supportive on the education sessions. Where they were not confident is where patients were not being directly referred to them from the Wards. They were now undertaking our formal PLACE assessments. For 2019 the DoH has said they have drastically changed the documentation for PLACE assessments, so we would not be able to compare the results against previous years but would still be able to benchmark against our peers. There was one PEG nurse based at DPoW but the Nutrition Support Nurse at SGH was getting more involved in PEG issues due to the fact the Trust does not have a PEG nurse at SGH. Mel Sharp had been in talks with Medicine this week to see whether they wanted to continue to push to have a PEG nurse at SGH; there was not a risk to patients but Mel felt the patients at SGH were not getting the same service as those at DPoW. It was not about risk but more about patient experience. Sandra Hills spent some time with Charlie recently and felt in terms of experience and cost people were staying in hospital for lengths of time and thought it would be helpful to have an in depth look at this. Dawn Harper asked if there was any information on admission avoidance as that would be useful to see. Jan Haxby asked if there was anything from a community perspective and if there was the same issue for children. AL asked about the length of time from coming in to insertion. Mel Sharp responded saying that while she didn’t have the average times to hand, she was aware it sometimes took as long as 20 days. Mel Sharp was assured about the care on the ward and after care because of the support of the Nutrition Nurses.
TPN audit – the audit results needed to be obtained and acted on. PIC insertions – the team were compiling an action plan at the moment as the results had only
recently come out. Dawn Harper asked with regards to patient experience what happens with the data collected from the
menus, Tony Bramley felt this was a lot more structured and planned. Mel Sharp advised that she would find out and pass this on.
The committee noted the report.
Quality & Safety priorities
219/19 Clinical Harm update (for September & October) – Kate Wood
Kate Wood advised that with regards to Ophthalmology, they had never come in through the Clinical Harm process, but had been identified through the standard incident / serious incident route. We had asked for external support in reviewing the harm for these cases, and Sheffield had supplied us with some external scrutiny. There was a huge amount of work with the failsafe officers to try to prevent clinical harm.
NHS digital were looking at the wider governance and Jug Johal is the Trust lead. Jan Haxby noted
that commissioners were quite concerned and were asking the same sorts of questions about the NHS digital review. Assurance had been given by Jug Johal in relation to a company coming in to undertake an audit of all system pathways to ensure the Trust had identified all potential cohorts.
Patient safety
220/19 Integrated Performance Report (IPR) and Mid-year review of quality priorities – Jeremy Daws
Jeremy Daws referred to the paper distributed and summarised the key points;
Quality priority 1, Learning from deaths – The Surgery recovery plan at SGH worked well, 100% of deaths were reviewed. General Surgery at DPoW and T&O process are still ineffectual. This has been added to the Surgery divisions risk register. Angie Legge noted that this was due to the extra temporary help given by the central governance team to the surgical division. The Medicine recovery plan developed by the DCD had been agreed and recruitment to support this from a dedicated divisional mortality clinical lead had just been completed.
The learning from deaths element missed the SHMI but it had increased. There were a high number of ‘priority NQB’ (National Quality Board) cases are outstanding a review. These priority cases had been escalated back to the DCDs in Surgery and Medicine and a recovery plan was in place. Quality priority 2a-b, deteriorating patient – the Trust had seen an improvement in terms of timeliness of NEWS scoring, but had not got the assurance data in a robust form which would have been the ideal. Concerns had been raised about the hardware on clinical areas to maintain progress during 2020/21; a meeting was held to mitigate this risk and a budget identified for replacement devices.
Quality priority 2c, Sepsis – this was the one area about where there remained a lack of confidence in
the data. The WebV team had been given a short period of time to try to see what they could pull out from the data, if they could not fix it, then the Trust would need to look at a plan B. This had not yet been put on the risk register. Kate Wood advised that the update to that was that there was optimism that this was being resolved. In addition Kate Wood was working with the Sepsis team and would be getting 2 weekly reports.
Quality priority 3a, Omitted doses – There was not enough data available to identify trends. Clinician
attendance continued to be a concern at the Safer Medications Group however, Quality Governance Group had asked divisions to consider using the newly appointed clinical leads and ensure representation was identified from each division. Quality priority 3b, Insulin incidents - The QGG had been informed that the Diabetes CNS teams were looking at this area; a report would be taken to the Medicine Divisional Governance meeting to then progress to Quality Governance Group.
Tony Bramley thought the summary was really helpful. Following conversations at the last meeting Colorectal would report back to this committee for quarter 4 and with regards to medication this would be reported to this committee in December/November.
Kate Wood asked if this committee could receive the actual dashboard as this would be an opportunity to see the information before it went to Board.
The committee noted the report.
221/19 Nursing Quality report – Dawn Harper
Dawn Harper referred to the report distributed which was taken as read and summarised the key points. The positive note of the report was the triangulation of reporting had come together. In previous months for Amethyst and B6 there had been level of a concern but having revisited, these areas had noticeably improved and Dawn was pleased with the level of scrutiny and the impact that was having. Tony Bramley agreed that he could see a gradual improvement but he mentioned about the reporting of past months i.e. looking at August data now in October. Tony Bramley suggested including an executive summary within the report to summarise the positives and negatives as it was a huge report to read through. Sandra Hills asked if was clear in the report the differences between the sites i.e. DPoW was not the same as GDH. Another issue was that beds were not always used to capacity but would need more detail on the risk.
Hayli Garrod referred to the report distributed and summarised the key points. The Trust was required to the report provided an outline of the Trusts current compliance against the national seven day service four priority standards. The four standards discussed were; For standard 2 (consultant review within 14 hours of admission) there has been a slight drop in compliance from 72% in April 2019 to 68%. For standard 5 arrangements/SLA for the provision of weekend echocardiogram to be formalised. For standard 6 arrangements/SLA for the provision of weekend cardiac pacing and interventional radiology to be formalised.
Standard 8 has also demonstrated a very slight drop from 62% in April to 56%.
This was the seventh bi-annual survey done by the Trust which was based on emergency admission dates. In comparison to the previous survey there was a slight drop from 74% to 68% for patients assessed by a suitable consultant within 14 hours of admission. The results showed that there was no obvious weekend effect but admission time continued to be a contributing factor i.e. patients were more likely to not receive a consultant review within 14 hours if they were admitted late afternoon / early evening regardless of day of week. Looking at the figures for the break down in days, Saturday was the best day. The Medicine Division scored really well and that was because their model differed to Surgery and Women and Children’s. 10% of the sample was lost due to documentation issues being so poor, some documentation was illegible. There were 44 cases that did not have the times documented.
Tony Bramley commented that the discussions at the last meeting was that this was a component
part of how things should be pushed forward but what Hayli Garrod was saying was that we could not
rely on it. Clinicians were adamant that they saw their patients daily, but there was insufficient
documentary evidence of this. Kate Wood commented that it was a shame that Arasu Kuppuswamy
could not attend today as he would have been able to articulate the work he was doing around
SAFER.
Kate Wood was disappointed that this had not progressed further although recognising there was
work going on.
The target nationally was 90% but the report, whilst it was very helpful, was only telling us the current
position.
Jan Haxby left the meeting at 15.05
Kate Wood requested for this to go to QGG to find that oversight. The committee noted the content of the report and the drop in compliance and approved the report in
terms of compliance but noted their continuing and growing concerns with the Trust in achieving the target. If the target was not achieved it would mean additionally scrutiny for the Trust. Kate Wood noted that she did not think it would have huge detriment to our patients by not achieving this target but this was a key enabling target.
223/19 National Audit outliers report – Angie Legge /Jason Baker
Angie Legge referred to the report distributed which was taken as read. This paper provided an overview of the status of actions in response to the 5 National Audits for which the Trust had received an outlier status. An outlier alert was raised when a parameter fell slightly outside of the expected range. The Trust had just received another outlier alert from the National Joint Registry concerning Knee Revisions. This was pending detailed review which will commence on the Trust receiving the data from the national audit body. The review may be sufficient to push the Trust back within the expected range.
The lung cancer alert actions were almost complete. The response to the 18 month stoma would be
finalised by the following week. National Hip Fracture Database – it was expected that this would no longer be an outlier after the next
national audit. Angie Legge explained that this report was in a relatively new format and had been brought here to
highlight the outliers. Kate Wood and Peter Reading to signed off the letters for these at Board level. The recommendation was to bring this report here quarterly. This recommendation was supported.
224/19 Maternity / CNST update and reporting arrangements – Sarah Smyth / Mr Manohar / Jane Warner
The committee welcomed Sarah Smyth, Mahadeva Manohar and Jane Warner Jane Warner referred to the update distributed. NHS Resolution’s Clinical Negligence Scheme for
Trusts (CNST) applied to all acute trusts that deliver maternity services and were members of the CNST (Clinical Negligence Scheme for Trusts). Members contributed an additional 10% of the CNST maternity premium to the scheme, creating the CNST maternity incentive fund. Members that can demonstrate they have achieved all of the ten safety actions as of 15
th August 2019 would be able to
recover the element of their contribution relating to the CNST maternity incentive fund and would also receive a share of any unallocated funds. There is a requirement for Board oversight, which necessitates quarterly updates to Quality & Safety for the clinical negligence team. Those 10 safety actions cover a wide range of areas including stillbirths, neonatal deaths, and transitional care services. We are coming towards the end of year 2 and there were 4 actions that we did not achieve. The first one was the perinatal inputting tool which was a data inputting omission; this was not specific to NLaG.
Medical staffing - Rota gaps had caused issues, picked up mainly from the GMC survey. This year
and last year had better survey results. With regards to the rota gaps in 2017 a meeting was held about how to improve the training but an action plan was not brought to the board as required. At the moment we have achieved the training that we had hoped to, any issues with training and any gaps in the rota were being monitored by the rota coordinator. Mahadeva Manohar has had meetings with the rota coordinators and tutors and as a result feedback had improved at each site. Sarah Smyth noted that standard 1 had been rectified and would be compliant. Standard 4, medical staffing should be compliant by December 2019. There had been a lot of discussions with the previous Head of Midwifery with regards to Standard 5 and after a meeting with Ellie Monkhouse the paper will be presented to the Trust Board in December.
With regards to the ODPs, Anaesthetist etc., there was a gap in that training so from January 2020
everybody will go through the training has all had signed up for.
Tony Bramley asked, given that Sandra Hills had been heavily involved in the CNST work, how she felt about it. Sandra Hills noted that she felt disappointed as she knew how much work had been put into it.
Kate Wood thanked the new maternity triumvirate for providing the report and requested for this to be
a quarterly update from now on.
Action: CNST/Women and Children’s report to be added to the schedule for a quarterly report
Kate Wood Drew the attention of the Quality & Safety Committee to the four HSIB reportable incidents. Sarah Smyth noted that there had been 4 cases in 6 weeks at the SGH site which had prompted some immediate actions. The division had considered whether there were any issues with a particular person and were able to assure themselves that this was not the case. An immediate rapid review was carried out to look for any key themes or trends and an action plan put together. Looking at a thematic approach, one of the themes was CTG training. Mahadeva Manohar has updated the training which was brought in a couple of years ago. This was looking at when the CTG was not obviously abnormal. This was part of weekly teaching for junior doctors and midwives for difficult CTGs. When they were completely abnormal it was easy to identify but the difficulties lay with those close to normal. Kate Wood noted that the Board needed to know that had been 4 incidents and that 5 cases was the trigger for further scrutiny. This would be an ongoing update through PRIM as well.
Clinical Effectiveness
225/19 Board Assurance Framework (BAF) – Jeremy Daws
Jeremy Daws referred to the most recent version of quality and safety cut from the BAF which was taken as read. The first page of the report provided an executive summary outlining the monthly highlight report and summarised the underpinning risks that relate to this strategic quality risk.
The heat map demonstrated the quality priorities that underpinned the strategic risk, the WebV
solution to the sepsis work which was reported into Quality Governance Group. There had been progress in correlating the gaps in performance.
Jeremy Daws confirmed that sepsis remained red rated. As the lead for the strategic objective Kate Wood felt that Ellie Monkhouse and herself were
responsible for the operational delivery of these objectives but could not do that without oversight. A discussion took place about responsibilities and agreed there should be names against each element to give clarity on those responsible for delivering areas of improvement.
Action: Jeremy Daws to change / add names for each element.
Patient & Staff Experience
226/19 2018 National Cancer Patient Experience Survey: Results
The report taken was taken as read; Sandra Hills would like this committee to take more time to go through this. Dawn Harper added that Medicine had released Karen Smith for 2 days a week whose first action will be to analysis this and can discuss it at the next meeting. A lot of it was nursing related but not all of it.
Action: To be added to the November agenda for discussion.
Items referred from other meetings
227/19 Quality Review Group (QRG) update – Ian Reekie
The update was taken as read; the only comment from Ian Reekie was that he commented that he felt the 15 steps was a very positive experience/role for the governors who are participating.
The committee received the update
228/19 QGG Highlight report – Kate Wood
Kate Wood referred to the highlight report distributed which was taken as read and highlighted the key points. Women and Children’s had reported four incidents to HSIB (Healthcare Safety Investigation Branch). The Register of External visits was presented. There was now a policy on new surgical procedures and terms of reference for a New Procedure Group in the organisation which we did not have previously. The meetings were set up. Kate Wood brought to the committee’s attention about duty of candour, whilst the Trust had always written letters for serious incidents; the evidence submission for the CQC had identified that some moderate harm which were not serious incidents had only had verbal apologies given. The Quality Governance Group was managing the process to improve this picture.
229/19 SI Review Group update – Angie Legge
Angie Legge referred to the highlight report which was taken as read and summarised the key points. The group has had their second meeting chaired by Peter Reading. The group has picked a couple of older SI’s to consider if anything further could be done in the organisation to mitigate the risk. From those there were a number of actions agreed which had been added to QGG for discussion and added to the action tracker.
Ian Reekie left the meeting at 16.40
Items for Approval
230/19 Annual Aggregate review of Complaints / PALS, incidents & Claims (CLIP) – Kelly Burcham
Kelly Burcham referred to the report distributed and summarised the key points. The report summarised data in relation to PALS complaints, and claims and incidents. Additional to this was the triangulation of themes for key areas. Some of the themes identified through the triangulation were on page 17. The complaints were broken down into categories on page 18. A lot of the data was collated through a manual trawl at the moment. For the subsets of codes there were plans in place to have a regular meeting with Dawn Harper, her team and the complaints manager with a view to standardising these across the modules to enable better thematic comparisons. Dawn Harper noted that in reference to her team Kelly Burcham meant the patient experience team
Tony Bramley commented that the report had been significantly improved since the last one and
would like to see a discussion about quality and priorities. The second thing was that when divisions pitch up they could talk to us about their patient experience and would like us to get to the position where we have this as a score card to check against to link the patient experience.
Sandra Hills commented with regards to CQC, particularly at GDH they gave a lot of attention to
unresolved complaints and there was something about ownership of the final resolutions and correspondence. The policy/process that they had designed makes one person the lead for the complaint they then manage that compliant so it is clear who is responsible and delegate where necessary. Dawn Harper noted that a new Complaints Manager would be in place shortly, which would help drive a change in process to improve ownership.
Action: Dawn Harper to provide an update for the January Committee.
231/19 Claims Analysis half yearly report – Angie Legge
Angie Legge referred to the report distributed which was taken as read. This was written just before Mel Hornsby left the Trust. At this time the second person in the Claims Team went on long term sick and the third member of the team had to be let go, leaving the organisation without a claims team. Angie Legge had just appointed a replacement for Mel who was a trained solicitor who would be able to take the team forward.
Sandra Hills asked about how claims benchmarked against other organisations. Angie Legge
responded that in its current format, that was difficult to say with confidence, but the new Claims Manager was going to other organisations to see how claims was run there, with a view to aligning reporting style so we could get a better view of our comparative position.
Angie Legge noted that at the beginning of the report it says we were going to provide the formal
response to GIRFT and that this did go on time.
232/19 Quality Safety Committee ToR – Angie Legge
Angie Legge referred to the Terms of Reference distributed which were taken as read. All comments had been incorporated and were highlighted in red and blue throughout the document. Tony Bramley commented that 7.3.1 no longer had the CCG Quality Lead included. Angie Legge confirmed that was an omission and she would add it back in.
Kate Wood feels that the COO should be listed as a member which may encourage him to send a
deputy. The Committee recommended adoption of the ToR with the changes above made.
233/19 Items to highlight to Trust Board and items to refer back to QGG
Items to highlight to the Trust Board;
Pharmacy EPMA being signed off and going live Tuesday
Pathology recruitment success and the sterling job they are doing
7 days service report to rec it is submitted
Sepsis continuing concern from the IPR report and optimistic if resolving WebV issues
CNST
ToR – recommending we adopt those
HSIB – 4 maternity cases (on QGG highlight report for QGG)
Assurance around register of external agency visit
Policy on new surgical procedures
Duty of candour
Items to go back to QGG;
Action plan for 7 day services
234/19 Any Other Urgent Business
Kate Wood advised that the Trust had an external pharmacy review from Northumbria over the last couple of days and the report with recommendations should come through in the next week but the points discussed seemed eminently appropriate.
Action: To add this on to the annual report and have the two together for the schedule
235/19 Meeting Review
236/19 Items for information (under review)
The items were noted for information purposes only.
The next meeting will be held on Thursday 21 November at 12.30pm – 3pm in the Boardroom at the Scunthorpe General Hospital.
Meeting: QUALITY & SAFETY COMMITTEE Date: Thursday 21 November 2019 Time: 12.30pm – 3.00pm Venue: Boardroom, Scunthorpe General Hospital, Grimsby
MINUTES
MINUTES OF THE MEETING
Sandra Hills Non-Executive Director (Chair of the meeting) Angie Legge Associate Director for Quality Governance Dawn Harper Deputy Chief Nurse Kate Wood Medical Director Peter Reading Chief Executive Tony Bramley Non-Executive Director In attendance Ben Wood (item 247/19) Project Manager, Improvement Team Hayli Garrod (item 257/19) Quality and Audit Manager Jeremy Daws (item 251/19) Head of Quality Assurance Karen Smith (item 241/19) Lead Cancer Nurse Jo Loughborough (item 253/19) Senior Nurse, Patient Experience Rob Pickersgill Governor Laura Coo PA to the Medical Director (for the minutes)
237/19 Apologies for Absence; Jan Haxby, Ellie Monkhouse (Dawn Harper representing), Kelly Burcham
238/19 Declaration of interest
There were no declarations of interest to note.
239/19 Minutes of the Previous Meeting, 17 October 2019
217/19 cancer update – CSS had been placed into special measures because of the Cancer performance, this was because of the way the performance framework had been set up (a speciality or pathway cannot be put into special measures, currently it has to be a division). Shaun Stacey has written a paper that has been considered which explains what that means. Extra support is being provided.
Kate Wood added that one of the things that had been highlighted was that the performance
framework needed to be reviewed, which was being done. Rob Pickersgill queried whether there was any link to diagnostics, Kate Wood confirmed that diagnostics did play a part in the cancer pathways.
The minutes were accepted as a true and accurate reflection of the previous meeting.
240/19 Matters Arising
241/19 2018 National Cancer Patient Experience Survey Results – Karen Smith
Karen Smith referred to the document distributed and summarised the key points. Karen had stepped into the Cancer Lead Nurse role recently and had only been in the role for a couple of weeks, her substantive role being Lead Oncology Nurse Practitioner. The report highlighted the Trusts overall
2
performance against the national average and included a detailed break down at tumour group level. The National report was looking at our cancer patient experience in 2018 but was not published until September 2019 as it was always a year behind. The report showed a good response rate for 2018 of 64%.
On question 59, Overall NHS care – Patients were asked to rate their overall care on a scale of zero to 10 (10 being very good) The Humber Coast and Vale Alliance’s aim is to achieve at least 8.9% on the overall patient experience question by 2020, the trusts score this year was 8.67 out of 10. While this had not met the target, it was encouraging progress.
The report showed the breakdown of scores for question 59 for tumour sites and where it fell below
the national average. The lowest scores were Haematology, Lung and Prostate all scoring below the national average. Gynaecology scored higher as well as Urology and Upper Gastro.
99% of Colorectal and Lower GI cancer patients felt they received all the information needed about
their tests. 100% of patients with Gynaecological cancers knew the name of the CNS (Clinical Nurse Specialist) who would support them through their treatment. 100% of Lung Cancer patients found it easy to contact their CNS. Colorectal and Lower GI cancer patients felt they received all the information they needed about their operation in advance.
There was a lot to celebrate in the report but there still remained areas that required improvement,
Patients on the Breast, Colorectal, Haematology and Lung pathways felt they could have had more information about how this could affect them in the future. Patients on most tumour site pathways indicated they would like additional information about how they could get financial help throughout their cancer journey. They also felt there was not enough help/support from Social Services throughout their treatment. Lung and Haematology cancer patients had been lower than expected due to resource challenges within the CNS teams over those last few months. Lung Cancer had an external peer review visit planned for December as part of the QSIS. There had been collaborative working with the Cancer Alliance and action plans will feed into the Alliance meetings. There was a lot of work happening in the Trust ensuring our site specific nurses meet the holistic needs of the patients. It was really important to try to improve this and Karen had asked every MDT to add this as a standing item to their agendas and for them to feed back every quarter to the Trust Cancer Board. Tony Bramley asked about the patient experience report and whether the results from the cancer specific survey would be joined up with the others. Karen commented that it would be wrong to look at this survey in isolation, and the committee agreed that this needs to be reviewed with the other Cancer performance metrics.
Karen invited any comments or questions Karen intended to get to every MDT to ensure it was highlighted high on the agenda. Assurance
would be going the Cancer Board and Quality Governance Group (QGG). Dawn Harper followed on by noting that this was not just a nursing issue however it could not be
ignored that some of these issues were within the scope of nursing to improve. Karen would be attending the nursing midwifery board and some of the CNS’s and nurses would be working together to strengthen our internal networks and prevent the cancer nurses from working in isolation. Peter Reading commented that some of the scores were particularly good but there seemed to be some clusters and asked whether there was any funding i.e. from Health Tree Foundation to get some funding for some leaflets etc., Karen agreed and suggested that maybe MacMillan could also help. Peter also asked Kate Wood about the tumour worksites which looked quite a small number for example in Gynaecology was that a safe amount to be doing and wondered whether it should be kept under active review. In response Kate noted that there were 2 Gynaecology Oncologists, Mr Gan at SGH and Mr Saha at DPoW, who was in the process of retiring. Mr Gan had close links with Hull. Tony Bramley asked from a practical point of view as he works as an advisor for citizen’s advice, whether it would be worth contacting them to provide that link, Tony would be happy to help and provide that link. Rob Pickersgill asked if anything could be addressed so that the information was more up to date, Dawn explained that the national surveys are always a year behind, however, there was a plan to capture some of the feedback within our local surveys when we are equipped with the software, currently in the pipeline in procurement.
3
242/19 Ligature risk relating to the CAS alert
Item deferred to December meeting
243/19 KPMG report and recommendations to QSC – Kate Wood / Angie Legge
Angie Legge referred to the report distributed which was taken as read. The report provided an update on the KPMG actions, the vast majority had been done. Angie highlighted the key points of the report; there was an issue around the governance groups not having enough time to discuss all the key topics required as part of the Governance agenda. As part of this, KPMG had recommended removing document review from divisional governance groups. While this wasn’t entirely appropriate, as divisional management needed to be able to be assured as to the quality of documents being approved, this could be made more efficient through the use of checklists, which divisions had been asked to use. The new agenda template guided divisions towards the checklists to help embed this change. Angie had also discussed having a centralised document group but this work would require detailed consultation and process mapping prior to commencement. Tony Bramley commented that the division with the biggest challenge in terms of document volume appeared to be Women and Children’s and they appear to do that very effectively; Tony asked whether the same process could be implemented in other areas. Sandra Hills does see all of the Women and Children’s documents that are sent out for comments and it is a very active process. Angie Legge agreed that this was an effective process. She outlined that she had set up a regular meeting with divisional Governance Leads, and that the Women and Children’s process had been shared through that with a view to other divisions setting up the same process.
One other recommendation in the document was for separate action plans to be generated and
monitored for each complaint. Actions were included in the letters but there was not a separate action plan for each one, to do so would add considerably to the administrative burden. Angie also noted that there was a plan in place to refresh the way complaints were managed going forward. A discussion took place about this. Tony Bramley commented that from an Audit Risk & Governance (ARG) side of things if an improvement in complaints was not seen it would be brought back here. Sandra Hills asked about the comment ‘business as usual’, Angie responded that the complaint actions would be looked at as part of the refresh and therefore this item should be considered as part of the business as usual for complaints, part of the refresh work.
Governance structures were discussed and the comment about supporting appropriate structures.
Angie advised that there were now Governance Leads for Medicine and Women and Children’s, and that she had set up regular meetings to support them, a meeting to which other divisions were sending a representative with a Governance role in the division. Angie had raised a concern that the Surgical Division had not appointed a Governance Lead with no other role, and this had been raised with Shaun Stacey as COO, who was picking up a discussion on that point with both finance and the division. Kate Wood noted that the overall responsibility for Governance would still sit with the DCD.
It was agreed that this would now be considered as business as usual.
244/19 Review of Action Log
October 2019 meeting
216/19 – Inappropriate referrals. Steve Griffin had followed up a number of the referrals already but
members agreed this was more an operational issue and would be best to be discussed at QGG
instead. Action closed.
June 2019 meeting
140/19 – CNST update provided to the October meeting. Action closed
April 2019 meeting
88/19 - Ophthalmology update. Update to be provided at the January meeting and regular updates
added to the schedule
4
92/19 – KPMG recommendations to QSC. Update to be given at today’s meeting and action to be
closed.
Regular Reports
245/19 Colorectal update
Item deferred to the December meeting. Mr Sasapu was going to join today’s meeting by vtc but the meeting required to provide an update did not take place, Kate Wood and Sandra Hills agreed that the update could be deferred to the December meeting.
246/19 Clinical Harm Update – Kate Wood
Kate Wood noted that a few months ago it was agreed that this report would be provided to the committee on a bi-monthly basis. However the reason for the verbal update today was that following the visit from the CQC and the potential section 31, Kate had agreed following discussion with other board colleagues, to review in more detail how clinical harm was managed within the organisation. Cobra was set up to look at long waiters, but Cobra was also used by lots of other people to monitor various other things e.g. IT. There was a need to strengthen the processes around clinical harm and be able to articulate where Cobra was used and have a consistent approach. The clinical oversight and the processes needed to be strengthened, Shaun Stacey had weekly calls to discuss. Kate would be asking the cancer and admin team to produce a slide for the performance meeting particularly focusing on the clinical oversight of long waiters as Kate needed to be comfortable to provide assurance across the piece. Kate would bring a paper to the December meeting which would try to cover off and provide an assurance for the future. RP – commented that it was of concern to the Governors and anything that could be done to provide assurance would be greatly appreciated.
