Board papers - August 2015 by Surrey and Sussex Healthcare NHS Trust

Surrey and Sussex Healthcare NHS Trust Board Papers

August 2015

Trust Board Meeting – IN PUBLIC Thursday 27th August July 2015 - 11:00 to 13:30 AD77, Trust Headquarters, East Surrey Hospital, Canada Avenue, Redhill, RH1 5RH

AGENDA 1

11:00

11:30

12:15

GENERAL BUSINESS 1.1

Welcome and apologies for absence

A McCarthy

Verbal

1.2

Declarations of Interests

A McCarthy

Verbal

1.3

Minutes of the last meeting held on 30th July 2015 - For approval

A McCarthy

Paper

1.4

Action tracker

A McCarthy

Paper

1.5

Chairman’s Report For assurance

A McCarthy

Verbal

1.6

Chief Executive’s Report For assurance

M Wilson

Paper

1.7

Board Assurance Framework & Significant Risk Register – For approval & assurance

G FrancisMusanu

Paper

SAFETY, QUALITY AND PATIENT EXPERIENCE 2.1

Patient Story For discussion & assurance

D Holden

Paper

2.2

Chief Nurse & Medical Director’s Report For assurance

D Holden/ F Allsop

Paper

2.3

Safety & Quality Committee Update For assurance

S Shaw

Paper

OPERATIONAL PERFORMANCE 3.1

Integrated Performance Report (M04) For assurance

P Bostock

3.2.1

Operational & Quality Key Performance Indicators

D Holden/ F Allsop

3.2.2

Workforce Key Performance Indicators

F Allsop

3.2.3

Finance Key Performance Indicators

P Simpson

Paper

3.2

Finance & Workforce Committee Update For assurance

R Durban

Paper

3.3

Charitable Funds Committee Update For assurance

P Lambert

Paper

12:55

13:25

RISK, REGULATORY AND STRATEGY ITEMS 4.1

Care Quality Commission Action Plan Update For assurance

S Jenkins

Paper

4.2

2014/15 Cost Improvement Plan â&#x20AC;&#x201C; Post Implementation Review For assurance

D Holden/ F Allsop

Paper

OTHER ITEMS 5.1

Minutes from Board Committees to receive & note 5.1.1

Finance and Workforce Committee

5.1.2

Safety & Quality Committee

5.1.3

Charitable Funds Committee

All

A McCarthy 5.2

ANY OTHER BUSINESS

5.3

QUESTIONS FROM THE PUBLIC

A McCarthy

Questions from members of the public may be submitted to the Chairman in advance of the meeting by emailing them to gillian.francismusanu@sash.nhs.uk 5.4

DATE OF NEXT MEETING 24th September 2015 at 11.00am

Minutes of Trust Board meeting held in Public Thursday 30th July 2015 from 11:00 to 13:30 Room AD77, PGEC East Surrey Hospital Present (AM) Alan McCarthy (MW) Michael Wilson (PS) Paul Simpson (FA) Fiona Allsop (DH) Des Holden (PBi) Paul Biddle (RD) Richard Durban (AS) Angela Stevenson (PL) Pauline Lambert (AH) Alan Hall

Chairman Chief Executive Chief Finance Officer / Deputy Chief Executive Chief Nurse Medical Director Non-Executive Director Non-Executive Director Deputy Chief Operating Officer Non-Executive Director Non-Executive Director

In Attendance (GFM) Gillian Francis-Musanu (SJ) Sue Jenkins (JM) Janet Miller (CP) Colin Pink 1.

Director of Corporate Affairs Director of Strategy (item 4.1, 4.3) Deputy Director of Human Resources (4.2) Notes

General Business 1.1

Welcome and Apologies for absence The Chairman opened the meeting by welcoming Trust Board members, staff and members of the public. Apologies for absence were noted from Paul Bostock (Chief Operating Officer) and Richard Shaw (Non-Executive Director).

1.2

Declarations of Interest The Chairman asked whether any of the Board members had any additional declarations of interest; none were recorded.

1.3

Minutes of the last meeting â&#x20AC;&#x201C; 25th June 2015 The minutes of the meeting held on 25th June 2015 were approved as a true and accurate record.

1.4

Action Tracker The following outstanding actions were updated and closed. TBPU-01 : In relation to Risk 3.1; the Board felt that the current risk scoring should be increased to 15 and asked the Chief Nurse to consider this proposal in advance of the next Board report. TBPU-03 : The Board would be keen to better understand the nature of concerns highlighted within the Staff Survey relating to bullying and harassment. Page 1 of 10

The remaining action remains open and was carried forward to the October public board meeting TBPU-02: The Chief Nurse agreed to provide an update to the Trust Board in relation to the Temporary Staffing Contract in the coming months. The Chief Finance Officer added that an update on the Agency Contract variations will also be reported to the FWC in advance. 1.5

Chairman’s Report for Assurance The Chairman announced that Richard Durban had accepted the role of Deputy Chair of the Trust, welcomed Alan Hall to the Board as a substantive NED and congratulated Angela Stevenson on her successful application to be the Trust’s new Chief Operating Officer. The Chairman congratulated the Trust on successfully being selected as one of the five Trusts to be included the Virginia Mason Institute development program and thanked the teams for their work on the application. It is a very good outcome for the Trust and has set the Trust the next phase of our journey of improvement. The Chairman reflected that the program would provide a good framework for the Trust to maintain its momentum as it endeavoured to become outstanding. The Chairman commented on the recent opportunity to meet some of the Trust’s new governors following the successful shadow governor’s election. The group includes a wide variety of skills and experience and will become a valuable part of the Trust’s governance framework. The Board duly noted the report.

1.6

Chief Executives report for Assurance The Board received and noted the Chief Executive’s report in advance of the meeting. MW introduced the report focussing on the recent Secretary of State’s speech describing the 25 year vision for a patient-led, transparent and safer NHS. There was a clear emphasis on transparency, choice, empowered patients and local decision making. A key issue was the merging of the two national regulatory boards Monitor and the Trust Development Agency, now falling under the banner of NHS Improvement. This would lead to significant changes in the national administration of NHS services, however the expectation is that changes will not commence before a new Chief Executive Officer is appointed. MW moved on to discuss Lord Rose’s report “Better Leadership for Tomorrow”. This review focuses on how to attract and develop talent from inside and outside the health sector into leading positions in the NHS with strong linkages to the Five Year Forward View. Lord Rose has identified three main areas of improvement; vision, people and improvement from which nineteen main recommendations have been made. The Trust will need to review the report and support implementation of the recommendations. MW was pleased to announce that planning permission had been given for the capital work to make improvements to medical records facilities and Page 2 of 10

congratulated Trust staff for being part of the top six cohort of Trusts in the Hospital of the Year Award. RD asked what work had been done to ensure that an appropriate 7 day service was in place to support the improvements detailed by the Secretary of State. DH reported that reviews had been completed and plans developed to meet the needs of strategies described. Divisional gap analyses demonstrate that consultant cover has improved over the last two years and that systems are now being embedded to support the changes in job plans. DH stated that a paper is due to be tabled at Public Board in two months time. MW commented that the speech had sparked a lot of national debate and, in particular, guidance is required on the expectations to provide appropriate outpatient and pathology services. The Board duly noted and took assurance from the report. 1.7

Board Assurance Framework and Significant Risk Register for Approval and Assurance GFM introduced the BAF and SRR for discussion and approval by the Board. Noting that actions from the previous Board to update the narrative and increase the risk scores relating to nursing staff had been completed. A new risk has been added to the significant risk register relating to the national quality board paper, 7 day working and Carter productivity report. RD asked what the trigger would be to change the amber risk relating to long term financial plan had become a red risk. PS stated the issue was under review and at present did not constitute a red risk. The Board noted that the emphasis of the reports’ focus needed to change from producing to delivering of a long term financial model. AH and PS debated whether the current likelihood of realisation of the Trust’s liquidity risk was scored appropriately noting that the issue has remained for a significant time without materialising as a strategic issue. This is being monitored appropriately, but part of the Trust’s mitigation is the delay in paying creditors. As agreement on the level of risk could not be agreed the Chairman asked that the FWC discuss the BAF risk relating to liquidity focusing on the level of risk and the balance between the amount of liquidity and the controls that continue to mitigate against adverse effect. The Board duly approved the report.

Safety, Quality and Patient Experience 2.1 Clinical for Assurance DH introduced the clinical presentation on the 2014 National Children’s Inpatient and Day Case Survey and Joanne Farrell (JF), Matron Children & Young People who had pulled together the survey’s findings with clinical audit. JF introduced her colleague Sara Cumming, Divisional Audit Facilitator who had been instrumental in reviewing national data set. JF stated that this was the first survey of its kind and had included 137 Trusts. Of the 300 Trust patients surveyed during July 2014, 23% (69) had responded. The Trust had scored better than national average and local average in a wide range of indicators; felt safe on the ward, staff explaining elements of care, pain management and good experience. The survey had identified national areas of improvement such as Page 3 of 10

management of patients with special needs, this issue was also highlighted in the Trust data. The Trust’s data for overall experience was significantly higher than national figures (10% higher). Unfortunately due to the low response rate, the CQC could not confirm statistical confidence but the overall picture and local benchmarking is good news for the Trust. DH praised the teams involved for their care and commitment to providing high quality services. JF discussed the conclusions that the divisional management team had formed, focussing on areas of improvement such as privacy for 8 to 15 year olds and the national need to improve experiences of service users with learning difficulties. Any significant issues are now being monitored by divisional governance and recorded on the risk register with mitigating actions. The Chairman thanked JF and SC for the presentation and the clinical teams involved. PL said that it was a good presentation and an excellent result for the Trust, asking what can be done to increase response rates. JF stated that it was a national issue that the CQC was considering. The Board took significant assurance from the presentation. 2.2

Chief Nurse and Medical Director’s Report for Assurance The Board received and noted the report in advance of the meeting. FA presented the first half of the joint report focusing on the Safer Staffing report for June 2015, which indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template. FA highlighted Burstow and Tandridge wards compliance, assuring the Board that plans are in place to increase compliance. FA went on to highlight that NICE intend to publish the emergency department staffing guidance in the coming months for reference and consideration. DH began by echoing the Chairman’s earlier words on the VMI development program and moved onto the Innovation Factory initiative. This initiative looks to facilitate and sharing of new ideas and is supported by a practical approach to the management of new ideas. The system will facilitate gathering ideas from front line staff which will then be reviewed for service development and even for commercial possibilities. The system is in use extensively in Scandinavia, and in a small number of CCGs and community providers, but is not in any UK acute trust. DH stated that the Trust have had 11 cases of CDI of which 5 had had identifiable lapses of care. It is felt that the decisions to identify lapses of care were not always issues that contributed to the development of the case. Therefore the Trust was in negotiation with the TDA and CCGs. The Trust’s root cause analyses had found a number of areas of improvement that we could make. We have taken a multi-step approach, focusing on doctors and nurses assessing and making plans together for patients with suspicious diarrhea. MW concurred with DH stating that decision process for identifying lapses of care is Page 4 of 10

open to interpretation. PL sated it was reassuring that the focus was on the management of suspicious diarrhea and asked what the impact for the Trust was outside of patient care. DH stated that the financial penalty is ÂŁ10,000 per avoidable case over the Trust threshold target. The Board duly noted and took assurance from the report. 2.3

15 Step Challenge â&#x20AC;&#x201C; update for Assurance The Board received and noted the report in advance of the meeting. FA introduced the report outlining the 15 Steps Challenge activity between April to June 2015 and the completed actions carried out as a result of recommendations from the 15 Steps team focusing on signage, storage, environmental improvements, information for parents and patient flow. FA went on to highlight how well received the visits are and the positive effect they are having on patient experience and staff morale. PL asked if other sites are included in the 15 Steps Challenge, FA indicated that there are plans to visit all areas relevant to the scheme such as Horsham and Crawley Day Surgery. The Chairman sked what the tangible outputs of the scheme had been to date. FA stated that each visit highlighted areas of potential improvement. FA reminded the Board that the current Trust focus on improving the experience of patients fasting before surgery was first identified as a need during a 15 Step visit. The Board agreed that the 15 Step Challenge remained a useful vehicle and that the newly elected governors should be invited to join the initiative The Board duly noted and the report.