247/19 QIA report – Ben Wood
Ben Wood referred to the document distributed and summarised the key points. The purpose of the paper was to show how many QIAs were being put forward.
A total 3 were approved and signed off;
- CT MRI Van (CSS) – this would see in-house existing staff replacing bought in staff and therefore achieving savings by eliminating the premium cost.
- Hearing Aids Moulds & Accessories (CSS) – an 8% reduction in existing costs through a three year contract with the existing supplier.
- EPMA Electronic Prescribing and Medicines Administration – implementation of an EPMA. This was a retrospective QIA.
- One QIA was rejected;
- Clinical Procurement Programme - it was agreed that this needed to become project level and needed multiple QIA’s.
- The Clinical Product Advisory Group was the launched this month which Kate Wood chaired and Elaine Coghill also attends. Kate commented that this showed the lack of QIAs coming through, but every CIP plan should be coming to Kate Wood and Ellie Monkhouse. Ben mentioned that there was an assessment of internal audit about the management of QIAs but the feedback had not been received yet. Ben invited any comments or questions. Sandra Hills asked for a copy of the QIA template to be provided as part of future reports so that committee members could see what was being measured. Tony Bramley commented that the QIAs should be built into the quality process itself and it should be flagged with the Board that the number of QIA’s does not reflect the number of projects throughout the Trust and suggested that there needed to be a critical milestone in the process. Kate was looking forward to seeing the internal audit report as there are a number of changes that could be made to the process.
5
248/19 Deviations of NICE guidance
None to report
249/19 SI & Never Events update – Angie Legge
Angie Legge referred to the document distributed that was taken as read. There had been a Never Event where the adrenal gland should have been removed but part of the pancreas was removed instead. .Angie noted that the central team and investigators in divisions were under significant pressure due to the number of pressure ulcers as we are required by Commissioners to declare all category 3 and 4 pressure ulcers. Large volumes on the same theme sometimes impacted on the capacity to dig into the causes behind an issue. In terms of the actions from serious incidents, there had been significant progress, at SI panel this morning there was a very clear understanding of what actions were required so Angie is hoping there would be a further significant fall in outstanding actions. Kelly Burcham had misinterpreted what was discussed at the last meeting with regards to learning and had taken the learning page out of the report completely so will add it back in for next time. Learning was a key area to develop; the learning on a page sheets were distributed to all wards and departments, but this had a significant resource implication, so discussions had been taking place with volunteers to assist with distribution.
Tony Bramley referred to the first page of the executive comment, the second bullet point in respect of actions which stated that ‘Focused work by the divisions to reduce this is on-going and whilst progress has slowed, demonstrable improvements are expected in the next few months’. Tony commented that he would be interested to see how this would be achieved as it was a very bold statement and suggested that it should be reworded to say ‘this would be monitored going forward’
Angie noted that one of the issues which had been identified is that many actions devised previously
were not SMART, and had gone through in the report with little scrutiny. One of the changes was with the SI panel where rather than trying to review the whole report, which was part of the central sign off process to ensure quality, the SI Panel but would now be focusing on the actions to ensure these addressed the key concerns and were deliverable.
Number of pressure ulcers in the community – Sandra Hills asked for assurance with regards to the
pressure ulcers and whether they should be attributed to our staff or arose from personal care in the home. Peter Reading agreed if somebody was in a care home or their own home why NLaG would take the responsibility for them in terms of the figures and SI’s. There was a difference between personal care and nursing duty. The savings were a core part of the plan but it needs to be clear there are two sides of it. Angie Legge agreed that there was a risk that not all of these were appropriately attributed and agreed to pick this up with Jenny Hinchliffe.
Action: Angie Legge to discuss attribution of pressure ulcers in Community with Jenny Hinchliffe to ensure the Trust were taking ownership of those which were genuinely attributable to NLAG.
Peter asked about the number of falls; 4 falls resulting in serious harm which seemed quite a lot. Dawn Harper commented that compared to other organisations she had worked for it was very low here but with regards to repeat falls there is a lot of work going on, a multi-disciplinary response happens looking at the patient as a whole which should have an impact. The aim is not simply to reduce the amount of falls but reduce the amount of falls resulting in harm.
250/19 Quarterly Incident analysis report – Angie Legge
Angie Legge referred to the report distributed which was taken as read. Angie would like it to be noted within the report in future, where there was already work going on, to better provide documentary links to key thematic work streams. The report focused on the top key themes;
- Pressure Ulcers and falls were the top key themes - Documentation - Administration Processes (Ophthalmology – delays in follow up/ Process Failures) - Maternity - Medication – this gets discussed in detail at the Safer Medication Group. The role of EPMA
was discussed in detail at that group, and how this would give a clearer indication of key errors.
6
Peter Reading asked if it would be possible for the report to include national benchmarking. In response Angie Legge advised that it could not be included at the moment unless a FOI request was made to the NRLS. The trust was able to access the national number of incidents and severity to benchmark, but not the level of detail such as the type of incidents. Angie has contacts at several other trusts and will try to get some information to compare.
Sandra Hills chaired the Women and Children’s Steering Group this week and found it reassuring and
interesting the level of detail they went through and with regards to the CTG readings; it was interesting that all of the midwives had annual training yet still struggled to interpret the CTG reports. The division are focussing on addressing this to improve safety and quality of care.
251/19 IPR & Quality Priorities – Jeremy Daws
Jeremy Daws referred to the report distributed and highlighted the key points; the trust SHMI had, since the report was written, deteriorated to 119 and remained higher than expected. Additional project management resources had been identified to support the delivery of the improvement plan with increased pace. The second element was the learning from deaths side of things, which had been escalated back to the teams, predominantly Medicine, but Jeremy was due to meet with their Mortality Lead later in the afternoon.
Deteriorating patient – NEWS escalation was improving, as evident in the trend for timeliness of NEWs. SGH had achieved 92.5%. There was lack of assurance regarding action taken in response but further assurance work is planned from the critical care outreach team collection of data. Sepsis - There was concern around sepsis, no assurance was yet available regarding compliance with sepsis 6 for reporting corporately. This had been identified as a data issue and the WebV team and information services had resolved the previous data issues and were now providing ward based data via PowerBI, this would be shared with Ward Managers during November in the same way as NEWS timeliness data was shared. This would support ward based improvements. Kate Wood confirmed the ward information would be available by the end of November. In terms of SAFER a more detailed update had been received and there had been agreement from NHSI to provide funding to recruit a project manager to support implementation of SAFER principles and roll out over a 6 month period. Recruitment was already underway with Medicine.
7 day services - this was discussed at length at the previous meeting. There are early signs of progress in Urology and Lung but not really any signs of change for Colorectal.
Jeremy invited any comments or questions. Tony Bramley thanked Jeremy for the useful summary but was struggling to see progress. Kate
Wood added that this was the reason the quality priorities were set and for some there had been significant progress made i.e. NEWs, SAFER. For 7 day services there was a plan and with regards to cancer pathways there were issues, but compared to where we were progress has been made. Tony noted Kate’s comments and welcomed the achievements but also commented that in the past this committee had mistaken a plan for a result and we needed to careful in our assessment of achievements. Sandra Hills requested for some kind of trajectory to be put in place with expectations and dates. Kate noted that with regards to mortality, 3 months ago Peter Reading and Kate agreed there needed to be a line in the sand and have now refreshed the group. Peter now attended the Mortality Improvement Group (MIG) meetings and as a result there was better divisional representation. This month would be focusing on the mortality strategy. There had been a bit of progress with regards to mortality and the focus had been the depth. Peter Reading felt that the first MIG meeting he attended was more like an academic discussion rather than agreeing any actions or changes.
252/19 Board Assurance Framework
Jeremy Daws referred to the quality cut of the BAF report distributed. A lot of work had been done to ensure it aligned with the IPR. Ophthalmology had a red rating however there were some improved assurances that the risks previously identified were being managed. There was a focus on
7
medicines and how they were stored, we were awaiting the findings from the external review. In general terms however, the Trust was still reporting a risk rating of 15. Tony Bramley asked about the heat map page and section 4, it only included Surgery and the Medical Directors office but Jeremy advised that was an omission. Kate Wood asked members if they were all were comfortable with the rating of 15 given our rising mortality rating. The risk rating currently sits at 20 but for the quality BAF it sat at 15. The SHMI was now received monthly although the lag was 6 months. It is the key to the scoring on the BAF, was that it was about how assured Board members felt, given our reputation and that NLaG were currently bottom of the country, having previously been third lowest in the country. Tony Bramley suggested to flag the conversation to the Board as well as the committees concerns and to review at QSC December.
Action: Kate Wood will provide a mortality update at the December meeting.
Peter Reading observed that the other trusts at the bottom of the league table were trusts that were marked as good or outstanding by CQC there does not seem to be any correlation.
253/19 Combined Patient Experience report (Quarter 2) – Jo Loughborough
Jo Loughborough referred to the report distributed. The report was in a new format and Jo noted that there were still some gaps in the information. Some of the highlighted themes were shifting, treatment and delays now formed the larger percentage and there had been a consistent reduction in the attitude and behaviour theme. There was a lot of work happening around the complaints process, involving working with the patients and families. DCD, clinical lead and division’s involvement had improved and was a real step forward. There was a significant piece of work to do around learning as it was not being captured in a way which learning could be evidenced.
The Complaints team was now reviewing the whole of the complaints policy, looking at how the
responses are managed and looking at where the delays currently sit within the response process. Although timescales remain high and we have not hit the KPI over the quarterly period, during October 45% were responded to within the timescale. Some of the issue was that the complaints that were being closed had been open for a very long time. The piece of work was to ensure that this consistently improved month by month.
Angie Legge asked about the level of PALs, given she had been picking up some intelligence about
operational teams referring patients to PALS rather than sorting the issue out directly. In response Jo advised that there had been some training of resolving issues at the point of care and this would be a huge message in the continued future training. Jo was picking up a lot of the issues which could just take a phone call to be resolved and was keen to develop staff skills in good complaint handling. It was about raising awareness and understanding when it was relevant to involve PALs office.
Rob Pickersgill noted that the staff recommended FFT tests results were a lot lower and wondered
why that was. Dawn thought it would be interesting to see the next results as they had recently held a staff workshop on attitudes and behaviours.
With PALs concerns Sandra asked what the comment ‘complexity increasing’ meant. Jo explained it
tended to be patients reporting issues with various points, people who had multiple access points into our service and who were not always seeing one speciality at one time.’
254/19 Annual Medication report – Simon Priestley
Item deferred to the December meeting; this would be presented to QGG and would include the Pharmacy review from Northumbria.
Highlight reports
255/19 Quality Governance Group (QGG)
QSIS is part of our cancer monitoring and the key was about the implementation of our actions. The current progress was a concern, and this would be going back to QGG in December, it was about getting that embedded ownership, and there was still work to do on that point.
8
256/19 Quality Review Group (QRG)
Rob Pickersgill gave a brief update following the QRG held on 6th November. The minutes from the
meeting were yet to be approved and would go through CoG for approval in January. With regards to mortality Ian Reekie had noted that the reviews in respect of deaths within 30 days of leaving hospital were undertaken by CCGs, but Kate Wood noted that they were undertaken with NLaG too however not all deaths are reviewed. This was part of the collaborative work to understand out of hospital deaths. Governors were asking why the crude mortality information could not be broken down into areas. There was a long conversation about insulin medication. The other major discussion was around 7 day services and there was an acceptance that there were resourcing issues in terms of we cannot provide safe cover. Kate Wood clarified it was about making sure we had SLAs in place it was not about us having a lack of resources. 15 steps were dear to the governor’s hearts, this was about the reporting and they had wondered if it could show cumulative up to date data.
Dawn Harper commented that it would be a huge report but instead a column could be included about where it was being reported.
Items for Approval
257/19 Seven Day Service Board Assurance Submission – Hayli Garrod
Hayli Garrod referred to the document distributed and noted it did not come to last month’s meeting but it needed board level approval. In principle there was nothing new so the board had already agreed this. The committee were happy to approve it for submission. It had been discussed at QGG and at great length at PIM yesterday. Tony Bramley would discuss with internal audit.
258/19 Items to highlight to Trust Board and items to refer back to QGG
Items to highlight to the Trust Board;
Lack of QIAs being presented to Kate Wood and Ellie Monkhouse for consideration as these do not correlate with the number of CIP projects and there should be step included in the process
Risk relating to mortality as discussed within the BAF about whether the risk rating should be changed from 15 given the rise in the SHMI
Formalisation of the 7 day services submission
To flag the detailed discussion about Cancer from the Interim Cancer Lead Nurse
Items to go back to QGG;
No items to highlight
259/19 Any Other Urgent Business
NED briefing feedback – Sandra Hills to contact Steve Griffin to circulate his presentation and to answer some questions.
Quality priorities – Angie Legge will circulate with a view to being agreed at the next meeting.
Meeting Review
260/19 Revised reporting schedule
Pharmacy review, Mortality report and the Colorectal updates for the December meeting
261/19 Items for information (under review)
The items were noted for information purposes only.
The next meeting will be held on;
Friday 20th December at 9.30am – 12noon
In the Main Boardroom at the Diana Princess of Wales Hospital, Grimsby.
Time: 9.30am – 12noon Venue: Main Boardroom, Grimsby
MINUTES MINUTES OF THE MEETING Sandra Hills Non-Executive Director (Chair of the meeting) Angie Legge Associate Director for Quality Governance Dawn Harper Deputy Chief Nurse Kate Wood Medical Director Tony Bramley Non-Executive Director Peter Reading Chief Executive In attendance
Paul Hinchliffe (item 270/19) General Manager, Surgery & Critical Care Jeremy Daws (item 272/19) Head of Quality Assurance Simon Priestley (item 276/19) Chief Pharmacist Ian Reekie Governor Laura Coo PA to the Medical Director (for the minutes)
262/19 Apologies for Absence; Jan Haxby, Ellie Monkhouse, Shaun Stacey,
263/19 Declaration of Interest
There were no declarations of interest to note.
264/19 Minutes of the previous meeting held on 21 November 2019
239/19 cancer – Kate Wood updated that CSS were put into special measures due to the Cancer performance and part of that action was for Kate Wood, Shaun Stacey and Ellie Monkhouse to have weekly meetings, although Kate had not managed to join those meetings yet, things were already beginning to improve.
One of the things that had been highlighted was that the performance framework needed to be reviewed. This is being reviewed by the Operations directorate. 259/19 NED briefing feedback – Sandra Hills to contact Steve Griffin to circulate his presentation.
The minutes were accepted as a true and accurate reflection of the previous meeting.
265/19 Ligature risk relating to the CAS alert
Angie Legge advised this was not discussed at QGG therefore requested for it to be deferred to the
January meeting.
2
266/19 Colorectal update
Update included in the Surgery and Critical Care highlight report.
267/19 Mortality update
Kate Wood referred to the document distributed and summarised the key points. The Trust SHMI was at 118, but the Trust was still in the same position related to peers; for the second month running NLaG was the worst in the country for mortality. Kate would therefore like this to become a standing item on this agenda.
With regards to the mortality strategy distributed, two specific bits had been added relating to EoL and
coding. Coding – the Trust had been receiving constant reassurance that the depth of coding was good and that it did not need to be focused on. Following the review from Prof Mohammed it became clear that recording and coding of the patient’s primary diagnosis and key co-morbidities (Charlson index) was not fully capturing and representing the patient’s risk factors leading to an inflated SHMI score calculation, those other trusts that had improved their SHMI had focused on coding. Colin Farquharson and Dr Kamath were working with coding to get co-morbidities added to Web V and hopefully a progress report will be provided to Mortality Improvement Group (MIG) in January.
EoL – this was now led by Community and Therapies. Two year funding had been secured for RESPECT which enabled us to promote GSF and the last 12 months of life. It was also hoped that it would improve the care of those patients in the community as they approached end of life, to reduce unnecessary admissions which was causing an issue with our mortality figures.
NHSI were keen that the Trust review the learning from deaths strand, and were more interested in
the care that delivered than the numbers. Tony Bramley raised concerns about MIG although he had not attended recent meetings there had been a lack of engagement in the meeting. Kate acknowledged this, but advised there had been a lot of work going on behind the scenes, particularly in Medicine and engagement had been improving.
Work continued to look at how deteriorating patient and sepsis effectively linked into the mortality
work. Only 28% of deaths were being reviewed, which was more than the trajectory but was below where the Trust was aiming to be in this regard.
Ian Reekie appreciated what Kate had said but asked if Kate would be presenting anything to the
Governors other than the coding aspect. Kate responded to reiterate the work continuing on learning from deaths and developing the divisional mortality meetings.
Tony Bramley commented that it worried him that we cannot be sure where the problem is, whether it is the system, the culture or the county we do not know the answer. Kate responded that we were now clearer and that this was multifaceted; coding would address some of the issue in relation to the SHMI, but that work was still needed in regards to learning from deaths and improvements in care. This would include the work being done as part of the Deteriorating Patient work stream on ensuring our standards of care.
Kate updated that for the last two MIG meetings Kate had gone back to chairing the meetings and Peter Reading now attended all mortality meetings which had encouraged better attendance and movement within the directorates. Dr Foster’s office did offer some support and a meeting had been arranged to discuss what support could be offered. Sandra Hills suggested there may need to be some sort of deep dive at board level. Kate advised that she had been given the resource of a Project Manager however he also supported the Flu Campaign and had need to prioritise that but the support would be there. Sandra queried in terms of the BAF whether it was worth us saying we want to raise the level of risk. Tony suggested that until we had seen evidence of improvements made, given our relative position on the SHMI, the risk concern should be raised, Kate agreed that EoL care needed a lot more work and agreed the risk rating should be increased in its broader terms up to 20.
3
268/19 Assurance regarding care of child in ED
Kate Wood referred to the paper distributed, Kate had asked for this to be added to the Trust Board agenda for discussion as well. Angie Legge provided a brief update: Following two SI’s being declared in ECC at SGH visits were undertaken by the Medical Director and Chief Nurse and actions were undertaken with the aim of increasing paediatric safety in ECC, the purpose of this paper was to give some assurance on the progress with those actions.
In respect of the direct oversight of the waiting area in SGH - staff had been unable to see if a child
deteriorated. This had now been addressed, and there was a member of staff able to visualise this area. A further key concern from the two Serious Incidents was that both of these children, after being triaged, were waiting over an hour and half, a more timely response was needed as children can deteriorate quickly. Measures had been put in place to address this risk. The next biggest issue was training, which would be coming out in the future 5 review, a lot of work had already been done but there was more to do, including the appointment of a band 7 twilight post.
Tony Bramley asked how fast the actions within the action plan were being completed and whether staff thought as a result we were getting safer i.e. if we did all the things in the paper we would be as good as we could reasonably expect us to be. Angie responded to say that the actions would make us as safe as other similar organisations in terms of timeliness and access to appropriately trained staff.
Sandra Hills added that there was a national shortage of paediatric trained nurses, and asked about
the percentage improvement the actions had made already. Angie Legge noted she had never worked clinically in an A&E department and was not paediatric trained, therefore could not put a definitive percent on it other than to say it had improved, but the key to the optimal care for an organisation such as ours, was to have the appropriate trained staff. Sandra asked whether there was a possibility of getting a nurse with a training uplift. Kate Wood confirmed there was an uplift course available and the organisation had been sending staff on that course.
Kate Wood noted that within the paper, the work with Mid Yorks, where they had done a review of our provision, had been missed out. Kate had personally spoken to Mid Yorks about the service. Kate noted her disappointment in the progress against their life support training and noted that she would pick that up. Tony added that the simulation training and the mannequin had been discussed at Health Tree Foundation (HTF) and the committee was minded to support those but wondered whether it might be worth a reference back to HTF from this committee. Kate agreed to flag with HTF. Angie agreed to ensure the paper was updated to address the identified gaps before the paper progressed to TMB.
All agreed for an update to come to this Committee in 2 months’ time to include any amendments
from Trust Board and progress.
Action: Tony Bramley will email Neil Gammon as above for HTF to say it is a priority
269/19 Review of Action Log
November 2019 meeting
249/19, Pressure Ulcers – Angie Legge had a conversation with Jenny Hinchliffe and was assured they use a tool within community which looks at where the team may have missed anything and it seemed to be quite a robust process. Dawn Harper added that on the case load for catheter care if patients developed a pressure ulcer, it was deemed as an acquisition for the Trust. They discussed the fact that those patients were given care in the community and agreed they would still be the Trusts responsibility. The Community Team were going to go back and look at a snap shot audit of the pressure ulcers identified to enable better understanding. Sandra Hills asked for clarity if, for example, a district nurse went to see a patient in a care home, would the staff automatically do a full assessment of pressure areas. Dawn responded that staff were expected to check pressure areas.
Regular reports
270/19 Highlight update report - Surgery & Critical Care – Paul Hinchliffe
Paul Hinchliffe referred to the report distributed and summarised the key points.
4
Items of positive progress:
The division had recruited 24 new qualified and overseas nurses, meaning that DPoW would be near to being fully established. It was anticipated that within 4 to 6 weeks the new nurses would all be on the roster.
The green light laser treatment was going to be a positive move avoiding surgery and thereby reducing bed days.
The mortality process was formulated and started to work with regards to the mortality reviews and was an improving picture.
Improved utilisation of GDH Ophthalmology Theatres, with improved efficiencies; this was now doing increased work
Intravitreal Injectors room at SGH – it was a much more efficient way of working, the nurse injectors were working well and it had taken these cases out of the theatre environment.
Fracture Neck of Femur - The big improvement this year was the improved outcomes and better patient experience as they were going to theatre within 36 hours.
Ambulatory care went live, incorporating urology. There was still more to do but it was progressing well.
Ophthalmology Fail Safe Officers were in post to ensure all patients were tracked and receiving treatment. Kate Wood asked about the 17,000 patients overdue how did they know there were only potentially 36 patients overdue. Paul responded to say they have now completed the PTL, going forward now have the conditions on the PTL which they did not have before so they could be tracked. Paul commented that it was interesting to note that all these patients were on the SGH and GDH site, not on the DPoW site.
Colorectal patients – all cancer patients had a named nurse, were tracked and followed up. 96% of patients came back as low risk or no harm the referral forms had been redesigned to give the GPs more guidance and would potentially reduce inappropriate referrals. There tended to be two specific conditions when the GPs refer to colorectal; unexplained weight loss and anaemia. The big win for us would be the patients would go to the right tumour site first off but it would take one or two months to agree those direct referral pathways. Paul would like to see a reduction in the 2ww referrals. Another big change following a meeting with Hull was about the urology referrals, previously had been managed by a visiting Urologist but it had been agreed that the moment they agree to take the patient it goes on to Hulls PTL. Tony Bramley commented that there had been some significant changes.
Performance - This now mirrored the performance meeting at divisional level. The vascular access team had improved, and improved treatments for in patients. When intensive care was full on the SGH site the team would try to identify additional staffing to open 23 hour beds in theatre which get classed as critical care beds which meet the standards, this was only done on the SGH site as DPoW has an HDU to take overflow but it allowed the Trust to expand care when needed Kate queried if this was 1:1 care; Paul noted that it met the ITU standards for care.
Action: Paul Hinchliffe to feedback at PRIM.
Items of concern;
The backlog in terms of out patients and especially Ophthalmology overdue follow up back log – a key concern to the Trust and CQC was our overdue backlog, the Trust would need to get the figure down to 5%. The challenge for Paul was for all of the services to get down to that.
Supra-pubic catheterisation – Retraining – following two serious incidents Suprapubic catheters were only put in by a consultant in conjunction with a radiologist until the consultants had all completed their ultrasound training
Now have a contract with NewMedica to take new ophthalmology cases to avoid adding to the follow up backlogs.
Ophthalmology and ENT are the areas that face significant challenges. These are monitored through the PRIMs meetings and on a weekly basis, which is a challenge. The fragility of ENT cannot be overstated however the clinicians have put on additional lists. Oral surgery had been quite successful in converting clinics to virtual clinics and it was planned to use this success to work with the other head and neck teams to develop their clinics.
Ian Reekie asked if there had been any indication of the willingness of patients wanting to be referred to NewMedica. Paul thought the uptake was approx. 50% initially.
5
Members felt the summary was very helpful. Angie Legge found the diagram outlining the
Governance in the division useful but suggested that the diagram clarify which meetings were divisional, and which corporate. Angie highlighted to members that Paul’s report included, as an appendix, the new integrated governance report which went to Divisional Governance, and therefore gave an illustration of the scope of governance discussed at the Divisional Governance meeting. The Committee welcomed the new integrated report.
Sandra Hills thanked Paul for the update.
271/19 Nursing Quality Report (bi-monthly)
Dawn Harper referred to the report distributed which was taken as read. Large numbers attended the first ‘One Stop Shop’ recruitment day held on 29
th November and a number of nurses were recruited.
The Event was very well publicised, it was tweeted and on LinkedIn. The post numbers of the 32 new nurses have not gone in yet so there would be a slight spike in vacancies. A discussion took place about the fill rate tables included within the report, some were less than 50%,
Safe care training software was live for transfers between wards overnight and out of hours which
meant transfers would be recorded on the system and could be monitored. There was a small increase in the lower categories of pressure ulcers. The team was aware of what
the problems were. Dawn talked about the ward improvements arising from the 15 steps. Ian Reekie commented from the Governor perspective that this was felt to be a very positive improvement, and the Governors relished being involved in this programme. It gave them a good perspective of the daily ward issues.
272/19 IPR & Quality Priorities
Jeremy Daws referred to the paper distributed and gave a brief update of the key points. The SHMI position had improved to 118 but our position relative to other organisations remained the
same. Quality Priority 2a-b, Deteriorating Patient – NEWS observations done on time had improved but
there was still some lack of assurance with regards to the response to NEWS. Quality Priority 2c, Sepsis – there was a one day snap shot audit planned across the Trust to assess
accurately the levels of sepsis screening and compliance with the sepsis 6 bundle. Quality Priority 3, medication omitted doses - there had been an increase in November for incident
reporting this did not necessarily mean there had been a higher number of incidents it could just be better reporting.
Quality Priority 3, Insulin incidents – was a regular feature as part of the Safer Medications Group
Quality Priority 4a, SAFER - Medicine non-elective length of stay had reduced. Recruitment was underway within Medicine.
Quality Priority 5a-b, Cancer pathways – there had been some improvement in the 28 day pathway
for Urology and Lung during October. There had been some work on a diagnostic triage system which was now in place and would help maintain focus.
Quality Priorities for 2020 / 21
Angie Legge explained that the purpose for this was to ask this Committee to agree the quality priorities for next year. The paper had already been to Trust Board for discussion, to QGG and Angie had discussed it with Commissioners who were broadly supportive. Given the discussions today and the clear position on mortality, this clearly needed to remain a priority. In determining the Quality Priorities, the level of risk in the organisation had been used, although work was ongoing to ensure to ensure all risks in the organisation were identified. Angie introduced a ‘Long
6
List’ of Quality Priorities, and. proposed retaining some of the existing priorities as work ,as outlined during the discussion on the IPR, was ongoing.
1. Clinical Effectiveness: Mortality Reduction. Mortality and EoL but including the deteriorating patient
in this. . 2. Patient Experience: Improved patient flow: 3. Patient Experience: Cancer pathways as they are in special measures 4. The plan was to postpone the current Quality Priority on Medication safety, omitted medication and
reduction in insulin incidents Angie outlined that accurate measurement was the cornerstone of good focused Quality Priorities, and that the figures currently available for medication safety was subjective, based on incident reporting. EPMA was being rolled out across the organisation in 2020/21, and this would enable the development of a clear baseline, managed through the Medication Safety Group, to enable a more effective Quality Priority for 2020/21.
Proposed 2020/21 Priorities (Long List from 5 year Strategy)
Angie proposed that the Quality Priorities for 2020/21 be:
Patient Experience Waiting lists
Mortality and End of Life, including deteriorating patient
Management of Diabetes
Patient Experience & Effectiveness of Cancer Pathways
Quality & Timeliness of Safe Flow and Discharge
This would mean dropping three of the ‘Long List’:
Improve the safety of Mental Health safety provision in the Trust – The role appointed in 2019 of a Mental Health Nurse in the Trust had ensured some focus, but most of the work in relation to the healthcare system for mental health sat with other providers. Peter thought it was quite timely as there were a lot of things being discussed and suggested for Shaun Stacey and Kay to be invited to give an update together on the progress made. It was suggested March or April time for the update.
Learning – this work was not measurable, but would continue through the development of the Learning Strategy, which would be brought to Quality & Safety Committee.
Medication Safety – which would be paused to allow for a baseline from the roll out of EPMA.
Angie proposed to have the 5 quality priorities as discussed. Kate Wood added that this was discussed with the commissioners yesterday and Kate had asked our
commissioners to consider the fact that they had confirmed aligning these with their contracting priorities for next year.
The committee reviewed and agreed with the recommendations.
273/19 Cancer Update
Kate Wood provided an oncology update based on discussions with HUTH to ensure a safe service was retained. KW noted the potential necessary reconfiguration of services, working with Hull with regards to moving to one site; the preferred site from a logistical perspective would be DPoW because of the bed state on Amethyst and facilities. There were two other aspects to consider; commissioning and timescales, the commissioners had not been as closely weaved into this as the organisation had originally believed, but a meeting would be held next week to discuss further.
274/19 Clinical Harm Update
Kate Wood referred to the paper distributed which was taken as read. Kate drew members’ attention to two key parts of the update that had changed slightly; for patients who do not drop into Cobra , Radiology had their own policy which was for all abnormal and all follow ups 25% over and prior to September. Urology have since started doing the same.
Tony Bramley asked whether it was working for the ones going through Cobra and whether we had at
least bottomed the new ones, and whether there was an end to new cohorts of patients with no follow
7
up. Angie Legge added that COBRA was proving effective, and there was an end in sight, a company was coming in to carry out an audit and as of next month Angie will be in a position to give an update.
Kate Wood invited any questions and none were received.
275/19 Deviations of NICE guidance
No new deviations
276/19 Pharmacy Review / Annual Medication report
Simon Priestley referred to the papers distributed and advised that the report was an interim report for the year to date and would bring a more comprehensive report covering an entire year following the end of the financial year. The report outlined the findings of the Northumbria review and the action plan.
Key achievements included successful funding for EPMA, the positive benchmarking for Model
Hospital, against which NLAG has the lowest stock holding. There had been a lack of the robust audit, clarification of processes would then enable these to take place. The Medicines code was going to be reviewed, this was anticipated to take 18 months. The dashboard was helping to encourage reporting and Simon would like to do the same with medicines optimisation. There was not a group currently formed to monitor Medicines Optimisation, but Simon would like to look at the Safer Medication remit and include it there as it is a multi-disciplinary forum with the appropriate level of representation. Tony Bramley commented that for him it was about understanding which issues were the most priority or would have the most impact, he could not tell from the plan what the priorities/risks were and suggested for some sort of explanation to be included within the report. Regular updates needed to be included in the QSC work plan.
Sandra asked about the review of medicines management documentation and queried if there was a
timescale. In response Simon noted that there was some work looking at gathering documentation but was unable to give a timescale at that juncture.
Angie Legge referred to the long list of incidents one of which was described as a Never event but
Angie was unaware of a Never event linked to medications so suggested it would be helpful to have a date range.
Tony Bramley asked about governance and whether external bodies would be shocked that we have
not had a Medicines report for 4 years. Simon clarified it was not statutory but was recognised good practice.
It was agreed that the annual report should come to this committee and then go to Trust Board. Sandra Hills to include in the highlight to the Board that this committee had received the report and
the Northumbria report had been discussed here. The annual report would go to Trust Board with a recommendation that it be discussed. The strategy will be coming to QSC in April.
The Committee received the report.
277/19 NHS Patient Safety Strategy
Angie Legge referred to the document distributed and advised that this had been brought to this committee for approval. The National NHS Patient Strategy published in summer last year recommending the trust produces their own and this document was based on that. Angie had been impressed with the whole ethos of the national document, which had been welcomed.. The draft strategy had already been shared in the organisation and comments had been incorporated. Angie asked for approval. There are a number of key recommendations including the Trust having a key Patient Safety Lead, which Angie had recommended to be herself. This was agreed by Committee members.
Tony Bramley commented that having seen this for the first time he presumed it would subsume or
eliminate other similar quality documents within the Trust. Angie responded that she had looked at
8
whether this could be merged with the Quality and safety strategy but at the moment it would not be suitable. Tony commented that the ‘patient safety partner’ role was new and we need to make sure we did not unnecessarily create a new job. It was agreed that there needed to be clarity on how this fitted with existing patient roles.
Dawn Harper added that it had become apparent that their volunteer team recruit differently so they
are trying to align them and looking at where they have a specific interest with a different set of skills. Ian Reekie suggested for a report to come on how this would fit to a future meeting.
The committee approved the strategy in principle but agreed there needed to be further discussion around the roles of the Patient Safety Partners.
Highlight reports
278/19 Quality Governance Group (QGG)
Angie Legge highlighted some key points from the report; the group had received the Medicine division highlight report, they had set up a number of risk workshops to support the Medicine division. Two things that came out of the highlight report was the lack of review of NICE guidance in the division, which needed to be addressed and an audit of sepsis which raised some concern about Divisional compliance with sepsis six. A re-audit had been planned, and the QGG had asked for an update on the findings from the re-audit.
279/19 Items for approval
No items for approval
280/19 Items to highlight to Trust Board & refer back to QGG
Trust board;
Continue to flag mortality and the fact that we have agreed to shift the risk to 20 on the BAF
Flag some of the successful things highlighted in the surgery update in terms of their capital bid
Assurance about the care of children in ED
Quality priorities – to recommend those that had been agreed
Patient Safety Strategy agreed today
Further work with regards to patient experience and the roles of the Patient Safety Partner
Discussion on Colorectal about improvements in place and the fact that we have seen it in March
To note the Ophthalmology position, tendering and out sourcing – it was felt there should be more pace in the process
To QGG:
Nothing to refer
281/19 Any Other Business
None raised
282/19 Meeting Review – Reporting schedule
Distributed for information and taken as read
Items for Information
283/19 Quality Governance Group (QGG) minutes
284/19 By exception - any private items to be discussed by the Committee
NLG(19)036
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Dr Kate Wood, Medical Director / Bryony Simpson, Guardian of Safe Working Hours
CONTACT OFFICER Dr Kate Wood, Medical Director / Bryony Simpson, Guardian of Safe Working Hours
SUBJECT Quarterly Guardian Report – August to October 2019
BACKGROUND DOCUMENT (IF ANY)
PURPOSE OF THE REPORT: For information
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
This is the Quarterly Guardian Report covering August to October 2019 for information purposes
TRUST BOARD ACTION REQUIRED
The Board is asked to note the document
GUARDIAN OF SAFE WORKING HOURS QUARTERLY REPORT ON SAFE WORKING HOURS: DOCTORS AND DENTISTS IN TRAINING
Executive summary
This is the quarterly report from the Guardian of Safe Working Hours for the period August, September, October 2019.
This quarter has seen some notable changes:
• The system that we use to record exceptions has changed from DRS4 to Allocate • The 2016 Junior Doctors contract has been revised and changed • The number of Exceptions reported in this quarter has increased from 34 to 75. • Our performance as a Trust with regard to resolving these exceptions has
significantly deteriorated, with only 2 out of 75 reports being resolved as at 31.10.19
Actions required by Board
As a matter of urgency:
• There needs to be a plan for accommodating the changes to the contract and ensuring we meet the requirements. This needs to be overseen and monitored by a Board level member such as the Medical Director or Director responsible for Workforce.
• Performance regarding the engagement with Junior Doctors who are logging ERs needs to improve so that we meet our own standards and that of the national contract. Once again this can be driven by the Medical Director as it requires a change in the behavior of Consultants. Essential data: for this quarter:
• Number of training posts (total) 217 • Number of doctors / dentists in training (total): 195 • Number of LTFT trainees (total) 9 • Number of training post vacancies (total) 22 • Number of trainees by site (if applicable)
Site 1 SGH 105
Site 2 DPOW 90
Site 3 GDH 0
Exception Reports (see Tables 1 and 2)
Total number of exception reports received per month within this quarter:
Many of the Exception Reports for August were not logged until September as Juniors did not have their log in numbers so were unable to upload them.
Immediate safety concerns
Total hours of work and/or pattern
Educational opportunities/ support
Service support available
TOTAL
August 2 19 0 0 19 September 1 21 2 0 23 October 7 31 0 2 33 QUARTER 10 71 2 2 75
Trend in Exception Reporting
This quarter has seen a large increase in ER from 34 last quarter to 75 this quarter. Compared with the same quarter last year there has been a decrease of 22 as in the same period 97 ERs were logged in 2018. Usually there is an increase in ERs this quarter as new doctors settle in and rotas are adjusted. Once again, the most common reason for ER is the need to stay over usual time due to staff shortages.
Resolutions (see Table 3)
Total number of exception reports per month within this quarter resulting in:
TOIL granted Payment for additional hours
Work schedule reviews
Resolved - No action required
Unresolved TOTAL
August 19 19 September 1 22 23 October 1 32 33 QUARTER 2 73 75
Commentary
Total of 75 ERs this quarter, an increase of 41 on the last quarter but a decrease of 22 compared with the same period last year.
The Immediate safety concerns are often resulting from lack of senior support / inadequate staffing at the time and from emergency events
Note the small number of Educational opportunities reported as missed.
Work schedule reviews
Month Specialty/ Department & Grade Details of work schedule review
Detail of immediate safety concerns and actions proposed and/or taken
Site Safety concern raised Action(s) proposed and/or taken SGH medicine Lack of senior staff to arrange
referrals and palliative care Spec Reg stayed and managed to coordinate necessary actions
SGH medicine Bowel obstruction requiring Surgical intervention
Spec Reg stayed over hours to manage
DPOW T&O Peri Arrest and inadequate staffing to manage
Managed to get Registrar for short time but still concerned about patient. Later discussed with team to prevent repeat
SGH medicine Lack of staff Reported SGH medicine Lack of staff Reported SGH medicine Lack of staff Reported- work with Rota
Coordinators to review reason for shortage when was predictable
SGH medicine Lack of staff 50% down reported SGH medicine Lack of staff Discussed with Rota coordinators
and supervisor
Commentary
Immediate safety concerns centre around lack of staffing especially when extra demands arise as a result of emergencies.
Commentary:
Only 2 ERs have been resolved and there are 73 outstanding some going back to August. This reflects the lack of preparation for the introduction of a new system that requires knowledge and training for the Educational Supervisors and Junior Doctors to fulfill their roles efficiently. The Guardian is currently investigating this and has issued many requests for action to date.
Commentary
SGH medicine Lack of staff meant 1 doctor for managing ward /assessing admissions and managing discharges
Discussed with Supervisor
Fines levied against departments this quarter
Department Detail Total value of fine levied Total fines levied None as yet but still checking
details, there are indications of 4 breaches relating to 72 hour working.
Site 1 (if applicable)
Site 2 Site 3 TOTAL
Balance at end of last quarter
Fines incurred this quarter
Cumulative total Total paid to trainees (£)
Total spent at each site (£)
Balance at end of this quarter
Rota gaps and vacancies this quarter
Post vacancies this quarter
Department Number of vacancies (Shifts)
Grade/detail
Acute Medicine DPOW 16 StR (ST3-8)
Acute Medicine SGH 5 StR (ST3-8)
Acute Medicine DPOW 13 Core Trainee
Acute Medicine SGH 12 Core Trainee
Cardiology DPOW 66 FY 1
Cardiology DPOW 68 Core Trainee
Commentary
As we are still chasing the resolution of 73 ERs we are not in a position to state that there are no breaches for this quarter. Information will follow in the next report.
Respiratory Medicine SGH 24 Core Trainee
Respiratory Medicine DPOW 65 StR (ST3-8)
General Medicine DPOW 1 Core Trainee
General Medicine SGH 20 Core Trainee
Gastroenterology SGH 3 StR (ST3-8)
Gastroenterology SGH 59 FY 2
Obstetrics and Gynaecology SGH 8 StR (ST3-8)
Orthopaedic and Trauma Surgery SGH 2 StR (ST3-8)
Paediatrics DPOW 1 FY 1
Paediatrics and Neonates DPOW 13 Core Trainee
Paediatrics and Neonates DPOW 12 StR (ST3-8)
Paediatrics and Neonates SGH 9 StR (ST3-8)
Rhuematology DPOW 1 Core Trainee
Total 202
Rota gaps this quarter, per specialty and grade
Specialty Grade Month 1
Month 2 Month 3 Total gaps (average)
Number of shifts uncovered
Total
Junior doctor forums and junior doctor engagement
Date Site Issue Action(s) agreed and/ or taken
28th November Cross site via VTC
Commentary
Support for Guardian role
Amount of time available in job plan for guardian to do the role: I PA per week - NLG and Navigo (3 hours per week for NLG and 1 hour per week for Navigo)
Admin support provided to the guardian (if any): None designated -reliant on ad hoc support from Med Education Dept
Amount of job-planned time for educational supervisors: 0.25 PAs per trainee per week
Doctors and dentists in training not on 2016 TCS (if applicable)
Key Issues and Summary
This quarter has been extremely challenging for all with the rapid introduction of Allocate in August, a new rostering and reporting system. This meant everyone was unprepared and no one had
Commentary
Since the introduction of the new Allocate system, coupled with the increased numbers of Junior Doctors, there is more pressure on the Guardian role. Fulfilling all the duties of Guardian is becoming challenging to fit into 3 hours per week.
Commentary :
A JDF was arranged with the Guardian for Monday 28th October but had to be cancelled as we require rooms at both main sites with VC facilities. We had booked the rooms but one was taken over by others and we were unable to find an alternative, so it was agreed with the JDs to rearrange.
This JDF will be vital in agreeing a way forward particularly with regard to the revisions to the Contract.
answers to queries. Unfortunately, its introduction coincided with the new intake of Junior Doctors many of whom are new to the workforce. The Guardian, Educational Supervisors, DME and JDs had received no training on this system and so were unprepared for the significant changes to the system. The Guardian still has not received training for the system and is currently unable to agree overdue ERs as per our agreed protocol. This has resulted in the vast majority of ERs going unactioned and JDs remaining unpaid for their extra hours for several months. An unacceptable situation.
The next Junior Doctor Forum will address the difficulties in detail and debate the changes to the contract. We need to agree a way forward that works for all and does not disadvantage our Junior Doctors and reflect negatively on NL&G as an employer.
Bryony Simpson
Guardian
November 2019
NLG(20)037
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors
REPORT FROM Linda Jackson, Acting Trust Chair / Chair of Finance & Performance Committee
CONTACT OFFICER Jim Hayburn, Interim Director of Finance
SUBJECT Finance & Performance Committee Minutes – September & October 2019
BACKGROUND DOCUMENT (IF ANY) -
PURPOSE OF THE REPORT: For Information
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
Minutes of the Finance & Performance Committees held on 25 September and 30 October and approved at its meetings on 30 October and 27 November 2019 respectively.
TRUST BOARD ACTION REQUIRED The Board is asked to note the report.
Jeff Ramseyer Sandra Hills Richard Eley Shaun Stacey
Acting Trust Chair (Chair) Non-Executive Director Non-Executive Director (rep Tony Bramley) Interim Director of Finance Chief Operating Officer
Jug Johal Sue Barnett
Director of Estates & Facilities Strategy & Planning Consultant
IN ATTENDANCE:
Brian Page Kathryn Helley Alex Bell Zoe Plant Damian Kitchen Mike Simpson Lynn Arefi
Lead Governor Improvement Programme Director Information Manager ( for item 6) Contracting Lead ( for item 5.2/5.3) Financial Planner (for item 5.3) Associate Director of Capital Development (for item 5.5) Executive PA/Administrator (for the minutes)
Item 1 Apologies for Absence 09/19
Apologies for absence were received from Peter Reading and Tony Bramley Item 2 09/19 Declaration of Interest There were no declarations of interest. Item 3 09/19 Minutes of the previous meeting
The Public minutes of the previous meeting held on the 28 August 2019 were agreed to be a true and accurate record – however it was noted that the second paragraph, page three contained an additional “a” in the sentence. The Private minutes of the previous meeting held on the 28 August 2019 were agreed to be a true and accurate record.
Item 4 09/19 Matters Arising / Action Log
Matters Arising
There were no matters arising from the previous meeting that were not included within the agenda. Action Log
The Committee reviewed the action log and agreed the following: 5.1 RTT potential 52WW penalties- kept on action log as a prompt but no further update required 5.1 ODT – completed
6 RTT – agreed only item on IPR that has not been actioned. October agenda. 6 Cancer – Shaun Stacey to follow up on the information received - completed
8 Savings Programme – new report from Kathryn Helley- completed 8 Prosthetic Savings – linked to T&O and debate at Q&S - completed ________________________________________________________________________________________________Finance & Performance Committee – 25 September 2019 Page 1 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________ 7 Finance – on agenda for discussion - completed 7 Grant Thornton – Update on coding on agenda - completed 6 IPR Revision – completed - completed 6 IPR Revision – forecast for the DM01 performance - leave on until October agenda
6 IPR Special Measures - Shaun Stacey outlined to the Committee the process which the Trust followed to put a Division/Directorate into “Special Measures”. In line with the current Scheme of Delegation the ultimate decision lies with the CEO. Once special measures has commenced, as is the current case of Surgery & Critical Care, then additional management resource/focus and enhanced monitoring is put in place to assist the division in ensuring actions are in place to make the necessary changes. Once improvement has been demonstrated, a recommendation is put to the CEO for the division to come out of special measures. If there has been no improvement within a flexible time period a performance management process will be started for managers. Shaun Stacey noted that he is currently reviewing the existing Special Measures policy and the revised document would be presented to the October meeting.
18 AOB – MSK mobilisation on agenda for October.( post meeting note this will now be presented in November’s meeting)
Item 5 09/19 Presentations for Assurance / Transformation Project Briefings The following item was taken out of sequence on the agenda. 5.5 Capital Update
Sue Barnett introduced Mike Simpson, Associate Director of Capital Development to the Committee. Mike Simpson joins the Trust from NHSI/E and formally started on the 24 July 2019. Mike Simpson took the circulated paper as read; Mike Simpson then went on to advise that, since the paper was produced there had been an update on the AAU figures as follows:
DPoW: Option 3 £16,854,050 – part new build and refurbishment Option 4 £16,201,454 – refurbishment and Preferred Way Forward (PWF)
SGH:
Option 4 £13,157,824 – refurbishment and Preferred Way Forward (PWF) Option 5 £19,026,690 – part new build, part refurbishment
It was noted that further work will be required and is ongoing. Sue Barnett went on to explain that the original request was £29.26mil for all the scanners and Assessment Unit; the Trust now only require 1 scanner through this funding (STP Wave 4) as other work involving the CT scanner and the 2 MRIs at DPoW are being covered through the Emergency Capital allocation. Under STP Wave 4, the Trust is still forecasting to be £4.5mil over due to the AAUs being over at £3.6m against a budget of £25.76m; with the SGH MRI at £0.9mil against a budget of £3.5mil. Clinical Lead for the AAU project is Dr Qureshi, he and other Trust representatives recently visited Airedale Trust and he is working closely with Elaine Coghill, Deputy Chief Nurse to ensure that the required standards are met. Sue Barnett added that it was also important to note that the CCGs were fully engaged. A proposal is due to be submitted to STP by the end of September; this has already slipped by one month; and was noted as a concern. Sue Barnett added that they are struggling to get succinct and robust income and expenditure information from colleagues. The STP has suggested that they will provide the Trust with an Independent QA to go through capital costs.
________________________________________________________________________________________________Finance & Performance Committee – 25 September 2019 Page 2 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Richard Eley asked what were the Committee’s thoughts of the over run on capital. Sue Barnett added that she had concerns, do we “live with” the £3.6mil over or, do we value engineer. Following brief discussion the value engineer option was favoured. This would ultimately be a Trust Board decision. Sue Barnett will take this back to the team ensuring we do not compromise. Mike Simpson noted that the capital costs had been built on the 5 year planning projection, accounting for growth with further learning taken into account from Airedale where they had made an error. There is a risk if the Trust decides to make the costs fit within the capital allocation, that at OBC stages a request is made to NHSI/E for further capital. Additionally, there is also a further risk of increasing design fees for detailed work which would normally occur at OBC stages. Mike Simpson added that the SOC is just the start, more detailed analysis will be undertaken at OBC stages, as much more specific information is required. The Chair advised that she would not be comfortable at this stage to agree to stay with the £3.6mil over spend. She added that she would like to see more work done to show that challenge, review and analysing has been carried out prior to a Trust Board decision. The Committee suggested that it would be beneficial for NED representation to challenge the process prior to any further presentation. Jeff Ramseyer volunteered to work with Mike Simpson and teams and this was agreed by Committee members. A further paper would be brought back to the October meeting. ACTION: Sue Barnett
5.1 Operational Deployment Team – Workforce Resource Centre
Shaun Stacey took the circulated report as read. Shaun Stacey went on to note that, since the last meeting, a permanent appointment has been made to the leadership role (Associate Director of Operations) responsible for developing and leading the “Workforce Resource Centre”. A business case has also been approved by TMB, subject to ratification at the Business Case Review Group for a Project Manager. The Chair welcomed the substantive appointment as a “good move” and asked if recruitment of the remaining posts were progressing on time. Shaun Stacey confirmed that support was still required but he was confident everything was on trajectory for the 4 October deadline. Sandra Hills commented that she had not seen a “deadline date” within the paper, and, as this project would require a change of working would a Consultation be needed. Shaun Stacey went on to explain the timeline for the project and processes related. Control measures had been applied rigorously; he noted that the biggest challenge would be moving staff to the central team. He went on to add that good progress had been made. Sandra Hills asked if Shaun Stacey was confident he had adequate resources to deliver within the timescale. Shaun Stacey confirmed he thought there were more than enough resources available to run the function. Jeff Ramseyer voiced his disappointment over the delay in getting the Workforce Resource Centre fully functioning; frustrated by the “bureaucracy” which is delaying recruitment, adding that this was a huge opportunity for the Trust to ensure this was implemented quickly and efficiently to realise staffing related savings. He suggested it be highlighted to the Trust Board. The Chair agreed that it had taken a long time to get off the ground; being such an integral project; she asked the reason for the delay in approval of the outstanding post. Shaun Stacey added that the original business case for the manager was presented to the Business Case Review Group for approval but unfortunately the content provided was not strong enough so was therefore, rightly so, not approved pending further information. Shaun Stacey added that, whilst the delay was very frustrating, process does need to be followed correctly. He went on to note that a project plan is in place and, as said previously, is moving forward at significant pace which will see an improvement in controls of bank and agency staff.
________________________________________________________________________________________________Finance & Performance Committee – 25 September 2019 Page 3 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Richard Eley added that the business case required further financial information and needed to demonstrate a tangible benefit. The business case will be re-submitted and it can be virtually approved rather than wait for the next Business Case Review Group. He noted that there were a lot of processes within the Trust that do requiring reviewing. The Chair agreed with this and requested that Richard Eley discuss process approvals with Jim Hayburn (new Interim DoF) to take this forward. Shaun Stacey added that the Leadership Programme will be held shortly and this should build upon management strengths and weaknesses in relation to the robustness of processes. The Chair thanked Shaun Stacey and offered the Committee’s support if he required it in relation to the Workforce Resource Centre. It was agreed that it would be useful for Ashy Shankar to provide an update to the November Committee outlining what has been achieved so far and plans for taking forward ACTION: Shaun Stacey/Ashy Shankar
5.2 Contracting Update
The Chair welcomed Zoe Plant, Contracting Lead to the meeting and invited her to outline the Contracting Update to the Committee. Zoe Plant outlined the presentation noting the current position at month 5 adjusted to reflect the drug gain share by CCG showed that NL are above plan by £1,146k which is cause for concern as part of the overall local system control total. East Riding of York CCG is also over trading by £690k which is one reason why they have requested us to look at the Blended Payment system for non-elective as this is a way of paying less (marginal rate) for activity above an agreed planned level. Lincolnshire East CCG is also over trading but once the contract variation is signed for an additional A & E £195k and £977k Non-Elective care they will deliver against plan. As part of the agreement for taking the extra activity East Lincs clinical leads have visited the Operations Room at DPoW to facilitate reducing stranded patients and to look at improving the repatriation of patients back to Louth Hospital. The issue of Pathology contracts with Lincolnshire both the CCG and the Trust is a current risk which Zoe Plant highlighted to the Committee. East Lincs are seeking reductions relation to Calprotech above the block discount and ULHT have suggested they might pull out of the contract and go with another Cambridgeshire Trust. Zoe Plant noted that there is a meeting set up with Peter Reading, CEO along with key individuals on 10 October to discuss internal strategy to this response. NHSI will look unfavourably at splitting up Pathlinks as it is an “exemplar service” and is currently supporting the overall financial position of the Trust. Zoe Plant went on to give an update on CQUIN concerning the proposal to delay the milestones for achievement of the schemes as a result of late changes to CQUINs and new NICE guidance. These proposals will be worked up by the Trust and the CCG will go to the Quality Review Group this month and should allow for a higher likelihood of achievement of the monies associated with these quality schemes. An overview of the Service Development Improvement plans was discussed including the development of the Urgent Treatment Centres (UTC), Outpatient Transformation Programme, Counting and Coding, High Cost Drugs and Daycase to Outpatient Procedures. The Committee was also updated on the actions that had been put in place to improve the processing of the clinical income for the accounts. This included updated checklists and procedures, reviewing of business rules between contracting and information, and capacity and capability review of the team and ensuring that activity is recorded in a timely manner.