2.4

Safety & Quality Committee Update for Assurance The Board received and noted the report in advance of the meeting. The report summarised some of the key discussion points of the last committee meeting held on 2nd July 2015. PL presented the report highlighting the presentation from the Obstetric team on its work to ensure that the Caesarean section rate is appropriate for the Trustâ&#x20AC;&#x2122;s patients taking into account their clinical condition. The SQC had taken good assurance as the presentation was both comprehensive and demonstrated values of safety and compassion. The Board duly noted the report for assurance.

Operational Performance 3.1

Integrated Performance Report (M1) for Assurance The Board received the Integrated Performance report in advance of the Page 5 of 10

meeting. 3.1.1

AS summarised the Trust’s recent operational performance focussing on June 2015. Highlighting ED performance increased non elective stays and increases in admitted patients. Ambulance handover KPIs have deteriorated recently and as such there is to be a meeting with SECAMB and CCGs to try and mitigate and improve the situation. There is assurance that appropriate systems are in place to manage the associated risk. AS briefed the Board on changes to national guidance for recording RTT, the key change being the switch to measuring incompletes, allowing Trusts to focus on the longest waiters and highest clinical priorities. The Board discussed escalation and bed usage focussing on the benefits for patients of closing escalation areas wherever possible. The conversation moved on to getting patients into the right clinical areas. The Board noted that significant effort was being spent on managing emergency admission pressures and asked that the winter pressures BAF risk be amended to reflect emergency admission pressures. The Board discussed the decrease in ‘Friends and Family’ scores, FA stated the main issue was improving consistency of report rates so that the patient experience teams could regularly triangulate information with ‘your care matters’. Reassuring the Board that it continued to be an element of focus.

3.1.2

FA highlighted the issues of leavers and turnover that had been discussed at the Finance and Workforce Committee. This had focussed on three groups of nursing staff, those employed less than three years, the middle group and those over the age of 45. The focus of the conversation had been on evidence that once someone had been employed by the Trust for more than three years the retention rate was much higher and as such efforts should be made to develop first class support for staff in the early years of their career. The Chairman asked that FWC discuss targeting retention on new and junior nurses to influence retention rates. The Board noted there was a very specific risk that implementation of nurse revalidation may have an impact on nurses retiring earlier than expected to avoid the heavy administration of personal revalidation and asked that efforts are made to support staff in this bracket.

3.1.1

PS introduced the finance section of the report, highlighting that the Trust is on plan at month 3 with a £2.0m deficit, but that the level of risk to end of year was £6.0m. The Board had reviewed the financial forecast for the year in its private session and had affirmed that the Trust would continue to report its forecast out turn of £1.6m, noting the significant level of risk. This position would be reviewed monthly. The main contributory factors are costs related to emergency admissions and unexpected delays in nursing recruitment plans. Because of the level of risk and expected delays of CCG payments a working capital facility application was being made by the Trust, noting that Private Board had recorded the necessary resolutions. RD highlighted issues relating to income and costs being affected by emergency activity. MW noted that the key was ensuring that outsourced activity was cost neutral. Page 6 of 10

The Board duly noted and took assurance from the report. 3.2

Finance & Workforce Committee Update for Assurance The Board received and noted the update in advance of the meeting. RD summarised some of the key discussions of the July meeting, highlighting that the cost improvement schemes for the Trust are on plan at month 3 with £0.8m delivered and the work to develop the Trust’s IT road map. The Board noted that reviews of future CIPs plans and IT developments are scheduled for August 2015. The Board duly noted the report for assurance.

3.4

Audit & Assurance Committee Update for Assurance The Board received and noted the update in advance of the meeting. PB summarised some of the key discussions of the July meeting. The Committee focused on the review of the board assurance framework and financial risks, took assurance from management’s review of internal controls for legal obligations and actions taking to improve controls for management of temporary staffing. The Board noted the annual external audit letter which had provided an unqualified opinion on the Trust’s accounts, a qualified opinion on the Trust’s value for money and an unqualified limited assurance opinion on the quality accounts. The committee took significant assurance from the strong position detailed in the annual audit letter. The Board duly noted the report for assurance.

Risk, Regulatory and Strategy Items

4.1

CQC Improvement Action Plan for Assurance The Board received and noted the report and action plan in advance of the meeting. Sue Jenkins, Director of Strategy, presented the update on the CQC action plan providing assurance that actions are being delivered and extra capacity is being implemented to enable staff to drive change. The Chairman questioned the speed of delivery of the action plan. SJ highlighted that new actions have been added and the majority of plans have been implemented. MW concurred but asked for assurance that the key issue of risk’s relating to management of temporary notes had been mitigated. The Board asked for an audit effectiveness of actions to reduce the use of temporary notes for outpatient clinics. The Board discussed the detail of the report, focusing on the number of cancelled clinics, the increase in demand for outpatient appointments and the Trust’s efforts to forecast and flex services to meet demand and create capacity in areas such as neonates. RD asked whether establishing a high quality efficient outpatients department would be a game changer for the Trust’s overall Page 7 of 10

performance. MW noted that it would be the step to delivering outstanding outpatient services, but is only one of the nine CQC domains of care provided by the Trust. The Board duly noted and took assurance from the report.

4.2

Staff Survey Action Plan Update for Assurance The board received and noted the report in advance of the meeting. Janet Miller, Deputy Director of Human Resources introduced the paper, highlighting the key focuses on staff engagement, improving systems for learning from incidents and numbers of staff exposed to violence. The Board discussed plans to tailor support for staff in areas of risk of violence and aggression. AH asked how the Trust monitored staff engagement and how it would know it had reached its aspirations. The Board noted that the initial target for the Trust was to get into the top 20% of results for the staff survey and that the new staff â&#x20AC;&#x2DC;Friends and Familyâ&#x20AC;&#x2122; test was providing useful information, mindful of the need to avoid over survey of staff opinion. PS asked if the Trust could achieve one hundred percent of its achievement reviews by winter. JM stated that it would be a challenge but that the HR business partners were considering all options for delivery. The board resolved to approve the report.

4.3

Annual plan update Q1 for Assurance The board received and noted the report in advance of the meeting. SJ introduced the Annual Plan update noting the improved position on delivery of actions in comparison to the previous year and the known main outstanding actions relating to non-elective care plans. The board resolved to approve the report, noting the above comments.

Other Items 5.1

Minutes of Board Committees to receive and note

5.1.1

Finance and Workforce to receive and note The minutes of the Committee were noted with no questions raised.

5.1.2

Safety & Quality Committee to receive and note The minutes of the Committee were noted with no questions raised.

5.1.3

Audit & Assurance Committees to receive and note The minutes of the Committee were noted with no questions raised

5.2

Any Other Business No further business was discussed by the Board. Page 8 of 10

5.3

Questions from the Public There was one question raised by e-mail by a member of the public. The Chairman asked the Board to read the email that had been received. ‘Dear Mr McCarthy I am a resident of Reigate and a huge supporter of East Surrey Hospital, however I am also a member of the tax payers alliance and was very concerned to read about one of your members of staff in Friday's Telegraph. As the Telegraph did such a through piece of investigative journalism with the MP's expenses scandal I believe that the story concerning Mr Omar Ali will have been thoroughly researched and be correct. Therefore, the questions I would like to ask and have answered at your public board meeting this week please are: 1) Has Mr Ali ever conducted any of his non hospital business activities on any of Surrey and Sussex Healthcare's hospital premises? 2) Have any of the Board members of the hospital have had any involvement with Mr Ali's outside interests or been entertained at Mr Ali's expense? 3) Does the hospital have a policy for such matters? I also find it incredulous that Mr Wilson is quoted as saying that Mr Ali has declared his independent business but that he has no actual knowledge of what he does in his own personal time. 4). What is it then that Mr Ali has declared and how has Mr Wilson satisfied himself that there is no conflict of interest? I believe that the public has a right to know how conflicts of interests are assessed and investigated to ensure that public money is not being wasted. I do not believe that any of these questions cannot be answered in a public board meeting and be on public record. I hope to be able to attend in person but if not please can you ask these questions on my behalf and record the answers in the public minutes? I look forward to hearing from you. Yours sincerely M Hancock’ The Chairman asked the Board to read the draft response and comment if there were any issues or amendments ‘Dear Mr. M Hancock The Trust has a Standards of Business Conduct Policy, which includes declarations of interest, and procedures that ensure interests are appropriately managed within the hospital. This issue has been referred to NHS Protect which is an organisation, independent of the Trust, responsible for investigating allegations of fraud and corruption. NHS Protect will take whatever action is appropriate. Page 9 of 10

Yours sincerely A McCarthyâ&#x20AC;&#x2122; The Board accepted the response without any queries There were no further questions from the public. 5.4

Date of the next meeting Thursday 27th August 2015 at 11.00am in Room AD77, Trust Headquarters, East Surrey Hospital

Note: This is a public document and therefore will be placed into the public domain via the Trustâ&#x20AC;&#x2122;s website in the interests of openness and transparency under Freedom of Information Act 2000 legislation.