________________________________________________________________________________________________Finance & Performance Committee – 25 September 2019 Page 4 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Specifically the Chair requested an update on the £1.4mil issue relating to flex position from last month. This was as a result of omitting to put in an estimate for missing activity as the extract of information was taken very early in the month. Zoe Plant confirmed that there is now a more robust process in place to ensure that this estimate is made and validated by the Head of Contracting each month. The risks then associated with contracting were explored and these included the review of the blended payment system as described earlier, over trading of local CCG, the ability of the Trust to sustain the Counting and Coding work to realise the maximum benefit, the unquantified achievement of Pressure Damage and the necessity to find a mitigation plan for non delivery and any demand management strategies that the CCG have that the Trust has not taken into account. Zoe Plant concluded the current position is favourable but there are significant variables and risks which will do some scenario planning in future months to get a more informed view of the risks and the impact on clinical income. The Committee agreed that Pathlinks issue would be highlighted to the Trust Board. ACTION: Trust Board Highlight 10:45 am Damian Kitchen joined the meeting.
5.3 SLR Utilisation
Linda Jackson welcomed Damian Kitchen, Financial Planner to the meeting and invited him to outline his presentation on SLR Utilisation to the Committee. Damian Kitchen went on to present to the Committee an update regarding SLR Utilisation. It identified the current methods of reporting and issues with this approach such as no ‘confirm and challenge’ of the figures and missed ‘opportunities’. Damian Kitchen also informed the committee that the last quarters information was shared with in the PRIM’s and was well received. Damian Kitchen then went on to outline the project plan which identified how SLR will be rolled out to the groups building on the information being presented to PIMS on a quarterly basis. A final slide showed ‘horizon scanning’ which highlighted that the underlying data for SLR will be used by NHSI to produce future tariffs and in the Model Hospital. Richard Eley stated that other trusts use SLR to identify income opportunities, cost savings, service reconfigurations or manage service performance. Kathryn Helley suggested that the roll out might be co-ordinated with the Model Hospital roll out. Sandra Hills queried if the Community Services was also part of the SLR process. Zoe Plant confirmed it was and went on to state that she wanted the work to link into a work stream which will review the block contract arrangement. Shaun Stacey highlighted that the clinicians were keen on using the information SLR particularly Orthopaedics. The Chair thanked Damian Kitchen for a very good presentation which clearly showed the plan moving forward.
10:55am Damian Kitchen and Zoe Plant left the meeting 10.55am Chris Evans, Associate Director of IM&T joined the meeting.
5.4 Clinical Data Improvement Programme
The Chair welcomed Chris Evans, Associate Director of IM&T to the meeting and invited him to update the Committee on the Clinical Data Improvement Programme. Chris Evans discussed the paper which had previously been tabled at TMB. Chris Evans went on to note that the programme has delivered £591k YTD additional income. The full year trajectory was a gap against the £3m target of 330k and clarified that work happening post the production of the paper has increased that gap to a shortfall of £ 676k.
________________________________________________________________________________________________Finance & Performance Committee – 25 September 2019 Page 5 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Further revision has been made to understanding the impact of POD changes (moving Day case to Outpatients). The impact of this was now estimated to be £509k which needs to be accounted for in the net delivery of the programme. This revision has increased the gap to delivery to £676k. The Chair noted the level of full year forecast gap against the anticipated £3m benefit from the coding work to the Trust was worrying based on the original reports received but acknowledged the further work to clarify Point of Delivery adjustments. Kathryn Helley had wanted to understand whether this was “real savings” and this was assured at Finance Recovery Board. The additional income is being generated for direct intervention in the form of validation of completed coding and then adding additional missing codes.
Sandra Hills asked if close relationships remain with CCGs and did the Trust have an understanding confirmed. Chris Evans confirmed that CCGs representation is on the Clinical Data Improvement Board and there is also a high degree of transparency for all stakeholders involved in this group.
Richard Eley noted a level of concern around the delivery of £10m over the 3 year period given the current risk around YTD delivery and asked for it to be noted that the leadership of the organisation needs to be “concerned of the gap”. Jug Johal noted that there was a “phenomenal” amount of work currently being undertaken and would hope that this is acknowledged. The Project Board is moving forward but should consider whether a full time Project Manager is required. Clinical engagement has also been excellent. Jug Johal went on to note that the project was due to be handed over to Ops in March he was not sure that the team would be in a position to complete this. Jug Johal added that there was currently a huge challenge within the Coding workstream. Chris Evans advised that meetings have been arranged in relation to the gaps and capacity of posts. Sandra Hills asked if the Trust were confident that Grant Thornton has delivered what was specified. Jug Johal confirmed they have delivered that and more.
The Chair thanked Chris Evans for his update and extended the Committee’s thanks to Chris Evans and the team for their hard work. The Chair confirmed that the Committee would wish an update on Clinical Improvement on a quarterly basis.
11:15am Chris Evans left the meeting.
11.15am Alex Bell, Information Manager joined the meeting. Item 6 09/19 Review of NLaG Monthly Performance and Activity Delivery (IPR) Shaun Stacey, COO was invited to present the IPR report. 6.1 Planned Care
Shaun Stacey took the report as read. He went on to highlight key areas contained within noting the following:
RTT – a continued reduction in the waiting list and 52 weeks continues to be managed. It was highlighted however, that Data Quality still poses a risk of more long waiters that may be identified. As at the time of the report been produced there were 6 live 52 week waiters. Jeff Ramseyer queried the control limits, having been the same for a number of months when would they be reviewed. Alex Bell confirmed that this would happen once a stable point is reached the control limits would change. Diagnostics – Shaun Stacey noted that both CT and MRI referrals are increasing both with GP and acute, however the numbers on waiting list is reducing. Alex Bell noted that diagnostic deterioration is also an issue with neighbouring trusts and wished to raise this issue with the Committee. Cancer – Shaun Stacey went on to note that he was aware that oncology had a number of ongoing problems; 62day backlog continues to rise with the Trust failing on both 62 and 31
________________________________________________________________________________________________Finance & Performance Committee – 25 September 2019 Page 6 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
day targets, it was noted that the impact of Hull shared breaches are relevant. There were also potential issues within upper GI MDT. Jeff Ramseyer questioned if “clock stops” are identifiable and could it be included in the narrative. There will be a Board to Board meeting to be held next week were cancer services will be debated. Shaun Stacey went on to note that the Trust was looking to see a radical improvement on out patients overdue in September. Jeff Ramseyer asked what the normal length of stay was. Shaun Stacey answered that this did depend on specialty but it was approximately 2.5 to 3 days for surgical and 3.5 to 4.5 day for medical specialities. Shaun Stacey added that there was still a large ability for improvement. To aid understanding it was agreed that a report would be brought to the next meeting. ACTION: Shaun Stacey
6.2 Unplanned Care
A&E – Shaun Stacey noted that whilst the Trust has failed to meet the performance trajectory, there has been a marked increase in the performance for August. It was highlighted that this was against continued growth in demand with no increase in admissions which demonstrates good A&E management providing the right outcomes for patients. The Chair thanked Shaun Stacey and Alex Bell for the update. 11.30am Alex Bell left the meeting.
Item 7 09/19 Review of NLaG monthly Financial Position (Finance Report) 7.1 Finance Report Month 5
Richard Eley took the Finance report for month 5 as read and went on to highlight the key issues contained within the report noting in particular:
• Income was ahead of plan by £1mil primarily driven by a £1.4mil income refresh benefit but concerns about the realisation of the clinical coding project had emerged
• Large adverse variance for central income budget. Divisions are aware of the impact on numbers (adverse)/positive variance.
• S&CC division is still overspent and being worked through in the PRIM’s and has targeted support to help move the division forward
• Community and therapies division was another area of concern with a year to date variance of 324k. Some of this is due to the funding of the virtual ward which is part of a bigger discussion with the CCG’s
• CSS division had an adverse move in month; slowed income from previous bought in services. Histopathology – waiting times down but at a cost of more staff.
• Pay was £650k overspent which was due to overspends on medical and surgical agency costs which needed to be bottomed out in the performance meetings
• Concern was raised in relation to A&E staffing – the Trust needs to keep an eye on this and look for support within A&E. The Chair asked Shaun Stacey how long before support was brought in to A&E. Shaun Stacey confirmed that he may need to look into substantive posts.
• Non pay was £397k underspent due to lower drug and clinical supplies spend. • Nursing establishment review– the approach to address the immediate risk areas
was agreed at the Trust Board .Following the trust Board TMB agreed a level of investment of £1.1mil to increase nurse staffing levels; the £1.1mil is based on substantive staff costs which are a note for concern given the ongoing difficulties the Trust faces with staffing. On call issues were noted and there was still work to do. Elaine Coghill, Deputy Chief Nurse is lead on this. Matt Clements, Finance Manager will continue to work alongside Elaine Coghill and would look to update the Committee at a future meeting. The Chair advised that the Committee would require more assurance on staffing / nursing.
The Committee received and noted the Month 5 Finance Report.
________________________________________________________________________________________________Finance & Performance Committee – 25 September 2019 Page 7 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Item 8 09/19 Savings Programme
Kathryn Helley referred the Committee to the circulated report and went on to provide an overview of the content. She advised that CIP oversight report has been revised to enable it to be visible in one place; it is now the same report as NHSI receive and is divided into two halves. The first section of the report provides a breakdown on a workstream basis and the second half provides a division/directorate view. A ‘deep dive’ into any areas of concern will also be included in future. Future developments include delivery of the £2m system CIP and any non-delivery of CQUINs. Kathryn Helley added that she would welcome any comments on the new format.
Kathryn Helley then went on to report that the two main areas of non-delivery related to access & flow and clinical workforce. Two of the initially identified projects in access & flow had not commenced as anticipated and so work was taking place to identify mitigating schemes to address this shortfall. In clinical workforce, although an under-delivery was noted this month, it was expected that this would be recovered by year end due to the planned recruitment of doctors which would mean a reduction in bank and agency spend. The Chair made an observation of the amount of unidentified savings for CSS/W&C and asked if these were in the pipeline. Kathryn Helley confirmed that both of the divisions were working on plans to bridge this gap.
Kathryn Helley apologised for the lateness of the report. The Committee received and noted the report.
Item 9 09/19 Strategy & Planning Nothing to note or update. Item 10 09/19 Estates & Facilities 10.1 BAF Risks - Water
Jug Johal took the report as read noting that the report did not contain detail for the Coronation Block. A paper would be presented to TMB and the Committee would receive a separate report and update at the November meeting. Jug Johal went on to note two key risks:
• Risk of failure of the Trust’s infrastructure; aging estate and equipment • Risk of failure of the Trust’s infrastructure; longer term estate
Jug Johal drew the Committee’s attention to page 4 of the report noting that the figures contained within the table for an overview of the outstanding defects across the three sites were “not good”. The action plan was embedded within the report; there were a number of low and medium risk outstanding actions from the last audit which was carried out in 2017 linking to capacity of the estates team. Jug Johal went on to note that there were also a higher than normal number of outstanding action which is due to the timing of the audit being undertaken in relation to the report being published. The Committee received and noted the report. The Chair added that, as from next month now the BAF has evolved, a monthly update would be added to the agenda to ensure appropriate grading. ACTION: Anne Barker
Jug Johal drew the Committee’s attention to the Trust Fire Alarm system, he noted that currently there are no major concerns but asked for it to be highlighted to Trust Board that there would be a requirement of significant expenditure in the future.
________________________________________________________________________________________________Finance & Performance Committee – 25 September 2019 Page 8 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________ Item 11 09/19 Next Meeting
Agreement of area for deep dive on a performance or financial risk – • Work plan items • Re look at the capital schemes for AAU and SGH MRIS&CC Division to attend and
present their plan to exit special measures Item 12 09/19 Items for Approval No items were presented for the Committee’s approval. Item 13 09/19 Items for Information The following items were circulated to the Committee for information: 13.1 Financial Recovery Board Action Log 13.2 Letters to Divisions PRIMs
13.3 Joint Planning Meeting – monthly briefing paper System Control Total. It was noted that this would be a regular report to both TMB and Finance & Performance Committee.
ACTION: Anne Barker Item 14 09/19 Matters to highlight to other sub Committees No matters were highlighted. Item 15 09/19 Matters for escalation to the Trust Board (Public/Private)
Contracting risks around income Clinical coding project full year forecast
Item 16 09/19 Any Other Business Terms of Reference – comments/amendments back to Anne Barker by 18 October. ACTION: All
The Chair, on behalf of the Finance & Performance Committee extended their formal thanks to Richard Eley, Interim Director of Finance who would be leaving the Trust on Friday 27 September. Jim Hayburn would take over from Richard Eley.
Item 17 09/19 Did we get sufficient assurance on the areas covered today; is there sufficient drive
and progress being evidenced? The Chair asked Committee members for their comments and feedback from today’s
meeting. The Chair suggested that Surgery & Critical Care Division representatives be invited to the October meeting in light of the division being in “special measures”. The Committee agreed that this would be very useful.
________________________________________________________________________________________________Finance & Performance Committee – 25 September 2019 Page 9 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________ Item 18 09/19 Date and Time of Next Meeting WEDNESDAY 30 October 2019, 9.00am to 12.00PM, CEDAR ROOM, DPOW Attendance Record 2019/20
Name Apr 19
May 19
June 19
July 19
Aug 19
Sept 19
Oct 19
Nov 19
Dec 19
Jan 20 Feb 20 March 20
Linda Jackson Tony Bramley Apols Jeff Ramseyer Apols Anne Shaw - Apols - Apols Apols Sandra Hills - - - - - Richard Eley Apols Peter Reading Apols Apols Apols Apols - Apols Shaun Stacey Jug Johal Apols Sue Barnett Marcus Hassall Brian Shipley Brian Page - - - TOTAL ATTENDEES 7 6 7 7 7 8
________________________________________________________________________________________________Finance & Performance Committee – 25 September 2019 Page 10 of 10
PRESENT: Linda Jackson Acting Trust Chair / F&P Chair Tony Bramley Non-Executive Director Jeff Ramseyer Non-Executive Director Jug Johal Director of Estates & Facilities Shaun Stacey Chief Operating Officer Sue Barnett Strategy & Planning Consultant Jim Hayburn Interim Director of Finance
IN ATTENDANCE: Kathryn Helley Improvement Programme Director Paul Hinchliffe Divisional Manager – Surgery & CC (For item 5.4) Sheldon Mill Divisional Finance Manager (For item 5.4) Anne Barker Finance Admin Manager (Minutes) Item 1 10/19
Apologies for Absence
Apologies for absence were received from: Peter Reading and Brian Page.
Linda Jackson referred to a recent meeting with Richard Barker, NHSI Regional Director who had emphasised that the £10m income given to the Trust to assist meeting the 2019/20 control total was all he had available to him and this all came to NLAG, Therefore, the message was clear – the Trust must deliver financial balance this financial year and by receiving the full 10m allocated to the Yorkshire and Humber region it demonstrated his faith in NLAG to deliver against expectations
Item 2 10/19
Declarations of Interest
There were no Declarations of Interest.
Item 3 10/19
Minutes of previous meeting held on 25 September 2019
The minutes of the meeting held on 25 September 2019 were reviewed. Jeff Ramseyer referred to Page 7 regarding LOS and queried how the benchmarking was undertaken - Shaun Stacey advised that a number of tools are available including Model Hospital, BI catalogue and Dr Foster. Advising that currently LOS is 2.5 days for Surgery and 3 days for Medicine against the national average of 1.5 days and 1 day respectively. But the benchmarks were more of an indication of where to look rather than absolute numbers given the differences in the way that Trust’s code activity and their clinical models. Jeff Ramseyer suggested it would be helpful to determine what LOS KPI’S the Trust would like to be. Jim Hayburn suggested that the Trust should develop KPI’s that monitor the determinants of LOS such as bed outliers and clinical variation. Jeff Ramseyer then referred to non-elective and non-achievement of the target of 2-4 days. It was agreed that a culture change is needed in a number of areas and targets need to be based on what Shaun Stacey feels can be achieved. Tony Bramley suggested an Org chart on the standard against our peers. Shaun Stacey highlighted that there is a Trust quarterly benchmarking report available. Sue Barnett suggested that part of the solution was in the strategy work but the biggest issue is Cardiology which is three times more than the national average. It was suggested that a deep dive into Cardiology would be useful and also for cardiology to be invited to this Committee to advise on their progress against the 4 day target.
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Linda Jackson asked Kathryn Helley about the CIP schemes for LOS who advised that there are some gains for this year. It was noted that the LOS had been reduced by 2 days since 2017, although also noted that non-elective beds have to be reduced in order to make savings. Following the discussion the minutes were agreed as an accurate record.
Item 4 10/19
Matters Arising / Action Log
The action log was reviewed as follows: • Item 5.1 – 52ww – Jim Hayburn understood that no penalties will apply but will hopefully
confirm later that day. • Item 6 – IPR – RTT – Alex Bell looking at whole matrix for the area to measure OPD. It was
confirmed that this is partially completed and the Committee asked that this is available for the November meeting. Post Meeting Note: Jug Johal confirmed that this has now been fully included in the IPR to give breakdown of Outpatient waits. The % of ”virtual clinics” is not there yet as this is not as clean cut but it is anticipated that this will be available for the next meeting.
• IPR Revision – Post Meeting Note: Jug Johal advised that the trajectories have not yet been refreshed. C&D for MRI and CT are now approaching completion, as well as performance standards being set for the 5-year plan going forward. Jug johal suggested waiting until Non-Obs Ultrasound is also completed and will check with Shaun Stacey and update at the next meeting.
Following review the action log was noted.
Item 5 10/19
Presentations for Assurance / Transformation Project Briefing
5.1 Capital Update
5.1.1 Acute Assessment Unit and SGH MRI
Sue Barnett talked the committee through the key aspects of the paper, the new financial projections and covered the updates that had taken place since the last committee meeting. The capital update at the last meeting had advised that the current plans exceeded the original budget of £29.26m capital funding and it had been agreed that a value engineer exercise was the favoured option. Today’s paper outlined the way forward which is to take out costs which were included to address the Trust’s critical infrastructure risks as well as a reduction of the equipment schedule.
The STP report was provided for information with the paper and Sue Barnett highlighted that the collective teams working on this should be commended in getting to this stage but felt that the project needs sufficient resource attached to it going forward. Linda Jackson asked Sue Barnett about the resourcing required to manage the current and future capital schemes. Sue confirmed that high level talks are taking place and that the Trust was considering the establishment of a strategic capital team and an early drawdown will be required to fund a business case; it is hoped this will be confirmed sometime this week. Jim Hayburn supported this approach and stated that if we did not submit a robust business case it would affect the credibility of the Trust. Jim Hayburn also stated that from a finance perspective we can capitalise developing the business case if the project goes ahead but if not it will be a revenue hit for the Trust. Sue Barnett wanted to flag this may be sunk costs if the bids for capital were not successful but saw no other way of addressing the needs of the Trust
It was noted that taking out the critical infrastructure costs and reducing the equipment schedule would put more of a strain on the already reduced BLM budget and Linda Jackson agreed to highlight this to the Trust Board so that everyone is aware of the decision taken and it’s implication.
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Following review and discussion the Committee were in support of the way forward prior to being presented to Trust Board.
5.1.2 CT Relocatable Options Paper
Sue Barnett highlighted that this is part of the emergency capital bid to bring forward the use of a modular unit and purchase of the CT scanner at DPOW; this is 18 months-2 years earlier than the original plan of using the current MRI space. Tony Bramley asked for an update on the revenue which Sue Barnett advised will be able to confirm a return on investment by circa July 2020.
The Committee approved the paper to be presented to the Trust Board.
5.1.4 Ward 29 – Full Business Case – Executive Summary
The report presented outlined the schemes costs including a contingency to upgrade wards which will allow a decant ward if required due to increased activity. This scheme will be provided out of the trust capital monies. Jim Hayburn queried the forecasted revenue for this scheme, which Sue Barnett advised will be included in the updated report being presented to Trust Board the following week.
Jug Johal highlighted that this is a complex refurbishment due to the location of NICU and ITU above and therefore there was a need for a significant contingency to manage the risks which had been included in the paper.
Sue Barnett highlighted the work involved with the recent office moves and Linda Jackson agreed to write to thank those involved. Sue Barnett and Kathryn Helley to provide names to Linda Jackson.
Action: Sue Barnett; Kathryn Helley and Linda Jackson
Jeff Ramseyer commented on the appointment of Mike Simpson, Associate Director of Capital Development, which was agreed by the Committee as a good appointment.
5.2 OPD Transformation Project
Shaun Stacey presented the report which was showing some overall improvement although Ophthalmology is still of concern due to the continued growth of the back log of waiting lists, despite following a programme of work for change in service delivery. Cardiology made an outstanding start but has slowed down recently.
Linda Jackson felt it was a good report but the overall position is not summarised which would be useful to pull the full project together for the next time it is presented. Shaun Stacey advised that he will continue with validation through the wider programme. Linda Jackson also commented that the report now contained a lot of useful indicators such as new to follow up ratios, non-face to face trajectories, follow up recovery forecasts. In light of the enhanced scrutiny from the CQC in this area and the fact this report was not incorporated into the IPR Linda Jackson felt that the report needed to come every month to the committee for review so that the reduction in the follow up list could be reviewed and challenged.
Action: Shaun Stacey
In terms of the seven specialities, Kathryn Helley advised that an additional slide will be added to the Integrated Performance Report (IPR) which will show the progress against the trajectories moving forward on a monthly basis.
Shaun Stacey added that it is recognised that growth factor needs to be considered and then the impact of the transformation will be confirmed system wide basis. The operational planning, including financial costings, is still to be concluded.
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________ The Committee was asked to note the importance of the pace required and a proposal is being
worked up for a dedicated individual project manager per scheme and specialty and Linda Jackson asked where this is being discussed. Shaun Stacey confirmed that this was being discussed within the divisions and with Ops. The aim was to use existing resources but that this was difficult because of the competing demands on the same staff. It was agreed that the pull on resources within the Ops Directorate, whilst managing “business as usual” should be highlighted to the Trust Board. It was suggested that this report is also presented to the Quality & Safety Committee.
Action: Anne Barker
5.3 Performance Review and Improvement Management Framework
Shaun Stacey provided a paper and highlighted that since the paper was produced further discussions have been held around cancer and the paper does not include how a service rather than a division would be put in special measures. Therefore he intended to revisit the paper in due course. Linda Jackson asked Shaun to explain what special measures means, including how you are put in, how you get out and what happens when you are in special measures. Shaun Stacey explained that performance is monitored through PRIMs and if Divisions continue to fail to appropriately deliver the agreed recovery plans TMB will make the decision on the next steps. Shaun Stacey was keen to point out that this is a supportive process and initially resource was available to help with the divisions but this is not now available. The Trust will need to look at where any additional resource would come from in future, if required. Jeff Ramseyer stated that when an organisation like ours is in special measures external support is provided from the regional office but it is not clear where that is provided internally. Linda Jackson suggested that the on-going support package for the division will need to be agreed when a division goes in to special measures so it is clear to all what that looks like and what is the expectation of the support given and the division itself.
Tony Bramley referred to the consequences of not delivering and felt that a set period of time should be agreed to come out of special measures then if the division did not achieve the agreed outcomes in that time, or the division’s performance deteriorated, then the divisions need to know what will happen then, so that things are not left open ended. Shaun Stacey advised that implementation of individual performance management processes through the usual channels of performance, including capability policy may need to be undertaken. Tony Bramley added that he was thinking more about a service failing where staff are working well but still failing to achieve what is required.
In terms of the management of agency spend it was felt that the Medical Director should be included within this and the framework needs to articulate that only as an exception will additional resource be put in. Shaun Stacey asked the NED’s to forward their comments on the paper for inclusion into the final version
Action: NEDs
5.4 S&CC Plan to Improve the Financial Performance of the Division
Paul Hinchlliffe and Sheldon Mill were in attendance and Linda Jackson welcomed them to the meeting.
Sheldon Mill explained that the S&CC division were put in special measures after Q3 (June) 2019 when the Division were £781k adverse variance against plan including £500k on pay and £476k on medical staffing.
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Sheldon Mill went on to say that at M06 the division are reporting £1.3m overspend including £242k income; £1.2m pay; and £260k non pay with an improvement in activity delivery of £242k. The forecast for the end of the year is £808k overspend and still forecasting £1.7m overspend of pay with £1.9m medical staffing with £1.3m income over delivery. Plans are in place to increase activity in Ophthalmology and Orthopaedics are committed to deliver to plan. Adult critical care will also increase delivery, noting that the number of patients remains the same but seasonal trends result in patient acuity increasing over the Winter period.
Linda Jackson commented that there seems to be a significant reliance on income and asked how secure the receipt of that income actually is, bearing in mind the system wide pressures. Jim Hayburn confirmed it may be a problem and that further analysis needed to be undertaken on the risks here and how this will impact activity. Jim Hayburn clarified that he would be looking at how much of the additional income is due to waiting list initiatives and how many referrals are actually out of area and is the funding flowing. Paul Hinchliffe explained that where seeing an increase of new outpatient referrals which is mainly from out of area CCGs and in Orthopaedics. Jim Hayburn commented the need to keep Ophthalmology support separate from the review. Shaun Stacey will be discussing the ophthalmology position and recovery with CCGs later this week. Pay expenditure is significantly over and need to take that and discuss at PRIMs.
Linda Jackson reiterated the message from Richard Barker for the benefit of the S&CC team that non-delivery of the financial targets is not an option and that this division was a major risk to the Trust’s financial performance in year. She reiterated that the recovery actions and forecast needs to be robust. Paul Hinchliffe stated that they are looking at where they can take costs out and today heard that additional resources were available from Hull that they were exploring. Linda Jackson stated that labour control is a key issue for the division - rota difficulties, sickness and annual leave cover and the management of these areas is not coming out of the paper and the Committee need to understand how the division are managing the pressures and asked if there were plans are for each speciality. Paul Hinchliffe stated that the main issue for the division is Anaesthetics where he feels there is the most opportunity for reducing costs and with better grip and control can already see improvement due to a refocus on annual leave. Paul Hinchliffe explained that at the DPOW site the anaesthetists self-manage the rotas. There has been a review by the management teams and discussions with the anaesthetists about what needs to change on the rota’s to reduce premium spend and get a consistent service in core times whilst still covering the on call requirements. It has been decided that the anaesthetists be given the opportunity to manage the changes required in the first instance . Linda Jackson asked where the grip and control of that sits. Paul explained that a culture change is required and whilst some improvement is being seen acknowledged pace is needed. Linda Jackson asked Paul to confirm when the rotas are to be in place and he confirmed that it could take 2/3 months to get the change and they will get there themselves in terms of the rotas etc. Linda Jackson asked what happens at that stage if they do not deliver as the project will not be recoverable in year. Jeff Ramseyer stated he had real concerns about this approach as we were asking the same people who are not currently controlling the rotas to make the required change at the required pace and there is no risk mitigation if this cannot be achieved.
Jim Hayburn commented that it is important that there is a joint plan drawn up as soon as possible with the Medical Director. He suggested it would be useful to have Brian Shipley to work on the development of this plan. Hopefully there will be improvement seen at the next PRIMs.
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Paul Hinchliffe acknowledged that support is needed in managing the annual leave.
Linda Jackson summarised the discussion and highlighted that the Committee heard that the key areas are anaesthetic rotas and the application of the annual leave policy and asked if there is enough support to make those improvements. She also highlighted that these are key drivers for increasing theatre productivity which is also a key CIP and is currently running behind trajectory. Tony Bramley commented that he thought that historically the main issues cited were vacancies and the cover to manage. He stated he was concerned that the vacancy position had not really moved, was one of the biggest reasons for premium spend and yet the division did not mention the actions in this area to the committee.
Linda Jackson asked that the top five areas for focus are identified which give the best return for the Trust in year and asked what support will be needed for that. She went on to say that whilst what is being heard is encouraging there is still a lot of risk to delivery here and a lot of work to do.
Jeff Ramseyer commented to Paul Hinchliffe that you want to make a change in 90 days but dealing with people’s behaviour is not something that can be done in that timeframe and should not underestimate the complexities when dealing with these issues. Are we assured you will get there – No, but acknowledge a lot of work is going on and would agree with Linda that the top five things should be identified where to put your efforts. Jug Johal added that in terms of the five priority areas he would like to see an improvement plan with timescales and the resource required and if there is a gap then we can help with that. Paul Hinchliffe suggested having a deep dive in all areas to help identify the bigger opportunities.
Jim Hayburn commented that he was not getting a sense of urgency from the Division and stressed that some real decisions need to be made to be able to manage the last 5 months of the financial year. He went on to say that he is happy that Brian Shipley offers some support with the deep dive but it is critical that those five things are identified. Linda Jackson asked Jim Hayburn to report back on progress at the next meeting. It was agreed that the top five things are brought to the PRIMs meeting and how that will be delivered by the end of the year. This will be added to the highlight report.
10.45am Linda Jackson thanked Paul Hinchliffe and Sheldon Mill for attending and summarised that she
could see there was a lot of work ongoing, and a lot of work still to be undertaken. The reason the division was asked to the committee today was to give assurance that they had grip and control and could demonstrate a robust trajectory for moving forward. Linda said that unfortunately she did not gain assurance from the discussion today. Tony Bramley and Jeff Ramseyer concurred and Tony said that he found the session disappointing. Jim Hayburn committed to taking the support and refocus for the division forward with Shaun Stacey
Once the S&CC team left Linda Jackson felt a discussion on the effectiveness of the support to date was had and suggested waiting for Shaun Stacey to return to the meeting to complete this section and conversation, which was agreed.
Item 7 10/19
Finance
7.2 NHS protocol for Changes to in-year Forecasts
Jim Hayburn presented the report which outlines the NHSI protocol for changing an in-year financial forecast. Any changes can only be made at the quarterly reporting point i.e. Q3 and will attract considerable scrutiny from the regulators. Jim Hayburn highlighted the areas for focus for the Trust including looking to accelerate CIP schemes and it has been agreed at TMB that a review of all business cases already signed off should be carried out ensuring prioritisation of clinical cases.
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Sue Barnett queried the availability of a forecast outturn and it was agreed that a quarterly outturn forecast should be available for the Committee to gain sufficient assurance in this area. Linda Jackson commented that this was an area that was focussed on in the CQC interviews as part of the recent inspection and that she would like more detailed information on forecasting coming to the committee moving forward but accepted there was further work Jim needed to implement to ensure the process was robust.
Action: Jim Hayburn
10.55am Shaun Stacey returned to the meeting and the conversation continued by the committee on the discussions with S&CC and their additional support.
Linda Jackson re-confirmed that the Committee were not assured on the division’s performance improvements as they are too reliant on income, therefore the Committee would like a focus on cost control reduction and specifically regarding the anaesthetics department particularly in terms of self-management of rotas. Linda Jackson re-iterated that she felt a refocus was required of the top five priority areas the division need to focus on and to identify what support was needed. Linda Jackson raised concern that only Paul Hinchliffe and Sheldon Mill turned up to the meeting as the committee were expecting the triumvirate. Tony Bramley commented that it was a disappointing paper, whilst a lot of useful information but would have expected to see prioritisation areas so did not instil confidence. Shaun Stacey commented on the self-management of rotas in that there needs to be a re-education of behaviours etc. and acknowledged the request for a focus on prioritisation areas and what will help the division and agreed to take that action away.
Action: Shaun Stacey
Linda Jackson added that they need to focus on the areas of concern and move away from providing lots of information. Jim Hayburn suggested that they need some support and it was agreed that Jim and Shaun would arrange to meet with them.
Action: Jim Hayburn / Shaun Stacey
Sue Barnett commented that the offer of help was managerial and maybe it would be better to offer help from the Deputy Medical Director level.
In conclusion Linda Jackson reiterated the clear message from Richard Barker for NLAG to deliver the control total. Shaun Stacey commented that whilst he agreed with what has been said to the Division he needed to be assured that he had the support from the committee and the Trust Board to support him moving this situation forward to deliver the required result. The committee agreed the support for this. It was agreed that will be highlighted to the Trust Board.
Post Meeting Note following the F&P meeting on 27 November 2019: Clarification was sought at the F&P meeting on 27 November, 2019 if S&CC were in special measures formally; Shaun Stacey confirmed that they were not but that additional support had been allocated to give increased focus at this time to help solve the financial challenges faced.
7.3 Financial Improvement Trajectories
Jim Hayburn presented the report which outlines the Trust’s financial improvement trajectories against the financial control totals for the next four years to 2023/24. The underlying principles consist of a more realistic efficiency requirement for all organisations; the minimum requirement is a CIP of 1.6% with a likely target of 2.1%.
Sue Barnett commented that the CIP is a sub-set of business planning and will also include investments that are required – so could be a bigger requirement than this would appear. All plans will also need to be triangulated with workforce implications. Jim Hayburn added that it was agreed at Exec Team that a sub group will be put in place to identify how the CIP will be delivered to include quality improvement and service reconfiguration.
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
7.1 Finance Report M06
The Finance M06 report summarised Jim Hayburn Key points emphasised were • The Trust’s financial position was £529k adverse against the NHSI plan and £31k favourable
year-to-date. • The month saw an over performance on income and a significant overspend on pay, with a
non-recurrent adjustment in month from the balance sheet; there was also some catch up with pay awards which contributed to the adverse position.
• Pay expenditure overspends in all divisions had been asked to resubmit their forecast outurn as a result along with recovery planning.
• CIP delivery – coding and contracting conversations with CCGs are ongoing and have agreed support and depending on where they end the financial year may be different from straight PBR ends will move away from PBR. There was still £1m outstanding system CIP to be addressed by all parties
Linda Jackson asked how the Committee can get a level of assurance on the pay costs and did not feel the current reporting gave sufficient detail for the committee to gain any assurance in this area, especially when it was the Trust’s biggest area of overspend. She went on to say that direct labour, agency spend and bank spend added together was the labour cost and there was nowhere in the financial reporting that this was portrayed sufficiently. Also, she went on to say that she needed this to then be measured against the budget so that variances were clear and able to be interrogated and assurance gained. Jim Hayburn agreed to review the information provided to the committee.
Action: Jim Hayburn
Temporary staffing costs were discussed and Jim Hayburn highlighted that it may be that a cap on agency spend is put in place.
Following review the report was noted.
Item 6 10/19
Integrated Performance Report
7.4 BAF Risk Review
The Committee reviewed the Board Assurance Framework – Finance & Performance “cut”. • To live within our means - this had a risk rating of 15 and the Committee suggested it should
be 20. Jeff Ramseyer suggested that the risk should be higher than the performance risk rating. The Committee noted that the heat map matrix does not give an indication that it should be higher than performance and the question was raised if the matrix needs to be reviewed. Tony Bramley said that it needs to consider the totality and how managed within that box. Jim Hayburn agreed to consider the risk rating and discuss with Jeremy Daws. It was agreed that Kathryn Helley will also be part of those discussions.
Action: Jim Hayburn
• Sue Barnett noted that risk 9 (to pursue a clear organisation strategy that staff and stakeholders are aware of and support) and risk 10 (a clear service strategy for the area to ensure long term service sustainability (includes the risk of not developing the required external relationships and linked to HASR)) should both be on the Finance & Performance risks. Risk 11 (risk of ineffective relationships with stakeholders) should remain with the Trust Board.
Linda Jackson agreed to notify Jeremy Daws to include risks 9 and 10 within the Finance & Performance Committee risks as suggested above.
The IPR was taken as read and the Committee reviewed the report and raised questions as necessary. The committee agreed due to the performance this month a greater proportion of time should be focussed on the improvement of the cancer position. The committee reviewed the key headlines for A&E and RTT performance as there had been progress made in both areas. The committee felt the briefing on the OPD follow up position had covered the debate in this area.
CANCER • Page 7 – Planned Care – Cancer – Shaun Stacey confirmed 62.7% achieved for September
which was unvalidated at this stage but noted that he was expecting a deterioration once validated. Shaun Stacey explained some of the reasons for this deterioration including the risk of the number of patients on the cancer PTL without a diagnostic outcome, which is linked to the changes in the clinical decision making process. Shaun agreed to change the report to ensure more transparency for the committee.
Action: Shaun Stacey • Jeff Ramseyer queried again that he was unsure what where the key action areas were that
would significantly improve the cancer performance moving forwards. Shaun Stacey confirmed these could be separated into 3 key areas for action
o The number of patients on the cancer PTL that do not have a cancer diagnosis/outcome. This is linked to the clinical decision making and moving patients have not been found to have cancer onto a 31 day pathway. Peer support via the Medical Director will need to be sought to give the clinicians the confidence to do this
o Length of diagnostic waits – which covers NLAG’s scanning and reporting capability, capital investment and making sure patients hit the inter provider time frames
o Access and availability of cancer services at HUTH which was a real concern
• Shaun Stacey described the difficulties of getting a decision made on the diagnosis of whether or not a patient has cancer. Shaun added that a discussion had been held at Exec Team on whether to put Cancer service into special measures and subsequently to TMB. Shaun has also asked for help from the Medical Director and the Chief Nurse as well as asking for support from the Cancer Centre.
• Shaun advised that following the recent Board to Board meeting it had been agreed to form a Cancer Board with Hull FT
• Jim Hayburn noted that if special measures are the correct way to go then we will need to be clear about what the financial consequences of that are
The Committee felt it was the right thing to do to put the cancer service under increased supervision as it was felt the team had gone as far as they could go and clearly a different focus was required. It was also noted that the Medical Director is on board with this.
• A&E – M06 achieved 85.5% compared to 83.0% in M05 against a trajectory of 88.3% • RTT – M06 improvement seen with 79.0% compared to 78.0% in M05 against a trajectory of
78.5%
It was agreed that a number of areas in the report could be clearer which Shaun Stacey agreed to address i.e. Page 5 – need to be clear what it is telling us and Page 11 – question if it is the right information. 6.3 BAF risk Review – Constitutional performance
The Committee after discussion agreed that the BAF risk rating remain reflected the current risks at 20 as there were still real risks in performance delivery.
Kathryn Helley presented the report and highlighted areas to note. • M06 over delivery by £950k against a plan of £8.35m for the first half of the year. Still
anticipating delivering £20m at the end of the year but risks are associated with that including clinical productivity schemes and medical workforce. Linda Jackson suggested that there should be a real focus on what actions can be taken to give the Trust the biggest impact in the remaining part of 2019, As mentioned in the S&CC section of the meeting Linda commented this may be only 4-5 key areas where focus will make the biggest difference
• Need to ensure pull forward any schemes that we can to mitigate any shortfalls • Linda Jackson noted that the divisions have gaps and Jim Hayburn commented that there is a
need to look at those CIPs that are not being delivered and see if there is anything that can be identified there to help the Trust deliver its financial control total.
• Agency spends – particularly the use of Thornbury and queried if this is just ad-hoc cover. Shaun Stacey explained that it is linked to late requests for cover due to sickness, A&E and high dependency areas, also there are a number of individuals currently not at work so all high cost fill rate. Previous discussions around the reduction of the cap on agency costs and now in phase 3 of that reduction their fill rate is reducing which is of concern to the Trust.
• Jug Johal commented that all calls at weekends are about agency requirements due to late sickness notification.
• Jim Hayburn suggested it is about understanding the areas with the biggest spend and what the issue are and which areas are driving these requests and need to think about what information is required in order to manage this better. It was agreed that the implementation of the Resource Centre will help with these controls.
Following the review and subsequent discussions the report was noted.
Item 9 10/19
Strategy & Planning
9.1 Trust 5 year strategy prior to submission to STP
Sue Barnett presented the report which was still work in progress and would be presented to the Trust Board the following week. It is anticipated that there be some system misalignment which Jim Hayburn noted was a risk to the Trust and the system overall, although there is a commitment to align. Sue highlighted some key drivers which were activity and the OPD transformation project, the change in the model of care in the UTC’s, OPD follow up trajectory following the CQC inspection and the potential moving out some RTT performance to 26 weeks to accommodate additional slots for follow up appointments
The Committee noted the current version of the 5 year strategy noting that a more detailed discussion will be held at the Trust Board.
Item 10 10/19
Estates & Facilities
10.1 BAF Risk Review - Fire
Jug Johal presented the report and highlighted that there are two key risks to note i.e. Fire Ring Main Deadlegs and Condition Risk; and Fire Compliance. Jug Johal highlighted that the ring main risk is across all sites with some specific issues at SGH with the valves and when the new scanner was installed had to divert the ring main; there is now additional problems with high/low voltage.
Jug Johal noted that an AE (Authorising Engineer) is not needed in terms of fire due to the close working relationship with the Fire Brigade. The Trust Fire Safety lead has however undertaken an AE course which will help having those skills. Jug highlighted that there are significant changes anticipated to the HTM 03-01 requirements which are as a result of the Grenfell Tower fire, noting the scrutiny around policies and procedures. There will be more detail when this report is published in the near future. The changes to the HTM 03-01 will have an impact on health care, local authorities and schools.
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Jug Johal drew the Committee’s attention to the fire action plan embedded within the document which demonstrates the actions taken to mitigate the risks identified and that there is full and transparent discussion on the plans with the local fire brigade. The fire alarm system across the Trust features as part of the business plan but this will have a significant financial cost and therefore will be done site by site. It was agreed that it would be highlighted to the Trust Board on the BLM budget and how much is used for fire. Linda Jackson asked Jug Johal to advise when the HTM0301 reports have been received and it can be a board briefing whereby the current fire compliance and actions can be reviewed in light of any legislative changes.
Action: Jug Johal
Item 11 10/19
Terms of Reference Annual Review
The annual review of the Terms of Reference had taken place with only minor changes made. The Committee reviewed the changes and approved the TOR being presented to Trust Board for final ratification.
Action: Anne Barker
Item 12 10/19
Workplan
The workplan was reviewed as follows: • Under the Strategy & Planning section need to include IT/Digital Strategy. The frequency to be
agreed and Jug Johal suggested delaying until the scope of Phase 3 is completed. Action Jug Johal
Following review the Committee noted the workplan.
Following the Annual Self-Assessment results that were considered at the August F&P Committee meeting, an action plan was produced by Linda Jackson. The Committee reviewed and noted the action plan. This will now be taken to Trust Board for information and actions will be owned by the committee chair
Action: Anne Barker
Item 16 10/19
Items for Information
16.1 Financial Recovery Board Action Log
16.2 Letters to divisions following performance Improvement Meeting
The Committee noted the items provided for information. .
Item 17 10/19
Matters to Highlight to other Trust Board Assurance Committees:
There were no issues raised to highlight to other Trust Board Assurance Committees.
Item 18 10/19
Matters for Escalation to the Trust Board (Public)
Linda Jackson agreed to draft the highlight report for the Trust with input from Shaun Stacey and Jim Hayburn.
27 November 2019 – 9.00am-12.30pm – Cedar Room, T&D, DPOW Attendance Record 2019/20
Name Apr 19
May 19
June 19
July 19
Aug 19
Sept 19
Oct 19
Nov 19
Dec 19
Jan 20 Feb 20 March 20
Linda Jackson Tony Bramley Apols Jeff Ramseyer Apols Anne Shaw - Apols - Apols Apols Sandra Hills - - - - - Richard Eley Apols Jim Hayburn Peter Reading Apols Apols Apols Apols - Apols Apols Shaun Stacey Jug Johal Apols Sue Barnett Marcus Hassall Brian Shipley Brian Page - - - Apols TOTAL ATTENDEES 7 6 7 7 7 8 8
REPORT FROM Neil Gammon, Independent Chair of Health Tree Foundation TC
CONTACT OFFICER(S) Kate Wood, Medical Director & Ellie Monkhouse, Chief Nurse
SUBJECT Minutes of the Health Tree Foundation Trustees Committees held on 3 October 2019.
BACKGROUND DOCUMENT (IF ANY) -
PURPOSE OF THE REPORT: For Information
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
Minutes of the Health Tree Foundation Trustees Committee held on 3 October and approved at its meeting held on 16 January 2020.
TRUST BOARD ACTION REQUIRED The Board is asked to note the report
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
MINUTES MEETING: Northern Lincolnshire & Goole NHS Foundation Trust
Health Tree Foundation Trustees’ Committee
Date: 3 October 2019
Present: Neil Gammon Independent Chair Peter Reading Chief Executive Officer Tony Bramley Non-Executive Director Jeff Ramseyer Non-Executive Director (Dialled in) Kate Wood Medical Director Jug Johal Estates and Facilities Director Ellie Monkhouse Chief Nurse Paul Marchant Chief Financial Accountant Victoria Winterton Head of Smile Health Clare Woodard Charity Manager Adrian Beddow Associate Director of Communications In attendance: Katie Hubbert Community Team Champion, DPOW (Item 3) Heather Lamont CCLA Investment Advisor (Item 4) Stacy Pope Safeguarding Liaison Nurse (Item 6.2) Matthew Balerdi Consultant Cardiologist (Item 7.4) Alex Quayle Anaesthetic Consultant (Item 7.5) Harriet Stephens Head of Education, Training and Development (Item 7.5) Clare Robinson Clinical Nurse Specialist (Item 7.6) Yvonne McManus Deputy Head of CT & MRI (Item 7.7) Carol Bond Head of CT & MRI (Item 7.7) Helen Turner Deputy Head of Nursing/Service Lead (Item 7.8) Graham Jaques EPR & Business Continuity Manager (Item 7.9) Simon Dunn Head of OD & Quality Improvement (Item 9) Lauren Short Finance Administration Assistant (for minutes) Item 1 10/19
Apologies for Absence
Apologies for absence were received from Linda Jackson; Sandra Hills; Jim Hayburn and Andy Barber
Item 2 10/19
Declaration of Interests The Chairman asked the members of the Health Tree Foundation Trustees’ Committee for their “Declaration of Interests” – none were raised. Tony Bramley proposed that the committee re-look at the process for approving financial bids. Following a short discussion the Committee agreed a revised protocol for dealing with bids for financial support. The preferred way forward is to consider all bids at a particular meeting before making final decisions on those that would be supported. Such decisions would either be at the end of the meeting – time permitting – or via email follow-up.
Item 3 10/19
Introduction of new Community Team Champion – Katie Hubbert
The Chairman welcomed Katie Hubbert the new Community Team Champion for DPoW who started 5 weeks ago and the Committee introduced themselves.
Victoria Winterton advised that the SGH Community Team Champion had also been appointed and started on the same date as Katie Hubbert but had unfortunately
Health Tree Foundation TC – 03 10 19 Page 1 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
recently resigned due to a change in personal circumstances. This position has been re-advertised with a closing date of 14th October 2019. The Chairman asked what impact that is having on the team and Clare Woodard confirmed she is covering part of the work alongside others within the team. She expressed that this is having a big impact and ideally the position needs to be filled as soon as possible.
9:45 am Ellie Monkhouse and Heather Lamont joined the meeting.
Item 4 10/19
Update from CCLA Investment Advisor – Heather Lamont
The Chair welcomed Heather Lamont, CCLA Director, Client Investments, to the meeting. She handed round a briefing giving details of the performance of the Ethical Investment Fund. Heather Lamont explained that the portfolio was currently valued at £1,813k with an income yield of 3.2%. The long term aim of the portfolio remains to achieve an average annual return of inflation (CPI) plus 5%. The total return for the 12 months to 30th June 2019 was 12.68% against a sector benchmark of 6.98%. 75% of the portfolio is invested in shares and strong performance in the equity selection has been the dominant factor in recent months. The most significant contributors have been healthcare, IT, consumer stocks and financials. Returns from infrastructure and renewable energy holdings have also been strong. Heather explained that global growth is expected to continue in 2019 but is facing a gradual slowdown. The UK outlook is uncertain but the portfolio has a low exposure to UK company shares and those which are held are larger companies with a significant overseas income stream.
10:00 am Peter Reading joined the meeting.
Item 7.4 10/19
Cardiology Electronic Diagnostic Testing
The Chair welcomed Matthew Balerdi, Consultant Cardiologist to the meeting to request funding for a software interface at a cost of £11,546 (VAT Exempt) which allows the WebV system to talk to the Cardio Vascular Information System (CVIS). This would allow complete electronic requesting in cardiology allowing each patient’s diagnostic journey to be logged accurately removing the need for paper requests. The high number and varied nature of diagnostic tests along with manual intervention makes the process difficult to track without automated systems in place. Roughly 10% of requests are lost, delayed or never requested, halting the patient journey before it has even started. Many hundreds of administration hours are put into this process that could be utilised more effectively elsewhere. This software would improve the patient experience by reducing delays and ensuring all tests are requested and tracked. Also, the results can be fed back to the clinicians to action in a timely manner, minimising delays in patients receiving their results and the commencement of any necessary treatment. Tony Bramley felt there is a high impact with low cost to this request and that there are other benefits apart from patient care. Ellie Monkhouse questioned whether there is a concern around patient safety due to the lack of the interface. Matthew Balerdi confirmed that there have been no reported Datix incidents that he is aware of. He further confirmed that no risk assessment has been completed to date. Jug Johal advised that a risk assessment should be completed and this request should be taken to the Digital Strategy Board for their approval.
Health Tree Foundation TC – 03 10 19 Page 2 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Jeff Ramseyer agreed there was a huge cost benefit to the request and would not want to slow it down. The Chair agreed and asked why the Trust would not fund this. Peter Reading shared his support and advised the committee that the Trust had limited capital funding available. He suggested Matthew Balerdi should speak to Jim Hayburn, Interim Director of Finance, with regard to sign off of any revenue savings associated with the scheme. Peter Reading also felt all future systems requests should go via the Digital Strategy Board. The Chair reminded Matthew Balerdi that all decisions will be made after the committee has taken place so that the funding requests can be prioritised.
10:25 am Matthew Balerdi left the meeting.
Item 6.2 10/19
Bereavement Castings
The Chair welcomed Stacy Pope, a SUDIC Nurse (Sudden Unexpected Death in Childhood) to the meeting. Victoria Winterton explained that there had been some issues with the way the bereavement castings are supplied and she had asked the team to review the process. It is then proposed to carry out a tender exercise however, this is challenging due to the limited number of suppliers. Stacy Pope explained that following the loss of a baby, child or young person, they offer the family a memory bear made from their loved ones clothing or a casting of their loved ones hands or feet. She presented a set of flowcharts, which explained how the process works. Ellie Monkhouse fully supported the process and stressed the significance of this for bereaved families. The Chair noted a wording mistake on the Keepsake Castings flowchart and Tony Bramley advised that some of the wording on the unexpected deaths form could be more sensitive. Stacy Pope shared her concerns around the quality of the castings. Unfortunately, there have been occasions when she has used her own money to improve the castings due to their being of a poor standard. The current supplier of the castings is a Trust employee. Ellie Monkhouse felt it would be a good idea to have someone who has received a gift to come to the committee to share their experience. Stacy Pope agreed however, it would have to be time sensitive. Victoria Winterton advised that a tender process would now be put in place.
10:30 am Stacy Pope left the meeting.
Item 9 10/19
Lottery
9.1
July and August 2019 Staff Lottery Minutes The chair queried why the staff lottery minutes come to this committee to be approved as this is not in the Health Tree Foundation Trustee’s Terms of Reference. Simon Dunn confirmed that the minutes have historically come to this committee and that they are not sent to the Trust Board. The July and August 2019 minutes were noted by the committee.
Health Tree Foundation TC – 03 10 19 Page 3 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________ 9.2
Staff Lottery Annual Report Simon Dunn presented the 2018/19 Staff Lottery Annual Report for approval by the Committee and confirmed it will then be sent to the Trust board for information. Tony Bramley raised a question around the audit arrangements for the staff lottery and advised that he would discuss this at his next meeting with Sally Stevenson. Simon Dunn confirmed that the lottery money is separately identified within the Finance department and Sheldon Mill is the lottery accountant. Peter Reading commented that he has previously met with Richard Eley and Simon Dunn to discuss the role of the lottery committee. The current lottery committee policy is that only lottery members can benefit from lottery funds and it would be helpful to re-visit this. Kate Wood supported Peter Reading’s concerns. The Chair informed the committee of previous discussions led by Andy Barber for a People’s Lottery (not just for staff). Jug Johal suggested that Alastair Brooks (Commercial Services Director) should be included in any future discussions. Victoria Winterton commented that we need to decide whether to widen the current lottery membership to the public or to set-up a separate lottery. The Chair requested that a proposal be put to the Trustee’s Committee outlining the options and suggested that SMILE and Alastair Brooks work together on this. Action: Andy Barber/Victoria Winterton Simon Dunn advised that Claire Low is recorded as the legal sponsor with the Local Authority.