These minutes were approved as a true and accurate record. Alan McCarthy Chairman:

Date:

Page 10 of 10

TRUST BOARD ACTION TRACKER Action Ref

Forum

Subject

Action

Date Open

Date Due

Date Closed

Status

ACTIONS FROM PUBLIC BOARD MEETINGs

TBPU-01

TBPU-02

TB Public

Chief Nurse report

FA agreed to provide an update to the Trust Board in relation to the Temporary Staffing Contract in the coming months. PS added that an update on the Agency Contract variations will also be reported to the FWC in advance. FA

25/06/2015

BAF & SRR

The FWC discuss the BAF risk relating to liquidity focusing on the level of risk and the balance between the amount of liquidity and the controls that continue to mitigate against adverse effect. RD and PS

30/07/2015

TBPU-03

TB Public

IPR

TBPU-04

TB Public

IPR

TBPU-05

TB Public

CQC Action Plan

The Board noted that significant effort was being spent on managing emergency admission pressures and asked that the winter pressures BAF risk be amended to reflect emergency admission pressures. PBo FWC discuss targeting retention on new and FA junior nurses to influence retention rates. SJ to initiate an audit effectiveness of actions to reduce the use of temporary notes forÂ outpatient clinics SJ

30/07/2015

29/10/2015

OPEN

27/08/2015 CLOSED

30/07/2015

OPEN

30/07/2015

OPEN

TRUST BOARD IN PUBLIC

Date: 27th August 2015 Agenda Item: 1.6

REPORT TITLE:

CHIEF EXECUTIVE’S REPORT Michael Wilson Chief Executive Colin Pink Head of Corporate Governance

EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

N/A

Action Required: Approval ( )

Discussion (√)

Assurance (√)

Purpose of Report: To ensure the Board are aware of current and new requirements from a national and local perspective and to discuss any impact on the Trusts strategic direction. Summary of key issues National: • NHS Constitution Handbook Updated • NHS launches next step of urgent care review Local: •

Virginia Mason Institute Development Program update

Recommendation: The Board is asked to note the report and consider any impacts on the trusts strategic direction. Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact

Ensures the Board are aware of current and new requirements.

Financial impact

N/A

Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication Attachment: N/A

Highlights national requirements in place to improve patient experience. Identifies possible future strategic risks which the Board should consider Includes where relevant an update on the NHS Constitution and compliance with Equality Legislation

TRUST BOARD REPORT – 27 August 2015 CHIEF EXECUTIVE’S REPORT 1.

National Issues

1.1

NHS Constitution and Handbook Updated

The NHS Constitution and Handbook to the NHS Constitution have been updated to reflect current policy and legislation and to make the Constitution a more practical document. In his inquiry into the failings at Mid-Staffordshire, Sir Robert Francis QC recommended amendments to the NHS Constitution based on: • • • •

prioritising patients protecting patients from avoidable harm providing assistance that patients need staff compliance with guidance

Each of these recommendations has been fully accepted and implemented within the new NHS Constitution. Standards of care The NHS Constitution now reflects a series of fundamental standards, below which standards of care must never fall. In April 2015, the way hospitals are inspected was changed with the Care Quality Commission becoming regulators of fundamental standards. Failure to meet these standards, and an inability to meet the high standards patients expect and deserve, will result in decisive action to protect patients.

Physical and mental health To close the gap between physical and mental health, the NHS Constitution makes it clear that each are equally important. This is an important part of the NHS Principles that guide the NHS in all that it does.

Armed forces The role of the armed forces is recognised by enshrining the Armed Forces Covenant in the Constitution to ensure equal access to services.

Duty of candour The Department of Health has also introduced a new duty of candour into the NHS Constitution, to promote a culture of openness within the NHS. The inclusion of a patient right to candour helps to achieve this. The Handbook to the NHS Constitution provides further information on the Constitution, including detail on important policies, such as whistleblowing. The Handbook is of particular use to organisations that support and advise patients, their carers and families, and staff. Full details of the updates are available at: https://www.gov.uk/government/publications/the-nhs-constitution-for-england

1.2 NHS launches next step of urgent care review NHS England Chief Executive Simon Stevens and the NHS Five Year Forward View partners recently announced eight new vanguards that will launch the transformation of urgent and emergency care for more than nine million people. This comes as NHS England also revealed the success of Regional Major Trauma Networks which, after they were set up just three years ago, have seen a remarkable 50 percent increase in the odds of survival for trauma patients revealed in a new independent audit by the Trauma Audit and Research Network (TARN). Building on the recent success in improving trauma survival rates, the urgent and emergency care vanguards are tasked with changing the way in which all organisations work together to provide care in a more joined up way for patients. Urgent care will be delivered, not just in hospitals but also by GPs, pharmacists, community teams, ambulance services, NHS 111, social care and others, and through patients being given support and education to manage their own conditions. Another aim is to break down boundaries between physical and mental health to improve the quality of care and experience for all. The eight new vanguards will spearhead this work and, like other vanguards, will benefit from a programme of support and investment from the ÂŁ200m transformation fund. Further details are available at: http://www.england.nhs.uk/2015/07/24/nhs-launches-next-step-of-urgent-care-review/

Local Issues

2.1

Virginia Mason Institute (VMI) Development Program

The initial setup of the Trusts involvement in the development program has been progressed with VMI and TDA. This has developed the details of the programme over the coming year and detailed what is required from the Trust. The five Trust CEOs will come together as the Transformation Guiding Board, meeting monthly from mid September. The Trust has agreed its transformation guiding team (TGT) which includes 7 leaders from the executive team and the Director of Strategy as overall lead for the programme. Training for the TGT is planned for the end of September at VMI. Monthly all day TGT meetings are being established which will be chaired by CEO and provide a report to the Board monthly. 3.

Recommendation

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

Michael Wilson Chief Executive August 2015 3

TRUST BOARD IN PUBLIC

Date: 27th August 2015 Agenda Item: 1.7

REPORT TITLE: EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

Board Assurance Framework & Significant Risk Register Paul Simpson Chief Finance Officer Colin Pink Corporate Governance Manager Executive Team 19th August 2015

Action Required: Approval (√)

Discussion (√)

Assurance (√)

Purpose of Report: The 2015/16 BAF highlights potential risks to the Trust’s strategic objectives and mitigating actions and the implementation of its programme of objectives for year two of the five year plan. The Significant Risk Register (SRR) details all risks on the Trust risk register system that are recorded as significant and the links to the Board Assurance Framework. Summary of key issues The BAF details 13 risks to the trusts strategic objectives, 7 of which are recorded as key strategic risks and red rated, including a proposal to increase the strategic risk related to delivery of medium term financial plan. The risk description relating to management of winter pressures has been amended to reflect management of emergency activity pressures. There are 8 significant risks recorded on the Trust risk register. Recommendation: The Board is asked to discuss and approve the report and consider the following: • Review the BAF and its alignment to strategic objectives • Does the Board agree with the recorded controls and assurances • Approve the proposals to increase the BAF risk relating to delivery of medium term financial plan. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model 1

An Associated University Hospital of Brighton and Sussex Medical School

Corporate Impact Assessment: Legal and regulatory impact Financial impact Patient Experience/Engagement

The report is a requirement for all NHS organisations. As discussed in sections 5 (Income generation linked to activity referred to throughout the document) Patient experience and engagement is one of the Trusts strategic objectives. .

Risk & Performance Management

These are highlighted throughout the report.

NHS Constitution/Equality & Diversity/Communication

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

Attachment: August 2015 BAF and the current SRR

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 27th August 2015 BOARD ASSURANCE FRAMEWORK and SIGNIFICANT RISK REGISTER 1.

Board Assurance Framework

The Board Assurance Framework (BAF) describes the principal risks that relate to the organisation’s strategic objectives and priorities. It is intended to provide assurances to the Board in relation to the management of risks that threaten the ability of the organisation to achieve these objectives. The Trust has identified five main strategic objectives for 2015/16: 1) Safe: Deliver safe services and be in the top 20% against our peers 2) Effective: Deliver effective and sustainable clinical services within the local health economy 3) Caring: Ensure patients are cared for and feel cared about 4) Responsive to people’s needs: Become the secondary care provider and employer of choice for the catchment population 5) Well led: become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model These objectives are broken down into specific areas and the BAF details the key risks that the Trust faces to the delivery of these priorities. Each risk details the controls that are in place, the sources and effects of assurance and mitigating actions to reduce the likelihood of the impact of the risk materialising. (Some priorities have more than one associated risk) The Significant Risk Register (SRR) supports the BAF and details the highest rated operational risks that have been raised by the Executive Team and Divisional Management. The SRR is regularly reviewed and moderated by the Executive Team to ensure alignment with the BAF and other key risks to the Trust. 2.

Current status

The 15/16 BAF (attached) details a total of 13 risks to the 5 Trust strategic objectives which are scored as follows (including proposal to increase risk 5.3): Objective 1.Deliver safe services and be in the top 20% against our peers 2.Deliver effective and sustainable clinical services within the local health economy 3.Ensure patients are cared for and feel cared about 4.Responsive - Become the secondary care provider and employer of choice for the catchment populations of Surrey & Sussex

Red (15-25)

Amber (8-12)

Green (1-6)

An Associated University Hospital of Brighton and Sussex Medical School

5. Well Led - become an employer of choice and

deliver financial and clinical sustainability around a clinical leadership model

Total

One of the purposes of the BAF is to ensure that all risks are mitigated to an appropriate or acceptable level. It is expected that not all risks will be able to have mitigating controls that reduce the risk to green (low impact, low likelihood). 2.1 Updates since last Board Review Since the last board meeting the Executive has reviewed and updated the BAF to reflect current as detailed in descriptions. There have been minor amendments throughout regarding controls, actions and assurances the main points of note are the proposed increase to the strategic risk of delivery of medium term financial plan (5.3) and following the discussion at the July Public Board meeting amendment of the description of strategic winter pressures risk to reflect emergency activity pressures (4.1). 2.2 Headline information by objective (BAF) Objective 1 - Safe Deliver safe services and be in the top 20% against our peers

Initial Risk Rating: Severity x Likelihood

1.1 There is a risk that the Trust will not meet its objective to deliver continuous improvement in reducing avoidable harm, if all national and local standards are not embedded within divisions and specialties. 1.2 Failure to maintain systems to control rates of HCAI will effect patient safety and quality of care

Objective 2 - Effective â&#x20AC;&#x201C;Deliver effective and sustainable clinical services within the local health economy 2.1 There is a risk that patient outcomes will not continue to improve if monitoring and benchmarking is not utilized to improve clinical outcomes across divisions and specialties 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.

Current Risk Rating: Severity x Likelihood

Target Risk Score

S4 x L3 = 12

S4 x L2 = 8

S4 x L1 = 4

S3 x L4 = 12

S3 x L3 = 9

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

S3 x L3 = 9

S3 x L2 = 6

S3 x L1 = 3

S5 x L3 = 15

S5 x L2 = 10

An Associated University Hospital of Brighton and Sussex Medical School

Objective 3 - Caring – Ensure patients are Initial Risk cared for and feel cared about Rating: Severity x Likelihood 3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and quality benefits.

S3 x L4 = 12

Objective 4 – Responsiveness – Become the secondary care provider for the catchment population 4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage pressures has a significant impact on the Trust's ability to deliver high quality care

Objective 5 – Well Led - become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model 5.1 Failure to deliver income plan 5. 2 Failure to stop divisional overspending against budget 5. 3 Unable to deliver realistic medium term financial plan 5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position 5.5 There is a risk we will fail to realize the strategic benefits of having an Achievement Review Process that effectively monitors and influences behaviour and performance. 5.6 If the Trust does not achieve authorisation as a Foundation Trust this would leave the Trust without local autonomy and an alternative organisational would be imposed leading to reduction in choice and focus on local health provision 5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems

2.3.