Item 11 10/19
Finance Updates
11.1 Finance Report August 2019 Paul Marchant presented the finance report and highlighted income of £377k which was £146 higher than the plan of £331k. The income figure includes legacy income of £164k. Expenditure for the first five months of the year of £422k is £27k less than the plan of £449k. This represented a total net increase in funds for the year of £63k against a planned decrease of £118k. Fund balances after commitments of £975k are £1,046k
11.2
Draft 18/19 Annual Report & Accounts Paul Marchant presented the draft 18/19 Annual Report & Accounts, explaining that these were subject to final sign off by the auditors PWC, but that no changes were expected. The committee were asked to note the draft Annual Report & Accounts and Letter of Representation and delegate authority to approve and therefore sign the accounts to Peter Reading and Neil Gammon, which was agreed. Paul Marchant also agreed to liaise with Sally Stevenson to ensure the accounts are taken to the Audit, Risk and Governance Committee.
Following review the minutes of the meeting held on 1 August 2019 were agreed as an accurate record.
Item 6.1 10/19
Rheumatology Fund
Dr Gillott has spoken with his team and they are looking to purchase a portable ultrasound machine.
Item 6.3 10/19
Laparoscopic Surgical Equipment (Rear into Gear)
Victoria Winterton confirmed that they were still waiting information from the clinicians to justify the cost of the higher priced equipment, which is £92k more. There is also the possibility that there may be a discount from the supplier but this is to be confirmed. Kate Wood expressed her frustration regarding this equipment not progressing and agreed to set up a meeting with the core people involved to get things moving. Action: Kate Wood
Item 6.4 10/19
Integrated Cardiac Unit Project Update
Clare Woodard confirmed that work started on Monday on the C1/C2 Approach Corridor and will take up to 4 weeks to be completed. Clare has met with Adrian Beddow to scope out plans for a publicity release. Ellie Monkhouse felt it wasn’t appropriate for the public to be walking around the ward now it was operational and suggested a meeting with Victoria Winterton, Clare Woodard and Adrian Beddow to discuss other options. Adrian Beddow felt the story would be enhanced if we could obtain further details of the donor. He also felt it would be better to wait until after an election/Brexit decision. The Committee members agreed that the Trust needs to celebrate this legacy. The Chair advised to highlight this to the executives via the Committee Highlight Report to the Trust Board. Action: Ellie Monkhouse and Clare Woodard
Item 8.2 10/19
Appeals Proposals
Clare Woodard explained that an appeal provides a good focus for fundraising and gave details of suggested appeals to be considered by the Committee:
• The Little Lives Appeal • End of Life Rooms Appeal • Dementia Friendly Wards Appeal • Goole Dementia Garden Appeal
The Chair asked committee members for their views on which appeal/appeals would be the best one(s) to focus on. Tony Bramley asked how many appeals can be run at any one time. Victoria Winterton confirmed that two appeals could run at once but if all appeals were supported by trustees the launch of them could be staggered and she would look for a steer in terms of priorities for appeals. Kate Wood thought that they are all worthy appeals but felt most strongly for the
Health Tree Foundation TC – 03 10 19 Page 5 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Dementia Friendly Wards as this would have a large impact. Further, she felt that the End of Life Rooms appeal needing more working up. Jeff Ramseyer asked for the views of the HTF team and Victoria Winterton believed that Dementia Friendly Wards would be strong and that it would also be good to have a focus on Goole. The Chair favoured the Dementia Friendly Wards appeal and the Goole Dementia Garden appeal but wondered if they could be wrapped into one appeal. Ellie Monkhouse was not a supporter of The Little Lives appeal as she felt the Trust has one of the best children’s wards available and that dementia is not visible enough within the Trust which has been a strong theme in previous surveys. Ellie felt the Goole Dementia Garden appeal would not benefit a huge number of patients. Peter Reading was of the view that Goole has been neglected by the Trust for some time now and that the garden would be of benefit to the community as a whole. Jug Johal agreed. The Chair summarised the views of the meeting and it was agreed the two clear winners were; Dementia Friendly Wards appeal and the Goole Dementia Garden appeal. The Health Tree Team would move forward with this decision.
Item 7.5 10/19
Mannequin – Obstetrics & Paediatrics
The Chair welcomed Dr Quayle and Harriet Stephens to the meeting to request funding of up to £106k for two mannequin simulation packages. Dr Qualye explained that since simulation training began at the Trust in 2015 over 2,400 training episodes have been delivered and there has been an excellent level of engagement. The Trust currently has an adult male and a baby mannequin. This request is to fund an advanced birthing mannequin and a 5 year old paediatric mannequin, both of which are portable to be used across the Trust sites. The purchase of these patient simulators would allow the Trust to take simulation training to a much higher level. Clinical simulation with realistic mannequins allows the staff to practice clinical scenarios in a safe environment. Investing in these high quality mannequins would provide a training service that would appeal to external specialty staff, potentially resulting in heightened levels of recruitment and retention of staff. The level of training provided for staff through these mannequins would increase staff confidence and competence when treating and caring for complex patients. Dr Quayle explained that the current mannequins are very basic and detract from the realism of clinical simulation and skills training. Good fidelity is crucial to making the learners perform in a natural and true life manner, contributing to a better and safer patient journey through the healthcare system. Training sessions are held almost daily and are fully audited. Dr Quayle explained trials have been conducted with mannequins from two suppliers. Jug Johal asked about the life span of the current mannequins which was confirmed as 10 years. He then questioned why an extended warranty should be purchased if the current mannequins had limited problems but acknowledged that the new mannequins are more technically advanced. Jeff Ramseyer asked what the life span on these new mannequins were. This was unknown since the equipment was more technical and their relative novelty meant that insufficient data was currently available. Dr Quayle highlighted that two members within the team will be fully trained to support with any technical problems which may occur as well as having the support of the warranty.
Health Tree Foundation TC – 03 10 19 Page 6 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________ 11:45 am Jug Johal left the meeting.
Tony Bramley, Jug Johal and Peter Reading were in support of this with Kate Wood
agreeing this is charitable. Victoria Winterton commented that no funds are aligned to this request and advised that on-going costs would not be funded by HTF. She also asked about the replacement of the older mannequins and questioned if they would be coming back to trustees’ committee to request they be replaced.
11:50 am Peter Reading left the meeting.
Item 6.5 10/19
Handyperson Review
The chair informed the committee that Linda Jackson’s review of the effectiveness of the handyperson would be incorporated within the review of the “Sparkle” programme. This item will be included on the agenda for the next meeting.
Item 6.6 10/19
Outpatients Toilets
Further information is still outstanding on this proposal. The Chair deferred this item to the next meeting.
Item 7.6 10/19
Fibroscan Machine
The Chair welcomed Clare Robinson to the meeting to request funding of £82k (excl. VAT) for the purchase of a Fibroscan machine. This machine will be used for scanning the liver of Hepatitis C patients and for other liver diseases across the Trust. The Trust currently borrow a machine one week a month from Hull University Teaching Hospitals NHS Trust. This does not allow for any expansion of the service and restricts the number of patients that can be seen. The need for a Fibroscan machine has been placed on the Trust risk register as an identified need. Patients require a scan before commencing treatment and this can prove difficult within the current one-week time frame. A number of patients are vulnerable, living chaotic lifestyles and sticking to appointments is very challenging. The purchase of a machine by the Trust will enable further service flexibility and opportunity to scan patients more frequently; reducing delays in treatment and help towards achieving the strategy to eliminate Hepatitis C. Tony Bramley questioned the sense that Trust ‘’borrow’’ a machine every month given that it seems to be an ongoing requirement for the service. Clare Robinson advised that a business case had been produced but had gone no further. Kate Wood offered to help Clare Robinson progress the purchase of the Fibroscan machine through Trust resources in the first instance. It was also recommend that the requirement should be taken to the Medical Equipment Group for consideration. Action: Kate Wood
12:05 pm Kate Wood left the meeting.
Item 7.7 10/19
In-Bore Ambient Experience for MRI
The Chair welcomed Yvonne McManus and Carol Bond to the meeting to request funding of £55k (excl. VAT) for an in-bore ambient experience for MRI.
Health Tree Foundation TC – 03 10 19 Page 7 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
The Trust is planning a purpose built MRI unit to house two MRI scanners at DPoW. As part of the project it is felt it would be beneficial to patients if one of the scanners could be installed with a patient ambient experience. At the moment all patients hear during a scan is a dreadful noise, which is not helpful for patients who are nervous and claustrophobic and can result in aborted scans. Over the last 3 years a total of 400 patients have required a general anaesthetic because of earlier aborted scans. The in-bore experience allows patients to view a screen on the end wall of the MRI scanner with pictures and various colours of lighting for the room, which can be chosen by the patient. This unique experience takes MRI scanning to another level by providing information and guidance to the patient during scanning as well as information about the scan progress. This would reduce patient’s anxiety, improve patient throughput and comfort which would result in a reduction in abandoned scans, sedation and general anaesthetic. Phillips is the only supplier who offers this piece of equipment. Ellie Monkhouse expressed how scary the process is through patients’ eyes and felt this piece of equipment would change how patients view an MRI scan for the better. The committee felt that there would be a huge cost and efficiency benefit from this and discussed the possibility of taking the proposal to the Medical Equipment Group for funding. However, due to other capital projects if was felt this would not be of sufficiently high priority to be approved. Carol Bond explained that work is commencing on the scanner project in December/January and the in-bore experience needs to be included as part of this. Victoria Winterton and Clare Woodard thought this would be a great fundraising opportunity and would be something the Sea View Street Cancer Shop would possibly support. Following a further discussion the committee approved the funding request and it was agreed to set-up an appeal in support of this.
Item 7.8 10/19
Implementation of RESPECT across NLAG
The Chair welcomed Helen Turner to the meeting to request funding for a fixed term Band 7 nurse level post for 2 years at a total cost of £97k. She advised that within the region at the Humber Coast and Vale STP level there is a commitment and drive for the RESPECT document to be used across its footprint. The RESPECT process creates individual recommendations for a person’s clinical care in a future emergency situation in which they are unable to make or express choices. Currently neighbouring localities have started to use the document or are planning to in the near future. With this in mind, Helen proposed funding for a two year, full time, fixed term position at a band 7 nurse level to act as a project lead and educator to lead the role out of the RESPECT document and process within acute and community setting across North and North East Lincolnshire. Ellie Monkhouse fully supported the proposal. Tony Bramley felt this is something the Trust should fund. Victoria Winterton explained that 2 years ago HTF had supported a similar End of Life post. It was agreed at the time that this post should have Health Tree Foundation in the name but this was never done. Action: The Chair
Health Tree Foundation TC – 03 10 19 Page 8 of 10
Northern Lincolnshire & Goole NHS Foundation Trust ________________________________________________________________________________________________
Item 7.9 10/19
AAU (Acute Assessment Unit) Request
The Chair welcomed Graham Jaques to the committee and explained that committee members had limited time to review the paper which they only received the previous day. Graham explained that last month the Trust were successful in a bid to NHSE/I for £1m to spend on elements to improve the Trust’s 4 hour A&E waiting time with a projected completion date of 14th December 2019. The Trust is working on a proposal to remodel some of the wards into an acute assessment unit. This is where patients are seen by a multi-disciplinary team of medical, nursing, therapy and pharmacy staff within reach of other services such as social services and mental health. The team would assess patients in one place and reduce overcrowding and allow the A&E team to deal with the sickest patients. The committee are asked to support the request for £200,000 to enable the estates work to be undertaken within a more realistic timeframe therefore ensuring all avenues are explored and it is fit for purpose. The Chair advised that more details from Claire Hansen were required along with some answers to further questions. Overall, the committee felt that this bid required significant further development. The Chair, with the Committee’s agreement, took the decision to defer this item to the next meeting.
Item 6.7 10/19
HTF Terms of Reference
Item deferred to the next committee meeting.
Item 6.8 10/19
Lobby Check In Desk System
Item deferred to the next committee meeting.
Item 6.9 10/19
Core Equipment Purchased by HTF
Item deferred to the next committee meeting.
Item 7.1 10/19
Smile Contract
Item deferred to the next committee meeting.
Item 7.2 10/19
Marketing Strategy
Item deferred to the next committee meeting.
Item 7.3 10/19
October 2018 Development Session Action Plan
Item deferred to the next committee meeting.
Item 8.3 10/19
Pressure Mapping
Item to be reviewed at the next agenda set meeting.
Item 8.4 10/19
Low Level Beds
Item to be reviewed at the next agenda set meeting.
Thursday, 28 November 2019 – West Arch Boardroom, DPOW – 9.00am-12.00pm Attendance Record: Name April 2019 June 2019 August 2019 October 2019 Nov 2019 January 2020 Anne Shaw Apols Apols Neil Gammon Linda Jackson Apols Apols Apols Tony Bramley Sandra Hills Apols Apols Nick Mapstone Jeff Ramseyer Peter Reading Apols Jim Hayburn Apols Richard Eley Marcus Hassall Jug Johal Apols Kate Wood Apols Ellie Monkhouse Apols Apols Paul Marchant Andy Barber Apols Victoria Winterton Apols Clare Woodard Simon Dunn - Apols Apols Adrian Beddow Total 11 12 13 12
Health Tree Foundation TC – 03 10 19 Page 10 of 10
NLG(20)039
DATE OF MEETING 04 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM
Jeff Ramseyer, Non-Executive Director and Chair of the Workforce Committee
CONTACT OFFICER
Jeff Ramseyer, Non-Executive Director and Chair of the Workforce Committee
SUBJECT Workforce Committee Minutes – October 2019
BACKGROUND DOCUMENT (IF ANY) N/A
PURPOSE OF THE REPORT: For information
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
Minutes of the Workforce Committee meetings held on Tuesday 29 October 2019, approved at the meeting on Tuesday 26 November 2019
TRUST BOARD ACTION REQUIRED
The Board is asked to receive and note the Workforce Committee minutes from meeting held on 29 October 2019 for information
1 | P a g e
WORKFORCE COMMITTEE
PUBLIC MINUTES
Meeting held on Tuesday 29 October 2019 at 2pm in the West Arch Boardroom, DPOWH Present: Jeff Ramseyer Non-Executive Director (Chair) Lee Brown Interim Deputy Director of People & Organisational Effectiveness Sandra Hills Non-Executive Director Linda Jackson Acting Trust Chair Claire Low Interim Director of People & Organisational Effectiveness Kate Wood Medical Director
In Attendance: Elaine Coghill Deputy Chief Nurse (deputising for Ellie Monkhouse) Claire Hansen Deputy Director of Operations (deputising for Shaun Stacey) Rachel Maguire Head of People Development, People & Organisational Effectiveness
(items 8.2 and 8.3) Lesley Mosley HR Business Partner (for agenda item 7.1) Wendy Stokes Executive Personal Assistant to Director of People & Organisational
Effectiveness (taking minutes) 1 Apologies for absence: Ellie Monkhouse, Peter Reading and Shaun Stacey 2 Declaration of Interest: The Chair invited members to bring to the attention of the committee any conflicts of interest relating to specific agenda items. There were no declarations of interest. 3 Minutes of the previous meeting held on Tuesday 30 July 2019: It was agreed that the minutes from the previous meeting held on 30 July 2019 were agreed and accepted as a true and accurate record. 4 Matters arising from the previous minutes: There were no matters arising from the previous minutes.
5 Review of Action Log: Action 20 – Combine the three People and OE strategies into a single draft strategy Draft strategy to be presented at the January 2020 meeting.
2 | P a g e
Action 24 – STP Local Workforce Action Plan – briefing paper to update the committee Action completed and it was agreed to remove this item from the action log. Action 25 – Deloittes Review – update Committee on the Review Report To be discussed under item 6 on the agenda. It was agreed to remove this item from the action log. Action 30 – Report on consultations document – adjust the dropdowns, include financial information and complete the red rag ratings Lee Brown is currently reviewing the report on consultations and combining this with the casework review. It was agreed to remove this item from the action log. Action 36 –Addendum to change management policy Claire Low and Karl Portz are working together to look at the quality of content of the quality impact assessments. It was agreed to add Karl Portz name to the action log and defer this item to the November meeting. Action 41 – ACP Report from Elaine Coghill – circulate to Workforce Committee Elaine Coghill reported that an updated paper on ACPs is going to be presented at TMB. There is an ACP working group and an ACP steering group to oversee the operational part of the project. There are some issues still to be resolved and agreements to be made around supervision and credentials. In the longer term, when NLAG has got qualified ACPs does it still want to continue to have ACP trainees. It was agreed that it would be useful for the paper presented at TMB to come to the November Workforce meeting. It was agreed to update the action log accordingly and to put Ellie Monkhouse down to update the committee. Actions 42 - Summer holidays - sickness, bank, agency and incident reporting This action was to reassure the committee that NLAG had the right amount of staff on site in the summer holidays. The Trust regularly plans for bank holidays but does not plan for summer holidays. Claire Hansen felt that the action states for all staff, and she wouldn’t have that information for all staff. Sandra Hills explained that when this was discussed at the last meeting the discussion expanded to cover all staff. The Chair reported that medicine is at less than 60% including annual leave and sickness. Claire Hansen added that all divisions come together to look at EPR ratings and plot any surges. Sandra Hills reported that other places have more robust processes, and she asked what is NLAGs approach and can this committee be assured it is applied properly. Kate Wood’s recollection was that the annual leave policy is very clear for medical doctors and is easy to read. The problem is that it is not followed. It was rewritten in 2018 and clearly states that directorates need to take the responsibility for this. Kate Wood added that at the Operations Management Group (OMG) meeting it was very clear that directorates do not read policies. Kate Wood cannot give assurance, although this has been discussed at OMG and directorates have been reminded it is their responsibility. It is about making sure annual leave is apportioned properly across the whole organisation. Sandra Hills felt that it is one thing to have a policy and another to implement the policy as envisaged. Kate Wood added that this went to TMB two months ago for re-discussion. Lee Brown suggested building the rules into e-Roster as all staff are on the e-Roster system and this would be an easier way of monitoring this. Kate Wood added that the policy for medical staff does not mention e-Roster, it only states on appropriate forms which may be paper or electronic. Rachel Maguire highlighted that a number of policies are being amended to include electronic forms going forward. It was agreed to keep this item on the action log for a further update on what is happening to be given in January 2020. Claire Hansen explained that there is a template that is used to detail who is around at key points throughout the year. There is a process in place and this is signed off but you cannot mitigate for sickness at short notice. It was questioned how many extra staff were needed for New Year ’s Eve. Linda Jackson highlighted that this action was from the June 2019 meeting and she asked was this summer better covered than in previous years. Claire Hansen replied that there were no issues out of
3 | P a g e
hours in medicine and some numbers were off in theatres around utilisation of theatre use. Kate Wood felt it was slightly better with a better fill rate from the Deanery. In 2017 the fill rate was at 67% and it is now at 87% therefore, the impact has not been as hard. Sandra Hills reiterated that for the NEDs it is about being assured. We may not be perfect, but we must have done all that we can to have appropriate levels of staff throughout the year and as an employer we do what we can to support staff to attend work. Claire Hansen added that Graham Jaques could show the committee what operations use for assurance. The Chair added it is about control, being fair and balanced with the annual leave policy and that is a difficult conversation. We want assurance that this is happening and the outcomes are what we want. It was agreed to keep the action open on the action log and to come back in January to see how preparations are progressing for the spring. Tony Bramley added that the costs do go up in the summer and they are not explained. Kate Wood felt that until we go fully onto e-roster it is not easy to get that information. From a medical perspective we cover emergency cover, you are talking about costs going up, and she asked is that for emergency cover or to cover elective things. Linda Jackson stated that the issue has always been around short term sickness and the question is; is NLAG doing the right thing and all it can do, from a nursing point of view. Rachel Maguire added that going forward as part of ESR development they have built an ESR interface through data warehousing that will correlate on a dashboard, so all the information will be in one place, and we are six months off that happening. This facility will only cost £100 per year. It was agreed to invite Graham Jaques to the January 2020 meeting to talk about what happened prior to Xmas. Action: Wendy Stokes Action 43 – Summer holidays – financial figures Discussed under action log item 42 and it was agreed to remove this item from the action log. Action 44 – Summer holidays – Crèche left site, look at figures to see the differences The committee talked about whether there was a difference and Sandra Hills asked can the trust do any more. It was suggested that this could be discussed as part of the greater reward package that Simon Dunn is leading on. It was agreed to remove this item from the action log. Action 48 – Clinical support services – identify sickness themes A written update had been provided. It was highlighted that identifying sickness themes in general is changing and the Trust needs to look more closely at ESR to see if the categories could be split. Claire Low agreed to update on this generally at the November 2019 meeting as part of the ‘Sickness Review Benchmarks’ item. It was agreed to remove this item form the action log. Action 49 – PADR and mandatory training compliance targets The PADR and mandatory training compliance targets have been changed. It was agreed to remove this item form the action log. Action 50 – To ensure job planning for therapists is focused on outcome of patients A written update had been provided. It was agreed to remove this item from the action log. Action 51 – Sickness Review Benchmarks – bring revised document back to the next meeting To be discussed as part of the agenda. It was agreed to remove this item from the action log. Action 52 – Policies/procedures for ratification – amendments to be shown clearly via track changes To be discussed as part of the agenda. It was agreed to remove this item from the action log.
4 | P a g e
Action 53 – Recruitment and Selection Policy – speak to Graig Ferris regarding training to identify vulnerable people It was confirmed that the recruitment and selection policy had been amended as discussed at the last meeting held on 30 July 2019. The committee had previously approved the policy at the July meeting once amendments had been made. It was agreed to remove this item from the action log. Action 54 – Recruitment and Selection Procedure – to amend with comments from Sandra Hills and Anne Shaw It was confirmed that the recruitment and selection procedure had been amended as discussed at the last meeting held on 30 July 2019. The committee had previously approved the policy at the July meeting once amendments had been made. It was agreed to remove this item from the action log. Action 55 – Recruitment and Selection Procedure – medical director and chief nurse to be added as responsible officers It was confirmed that the procedure had been amended as discussed at the last meeting held on 30 July 2019. The committee had previously approved the policy at the July meeting once amendments had been made. It was agreed to remove this item from the action log. Elaine Coghill reported that a draft nurse recruitment and retention strategy had been written and this will go to the Nursing and Midwifery Board for approval. It was agreed to bring the strategy back to this committee for assurance not approval. Action 56 – Staff Survey Results – discuss redoing the morale barometer The trust is currently in the process of doing the live 2019 staff survey. NLAG has a return rate of 21% with the average of acute trusts being at 27%. The committee asked for all present to encourage their staff to complete the survey. Claire Low had spoken with Simon Dunn and the morale barometer will need further consideration going forward when results of the active staff survey are known. It was agreed to remove this item from the action log. Action 57 – Staff Survey Results – discuss a division attending a committee meeting to discuss their action plan Sandra Hills asked if the committee could have an update on what has already been implemented. It was confirmed that this is discussed as part of the PRIMs meetings as confirmation is needed of what has been implemented. HRBPs are leading this piece of work and it was suggested that they could give an engagement update as part of their dashboard update to this committee. It was agreed to remove this item from the action log. Action 58 – DBS Policy – to look for a legal view It was questioned whether the DBS policy is watertight from an enforceability point of view. It was confirmed that as a trust we are not subscribing staff to the live data base system. New members of staff will pay the cost of the DBS and if staff move to another role in the trust, the trust will pay the cost. It was agreed to remove this action from the action log. Action 59 – BAF (Workforce) Update – page 22 no risk assigned Claire Low reported that she had not had the opportunity to speak to Jeremey Daws. It was agreed to defer this tem to the November meeting. Action 60 – Monthly staffing report – 11.3 w.t.e. vacancies in estates and facilities The restructure to be discussed under agenda item 7.1 and it was agreed to remove this item from the action log. Action 61 - Policy on use of CCTV
There had been some debate regarding this at ARG. They raised the issue of the trust having to be
5 | P a g e
registered in a certain way before it could allow CCTV footage to be used. This was questioned from an HR perspective whether we should be able to do that. Sandra Hills had sat on an appeal panel and it was noted that the policy stated CCTV footage cannot be used against staff in disciplinary cases. Kate Wood added there was no CCTV facility in clinical areas only in corridors, car parks and waiting areas in A&E. She questioned if there was some merit in revisiting the policy and was thinking about the child who deteriorated in the waiting area in A&E and whether they would have been able to use for CCTV footage for anything. It was highlighted that the police could request CCTV footage but the trust could not. Lee Brown stated that as a witness anyone can record on a mobile phone and use that as evidence. The Chair questioned if there was a CCTV footage policy. It was agreed to discuss this further at the November meeting and to review the Internal and External Surveillance Systems Policy and the Disciplinary Policy and Procedure.
6 General update on the Directorate of POE: With regard to the Deloittes review Peter Reading, Jayne Adamson and Claire Low have met and agreed a milestone plan and pod. 1:1s are being booked in with senior members of POE and each senior member of the team has a copy of the Deloittes report. 7 Invited attendance:
7.1 Update on Estates and Facilities dashboard from HR Business Partner
The dashboard uploaded to SharePoint was presented to the Estates & Facilities PRIMs meeting on 24 October 2019. Lesley Mosley had been asked to create an overview slide which is slide 2 in the presentation.
The NHS Staff Survey Response rates are increasing and paper versions are also being used to try and get more staff to participate.
The vacancy rate is well above target and this is due to the band 2 to band 5 restructure being completed. The recruitment team is promoting the current vacancies because there is a lack of understanding of the role. They have joined LinkedIn at the football stadium to promote the role and are hopeful that vacancies should be on track by the end of this week.
There is a month on month vacancy rate at SGH because they tend to bring in porters and support assistants on the bank to test them first as there have been some behavioural issues and high sickness rates in the past. Lesley Mosley is trying to encourage E&F to move to values recruitment rather than using the traditional route. They can do an internal transfer panel if going through the bank and there will be no lag in transfer time. Perhaps they could do one run every quarter.
Band 1 to band 2 progressions is moving forward with dates being set and this will shortly start to be delivered.