Current Risk Rating: Severity x Likelihood S3 x L5 = 15

Target Risk Score

S3 x L2 = 6

Initial Risk Rating: Severity x Likelihood

Current Risk Rating: Severity x Likelihood

Target Risk Score

S4 x L4 = 16

S4 x L2 = 8

Initial Risk Rating: Severity x Likelihood S5 x L3 = 15

Current Risk Rating: Severity x Likelihood S5 x L3 = 15

Target Risk Score

S5 x L3 = 15

S3 x L2 = 6

S5 x L3 = 15

Proposed 5 x 3 = 15

S4 x L2 = 8

S5 x L3 = 15

S4 x L3 = 12

S3 x L3 = 9

S3 x L2 = 6

S4 x L2 = 8

S4 x L1 = 4

S5 x L3 = 15

S4 x L3 = 12

S3 x L3 = 9

S4 x L2 = 8

Key risks Strategic risks Identified

The BAF highlights the following 6 key red risks (including proposed increase) to the Trust objectives that have been identified at time of updating the framework. These are: Risk description 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity to deliver the activity income that underpins the LTFM. 3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trust’s ability to maximize financial and

Current rating

Target risk score

S5 x L3 = 15

S5 x L2 =10

S3 x L5 = 15

S3 x L2 = 6

An Associated University Hospital of Brighton and Sussex Medical School

quality benefits. 4.1 Failure to maintain Emergency Department performance because of lack of capacity in health system to manage pressures has a significant impact on the Trust's ability to deliver high quality care 5.1 Failure to deliver income plan 5. 2 Failure to stop divisional overspending against budget 5. 3 Unable to deliver medium term financial plan 5. 4 Liquidity: Inability to pay creditors / staff resulting from insufficient cash due to poor liquid position

S4 x L4 = 16

S4 x L2 = 8

S5 x L3 = 15 S5 x L3 = 15 Proposed 5 x 3 = 15

S4 x L2 = 8 S3 x L2 = 6

S5 x L3 = 15

S4 x L3 =12

S4 x L2 = 8

3. Significant Risk Register The Executive Committee has reviewed and agreed the content of the significant risk register. There are now 8 risks on the Trust significant risk register. Each is in date and has mitigating actions to reduce the level of risk to an acceptable level. To note as part of the development of the BAF and financial papers, the finance team have reviewed the scores of the financial risks on the risk register relating to liquidity, delivery of financial plan and agency spend each of which will need to be reviewed by the Executive team before inclusion in the SRR. 3.1 SRR Breakdown ID

Title

Initial Rating 16

Current Rating 15

Residual Rating 9

Next Review 30/10/2015

1401

Risk of outbreak of viral gastroenteritis

1491

Failure to maintain Emergency Department performance

31/08/2015

1501

Patient admitted to the right bed first time

31/08/2015

1672

Increasing Sickness Absence Levels with impact on day to day management and expenditure Cancelled and / or delayed elective operations

31/08/2015

1688

Risk of potential overspending from operational pressures

31/08/205

1696

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

31/08/2015

26/08/2015

1678

1697

An Associated University Hospital of Brighton and Sussex Medical School

4. Discussion/Action This report brings together the BAF for the Trusts strategic objectives and the Significant Risk Register into one report. The Board is asked to discuss and approve the report and consider the following: • Review the BAF and its alignment to strategic objectives • Does the Board agree with the recorded controls and assurances • Approve the proposals to increase the BAF risk relating to delivery of medium term financial plan.

Paul Simpson Chief Finance Officer August 2015

Colin Pink Corporate Governance Manager

An Associated University Hospital of Brighton and Sussex Medical School

Appendix 1: Risk Appetite â&#x20AC;&#x201C; 2015/16 The Board of Directors has developed and agreed the principles of risk that the Trust is prepared to accept, seek and tolerate whilst in the pursuit of its objectives. The Board actively encourages well-managed and defined risk management, acknowledging that service development, innovation and improvements in quality requires risk taking. This position is based on the expectation that there is a demonstrated capability to anticipate and manage the associated risks as well. The key following principles further define this stance with an opinion from the Board: Quality: The quality of our services, measured by clinical effectiveness, safety, experience and responsiveness is our core business. We will only put the quality of our services at risk only if, upon consideration, the benefits of the risk improve quality are justifiable and the management controls in place are well defined and practicable. Target: Green Innovation: The Trust is highly supportive of service development and innovation and will seek to encourage and support it at all levels with a high degree of earned autonomy. We recognise that innovation is a key enabler of service improvement and drives challenge to current practice both internally and across the wider health economy. Target: Amber Well Led: The Board acknowledges that healthcare and the NHS operates within a highly regulated environment, and that it has to meet high levels of compliance expectations from a large number of regulatory sources. It will meet those expectations within a framework of prudent controls, balancing the prospect of risk reduction and elimination against pragmatic operational imperatives. The Board will seek to innovate and take risks where there is potential to develop inspirational leadership as it recognises that this is key to both becoming the local employer of choice and developing strategic partnerships with new bodies. Target: Green Financial: The Trust is prepared to invest for return and minimise the possibility of financial loss by managing risk to a tolerable level. The Board will take decisions that may result in an adverse financial performance rating in the face of opportunities that balance safety and quality and are of compelling value and benefit to the organisation. There will be an expectation of aggressive risk reduction strategies and increased scrutiny of mitigating actions. Target: Amber Reputation: The Board is prepared to take decisions that have the potential to bring scrutiny of the organisation, provided that potential benefits outweigh the risks and by prospectively managing any reputational consequences. Target: Green Workforce: The good will of our staff is important to the Trust. Any decision that places at risk staff morale and has the potential to adversely affect any aspect of the working life of our employees will be balanced very carefully against any potential consequent benefits and will only be considered if the inherent risk is low. The Board recognises the complications attached to recruitment and retention that are caused by geographical and national position and takes this into account when reviewing workforce related risks. Target: Amber 8

An Associated University Hospital of Brighton and Sussex Medical School

Appendix 2: SASH risk quantification matrix

An Associated University Hospital of Brighton and Sussex Medical School

Abridged consequence chart Risk Type Patient Safety

Insignificant • No obvious injury / harm

Minor

Moderate

• Non-permanent avoidable injury / harm requiring only first aid / minor treatment

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

Health & Safety

• Avoidable death

• Minor harm event involving >5 patients

• Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

• Major unsatisfactory patient experience • Upheld complaints regarding death in the related to poor treatment / care Trust

• Informal complaints raised / PALS contacted

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

• Legal action against the Trust initiated / • National media coverage / political action local media involvement against the Trust

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

• Care pathway problems resulting in • Care pathway problems resulting in medium term delays (up to 1 month) or 5medium term delays (1-6 months) or 1010 patients affected 20 patients affected

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

• No harm injury

• Short term / non-permanent injury / ill health. • Injury / ill health resulting in 0-7 days absence from work.

• Medical treatment required

• Permanent or extensive injury / ill health / permanent disability or loss of limb • Injury / ill health resulting in >7 days (RIDDOR reportable) absence from work or restricted duties for >7 days (RIDDOR reportable)

• Death (RIDDOR reportable)

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

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

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

• Suspension of services provided due to • Permanent removal of services and / or a failure to provide “well led” services as prosecution due to a failure to provide described by the CQC “well led” services as described by the CQC • Any issue that would have to be recorded in annual governance statement or annual report (e.g. significant issue “red risk” audit produced by Internal Audit)

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

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

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

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

Financial Management • Small loss <£1K Governance Arrangements

Quality of Service

Extreme

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

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

Patient 'Experience' & • No significant impact on patient Care Pathways and experience Involvement of • No complaints / concerns raised Service Users

Major

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

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

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

An Associated University Hospital of Brighton and Sussex Medical School

Page 1

Objective 1 - Safe â&#x20AC;&#x201C;Deliver safe services and be in the top 20% against our peers Priority ID and reference

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

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

Director responsible

Chief Nurse

Initial Risk Current rating

S4 x L3 = 12 S4 x L2 = 8

Target risk score

S4 x L1 = 4

Linked to Risk

1009,1055

Controls in place (to manage the risk)

Gaps in Control

1. Clinical teams to implement patient safety plans in the Trust (falls, pressure ulcers and infection control) 2. Regular review of patient safety data including the Safety Thermometer at divisional, executive and board level 3. Groups/Committee established including SQC, ECQR and its subcommittees, N & M and Divisional Governance. 4. Policies, procedures and guidelines provide the framework by which risks and incidents are managed. 5. Matron on site 7 days a week 6. Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) 7. Nursing staffing levels with daily real-time escalation 8. Incident reporting policy to be reviewed to include recent structural changes 9. Ward safety boards 10. Serious incident review group established to monitor and evaluate investigation progress and progress against actions 11. Training undertaken for clinical staff in the assessment and management of patients at risk of falls 12. Patient falls strategic group meet monthly and report KPIs to the patient safety and clinical risk committee. 13. System developed to split Trust and Community acquired VTE events

1) Developing and embedding ward safety dashboards 2) Updating and planning RCA analysis training for new managers/leaders 3) Embedding DATIX incident review process within 14 day timeframe

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

1) 2)

Positive (+) CQC Chief Inspector of Hospitals Report (+) CQC risk rating, lowest possible (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) QGAF assessment and action plan (+) New EWS trialed and audited (+) Increase in reporting trends (+) Meeting minutes and action plans, evidence of presentations and board discussion (+) Patient safety related KPI agreed and monitored at Board and Divisional Level (+) Datix incident reporting and analysis (+) Monthly trust wide reporting using national benchmarking (+) Falls Training data (+) Annual Falls Report 14/15 (+) Clinical Nurse Consultant for Falls and Patient Safety commenced 4 December 2014 (+) 15 Steps quality program

External reports and visits both scheduled and unscheduled Patient tracking and analysis (Whiteboard project)

Page 2

(+) Annual Falls report 2013/14 reduction in falls with harm in year (+) Resource focus on patient safety and falls (+) Evidence of improved SI investigation management and closures (+) Improved reporting of patient falls has enabled the Trust to understand fall profile and identify gaps in the falls management strategies available (+) Established links with falls team within community Negative (-) Never events incidence low (-) NRLS reporting

Gaps in assurance

Assurance Level gained: RAG

Ability to benchmark in real time

Mitigating actions underway

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

1) Develop Emergency Department falls pathway

Update by

Page 3

FA 14/08/15

Date discussed at board

Ongoing

To be discussed at August Board

Objective 1 - Safe â&#x20AC;&#x201C;Deliver safe services and be in the top 20% against our peers Priority ID and reference

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

1.A.1 Consistently meet national patient safety standards in all specialties and across divisions 1.2 Failure to maintain systems to control rates of HCAI will affect patient safety and quality of care

Controls in place (to manage the risk) 1)IPCAS Team and Group in place, Weekly taskforce in place 2)Infection control manual in place and information resources available 3)Antibiotic policy and guidelines in place 4)Daily (Monday to Friday) Infection Prevention & Control Nurses (IPC), to facilitate assessment and advice for infection control issues. 5)MicroApp implemented for antimicrobial stewardship guidelines 6)Consultant led RCA and presentation of HCAI (MRSA, MSSA, C. diff). This presentation is done in departmental meetings with IC doctor and Nurse attendance. This increases learning in the clinical team when compared to consultant attendance at IC meeting. 7) Discussion group being setup to discuss any lapses of care in C. diff cases. 8) Prevalence studies and Enhanced surveillance of catheter-associated UTI part of annual programme. 9) 3 ICE-POD units in place â&#x20AC;&#x201C; ED, HDU and Hazelwood. 10) Developed a system where site team and matrons during the weekend are responsible in checking wards that have received positive results (See 4 above) 11)Focus on risk and mitigation of VHF involving ED/Micro/ITU/PHE 12)Antibiotic Stewardship group revitalized 13)Decontamination group informing development of strategy for IPCAS 14)Policy on screening appropriate patients from abroad for CP Enterococci. Potential Sources of Assurance (documented evidence of controls effectiveness) 1)KPI indicators 2)Reducing numbers of cases of C. diff year on year 3)Divisional and departmental governance meeting minutes 4)Output of CCG and Trust meetings regarding lapses of care in C. diff cases

Director responsible

Medical Director

Initial Risk

S3 x L4 = 12

Current rating

S3 x L4 = 12

Target risk score S3 x L3 = 9 Linked to Risk 1049, 1050, 1401, 1514 Gaps in Control 1)Risk assessment of patients with diarrhoea is not consistent, in particular on admission and at first onset 2)Variation in line care demonstrated by audit 3)High bed occupancy can cause infection control risk to increase (e.g. side room availability)

Actual Assurances: Positive (+) or Negative (-) Positive (+)Incidence of CDI 2014/15 (-)0 MRSA BSI 2014/15 (+)Antimicrobial prescribing audit compliance (+)Actions taken as part of annual program (updated April 2015) (+) Recent CQC inspection highlighted improvements in MRSA screening (+)TDA visit inspecting controls and procedures (+)PHE and NHSE walkthrough ED for VHF risk provides good assurance

Negative (-)Period of increased incidence of CDI Godstone ward, typing suggests cross infection (-)Period of increased incidence of CDI Meadvale ward, typing suggests cross infection Page 4

Gaps in assurance Extensive auditing and monitoring in place. Trust position known

Mitigating actions underway 1) Roll out of Urinary catheter Passport 2) Full list of actions in IPCAS Annual Programme of work (2015/16) 3) Ongoing discussion with commissioners about penalties applying only to cases with poor/inadequate care. This conversation is nationally mandated 4) Considering implementation of two low risk C.diff Antibiotics (Sidoxamicin and Chloramphenicol IV) Update by Date discussed at Board DH 17/08/15

Page 5

Assurance Level gained: RAG

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Embedding 2) 2015/16 3) Ongoing 4) Under review To be discussed at August Board

Objective 2 - Effective â&#x20AC;&#x201C;Deliver effective and sustainable clinical services within the local health economy Priority ID and reference

2.A Achieve the best possible clinical outcomes for our patients

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

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

Director responsible

Medical Director

Initial Risk Current rating

S3 x L3 = 9 S3 x L2 = 6

Target risk score

S3 x L1 = 3

Linked to Risk

1460

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

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

Potential Sources of Assurance (documented evidence of controls effectiveness) 1. PROMS 2. Minutes of divisional meetings including M & M 3. Minutes of Clinical Effectiveness and Patient Safety and Risk subcommittees 4. Patient tracking and analysis (whiteboard project) 5. Datix reporting and analysis 6. Clinical Nurse Consultant for Patient Safety and Falls commenced 02/12/14 7. Results from National Clinical Audit Programme 8. Benchmarked reports from Academic Health Science Network Enhancing Quality and Recovery Programme 9. Reviewing all deaths proactively where coding wish to apply diagnostic code 10. Working with the 4 other successful Trusts in the TDA/Virginia Mason development program

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

Gaps in assurance Ability to benchmark in real time National Safety Dashboard to be implemented when available Mitigating actions underway

Positive (+) Sharing data through VM program with identified peers (+) CQC Chief Inspector of Hospitals Report

(+) CQC risk rating, lowest possible (+) The latest HSMR data shows overall Trust mortality is lower than expected for our patient group (+) CNST level 2 Maternity (+) Numbers of Hospital Acquired Pressure Ulcers reduced and sustained (+) MUST 100% (+) New EWS implemented (+) Increase in reporting trends (+) National falls data benchmarks favorably (Trust desire to improve position) Negative (-) Never events incidence (-) NRLS reporting (-) HSMR for low risk procedures is 198 Assurance Level gained: RAG

1) Development of ward based performance dashboards Update by Page 6

DH 17/08/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Start date 01/04/2015 To be discussed at August Board

Objective 2 - Effective â&#x20AC;&#x201C;Deliver effective and sustainable clinical services within the local health economy Priority ID and reference

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

2.B Deliver services differently to meet need of patients, the local health economy and the Trust 2.2 There is a risk that if the Trust does not deliver the planned efficiencies it will be unable to create the capacity desired to deliver transformational changes.

Controls in place (to manage the risk) 1) Local Transformation Board 2) 3x3 meetings 3) CEO strategic meetings 4) Partnership boards 5) Establish Frailty Service in community staffed with HCE Consultants to reduce need for readmission 6) White board project facilitates agreement and work towards agreed date of discharge. Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Contracts 2) Plans 3) Referral activity 4) GP Support 5) Breaking the cycle

Director responsible

Chief Operating Officer

Initial Risk

S5 x L3 = 15

Current rating

S5 x L3 = 15

Target risk score

S5 x L2 = 10

Linked to Risk

1221, 1480, 1601, 1405, 1547

Gaps in Control 1) Pathway redesign needs to ensure its appropriate and fit for purpose 2) Still to agree 15/16 contract with BICS 3) Repatriation of tertiary services effected and influenced by external factors 4) Medical Division plans to reduce length of stay (business case in early stages of preparation)

Actual Assurances: Positive (+) or Negative (-) Positive (+) Contract 14/15 signed with BICS (+) Internal audit of readmission figures provides positive assurance (+) Feedback following initial work on discharge process 2013/14 (+) Joint working with Royal Surrey County ( Chemo and Radiotherapy) (+) Pathology joint venture BSUH (+) Bowel screening (+) BOC respiratory unit (+) Initial work on repatriating Cardiology Lab (8 wk pause to support winter pressures) (+) Extended theatre working days Crawley (20% increase capacity)

Negative (-) Medically ready for discharge (100 pts vs target 90) (-) Nationally an outlier on emergency length of stay by 1 day (-) Unplanned increase in >1 LOS emergency admission patients (8% vs 2% plan) Gaps in assurance Assurance Level gained: RAG Agreed activity modelling across SECNational policy decisions and effective of general election Mitigating actions underway 1) CQC Action plan (Outpatient Action Plan) 2) Theatre efficiency action plan 3) Breaking the cycle and reducing LOS action plan 4) Implement transformation team Update by PB 19/08/2015 Page 7

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1)Ongoing 2)End of quarter 1 3)End of quarter 2 4)End of quarter 2 To be discussed at August Board

Objective 3 - Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about Priority ID and reference

3.B Deliver high quality care around the individual needs of each patient

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

3.1 The continuing challenge to recruit and retain clinical staff is impacting on the Trustâ&#x20AC;&#x2122;s ability to maximize financial and quality benefits.

Controls in place (to manage the risk) 1. Workforce KPIs including vacancy rates, turnover and temporary staffing monitored by Workforce subcommittee, Exec Committee and the Board 2. Monitoring of Safety Thermometer, patient experience and staff turnover, sickness at ward level 3. Planned versus actual staffing levels monitored on a shift by shift basis, reported daily by Matrons and issues escalated to DCNs with evidence actions taken 4. PMO in place to monitor agency use and progress of the five related work streams a. E-roster- migration to v10 approved b. Nursing recruitment plans developed by DCN and DCM in response to Right Staffing review and monitored through Agency PMO, Workforce subcommittee and divisional team meetings c. Recruitment process reviewed, KPIs under development to provide assurance d. Bank recruitment in progress to reduce use of agency nursing staff e. International recruitment undertaken but start date has been delayed. Further local and EU recruitment in progress. Monitored via temp staffing PMO f. Nursing temporary staffing utilization (hours/costs) monitoring using Base Usage Value reports monthly 5. SNCT/Birthrate Plus tool utilized to monitor patient acuity and dependency presented to relevant committees including Board to determine future staffing demand 6. Pilot site for Department of health project analyzing agency spend across all clinical staff groups 7. Work underway to develop SASH recruitment brand and retention strategy including the development of new nursing roles 8. SASH funded by HEKSS to develop and lead on physician associate training and recruitment for SEC 9. Foundation doctors workloads re-modelled such that 95% of time is spent with no more than 14 patients. 10. Strong relationship with HEKSS who place junior doctors in the Page 8

Director responsible

Chief Nurse and Medical Director

Initial Risk Current rating

S3 x L4 = 12 S3 x L5 = 15

Target risk score Linked to Risk

S3 x L2 = 6 770, 1295, 1580, 1652

Gaps in Control 1. E-Roster system is not updated out of hours 2. Unfilled agency shifts both nursing/midwifery and medical 3. The Trust still carries a volume of vacancies specifically within theatres 4. Imperfect induction for short notice, short term medical locums 5. Aiming for full nursing/midwifery and medical recruitment (influenced by HEKSS) 6. Medical trainees select a preference that affects the decision

organisation Potential Sources of Assurance (documented evidence of controls effectiveness) 1. Ward staffing templates monitored daily by Matrons and escalated to the Divisional Chief Nurses to ensure safe levels to meet patient needs. 2. Staff absence reports 3. % of vacant shifts filled by Trust and agency staff 4. Revalidation (GMC) for locums 5. Monitoring agency utilistation and spend at PMO

Actual Assurances: Positive (+) or Negative (-) Positive (+)SNCT data (+) Recruitment plans developed by ward and reported monthly (+) Matron for workforce recruited (+) International recruitment for nurses undertaken (+) CQC Chief Inspector of Hospitals Report - Good rating (+) Daily ward staffing review (+) Reports regarding reducing vacancy rates, sickness, absence (+) Incident reporting via Datix (+) Patient experience data by ward or unit (+) Junior Doctors feedback regarding quality of experience and breadth of exposure Negative (-)Benchmarked high proportion of agency staff usage against other Trustâ&#x20AC;&#x2122;s (-) Vacancy rates and turnover rates (-) Temporary staffing Internal Audit (-) Junior Doctors feedback relating to high workload

Gaps in assurance Trust position known - no identified gaps in assurance Mitigating actions underway 1. Continue to monitor effectiveness of recruitment plans 2. 7 day working plans for medical staff under development across the Trust 3.