There is an issue around the quality of PADRs. There are several boxes of them to be put into personal folders and the same types of things are being seen. If people have other skills the trust needs to tap into them. A PADR audit was going to be undertaken but that has not been possible at the moment. All were keen for that to go ahead and a systematic approach may be beneficial. If the quality of PADRs is not good in silos then it is a quality assurance process. Claire Low added that Harriet Stephens and Rachel Maguire are looking at PADRs for bank staff and this will become much easier with manager self-service and should be more meaningful. Mandatory training is positive and E&F are trying to push on that to stay on target and maintain a rate of 95%.
Sickness rates are slightly higher than the corporate target. Figures are being drilled down to
6 | P a g e
zones and where compliance is high they are mapping the reasons month on month and supporting staff. Two case reviews are held each month and fifteen long term sickness cases are going to review. Three individuals were saying that they were going to commit suicide. Lesley Mosley is a mental health trainer and she recently attended an event with line managers to go through the signs and symptoms of mental health and to make sure that they are also looking at their own mental health. Lesley Mosley may be starting to spend more time in Goole for the HRBP sessions on health and wellbeing in general and trust policies. Kate Wood asked if it was higher banded staff and Lesley replied that she is tracking individual teams to see if there is a pattern. The introduction of manager self-service will also help with this.
The Chair asked with regard to culture do band 1 and band 2 porters work central to one manager. Lesley replied that all porters report to Karl Cliff and his deputy is Alison McCulley. The chair asked how Lesley was working with them to change the culture. Lesley replied that she is trying to encourage them all to do Pride and Respect (P&R) training. Yesterday seven HSAs attended P&R training and they all said that they were told they had to attend. At the end of training all of them agreed it was beneficial and Lesley asked them to encourage others to attend. The chair highlighted that culture comes from manager and the leadership. It is about tightening up the recruitment process, looking at the leadership strategy and mandatory training. The Chair suggested perhaps highlighting this to Jug Johal. Sandra Hills felt that we needed to understand the base line of what happens with leadership training. Claire Low reported that they had previously tried to recruit champions in facilities and perhaps they need to try to do that again.
The Chair asked with regard to the E&F hiring strategy of using bank staff is the cost of that understood. Lesley Mosley replied that bank staff are paid the normal rate and there is no difference.
Linda Jackson asked about engineering vacancies. Lesley Mosley replied that at the LinkedIn event everyone thought that NLAG were there to recruit nurses not engineers. The recruitment teams have been asked to tap into external events and to also try and tap into women into engineering events. Lesley added that recruitment needs to be thought about in a different way and they need to look at staff both stepping up and stepping down.
8 Items for discussion:
8.1 Sickness Review Benchmarks The paper circulated shows regional information and where NLAG sits with its peers. NLAG is in the middle range and not an outlier. Sandra Hills asked about NLAGs peers. Claire Low replied that York and Hull are doing slightly better than NLAG and there may be something we can do through the STP route. Claire Low added that with the help of Lee Brown they can start to do some deep dives into sickness. 8.2 Briefing on Pre-approval Process Rachel Maguire reported there was a workforce planning support group. The Chair asked if this was the resource centre project. Rachel Maguire replied no but they do have a huge impact on each other. Rachel Maguire has met with Ashy Shanker on two occasions to see how they will manage this, particularly the medical hierarchy. Decisions need to be made around rota co-ordinators and who is going to manage the doctors system. This may need a change in the rota co-ordinator job description and a review in what they do. Rachel Maguire added that Jane Heaton is on the group to represent the medical directorate and she will feed back to Kate Wood. Kate Wood asked Rachel Maguire to remind Jane Heaton to make sure she gets feedback. There is an issue with where medical staff sit in the ESR system. It is also about PADRs and mandatory training and who is involved in their change processes. Claire Hansen stated this would be the same for any line manager. Rachel Maguire added in manager self-service URP is
7 | P a g e
the administrator and you have supervisors. In the bank office band 2 staff are the supervisors and we are testing this model for rota coordinators to manage medical staff in the same way Linda Jackson asked if this replaces the establishment control group. Rachel Maguire replied that the new workforce group will report into here, this is for assurance only and it is not managerially responsible for people. The workforce group will take operational reports to PRIMS and Rachel Maguire questioned where the workforce planning support group should report. It was agreed that the Chair, Claire Low and Rachel Maguire have a conversation outside of this group. Action: Jeff Ramseyer, Claire Low and Rachel Maguire 8.3 Update on ESR Manager Self Service Project Rachel Maguire reported that the project was started in April this year and NLAG is leading in the region with the progress it has made. On line pay slips have been implemented and factual referencing has commenced Trust wide for all staff. An inter authority transfer system is being implemented to aid recruitment for staff between trusts and accept mandatory training service and references etc. NLAG is leading the region on streamlining of mandatory training to enable that to happen. Part of the employment journey from ESR is the applicant dashboard before people come to work at the trust. They will be able to see the progress of their employment journey, to do their corporate induction prior to starting work with the trust and see the progress against their DBS check. This is just waiting for Peter Reading to do a welcome video to be part of the process. The trust has gone live with employee self-service for changing personal data and stopping forms being lost in the post. This has attracted extra support from the ESR central team and we have identified a large amount of data issues. We are starting to cleanse data and realigning processes to core process systems. We have developed and set up a portal and dashboard to make the system more user friendly. We are starting an interface around data housing to triangulate data with much more operational data. Managers will have the responsibility to hire and fire staff. A pilot has started for manager self-service in the POE directorate and finance. Rachel Maguire met with Elaine Coghill to confirm naming conventions in ESR. We have identified a data breach with applicants’ data that we shouldn’t have been holding. Susan Meakin, Data Protection Officer and Lead for Information Governance took advice from the Information Commissioners’ Office (ICO) and completed a matrix from NHSD and has followed the advice and instructions given. Rachel Maguire will update on progress. From 2008 we have had 30,000 applicants and we have now cleansed a large number of them and are down to 8,000. Sandra Hills asked if this would give a cash releasing saving and in terms of benefits realisation, what is the plan and can we be assured that staff are coping with that. Rachel Maguire confirmed that the business case has been signed off at TMB based on over payment of wages and reducing that. Getting details of any overpayments made will not be solved moving from a paper system to electronic. Sandra Hills then went on to ask how we will know the ambition has been achieved. Rachel Maguire replied that there are ten overarching KPIs, both financial and quality coming out of culture change, it is about managing staff, data and the workforce. This will empower managers to manage and Rachel Maguire went on offered to share the project plan and KPIs with the committee. The Chair asked for the project plan and KPIs to be added to the next agenda as an item for information. Action: Wendy Stokes Claire Low and Rachel Maguire met with the regional link person and she was very complimentary about the NLAG team. The project end date is April 2021. ESR do a self-assessment each year and are doing this in November with the results going to TMB in January to show the differences and benefits of that. One benefit is that every member of staff has an e-mail address, for the first time ever. It was agreed that Rachel Maguire would come back to the committee in March 2020
8 | P a g e
to give a further update. Action: Wendy Stokes
8.4 Baroness Harding Guidance Letter – Implications for the Trust Claire Low reported that the letter is outlining a particular case of a person who went on to commit suicide. We are taking this forward and doing a deep dive on all exclusions. This is on the agenda for Trust Board, to give them an oversight and to discuss what we are doing as a trust and from an HR perspective. This is work in progress and as a trust we are taking this very seriously. We are making a recommendation that exclusions should only be made with consent from an appropriate director as they come at a high cost and have a massive impact on the organisation. Linda Jackson added it is about how the Trust Board gets that data and how this committee is assured of the steps that it needs to take are taken and risk assessed. Claire Low and Lee Brown are looking at the blockages in the casework summary and unpicking them. Claire Hansen stated that the letter alludes to the disciplinary investigation process. Claire Low felt that firstly we need to look at exclusions and then the policy. The trust needs to do the right thing for its staff and a proper risk assessment needs to be undertaken. Lee Brown has started to look at exclusions. Linda Jackson stated that the grievance process can take so long when applying the policy. Claire Low added if timescales are not realistic the policy needs to change. Casework is discussed as a standing agenda item under the HR item. Linda Jackson added that main stream AfC workforce, doctors and very senior executives need to look at each group. It was agreed to add this to the Casework Summary Report. Action: Claire Low
8.5 NHS People Plan – Considerations for the Trust This has been reviewed and will be out for issue in December. This has an impact on a number of policies especially the leadership strategy. Jayne Adamson and Harriet Stephens are working on some engagement groups and feedback from senior colleagues. Peter Reading has agreed to delay ratification of the strategy to incorporate the people plan into that. Kate Wood asked when the leadership strategy will be ready. Claire Low replied this had gone to the executives and the next wave is to take that out for engagement with senior managers in the Senior Leadership Community to see what that looks like. Kate Wood stressed the need for this as it has slowed a lot of things down. Claire Low added this could potentially be a complete re-write of the leadership strategy. 8.6 Humber Acute Services Review Claire Low reported this is work in progress and that Sue Barnett is leading on what the workforce and establishment will look like. This will come back to the committee when the five year plan has been approved. 8.7 Workforce Committee – Draft Work Plan Claire Low asked if the draft work plan could be brought back to the November 2019 meeting with the Terms of Reference as Wendy Booth is currently renewing the executive Terms of Reference. Linda Jackson stated that particularly with CQC the trust keeps getting asked how it gets assurance on key risks and how that is taken to the Board. The key risks are not going to the assurance groups. It is about assurance not management and key risks must be assured all the way through to the Board. This is something that we want to do over the next few months. 8.8 Workforce Committee – Membership and Terms of Reference (DCT093) Discussed above under agenda item 8.7 and deferred to the November 2019 meeting
9 Items for ratification and assurance:
9.1 Policies 9.1.1 Travel and Subsistence Policy
9 | P a g e
This policy is for ratification with a caveat. Harriet Stephens highlighted the need to be very clear what is classed as ‘trust business’ when it comes to doing a MBA as an apprentice. Harriet Stephens would like to put clarification into the policy so it is very clear subsistence is not available for travel if studying as an apprentice. Claire Low suggested adding that information, doing a track change and resending the policy. This has been discussed at TMB and there was also debate when the apprentice levy came in. It was agreed the trust would not support this as apprentices had the levy and were told they could not claim expenses. Elaine Coghill added that more issues are being raised and there are mixed messages in the organisation. Sandra Hills asked if the policy is a revision and is it necessary to have two paragraphs about fraud in bold text. The travel grievance had been solved and the trust has reverted back to national AfC terms and conditions. The fraud element was mandated by our finance department. The Chair confirmed that the committee is happy to approve the travel and subsistence policy with the bold text changed to normal text for the two paragraphs relating to fraud. The committee also agreed that the study leave policy does need some challenge.
10 HR:
10.1 Escalation of overdue policies/procedures Claire Low highlighted this is an issue and Lee Brown is in the process of tracking which policies/procedures are in date and reviewing the whole process. This is a massive piece of work and is rated as a red risk. Linda Jackson asked how many overdue policies there are and if it is only titles could these be amended for a fast win. Lee Brown replied that he is working through that at the moment and trying to prioritise those that are urgent and he will prepare a schedule to prevent this happening again. We also need to look at how policies are approved, and if taken as read we need to ask does anyone have any changes and what are we debating. The policy sub group should be able to review two to three policies at a time. It was confirmed to put the schedule of overdue policies/procedures onto the action log for discussion at the November meeting. Action: Wendy Stokes 10.2 Staff Health and Wellbeing – Flu Campaign Preparation The trust ran out of vaccines before the second delivery came in. A paper is to be tabled at Trust Board as a review of where the trust is up to with the campaign. Maurice Madeo has done a sterling job in the absence of Annemarie Talbot and Lee Brown is helping with oversight of the campaign. Two further drop in sessions have been scheduled in each week up to the second week in December. The campaign will then be reviewed. Linda Jackson left the meeting at 16.28 pm
10.3 Update on Removal of Band 1 Pay Scale Discussed previously under agenda item 7.1
10.4 Report on active consultations The report is being reviewed for this committee and this links into the operational plan that must have oversight at executive level. Active or pending consultations should be reported at PRIMs meetings. A new report will be available from January including financial implications and this will be a standing agenda item under the HR agenda item. 10.5 Casework Summary Report This is an oversight of HR activity with exclusions noted at the top. This needs to be put into a spreadsheet and does link it into the Baroness Dido Harding letter.
10 | P a g e
Sandra Hills asked about employment tribunals. In June there was one in Surgery and Critical Care and she asked if there is an update. She didn’t know about the risk, financial implications, whether the case was won or lost and whether there was a need to do a deeper dive. This also links in with Rem Com and the risk that some of those cases carry. Lee Brown reported that he has arranged monthly meetings with the HR team to review case work and grievances. It was agreed to bring the casework report back to the November 2019 meeting. Sandra Hills stated that there are an increased number of formal investigations and she asked Claire Low and Lee Brown if they knew why that was. Claire Low replied it is a combination of things such as P&R, FTSJU and a lack of tolerance of unacceptable behaviours which is increasing the casework load. POE is looking at how they can bolster that increase in work.
11 Confirming schedule of invited attendees:
11.1 November 2019 – Women and Children’s dashboard from HR Business Partner Gemma Downs, HRBP has confirmed her attendance at the November 2019 meeting.
12 Risks identified: 12.1 BAF – Workforce Sub-Committee ‘Cut’ Does the trust have an appropriate number of skilled staff and is the number increasing or decreasing. Claire Low stated the trust needs to consider what it gets from the BAF and what this committee needs to discuss. Medical recruitment is in a better position and investment in nursing is bringing more workforces into the organisation although we will struggle to recruit and that is why the nursing directorate has their own recruitment strategy. The Chair asked if the trust is getting control of the mandatory training and PADRs or are they still red. It was noted that recruitment and the plan for that are amber, retention and turnover is slightly down although above average. Future talent management is amber and linked to the Deloittes review and Rachel Craven’s work on workforce planning. There is a lot of apathy in the organisation and the culture is at amber. Claire Low is picking the BAF up with Jeremy Daws. 12.2 Highlight to Trust Board
The Baroness Dido Harding letter and the relevance of that
Approval of the travel and subsistence policy as written with the exception of taking the bold off the two paragraphs on fraud
Delay of the leadership and development strategy
Receipt of Annual Guardians Report
Receipt of FTSU Quarterly Report
13 Any Other Urgent Business: Nothing discussed 14 Items for information:
14.1 Operations Workforce Dashboard Sandra Hills asked does the trust have a problem with decreasing numbers of AHPs across the trust, if so, is there a trend and how is the trust dealing with that. Elaine Coghill replied moving forward this with come to the nursing and midwifery board, we have education groups including AHPs, starting to come together much more. Claire Hansen added that the trust has lost some AHPs to provider colleagues as they are paying a different progression structure. This is being picked up with CCGs to see how we are going to address this moving forward, as they are taking trust staff. It was also noted that AHPs move on to become ACPs. The committee agreed a new action for Ellie Monkhouse to come back to the November 2019 meeting
11 | P a g e
to give an update on AHPs. 14.2 Monthly Staffing Report Nothing discussed 14.3 North of England Talent Board Progress Claire Low reported that there is a Regional Talent Board meeting in Leeds next week to see where NLAG fits in with the region. HRBPs are leading on this and there has already been some engagement. They have held two workshops with HR, finance and divisions to work through the next five years. It was agreed this be put this onto the agenda as a standing item and that the strategy should come to the January 2020 meeting.
14.4 Freedom to Speak Up(FTSU) Guardian Report Q2 2019-20 Kay Farquharson stated that the report is quarterly and quite new reporting up to the end of September 2019. Kay Farquharson asked if there were any questions about the report. A report also goes to Trust Board at six and twelve months. The Chair agreed that receiving the report in arrears is fine and this should be put onto the work plan quarterly. Kate Wood asked about the advert going out in December for a permanent post. It was confirmed that this would go out to the POE directorate first after the Pride and Respect roles had been appointed. Claire Hansen stated that in terms of numbers the majority of staff are reporting through the confidentially route. Kay Farquharson replied the majority are anonymous and the rest are confidential with the aim being to have less than 10% anonymously. In the strategy it states to increase the numbers to 25%. 14.5 Quarterly Guardians Report – May to August Report received and noted 14.6 Annual Guardians Report – June 2019 Report received and noted
15 Date, time and venue of next meeting: Tuesday 26 November 2019 from 2.00 pm to 4.30 pm in the Main Boardroom, DPOWH Committee Performance The Chair asked the committee members if they thought the agenda was appropriate; had the appropriate issues been debated, was there anything missing and had the relevant items been focussed on. The committee members confirmed that they were satisfied. The meeting closed at 4.45 pm
NLG(20)040
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Tony Bramley, Non-Executive Director / Chair of Audit, Risk & Governance Committee
CONTACT OFFICER Jim Hayburn, Interim Director of Finance
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
Minutes of the Audit, Risk & Governance Committee held on 23 October 2019 and approved at its meeting on 22 January 2020.
TRUST BOARD ACTION REQUIRED The Board is asked to note the report.
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________ MINUTES MEETING: Northern Lincolnshire and Goole NHS Foundation Trust Audit, Risk and
Governance Committee
DATE: 23 October 2019
PRESENT: Tony Bramley Chair of ARG Committee / Non-Executive Director Sandra Hills Non-Executive Director IN ATTENDANCE: Jim Hayburn Interim Director of Finance Sally Stevenson Assistant Director of Finance – Compliance & Counter Fraud Nicki Foley Local Counter Fraud Specialist Tom Watson Internal Audit Manager (Audit Yorkshire) Mike Norman Senior Manager (Mazars) Kay Farquharson Assistant Director of Cultural Transformation (Item 6.1) Steve Mattern Associate Director of IM&T (Item 6.2 – Confidential report) Sue Meakin Data Protection Officer (Item 6.4) Ivan Pannell Acting Head of Procurement (Item 6.5) Jeremy Daws Head of Quality Assurance (Item 7) Anne Barker Finance Directorate Administration Manager / PA to DoF Item 1 10/19
Apologies for Absence
Apologies of absence were received from Helen Kemp-Taylor (Audit Yorkshire); Mark Surridge and Jon Machej (Mazars). Tony Bramley also advised that Wendy Booth was not attending the meeting due to an urgent CQC issue.
Tony Bramley advised that this was his first meeting since formally being appointed as Chair of the ARG Committee and advised that some re-allocation of NEDs’ attendance at sub-committees had taken place, as we are two NED’s short but would hopefully be back up to full strength soon. It had been agreed that a minimum of two NEDs will attend the meetings, instead of the usual three, until appointments of new NEDs had been made.
Item 2 10/19
Welcome to new External Auditor (Mazars) and introductions
Tony Bramley welcomed Mazars, the Trust’s new External Auditors, to the meeting. Mike Norman attended the meeting on behalf of both Mark Surridge and Jon Machej who were unable to attend today’s meeting.
Item 2 10/19
Declarations of Interests
Tony Bramley advised that he had now stood down as the Chair of WebV Solutions Ltd. He also advised that he was no longer the Chair of the Quality and Safety Committee. These changes had both taken place as a result of becoming Chair of the ARG Committee. There were no other Declarations of Interests.
Item 3 10/19
Minutes of the previous meeting
The Public minutes from the last meeting held on 24 July 2019 were agreed as an accurate record. The Highlight Report for the Trust Board was also noted.
Item 4 10/19
Action Log
The action log was reviewed and the following noted: • 11.2 - Scheme of Delegation (SOD) – The revised draft was discussed at the Trust
Board on 3 September 2019 with two Directors wanting to add comments. Tony Bramley queried whether those comments had been received and Sally Stevenson confirmed that they had. Jim Hayburn stated that he was hoping that the further
Audit, Risk and Governance Committee – 23 October 2019 Page 1 of 12
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________
revised draft would be submitted to the November 2019 Trust Board meeting, but may be delayed depending on the comments received. 9.1 – Annual Fire Report – Confirmation received via email from Bill Parkinson that the report had been updated with the comments made at the July 2019 ARG Committee meeting, and that it would be fed into the next TMB/TB cycle.
• 12 – BAF/SRR – it was previously agreed that it would be taken to the Exec Team for discussion/debate/challenge as well as going to TMB. Wendy Booth had emailed to state that the minutes should read TMB not ET, and that the arrangement for TMB to review the BAF/SRR was now in place. The Committee confirmed that the discussion at the last meeting had been around it going to ET as well as TMB, and therefore it was agreed to leave the action point as stated.
Following review the Committee noted the Action Log. A number of items were then taken out of sequence on the agenda in order that attendees for ad-hoc items only could speak to their paper and then leave the meeting.
Item 9 10/19
Management Reports for Assurance - Invited Attendees
6.1 Annual Review of Freedom to Speak up Arrangements - Freedom to Speak Up Guardian
Kay Farquharson attended the meeting to present the report which was taken as read and Kay was asked to highlight the key issues to note. Kay Farquharson advised that NLAG is one of the first Trusts to have formal FTSU arrangements in place. Following the 2017 case review of FTSU within the Trust the National Guardians Office (NGO) made 23 recommendations; an action plan was produced and Kay advised that all actions have now been completed. Kay Farquharson highlighted from the report the key improvements including up-to-date policies e.g. Freedom to Speak Up Policy and Procedure, which is now completed and was attached to the report for information; and the FTSU Communication plan as well as, importantly, the FTSU Strategy 2019/20. Kay also stated that there had been an improvement in response times. The FTSU has two defined aspects i.e. reactive aspect, relating to concerns raised; and proactive aspect, which includes the Pride and Respect Training noting that 2,500 members of staff have now undertaken the training. A booklet entitled “How to Handle Concerns” has been produced for managers to promote a safe “speaking up” culture throughout the Trust and is included in both the Pride and Respect training and also line-manager training.
Kay Farquharson referred to the next steps and priorities and highlighted that new national FTSU guidance has been released (August 2019) and over the next few months they will be working on producing a new action plan, in conjunction with NHSI, to identify any gaps. Kay Farquharson also highlighted the available resource and capacity issues of the FTSU Guardian provision, and that they had been scoping out the manpower required. It is hoped that there will be two posts, a Lead Guardian for three days and a Deputy Guardian for two days which will give improved provision to cover holidays / sickness. Kay Farquharson confirmed that quarterly Trust Board reports are produced, with the next one due on 5 November 2019; this will also include the analysis of reactive concerns. Sandra Hills commented that the reports also went to the Workforce Committee. Kay Farquharson confirmed that the quarterly reports are taken to TMB, followed by Workforce Committee prior to Trust Board, adding this was a very quick turnaround for the reporting process. Tony Bramley advised that the ARG Committee’s focus is on compliance with standards and best practice, not individual cases. A report will also be brought to the ARG Committee for assurance on compliance against the guidance and also annually for assurance on progress against the FTSU Strategy.
Audit, Risk and Governance Committee – 23 October 2019 Page 2 of 12
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________
Sandra Hills confirmed that Jeff Ramseyer is the NED lead and Jayne Adamson the Executive Lead for FTSU.
Kay Farquharson was asked if she thought there could be a lot of work required as a result of the new guidance and she stated no, that she thought there would be very few gaps due to the use of the self-assessment tool but noted that the results from the CQC inspection and the staff survey are still to be received and will need to be taken into consideration. Tony Bramley queried when the new posts would be in place, and Kay Farquharson stated that she was not involved in the recruitment process but hoped it would be in the next few months. Tony Bramley asked if this was an area covered by the internal audit plan, and Tom Watson confirmed that it was in this year’s plan and a piece of work was about to commence.
Nicki Foley highlighted that within the Freedom to speak Up Policy & Procedure, Item 20.0 on page 8, the last bullet point referred to ‘NHS Protect’ which should now read ‘NHS Counter Fraud Authority’ (NHSCFA), which Kay agreed she would amend.
9.45am Kay Farquharson left the meeting.
6.2 This section removed due to confidential nature.
9.8 Waiving of Standing Orders Report
Ivan Pannell presented the report which gives details of waivers approved during the period 1 July to 30 September 2019. There were a total of 26 waivers recorded during the period i.e. three – non-compliance with SFIs; eight – standardisation; ten – insufficient suppliers; four – maintenance agreements; and one – rejection of lowest tender. Tony Bramley commented that the report was much easier to follow with the additional written commentary.
Ivan Pannell stated that there had been a lot of waivers in the last quarter, as could be seen from the details in the report, and commented that he was not sure if there was a particular pattern. Tony Bramley noted there were a number asking for an extension to a contract pending decisions on re-tendering/future requirements e.g. Gen med £600k; path links £234k and £230k and whilst no doubt genuine reasons existed, he considered if this was a sign of services being under pressure and not managing contracts effectively. Ivan Pannell explained there were a few managed services particularly in path links which are coming to an end after ten years and both the path links service and procurement team are under pressure.
Sandra Hills asked Ivan Pannell if all Trust contracts have been captured and are ensuring that we are being proactive. Sandra added that this was not being critical, she was aware that lots of improvements had and were being made. Ivan Pannell stated that it had been known for some time that there was a need for a comprehensive contracts register. Ivan added that it had only been within the last six months that the Procurement team had been able to work on developing the contracts register. The information collated by the Procurement team had been validated by the Divisional Finance Managers with their respective areas. However this exercise had identified over 500 contracts, including those expired or due to expire soon. Ivan Pannell went on to explain that these had also all been RAG rated which has identified that 400 contracts need actioning within the next year. Ivan informed the Committee that the Procurement team consists of two people plus one training to deal with contracts.
Audit, Risk and Governance Committee – 23 October 2019 Page 3 of 12
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________ Tony Bramley referred to the Amvale contract, noting previous discussions and noting that
a significant amount of money has been spent by the Trust but that it has still not decided how it wants to deliver patient transport, which is not good practice, but again this comes back to operational pressures within Ops. Tony added that there was also a need to recognise the pressures on the Procurement team. Jim Hayburn concurred with Tony Bramley and added that whilst we need to understand the 500 individual contracts the Trust also needs to look at available resources and what can be achieved with additional resources and where the risks are. Sue Meakin commented that it was fantastic that a register was now in place from a GDPR perspective. Sandra Hills stated that it was a credit to the Procurement team that they had now managed to pull this information together. Tony Bramley commented that the Committee was there to support the Procurement team and to inform the Trust Board about the risks of not managing contracts effectively. Jim Hayburn added that there were financial challenges. Tony Bramley stated that the Trust should have realistic expectations and should understand the exposure to risk. It was agreed that this needed to be flagged to the Trust Board. It was agreed that Jim Hayburn would flag the continuing Amvale issue to the Ops Division.
Action: Jim Hayburn It was agreed that Jim Hayburn would have the necessary conversations operationally in order to manage the moving forward of the contracts register, specifically the 400 contracts needing attention in the next twelve months.
Action: Jim Hayburn 6.6 Invoices without Purchase Orders (PO) Report.