Implement e-roster upgrade and utilize core functionality (bank and messaging)

4. Implement plans to manage staffing issues in Theatres 5. Increasing direct entry nursing students by 100% (40 to 80) from February 2016 Update by Date discussed at Board FA 14/08/2015 and DH 17/08/2015

Page 9

Assurance Level gained: RAG

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1. Ongoing 2. Being implemented 3. Embedding and under review 4. Being implemented 5. February 2016 To be discussed at August Board

4 - Responsive to peopleâ&#x20AC;&#x2122;s needs â&#x20AC;&#x201C; Become the secondary care provider of choice for the catchment population Priority ID and reference

4.A.1 Deliver access standards

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

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

Director responsible

Chief Operating Officer

Initial Risk Current rating

S4 x L4 = 16 S4 x L4 = 16

Target risk score

S4 x L2 = 8

Linked to Risk

1220, 1491

Controls in place (to manage the risk) 1) EDD Patient Pathway 2) Site management team and Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches on weekly to implement lessons learnt 5) Site Management Team and Discharge Team 6) Circa 50 additional community beds made available 7) 7 day medical consultant ward rounds established 8) Additional community beds 9) Tilgate annex opened providing extra surgical capacity th 10) 10 Theatre opened (May 15)

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

Potential Sources of Assurance (documented evidence of controls effectiveness) 1) NHS England aware 2) Combined weekly Quality and Performance Dashboard for ED reporting on a combination of quality and safety standards and the ED national indicators reported to exec meeting weekly 3) Performance Management Framework and reporting to Trust Board 4) External stakeholder inspections 5) Daily sit rep reporting to the TDA 6) Daily winter Sit Reps (Commenced November) Urgent Careboard Area Team. 7) Whole system operational resilience plans signed off for 14/15 8) 2020 whole system review of discharge process, reviewing recommendations 9) Clinical audit of clinical pathways which impact on reducing emergency re-admissions.

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

Page 10

Positive (+) MRD Summit June agreed map capacity available across Surrey and Sussex (+) ED Standard delivered March, April and May 2015 (+) Maintaining top 20% performance (+) Process improvement (+) Working with partners commissioners / partners to expedite flow through hospital (Medihome and community beds) (+) Top 20 patient delay weekly meetings (+) Monitoring and managing compliance #NOF, Stroke and medical outliers (+) Bed modelling refreshed including emergency demand increases Negative (-) ED standard not delivered June 2015 (-) Quality indicators for time to assessment / treatment. Surrey and Sussex local lead. (-) EDD Section 2 and section Patient tracking system (-) Number of patients safe to discharge at any one time (-) Adult Bed occupancy remains higher than plan due to increased activity Circa 100 medically fit for discharge patients (-) Local availability of Nursing home beds / ability to start complex packages of care (-)Unplanned increase in >1 LOS emergency admission patients (8% vs 2% plan)

Gaps in assurance Winter plans and local health economy position going into winter months Mitigating actions underway 1) 2) 3) 4)

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

Agreed breaking the cycle 2 encompassing internal and external bodies

Update by

Page 11

PB 19/08/15

Date discussed at Board

Assurance Level gained: RAG

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) July 2015 2) July 2015 3) Aug 2015 4) Sep 2015 To be discussed at August Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5.1 Failure to deliver income plan

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score Linked to Risk

S4 x L2 = 8 1689

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

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

Gaps in Control 1) Risk share agreement (for emergency activity) with Sussex CCGs and Sussex Community Trust cannot now be agreed – there is an ongoing discussion with Sussex CCGs over MRET adjustments. 3) Chief Officer meeting – meeting is proving more effective but streamlining of system resilience process is being discussed and that is not yet in place. The strategic management of activity is not currently effective, but the Trust is doing all it can to support making it so. 4) CCG plans make assumptions on activity reductions that are only partly adjusted in Contract plans – to be reviewed quarterly; 5) Activity growth above CCG assumptions, including market share, is referred to as an assumption in Activity Planning schedule – activity plans to be reviewed and amended quarterly; 6) Some actions long stopped to resolve – this includes payment for safer staffing, ambulatory attendance pricing and payment for hospital @ home services – not all deadlines have been met but all are in a process. 7) NHS England instruction for CCGs to increase volume of activity in plans not being applied to local CCGs, with NHS England agreement.

Actual Assurances: Positive (+) or Negative (-) Positive (+) 2014/15 activity and income met the Plan (noting that individual elements (e.g.: elective activity) did not) (+) Reconciliation process working with CCGs in 2014/15 and year end settlement achieved with all commissioners in 2014/15 with no outstanding disputes. (+) Contracts include clauses to allow inclusion of growth in indicative activity plans, and (vice versa) for any emergency activity reductions Negative (-) Risk over income growth assumptions. (-) Adverse income variance at M04 9although not worsening, and adjustment in forecast remains on track) (-) Monitor response to MRET complaint provided no useful application in 2015/16 (-) Too much non elective activity, not enough elective – risk over emergency demand in 2015/16.

Gaps in assurance Red at start of year because of level of risk and issues with strategic health system management of urgent care activity and transactional processes with CCGs. Page 12

Assurance Level gained: RAG

Mitigating actions underway 1) COO meetings have been held, COG updated and action plans being provided to manage urgent care activity better across the health system. 2) Complete all contractual commitments by long-stop dates (end date â&#x20AC;&#x201C; now Q21 reconciliation); 3) Revised forecast for exlective activity comepleted, now being monitored 4) Specific action around dermatology, diabetes and cardiology where there is underdelivery (and there is improvement in all these areas at M04) Update by Date discussed at Board PS 18/08/15

Page 13

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

To be discussed at August Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5. 2 Failure to stop divisional overspending against budget

Controls in place (to manage the risk) 1) Business Plans and budgets (activity and financial) savings / transformation plans 2) Divisional activity plans 3) Internal Performance Review (PMO) process and CEO review 4) Forecast scenarios presented to Board – a detail forecast was provided to Board in July and internal PMOs are based on that forecast. Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Financial performance and contractual reporting to Exec Committee, Finance & Workforce Committee and Trust Board UIN reporting process). 2) Performance Review (PMO) and Exec Quality and Risk process with Divisions, monthly contract cycle with CCGs. Service line reporting process 3) Outputs and reporting from contract and information teams 4) Output in financial reporting describes improvement and risk mitigation. 5) Agency PMO.

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score S3 x L2 = 6 Linked to Risk 1663,1688 Gaps in Control 1) Management of increased levels of emergency activity subject to review; 2) Investment in incremental changes to meet additional activity demand subject to review (at M04 budget changes have been made) 3) At M04 cost improvement plans are largely included in Divisional budgets but there is adverse performance on agency and escalation. Red rated savings have been partially mitigated. The forecast provides a £3.3m risk to savings delivery. Actual Assurances: Positive (+) or Negative (-) Positive (+) 2015/16 budgets were set based on the M06 2015/16 FOT and there will be a quarterly adjustment for activity changes (completed – and which improves the adverse variance significantly in Divisions) (+) Contingency reserve of £1.9m established and, after taking account of “must dos”, no commitments for investment to be made. Agreed with Board within the forecast that contingency will be applied to ameliorate overall position. Negative (-) Emergency activity pressures have continued to be greater than expected (-) Overall agency costs remain very high, with escalation still in use and significant. (-) At M04 there is significant overspending in Divisions and adverse delivery on the medical agency and escalation CIPs, and anticipated adverse performance on nursing agency as the year progresses. (-) The forecast describes significant risk to delivery of the Plan.

Gaps in assurance Assurance Level gained: RAG Overspending is the main area of risk and the ability of the Trust to reduce the rate of spend while maintaining services adequately. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) PMO/Performance structure continues - Divisions have been required to produce recovery plans Actions proceeding to timetable and PMO meetings have become weekly for Medicine, likely for Surgery too. 2) Controls are being exercised in divisions and centrally – vacancy restriction and non clinical procurement.. Update by

Page 14

PS 18/08/15

Date discussed at Board

To be discussed at August Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

5. 3 Unable to deliver medium term financial plan

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score S4 x L2 = 8 Linked to Risk 1603 Controls in place (to manage the risk) Gaps in Control 1) Items referred to in 5.A.1 and 5.A.2 above 1) Items listed above (5.A.1, and 5.A.2) are applicable here 2) V7.0 long term financial model and integrated business plan 2) Lack of alignment between CCG activity plans and actual performance. 3) Reliance on centrally determined rules for PbR, Better Care Fund and the completed (submitted to Monitor in April 2015) 3) TDA Plan submitted in April 2015 wider NHS finance regime. 4) Board to Board held with the TDA in November 2014, Monitor 4) Risk over capacity from other operational pressures 5) Process being initiated (M02) with health system partners to provide overall assessment now in train culminating in Monitor Board to Board in health system financial view (Chief Officer’s Finance Sub-Group) – that is now June 2015. 5) Cost improvement plan process in place (including PMO structure) complete and it describes significant loss of resource to BCF funding – this 6) Elective/outpatient activity growth and income plan in place – reduces resource available for health and social care overall. 6) Lack of clarity over tariff assumptions for 2016/17 – this is crucial to medium capacity created 7) Contracts with CCGs allow for payment for “over performance” term planning 7) Central actions over managing NHS overspending are being developed that may have an impact on Trust financial planning assumptions Potential Sources of Assurance (documented Actual Assurances: Positive (+) or Negative (-) evidence of controls effectiveness) 1) Delivery of 2014/15 financial position and delivery of Positive 2015/16 financial plan (+) Delivery of performance in 2014/15 (noting a deficit was recorded, but position was as forecast) 2) Production of 2016/7 budget, revised long term financial Negative model and integrated business plan documentation, and (-) alignment with CCG plans is not complete with significant variances between actual performance on delivery against them activity and CCG plans. (-) overall health system loss of resource Overall, on basis of current assumptions, RAG has turned red with the impact of urgent care activity and the level of risk to the forecast. Assurance RAG red. Gaps in assurance Assurance Level gained: RAG Central action sto manage costs across the NHS are not yet clearly described and the tariff is not yet defined. Mitigating actions underway

Please see items above. Additional CIP contingency is identified, more is being sought. Letter has been sent to Monitor advising on review of current position and re-joining assessment process when more information is known about the tariff. The 2016/17 budget process will begin in September. Update by

Page 15

PS 18/08/15

Date discussed at Board

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

To be discussed at August Board

Objective 5 – Well Led Priority ID and reference

5.A Live within our means to remain financially sustainable

Key Action for 2014/15 objectives and description of any potential significant risk to this priority

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

Director responsible

Chief Finance Officer

Initial Risk Current rating

S5 x L3 = 15 S5 x L3 = 15

Target risk score

S4 x L3 = 12

Linked to Risk

1604

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

Gaps in Control 1) No agreement on medium term solution to liquidity – being pursued during 2015/16 – a loan application has been drafted and submitted, but has not been actioned. 2) Contractual over-performance may see delay means delay in receiving cash payments to match accrued income from CCGs

Potential Sources of Assurance (documented evidence of controls effectiveness) 1) Twice monthly reporting to CFO by finance team, SBS reporting on bank balance 2) Monthly finance reporting to Executive Committee, Finance and Workforce Committee and Trust Board 3) Confirmation of working capital injection (either through a loan, working capital facility or, if available, PDC)

Actual Assurances: Positive (+) or Negative (-) Positive (+) Cash targets met in 2014/15 (+) Liquid ratio has followed expectations (+) Cash has been managed well in 2015/16 to date, largely as a follow on from income agreements with CCGs at end of 2014/15 and capital slippage Negative (-) no confirmed additional cash to resolve underlying liquidity problem – can only be resolved in FT application process (through a working capital loan) and which is now paused (-) cash flow dependent on financial outturn described in 5.A.1 and 5.A.2 above. Overall rating “red” noting risk to forecast I&E. Assurance RAG "amber" - no current cash problem but underlying problem unresolved.

Gaps in assurance Assurance Level gained: RAG In terms of cash flow management to end year, no material gaps in assurance. In terms of resolving the actual risk (liquidity), there is no confirmation of additional cash to resolve SoFP weakness. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Day to day cash control is main action currently, coupled with actions to maintain service income and Actions proceeding to timetable manage spend 2) Long term financial model, and TDA plan now provides additional validation of the level of cash injection required and the interaction from an improving financial position within the model 3) Discussion will continue with the TDA as the FT timeline progresses. Update by Date discussed at Board PS 18/08/15 To be discussed at August Board

Page 16

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

5.E We are an organisation that is clinically led and managerially enabled. Key Action for 2015/16 objectives 5.5 There is a risk we will fail to and description of any potential realize the strategic benefits of significant risk to this priority having an Achievement Review Process that effectively monitors and influences behavior and performance. Controls in place (to manage the risk) 1) 2)

3) 4) 5) 6)

New Achievement Review Policy with implementation /communication and training plan. Personal objectives are being linked to Trust/Divisional and team objectives and the SMART methodology is being used to assess performance New AR process includes assessment of Behaviours against Trust value Personal Development Plans as part of AR identify development needs Training Need’s Analysis at Divisional level extrapolated to Trust level inform strategic planning of development priorities. AR Task and Finish group continues to embed new process and implement for medical staff during 2015/16

Director responsible

Director of Human Resources

Initial Risk Current rating

S3 x L3 = 9 S3 x L3 = 9

Target risk score

S3 x L2 = 6

Linked to Risk

910, 1674

Gaps in Control 1) 2) 3) 4)

new system yet to reap full benefits activity levels in the Trust affecting capacity for compliance change to annual timetable with delivery in first part of financial year yet to embed an agreed model for medical and dental Achievement Review yet to be agreed.

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

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

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

Gaps in assurance

Assurance Level gained: RAG

New AR process is yet to provide any evidence that demonstrates mitigation of this risk or completion of AR’s

Mitigating actions underway 1) 2) 3) 4)

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

Series of training courses to support implementation commenced and will run throughout 2015/16 T&F to support development of AR for Doctors and dentists – acceptance that AR process needs to be the same across all staff groups Trust wide culture champion launch to include significant focus on the trust values and behavioural anchors Establish process for annual performance review to identify and talent map for Medical Dental, 8a’s and above

Update by

Page 17

18/08/2015 JM

Date discussed at Board

1) 31 March 2016 2) 30 October 2015 3) Complete and ongoing 4) February 2016

To be discussed at August Board

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

5.G.2 We are a well governed organisation

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

5.6 If the Trust does not achieve authorisation as a Foundation Trust this would leave the Trust without local autonomy and an alternative organisational would be imposed leading to reduction in choice and focus on local health provision.

Controls in place (to manage the risk) 1) Successful outcome from the formal Monitor assessment process 2) Achievement of FT project plan milestones 3) Formal approval by TDA Board to move to Monitor assessment phase target 4) Successful elections to the Council of Governors 5) FT Project Board 6) Implementation of Board development programmer Potential Sources of Assurance (documented evidence of controls effectiveness) 1) LTFM agreed by the Board 2) Submission of Integrated Business Plan to TDA & Monitor 3) Public Consultation completed with positive outcome 4) QGAF External assessment completed with implementation of action plan 5) TDA Formal approval to move to the Monitor stage 6) Chief Inspector of Hospitals Inspection 7) Elections to Shadow Council of Governors 8) HDD to be completed as part of Monitor phase 9) Submission of Monitor information requests

Director responsible

Director of Corporate Affairs

Initial Risk Current rating

S4 x L2 = 8 S4 x L2 = 8

Target risk score

S4 x L1 = 4

Linked to Risk

1531

Gaps in Control No significant gaps in control identified

Actual Assurances: Positive (+) or Negative (-) Positive (+) Completion of Monitor pre-assessment phase (+) Monitor formal assessment underway (+) Election to the Council of Governors complete with all seats filled (+) FT membership over 10,000 st (+) Monitor Exe to Exe Challenge took place on 1 June 2015 (+) External assessment of QGAF score 3.5 (+) Quality Governance Memorandum submitted to Monitor with score of 2.0 (+) Monitor to review and confirm timescales & remainder milestones (+) Monitor confirmed QGAF score as 3.5 â&#x20AC;&#x201C; Further actions being implemented

Gaps in assurance Completion of Historical Due Diligence Mitigating actions underway 1) Elections to the Council of Governors completed in July 2015 and shadow Council being set up 2) Monitor formal assessment in progress Update by Date discussed at Board GFM 04/08/15

Page 18

Assurance Level gained: RAG

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Ongoing 2) Plans are on track To be discussed at August Board

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

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

5.F. Ensure IT support/optimise patient experience by improving patient interface, sharing and capture of patient information and patient communication 5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems

Controls in place (to manage the risk) 1) Move to direct contract with Cerner now happened and Trust has exited NPfIT well ahead of schedule 2)IT Strategy aligned with Clinical Strategy and IBP and reviewed Oct 14 3) Clinical Informatics Group 4) Clinical IT leads 5) Various project groups (EPMA etc.) 6) Project management controls (Descried in Internal Audit of project management) 7) EPR costs identified in LTM 8) CCIO and CNIO roles being implemented – greater clinical buy-in 9) Cerner Optimisation Group now in place 10) IT Road Map presented to FWC and Executive Potential Sources of Assurance (documented evidence of controls effectiveness) Efficiencies being delivered through IT enabled change

Director responsible

Director of Information and Facilities

Initial Risk

S5 x L3 = 15

Current rating

S4 x L3 = 12

Target risk score

S3 x L3 = 9

Linked to Risk

1428, 999, 1483

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

Actual Assurances: Positive (+) or Negative (-) Positive (+) Improving infrastructure (e.g. Wi-Fi move to Windows 7) (+) Development of existing EPR platform (e.g. EPMA and move to Cerner) (+) EPR Contract signed and data center move finished (+) Business Continuity System now in place (7/24)

Gaps in assurance Trust position known, no identified gaps in assurance

Assurance Level gained: RAG

Mitigating actions underway 1. Procurement of replacement EPR as national contract ending November 2015 - contract signed and implementation commenced 2. Establishment of Chief clinical Information Officer role 3. Clinical Cerner Optimisation Group now in place with strong leadership 4. Greater focus on IT in Capital Plan for 2015/16 and future years

Update by Page 19

IM 18/08/15

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. EPR Contract awarded October 2014 – preferred supplier now selected. 724 Go-live November 2014. PC Upgrade plan in-place, funded and business continuity almost complete Network review first draft now complete and action plan being prepared. To be discussed at August Board

Appendix 1

Page 20

Abridged consequence table taken from Trust guidance

Risk Type Patient Safety

Insignificant • No obvious injury / harm

Minor • Non-permanent avoidable injury / harm requiring only first aid / minor treatment

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

Health & Safety

• Avoidable death

• Minor harm event involving >5 patients

• Moderate harm event involving >5 patients

• Major harm incident involving >5 patients

• Minor unsatisfactory patient experience related to treatment / care given

• Unacceptable patient experience related to poor treatment / care

• Major unsatisfactory patient experience • Upheld complaints regarding death in the related to poor treatment / care Trust

• Informal complaints raised / PALS contacted

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

• Legal action against the Trust initiated / • National media coverage / political action local media involvement against the Trust

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

• Care pathway problems resulting in • Care pathway problems resulting in medium term delays (up to 1 month) or 5medium term delays (1-6 months) or 1010 patients affected 20 patients affected

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

• No harm injury

• Short term / non-permanent injury / ill health. • Injury / ill health resulting in 0-7 days absence from work.

• Medical treatment required

• Death (RIDDOR reportable)

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

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

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

• Adverse Monitor continuity of service rating <1 month

• Adverse Monitor continuity of service rating > 1 month

• A breach of Monitor Terms of authorisation

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

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

Financial Management • Small loss <£1K Governance Arrangements

Quality of Service

Extreme

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

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

Patient 'Experience' & • No significant impact on patient Care Pathways and experience Involvement of • No complaints / concerns raised Service Users

Major

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

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

Page 21

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

Patient Safety Involvement of Service Users

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

If the Trust does not maintain and improve ability to allocate the right bed first time there is an increased risk of receiving poor quality of our care (effectiveness, experience and safety)

1) Operational meeting three times a day chaired by Chief / Deputy Chief Operating Officer with clinical involvement from Matrons, Nurse Specialists and therapists 2) Daily Board rounds by clinical site team. Focusing on #NOF, Stoke and Medical outliers 3) Live 'To come In' lists available to view in all specialty wards to encourage active pull of patients from AMU to the correct specialty bed 4)Matrons walk round 5) Additional screens arriving to reduce chance of mixed sex accommodation breaches during winter pressures 6) Matron on site 7 days a week

Treatment Plan

Done date

31/03/2013 30/06/2013 01/04/2013 02/09/2013 31/03/2014 31/03/2013 20/03/2015 01/03/2015 22/09/2014 31/03/2014 30/03/2013 25/09/2013 31/01/2013

06/12/2013 26/07/2013 26/07/2013 02/09/2013 11/02/2014 06/12/2013

As described on the board assurance framework

31/03/2014

5 15

30/10/2015

31/08/2015

4 16

As described on BAF Reviewing compliance to establish a key baseline target

22/09/2014 21/05/2014 26/07/2013 25/09/2013 26/07/2013

Next Review

Due date

Develop RAG rated system for terminal cleaning Audit terminal cleaning Implement ATP testing Dedicated internal norovirus planning meeting. Use of red aprons during outbreaks of D&V Meeting with stakeholders regarding norovirus preparedness Audit of post-outbreak cleaning Pilot Patient Hand Hygiene Champions in Elderly Care Stakeholders meeting to discuss health system norovius planning Monitor use of ED risk assessment for patients admitted with diarrhoea and/or vomiting Monitor ward refurbishment programme Stakeholder norovirus study day Prepare options appraisal for emptying bays to facilitate terminal cleaning following outbreak

Residual Rating

Current Rating

Current Likelihood

5 15

1) EDD Patient Pathway 2) Discharge management 3) Plans for escalation areas agreed and management tools in place 4) Reviewing all breaches on weekly to implement lessons learnt

Patient admitted to the right bed first time

Current Consequence

Existing controls D&V policy Hydrogen peroxide system for terminal cleaning Use of Actichlor Plus for environmental cleaning Use of Tristel Jet for commode and bed pan cleaning Use of SEC Norovirus Toolkit Outbreak control Group Surveillance of diarrhoea and vomiting Red aprons system Stat and mandatory training Policy Communications messages to staff, visitors and patients Norovirus leaflets Hand hygiene facilities Restricted visiting Use of signs at entrance to wards and bays, and red aprons to facilitate communication that an outbreak is taking place.