Ivan Pannell presented the report which is the second report since it was re-instated for the
Committee, adding that it has been refined further since the last report as a result of working with the Payments team Ivan also informed the Committee that the first quarter’s data had not been included in the report, so unfortunately it was difficult to see the trends emerging over time. Ivan stated that he would include previous quarter’s data in future for trend analysis purposes, and improve the format of the report in certain other respects. Ivan Pannell then referred to the breakdown by division which identified areas where assistance may need to be given in the form of training, etc. to ensure compliance with raising official Trust purchase orders for goods and services required. He commented that the Committee may find this level of data interesting and the Committee confirmed that they did. Ivan highlighted certain areas/categories of goods and services including Clinical Support Services, Estates and Facilities, utilities invoices and healthcare orders Tony Bramley queried what HESP stood for, and it was stated that this referred to Hospital Eye Service Prescriptions. Ivan Pannell also explained that within table 4 the first area referring to ’Balance Sheet’ is actually pharmacy and supply chain stock spend, hence the high values.
Ivan Pannell went on to explain that work is ongoing on the Procure to Pay (P2P) Policy which will set out the environment for the end user; currently the paper-based system is not all that it should be, so work is ongoing behind the scenes on that.
Jim Hayburn stated that it was important that the procedure is reiterated to Divisions. Tony Bramley commented that compliance with the ordering process needed to be habit by those involved, as having a No PO/No Pay policy will only go so far. Tony Bramley also referred to the fact that in another organisation that he had worked in it was a case of ‘two strikes and out’ if ordering was not done correctly, adding that there was too much discretion. Sandra Hills queried whether it was about automation rather than discretion.
Audit, Risk and Governance Committee – 23 October 2019 Page 4 of 12
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________
Jim Hayburn stated that he would write out to Divisions, indeed the whole of the Trust, regarding the need to raise official Trust orders for goods and services and that if they did not then those not complying would be asked to come to the ARG Committee and explain the reasons for their non-compliance. The Committee agreed and endorsed this course of action. Ivan Pannell suggested that they could maybe use the launch of the new P2P Policy to send this message. Jim Hayburn stated that he and Ivan would draft something to issue to the organisation.
Action: Jim Hayburn / Ivan Pannell
Following the discussion and review of the report Ivan Pannell left the meeting.
10.30am Jeremy Daws arrived at the meeting.
6.4 IG Steering Group Highlight Report
Sue Meakin attended the meeting to present the report which was taken as read and Sue was asked to highlight key areas for the Committee to note. Sue Meakin noted the additional requirements on Cyber Security which will have a big impact on the organisation. Sue Meakin referred in particular to the completion and submission of an interim assessment by the end of October 2019. The Trust will be submitting its assessment as ‘Standards not met’ for the baseline submission as this takes into account the new assertions for 2019/20 and the lack of published guidance from NHS Digital; it is expected that most organisations will be making similar submissions at this stage. The main submission date is the end of March 2020 and work will continue on the assertions and the action plans will be monitored through the IG Steering Group to meet that deadline and ensure all boxes are ticked.
Tony Bramley commented that it was difficult from this to work out where the Trust was at. Sue Meakin advised that a review of the Data Security and Protection Toolkit (DSPT) will be undertaken by the Internal Auditors, Audit Yorkshire, at the end of Q3, noting that the internal audit and assessment guidance is still awaited. Tom Watson confirmed that an internal audit review was scheduled to support the completion of the year-end submission. Following the interim submission and the audit review, Sue Meakin advised that the findings and any gaps identified would be reported back to this Committee. Sandra Hills commented that the Committee would need assurance that the March 2020 submission would be compliant and queried whether or not there was a workplan. Sue Meakin confirmed that there was a workplan and that it was being monitored through the IG Steering Group and IT & Information Governance Group as well as WebV. Sue added that there were some big items to address, including resource issues. Sandra Hills commented that such roles would be at a premium.
The Committee was assured that work was ongoing to ensure the required standards would be met by the March 2020 deadline. It was agreed that the issue of the interim submission being assessed as ‘Standards not met’ would be highlighted to the Trust Board. An update will be brought back to the ARG Committee meeting in January 2020.
Following review and discussion the Committee noted the updates provided and Sue Meakin left the meeting.
Item 7 10/19
Review of Board Assurance Framework and Strategic Risk Register
Jeremy Daws presented the report and highlighted issues to note. The risk register now identified when new risks have been added and Jeremy advised that he meets with the individual Executive Directors who then discuss with their teams to determine that all risks are captured and the rating is appropriate.
Audit, Risk and Governance Committee – 23 October 2019 Page 5 of 12
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________ The Committee reviewed the individual risks as follows:
• Strategic Risk 6: Staffing – The Committee asked that this should be discussed at
Workforce Committee to ensure they are comfortable with the reduction in the rating from 15 to 10. It was confirmed that this was going to the Workforce Committee the following week.
• Strategic Risk 8: Trust’s Leadership – It was noted that this risk had been reduced from 16 (high risk) to 12 (moderate risk) at the suggestion of Peter Reading. It is overseen by the Trust Board with an appropriate confirm and challenge process.
• Strategic Risk 3: Quality - Tony Bramley suggested that this is discussed at the Quality & Safety Committee to determine if they are comfortable that the challenges identified are now shifting, noting that the ARG Committee are not necessarily suggesting a reduction in the rating simply a review of it. Sandra Hills commented that if following a particular route is not paying dividends it needs to be considered if it is the right route or just needs more time to get established.
Jeremy Daws advised that further work on the heat map needs to be undertaken to make it
clearer and easier to use.
Tony Bramley commented that there was an expectation that each Committee robustly reviewed its own areas of the document. Sandra Hills suggested having BAF/SRR discussions from each Committee on their respective Highlight Reports to the Board as assurance of this. Tony Bramley agreed to pick this matter up with each of the Committee Chairs.
Action: Tony Bramley
10.50am Following discussion and review of the BAF / Risk Register, Jeremy Daws left the meeting.
6.3 Document Control Quarterly Report
In the absence of Wendy Booth to present the report the Committee took the paper as read. The Committee noted the number of overdue documents had decreased since the previous month i.e. 151 overdue which is a 1.6% decrease but still not meeting current KPI target of <10%. The number of overdue documents within some Divisions was still high and Tony Bramley commented that it is a continual battle for the ARG Committee to get divisions to get their policies up to date. Jim Hayburn noted that the Women & Children’s Division appear to be performing well and suggested that positive feedback should be given to the Division by congratulating them for performing well in this regard. Conversely it was noted that the Surgery & Critical Care Division and the Medicine Division were still not performing well in terms of document control management and should be asked to provide an explanation as to why. Sally Stevenson reminded the Committee that a previous action from the Committee had been for document control issues to be monitored via the PRIMs meetings with each area. It was agreed that Tony Bramley would write to the Women and Children’s Division, copying in the Medical Director, to congratulate them on performing well. Similarly, it was agreed that Tony Bramley would write to the Surgery & Critical Care and Medicine Divisions., again copying in the Medical Director, to ask them for an explanation of why they were not performing well in this regard.
Action: Tony Bramley
6.7 Salary Overpayment Report
Sally Stevenson presented the report and was pleased to report a significant decrease in the value of overpayments from £105k in Q1 to £68k in Q2, adding that this was the lowest quarterly figure since Q1 of 2017/18. Sally stated that she was hoping that the periodic reminders to managers on the Hub were starting to have a positive effect. The Committee noted the positive reduction.
Audit, Risk and Governance Committee – 23 October 2019 Page 6 of 12
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________
Tony Bramley referred to the last page of the report where salary overpayment non-
compliance letters had been sent out to managers, yet on a couple of occasions no contact had been made by the recipient of those letters. Sally Stevenson explained that whilst a reply is not specifically requested, the letters do not contain any detail of the overpayments involved so would expect contact to be made asking for that detail. Tony Bramley suggested that it might be worth revisiting the content of the letters to ask for a response within 14 days.
Action: Sally Stevenson Following review the report was noted.
6.8 Hospitality and Sponsorship Declaration
Jim Hayburn presented the report which gives details of all hospitality, sponsorship and gifts declared by staff for 2019/20, as well as details of any interests declared by staff. Sally Stevenson advised the Committee that Peter Reading had asked that the sign off of these declarations is done by the Trust Secretary rather than the Director of Finance. Sally added that she had met with Wendy Booth to discuss the practicalities of doing this, and that it had been agreed that this would be trialled during November 2019 and its success evaluated at the end of the trial period. If there were not many declaration forms submitted in November, it had been agreed that this would be extended through December also. Following review the report was noted.
Item 8 10/19
External Audit (Mazars)
Mike Norman reiterated the apologies from Mark Surridge and Jon Machej that they were unable to attend the first meeting, but this was unfortunately unavoidable. Mike presented the report which he explained, given the early stages of the external audit contract, was an example of the format of the report that the Committee would see going forward. Mike added that it would be similar to what the Committee would have seen from the previous External Auditor.
Mike Norman stated that the audit process would also be similar to that of the previous External Auditor, and that a meeting had been arranged with the Finance team in a couple of weeks’ time. Mike Norman highlighted the provisional timetable of work which was set out in the report. On completion of the initial planning and risk assessment an Audit Strategy Memorandum will be brought to the ARG Committee for consideration.
Mike Norman advised that Mazars would be liaising with PwC in order to take a view on opening balances, etc., as part of the transition process. Work on the Quality Report would commence with meeting with key officers and agreeing the scope of the audit work, anticipated to be before Christmas. Tony Bramley highlighted the difficulties encountered last year with the provision of the Annual Complaints Report in order to complete the Quality Report audit work, and stated that it needs to be clear to officers what the audit requirements and the deadlines are. The Committee were reminded that this was a particular issue last year because of the change of team producing the report at year end, and should hopefully not be repeated.
Mike Norman drew the Committee’s attention to the national publications outlined within the report, specifically a new Code of Audit Practice from 2020/21; and IFRS 16 implementation guidance for NHS providers. In respect of IFRS 16 , Mike stated that the Trust needed to prepare for this in advance and that it would be discussed at the meeting with the Finance team in a couple of weeks’ time. Tony Bramley asked if the Trust was aware of the amount of work this could involve and Jim Hayburn advised yes, explaining that it involved finance leases becoming operating leases.
Audit, Risk and Governance Committee – 23 October 2019 Page 7 of 12
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________
Jim Hayburn commented that the new External Auditors need to be clear that they are adding value, over and above the work of the Regulators. Mike Norman stated that they would be challenging the Trust in terms of use of resources, etc.
Following the discussion and review the report was noted.
Item 9 10/19
External Audit (PwC)
9.1 9.2
Charitable Funds Accounts Management Letter WebV Accounts Management Letter
The above two items were presented to the Committee for information. A query was raised over the timing /order of these documents for the Charitable Fund Accounts and the WebV Accounts and the impact on NLAG’s financial statements. It was noted that the two sets of accounts were audited around the same time as the NLAG financial statements were audited, because they are consolidated as part of the Group Accounts (NLAG/Charity/WebV). Jim Hayburn stated that the DoF would be informed if there were any issues before reporting formally on their opinion on the accounts.
The Committee also queried its role in regard to the audit process for Charity and WebV. Tony Bramley suggested that a conversation with the Trust Secretary may be useful in the first instance.
Action: Tony Bramley
Following the discussion the two management letters were noted.
Item 10 10/19
Internal Audit (Audit Yorkshire)
10.1 Internal Audit Progress report.
Tom Watson presented the report and highlighted that three reports had been finalised since the last Committee i.e. GDPR Compliance and Health Records Management, both receiving significant assurance; and Medical Staff Personnel Files receiving limited assurance. There were also two advisory reports provided i.e. Provider Board Assurance Framework Benchmarking; and Use of Resources.
Tony Bramley referred to the re-audit of the Fit and Proper Persons files, in light of the CQC visit findings, and when this was to be undertaken. Tom Watson advised that they were due on site the following day to revisit the files, etc. Tony Bramley referred to the number of audit reviews now deferred to later in the year and whilst understanding the reasons given, queried if the workload was manageable for the audit team, which Tom Watson confirmed it was. Tom Watson highlighted to the Committee that they were struggling with some Executive Director engagement, particularly around audit scopes and agreement on draft reports. Tom Watson advised that this is being worked through and an escalation plan is in place if required. Tony Bramley asked for the Committee to be notified if these issues persist. It was agreed to highlight to the Trust Board the low assurance rating for the Medical Staff Personnel Files due to weaknesses in the design and operation of controls in relation to the management of files; there were seven recommendations made (six major and one moderate). Tom Watson informed the Committee that although the report had been agreed with Kate Wood, Medical Director, she had now asked for buy-in from the POE Directorate. Tony Bramley asked if the report would still stand and Tom confirmed that it would. Following the review the report was noted.
Audit, Risk and Governance Committee – 23 October 2019 Page 8 of 12
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________
10.2 Insight Technical Updates Report
The Committee received the Insight Reports for July to September 2019 for information. Tom Watson drew the Committee’s attention to the following: Page 3 – Freedom to Speak Up – updated guidance; Page 5 – NHS Patient Safety Strategy; briefing to be presented to Quality & Safety Committee; Page 7 – NHS Oversight Framework for 2019/20; Tony Bramley queried who received this document in the Trust and where it was discussed. Tony Bramley agreed to find out; Page 9 – HFMA Financial Reporting Brief September 2019 which highlights recent guidance on the application of IFRS 16; to be discussed at Finance & Performance Committee once the impact for the Trust is known.
There was some debate as to whether all the NEDs had been receiving the Insight Reports and it was agreed that this would be clarified after the meeting.
Action: Tom Watson / Anne Barker
Post Meeting Note: The last Insight Report circulated to all NEDs was June 2019. The latest report from October 2019 (containing July, August and September monthly reports) was circulated to all NED’s on 8 November 2019.
10.3 Internal Audit Recommendation Follow Up Report
Tom Watson advised that the aged recommendations relating to 2014/15 to 2015/16 have now been closed with only one still outstanding from 2016/17. There were 44 recommendations completed since the last ARG Committee meeting. Sally Stevenson advised that in relation to the final outstanding recommendation from 2016/17 i.e. TOR for Executive Team, she had been advised by Wendy Booth that these are now in draft form and should be finalised shortly. Tony Bramley commented that good progress had been made clearing off the older recommendations and also newer ones. The Committee noted the status of the recommendations follow-ups.
10.4 Fit and Proper Persons Review
The Committee noted that this review is in hand, as discussed earlier in the meeting.
Item 11 10/19
Counter Fraud
11.1 LCFS Progress Report Nicki Foley presented the latest report and highlighted specific areas to note: • Met with Humberside Police Economic Crime Unit with a view to working more closely
together, including having a joint stand at Fraud Awareness Month events held at Trust sites. Nicki added that she is also to be invited by them to attend future meetings of North Lincolnshire Fraud Forum;
• Fraud Awareness Month (FAM) to be held in November 2019; • National Exercise (Prevention of Procurement Fraud) was launched in May 2019.
Phase 1 was completed in July 2019 and following implementation of fraud prevention guidance Phase 2 is due to commence in April 2020 to repeat the exercise to assess the impact of the guidance;
• There have been three new referrals received since the last report;
Audit, Risk and Governance Committee – 23 October 2019 Page 9 of 12
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________ • Tony Bramley referred to the table listing the 20219/20 referrals specifically a member
of staff suspended from duties by HR pending the outcome of their enquiries which was from June 2019. Tony suggested that four months suspension was a long time without action being evident. Nicky Foley agreed to follow this up for an update at the next meeting.
Action: Nicki Foley
Tony Bramley commented that the LCFS progress report was an interesting read. Following the update the Committee received and noted the report.
Item 12 10/19
Losses & Compensations Report
The report gives details of all losses, compensations and special payments made during the period 1 July to 30 September 2019. The Committee specifically noted the lost equipment i.e. laparoscopic camera at a value of £22k. Jim Hayburn and Sally Stevenson provided additional details to the Committee, as per the losses and compensations form and associated email. Sandra Hills stated that in her view it was a clinical incident and queried if it had been reported as an SI. It was not known whether it had been reported as an SI. Jim Hayburn agreed to find out.
Action: Jim Hayburn
Sandra Hills commented that this should be part of the process whereby equipment should be counted in and counted out and therefore this was a clinical risk. Tony Bramley questioned if there was anything further that the Trust should be doing and asked if the necessary changes have been made to minimise this happening again. The remedial actions were read out from the documentation and duly noted by the Committee. Tony Bramley commented that this was the second issue to come out of theatres, referring to a previous issue regarding medicines being left in a cool box rather than in a fridge, although it was acknowledged this was a different set of circumstances. Following the review the report was noted.
Item 13 10/19
Highlight reports from other Board Sub-Committees
Highlight reports and action logs from the following Board sub-committees were provided for information for the Committee. • Finance & Performance Committee • Quality & Safety Committee • Workforce Committee • Health Tree Foundation Committee
Tony Bramley highlighted that he is keen to move towards doing more than just noting the highlight reports and action logs and to be aware of what other committees are discussing and where the ARG Committee want or need to be involved.
13.1 Finance & Performance Committee – Tony Bramley referred specifically to procurement issues and the capacity to keep on top of procurement arrangements. Tony advised that he was speaking to Linda Jackson as Chair of F&P Committee, to ensure that parallel discussions are held at both Committees;
13.2 Quality & Safety Committee – Medicine Management issues;
13.3 Workforce Committee – Freedom to Speak up Guardian report which was on today’s agenda;
Audit, Risk and Governance Committee – 23 October 2019 Page 10 of 12
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________
13.4 Health Tree Foundation – Staff Lottery – there had been a question on audit arrangements for the staff lottery raised. Sally Stevenson advised that Simon Dunn had raised this at the Lottery Committee meeting following the Health Tree Committee conversation. Sally confirmed that an audit had been undertaken, by the Trust’s internal auditors at that time, shortly after the lottery had been set up in 2013 and that it received a significant assurance rating. However, given that it was six years since the last audit review the Lottery Committee agreed that they would welcome a further audit review to be carried out in the current year.. The ARG Committee agreed that a review should be included in the 2019/20 Internal Audit Plan, as there were sufficient contingency days in the place to accommodate this.
Action: Tom Watson The discussion at the Health Tree Committee had also raised the question of whether or not the Staff Lottery should have a separate bank account, Sally Stevenson advised that Nicola Parker and Paul Marchant had been contacted by Sheldon Mill (Finance Manager for the Staff Lottery) and they had provided reasons as to why this would create extra work for the Finance team. The Committee noted both the pros and cons of a separate bank account, and it was agreed that this issue could be included for consideration as part of the internal audit review to be performed. Sandra Hills commented on the allocation of lottery staff benefit fund monies, and Sally Stevenson responded to this by explaining how the staff benefit fund operated. Sally also referred to the fact that a query had been raised on “Ask Peter” as to why someone not in the lottery could not apply directly for tickets to an event (although could accompany a lottery member to the event as their guest, and that an explanation had been given to that person.
Item 14 10/19
Any other business
14.1 Schedule of ARG Committee Meeting Dates 2020
The meeting dates for 2020 were noted.
14.2 Any other Urgent Business
There was no other business raised.
Item 15 10/19
Matters for Escalation to the Trust Board – Public
The following issues were agreed to be escalated to the Trust Board:- • Waiving of Standing Orders Report • Invoices without Purchase Orders • Information Governance Highlight Report • Internal Audit Progress Report
Item 16 10/19
Matters to highlight to other sub-committees • BAF Report – Quality & Safety Committee and Workforce Committee in terms of BAF
ratings.
Item 17 10/19
Review of ARG Committee Workplan
The workplan had been updated following the July 2019 ARG Committee meeting to include the invoices without PO Data Report. The Committee noted the updated workplan.
Item 18 10/19
Review of the Meeting
Jim Hayburn commented that this was his first ARG Committee and he felt that the right issues were discussed and debated. He also felt the Committee was well chaired.
Audit, Risk and Governance Committee – 23 October 2019 Page 11 of 12
Northern Lincolnshire and Goole NHS Foundation Trust ________________________________________________________________________________________________
Mike Norman commented that there was good input from managers at the Committee. Tony Bramley added that he wanted to ensure that issues are going to the right place, so will be asking “should this item be here?” in future, and also ensure the Committee are assured that other Committees are discussing and taking matters forward.
Item 19 10/19
Date, Time and Venue of the next Meeting Wednesday, 22 January 2020 – 9.30am-12.30pm – Cedar Room, T&D, DPOW.
Audit, Risk and Governance Committee – 23 October 2019 Page 12 of 12
NLG(20)041
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Tony Bramley – Chair of Audit, Risk and Governance Committee
CONTACT OFFICER Jim Hayburn, Interim Director of Finance
SUBJECT Audit, Risk and Governance Committee Annual Work Plan 2020/21
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The existing Audit, Risk and Governance Committee Work Plan has been updated for its scheduled 2020/21 meetings. It was discussed and approved at the Audit, Risk and Governance Committee meeting held on 22 January 2020.
TRUST BOARD ACTION REQUIRED The Trust Board is asked to note the Audit, Risk and Governance Committee Work Plan for 2020/21.
TRUST AUDIT, RISK AND GOVERNANCE COMMITTEE WORK PLAN - year ended 31st March 2021
Item of Business 21 Apr 20
18 May 20 (Public
Disclosure Statements
meeting)
23 Jul 20 22 Oct 20
21 Jan 21
Audit Committee - Annual Review of Terms of Reference X Audit Committee - Annual Review of Work Plan X Audit Committee - Annual Self-Assessment Exercise & Results X Audit Committee - Annual Report to Trust Board / CoG X Audit Committee - Annual meeting dates/times/locations X Private Discussion with Auditors (internal and external) as needed X as needed as needed as needed Receive highlight reports & action logs from other Board sub-committees X X X X
External Audit - Annual External Audit Plan / Timetable / Fees X External Audit - Routine Progress Reports X X X X X External Audit - Year End Report & Letter of Representation X External Audit - Report on Trust’s Quality Account X
Internal Audit - Annual Internal Audit Plan X Internal Audit - Routine Progress Report / Technical Updates X X X X Internal Audit - Head of Internal Audit Opinion X Internal Audit - Annual Report (inc. client feedback survey results) X Internal Audit - IA Plan strategic workshop results X Receive Status Report on Implementation of IA Recommendations X X X X
Annual Governance Statement X
Public Disclosure Statements: Review changes to Accounting Policies
X Draft annual accounts, quality accounts and VFM conclusion X Audited annual accounts X
LCFS - Annual Counter Fraud Report X LCFS - Annual Counter Fraud Work Plan X LCFS - Written Progress Reports X X X X LCFS - Concluding investigation reports / related issues as needed as needed as needed as needed 1
Item of Business 21 Apr 20
18 May 20
23 Jul 20 22 Oct 20
21 Jan 21
LCFS - Annual review of Fraud and Corruption Policy X LCFS - Results of Annual Staff Fraud Awareness Survey X
LSMS - Annual Security Management Report X LSMS - Annual Security Management Work Plan X LSMS - Ad-hoc reports and updates as needed as needed as needed as needed
Review of Waiving of Standing Orders X X X X Review of Losses and Compensations - quarterly X X X X Review of Hospitality and Sponsorship X X X X Review of Salary Overpayments & Underpayments - quarterly X X X X Review of data re: Invoices without Purchase Orders X X X X
Review of finance related policies (SFIs / Standing Orders / Scheme of Delegation, Recovery of Salary Overpayments Policy, Standards of Business Conduct Policy, etc.)
as needed as needed as needed as needed
Annual Review of Policy for Engagement of External Auditors for Non-Audit Work X
Board Assurance Framework (BAF) and Risk Register report - quarterly X X X X Annual Review of Risk Management Strategy X
Annual Review of CQC Statement of Purpose X Annual Review of Trust’s freedom to speak up arrangements X Freedom to Speak Up Guardian X Annual IG Toolkit Return X IG Steering Group Highlight reports - quarterly X X X X Document Control report - quarterly X X X X Annual Fire Report X Annual Health and Safety Policy statement X Annual Emergency Preparedness, Resilience and Business Continuity Report X 2
Item of Business 21 Apr 20
18 May 20
23 Jul 20 22 Oct 20
21 Jan 21
Annual Review of Web V Solutions governance arrangements X Clinical Audit Annual Work Plan X Review of Data Quality Dimensions (new item from HFMA checklist 2018) as needed as needed as needed as needed as needed New HFMA NHS Audit Committee Handbook Items – July 2018 Cyber security – invite Trust’s IT team to explain cyber security arrangements at least once a year. as needed as needed as needed X as needed
Mergers and acquisitions – review new arrangements as needed as needed as needed as needed as needed
Working with regulators - oversee action plans relating to regulatory requirements (e.g. single oversight framework; use of resources) as needed as needed as needed as needed as needed
Working at Scale – oversee developing partnership arrangements (e.g. accountable care organisations) as needed as needed as needed as needed as needed
3
NLG(20)042
DATE OF MEETING 4 February 2020
REPORT FOR Trust Board of Directors – Public
REPORT FROM Wendy Booth, Trust Secretary
CONTACT OFFICER As above
SUBJECT Documents Signed Under Seal
BACKGROUND DOCUMENT (IF ANY) Trust Standing Order 60.3 – Register of Sealing
PURPOSE OF THE REPORT: For Information
EXECUTIVE SUMMARY (PLEASE INCLUDE: A SUMMARY OF THE REPORT, KEY POINTS & / OR ANY RISKS WHICH NEED TO BE BROUGHT TO THE ATTENTION OF THE TRUST BOARD AND ANY MITIGATING ACTIONS, WHERE APPROPRIATE)
The report provides details of documents signed und er Seal since the date of the last report (November 2019 – NLG(19)289 )
TRUST BOARD ACTION REQUIRED
The Board is asked to note the report
Use of Trust Seal – February 2020
Introduction Standing order 60.3 requires that the Trust Board receives reports on the use of the Trust Seal. 60.3 Register of Sealing “An entry of every sealing shall be made and numbered consecutively in a book provided for that purpose, and shall be signed by the persons who shall have approved and authorised the document and those who attested the Seal. (The report shall contain details of the seal number, the description of the document and date of sealing)”. The Trust’s Seal has been used on the following occasions:
Seal Register Ref No.
Description of Document Sealed
Date of Sealing
261 Demolition of Modular Building & single story access area for erection of new MRI Unit, DPOWH
06.01.2020
262 Licence to occupy premises at SGH for provision of AAA Screening Services
28.01.2020
263 Deed of Covenant, 66 Woodland Avenue, Goole 28.01.2020
Action Required The Trust Board is asked to note the report.