Failure to maintain Emergency Department performance

Involvement of Service Users

Holden, Des - Medical Director Bostock, Paul - Chief Operating Officer Bostock, Paul - Chief Operating Officer

Medical Director's Office Operations Operations

CORP CORP CORP

23/01/2013 29/08/2013 19/09/2013

Safety Responsiveness Responsiveness

1401 1491 1501

Description Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on patient safety and trust reputation. Has operational impact due to bed closures.

Initial Rating

Risk Type

Risk Owner

Specialty

Directorate

Open Date

Committee

Title Risk of outbreak of viral gastroenteritis

27/06/2014 31/08/2015

31/03/2014

31/08/2015

Staffing - general

Continuing risk to the delivery of effective services and Trust Strategic Objectives caused by the resources required to actively manage the Trusts rising Sickness Absence rate and ensure safe services. This is also having a significant effect on the ability to control the Trusts temporary staffing costs.

Firstcare real time sickness absence monitoring reports and daily updates to managers inbox. Daily sit reps at ward level used to ensure shift by shift safe levels of service. eRostering software to manage rota's prospectively. Agency PMO.

Financial Management Financial Management

Actions described in the Agency PMO Focused interventions to support the Trust's Stress Management Policy (Anxiety/Stress/Depression has been highest reason for absence for past 8 months)

31/08/2015

Manage the number of IPs booked on lists to avoid cancellations Improve Theatre Utilisation Ring-fencing of Tandridge and Woodland Wards

31/03/2015 31/08/2015

5 15

1. Access Policy revised 2014 2. Weekly PTL / performance meetings to monitor progress. 3. Plans to increase elective surgery from May, with an additional theatre and ward approved and on track.

Service Access

Cancelled and / or delayed elective Due to on-going operational pressures and operations increasing demand for emergency inpatient beds, elective inpatient surgery is being cancelled and / or postponed. Longer waiting times result in poor patient experience and increase the number of formal and informal complaints.

Financial Management

Hare, Natasha - Assistant Director, Clinical Services - Parker, Yvonne - Director of Human Surgery Resources Simpson, Paul - Chief Financial Officer Simpson, Paul - Chief Financial Officer Simpson, Paul - Chief Financial Officer

HR - Workforce Admissions / Waiting List Finance - Fin. Management Finance - Fin. Management Finance - Fin. Management

CORP SURG CORP CORP CORP

01/02/2015 23/03/2015 20/05/2015 11/06/2015 11/06/2015

Workforce Responsiveness Executive Committee Executive Committee Executive Committee

1672 1678 1688 1696 1697

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

27/02/2015 20/06/2015 15/05/2015

5 15

09/02/2015 05/08/2015

31/08/2015

Risk of potential overspending from Risk of failure to meet the Trusts financial plan due i) Divisions to implement action plans and contingencies to control/or recover operational pressures to overspending. overspending. Specific action is required in all Divisions. ii) Divisions to take action to improve length of stay (being discussed at Execs in June) iii) Action on medically Ready for Discharge patients is being taken forward with health system partners.

31/08/205

Risk from agency overspending

4 16

Risk of failure to achieve financial plan as a result CIP PMOs and nursing agency PMO to deliver outputs in respect of reduced of overspending on agency staff agency usage following recruitment. Position being reviewed (ongoing).

31/08/2015

Financial risks linked to National Risk of failure to meet the financial plan as a result Quality Board Paper, 7 day working of a) increased costs to deliver staffing ratios, 7 and Carter productivity report day costs and expectations detailed in national guidance and plans, and b) failure to deliver adequate adjusted treatment index (Carter).

4 16

The Trust has set aside reserve budget for the cost of proposals to increase nurse/midwifery staffing, but this is funded partly by income from CCGs, which is not secure. 7 day working is already in place partially (part of the forecast). Additional nursing staff to deliver agreed ratios have been agreed, with implementation spread over 2 years and recruitment starting when agency is at acceptable levels.

Review and develop plans; to brief the Board on progress against risks of establishment targets not being met and any potential action to review the Board's decision on implementation.

5 15

30/09/2015

26/08/2015

TRUST BOARD IN PUBLIC

Date: 27.8.15 Agenda Item: 2.1

REPORT TITLE:

SI with missing theatre specimen

EXECUTIVE SPONSOR:

Dr Des Holden (MD)

REPORT AUTHOR (s):

Des Holden and Fiona Allsop

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

N/A

Action Required: Discussion (√) Purpose of Report: To inform the Board of work designed to reduce risks of clinical specimens not arriving in pathology laboratories. Summary of key issues The Board has previously heard presentations of surgical never events with wrong operation performed. In the case presented here the removal of a gall bladder by laparoscopic (minimal access surgical approach) was correctly performed but no specimen arrived for histological analysis in the laboratories. By the time this was discovered it was not possible to go back and find the organ. At the time this was the fourth incident of its type. A specimen group was set up and made and carried out recommendations strengthening specimen sign out procedures in theatres. Since then there have been no further such incidents from theatres but there have been two further sample losses from out-patients. Dr Julian Webb has re-convened the specimen group and is now extending its remit to all areas from which ‘wet’ specimens requiring histological analysis might be sent.

Recommendation: To discuss incident and to receive a report in 6 months from Dr Julian Webb Chief of Safety on procedures and safeguards put in place to make processes as reliable as possible. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about Corporate Impact Assessment: Legal and regulatory impact

Relevant to regulation

Financial impact

minor

Patient Experience/Engagement

Poor experience for patient and family

Risk & Performance Management

Relevant particularly in relation to patient discharges and use of discharge lounge

NHS Constitution/Equality & Diversity/Communication Attachment:

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT â&#x20AC;&#x201C; (27.8.15) Incident Description On Thursday 21st November 2013, a routine laparoscopic cholecystectomy was performed in theatre 9. This particular surgical list was being used as a master class for the teaching of regional blockade by the anaesthetists. This was not an unusual occurrence and the theatre staff on duty had experienced this before. The gall bladder was excised without complication and the specimen was received in a retrieval bag through a laparoscopic port. The scrub nurse recalls preparing to hand the specimen to the healthcare assistant but as she was engaged in another task, and she was required back at the operating table, she put the specimen on her trolley to pot later when the healthcare assistant was available. The operation finished and the trolley was cleared except for the specimen pot. The scrub nurse checked the details on the histology form with the label on the pot and once she had helped the scrub nurse prepare for the next case, she entered the details in the specimen book and prepared the pot for collection. Other than the failure to place the specimen in the pot the correct procedure was used for the labelling and transfer of the specimen. The specimen pot was signed out of theatres and was received in histopathology the same day. On Friday 22nd November 2013, the pot was opened in the laboratory and was found to be empty. This was the fourth specimen to go missing in less than a year. Root Causes In this case, there was a delay in the potting of the specimen once collected, due to other tasks being performed during a very busy theatre list and this resulted in an empty pot being dispatched to histopathology. In the previous cases, the only commonality was that three of the cases involved laparoscopic surgery. Of the four cases, two were in opaque pots, one in a transparent pot. The 4th pot remains unknown. Recommendations The sign out procedure within theatres for the potting of specimens needs to be more robust. A working group, made up of the members of this investigation team, to consider the level of risk of similar events occurring in other areas of the Trust.

What we have done A stock take of progress was completed in June 2015. This found that considerable work on SOPs in theatres and in endoscopy had taken place and an update of the transport policy which would extend to the transport of pathology specimens was available in draft form. However the review found evidence that occasional mislabeled or even empty pots still arrived in pathology reception, timings of collection of specimens from clinical areas presented some operational problems within the pathology laboratory, porters are not trained specifically in the process or risk (clinical) in relation to specimen transport. New actions Jane Weston who chaired the original specimen group has retired and although the group elected Mike Rayment as its chair in the interim the make-up of the group as now meets is 3 An Associated University Hospital of Brighton and Sussex Medical School

not constituted with enough authority to ensure the right actions are taken an added safety is achieved. For this reason the group will be chaired by Dr Julian Webb, Chief of safety, have stronger nursing representation, and will work to time scale that delivers safer processes through training and audit by the end of this financial year. The board should receive a report from the MD, or the Chief of safety in February or March 2016 to assure itself that further progress and safety has been achieved.

Dr Des Holden Medical Director August 2015

4 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 27 August 2015 Agenda Item: 2.2

REPORT TITLE:

Chief Nurse & Medical Director Report Fiona Allsop, Chief Nurse Des Holden, Medical Director Fiona Allsop, Chief Nurse Des Holden, Medical Director

EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

N/A

Action Required: Approval ()

Discussion (√)

Assurance (√)

Purpose of Report: To provide an update on continuing work in relation to safe and quality focussed patient care that sits outside the operational performance reports including monthly Safer Staffing information and exception reports. Summary of key issues     

The Safer Staffing report (July 2015 data) indicates that the Trust has delivered the planned versus actual staffing levels in the inpatient areas and maternity unit against existing template. The recent advice received on Agency Spend is also outlined Four consultant Radiologists offered fixed term contracts Further action in relation to CDI diarrhoea QIA of CIP with higher risk scores has taken place

Recommendation: To note the report. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment: Legal and regulatory impact

Yes

Financial impact

Yes

Patient Experience/Engagement

Yes

Risk & Performance Management

Yes

NHS Constitution/Equality & Diversity/Communication

Yes

Attachment:

2 An Associated University Hospital of Brighton and Sussex Medical School

Chief Nurse/ Medical Director Report – 27 August 2015 Chief Nurse Report 1. Introduction To provide an update to the Board on nursing staffing in relation to planned versus actual staffing, a summary of recent changes to National Institute for Clinical Excellence (NICE) guidance in relation to safer staffing for nursing and the impact of DH advice regarding agency staffing spend. 2.

Staffing Planned versus Actual – July 2015

Ward

Ward Specialty

Entries

RN Day

RN Night

NA Day

NA Night

Total Day

Total Night

Overall

Abinger Ward

430 - GERIATRIC MEDICINE

89.63%

98.33%

95.84%

97.14%

92.92%

97.69%

94.59%

Acute Medical Unit

300 - GENERAL MEDICINE

92.79%

97.7%

86.89%

98.39%

91.08%

97.95%

94.14%

Birthing Centre

501 - OBSTETRICS

95.16%

88.71%

N/A

95.16%

88.71%

91.94%

Bletchingley Ward

300 - GENERAL MEDICINE

93.2%

98.06%

97.31%

98.39%

95.18%

98.21%

96.26%

Brockham Ward

502 - GYNAECOLOGY

92.09%

97.47%

90.67%

97.56%

91.63%

97.5%

93.93%

Brook Ward

100 - GENERAL SURGERY

100%

97.87%

100%

99.3%

100%

99.6%

Buckland Ward

101 - UROLOGY

96.01%

94.83%

98.46%

89.66%

96.78%

92.24%

95.15%

Burstow Ward

501 - OBSTETRICS

82.99%

67.74%

83.73%

93.55%

83.24%

78.06%

80.89%

Capel Annex l Ward

100 - GENERAL MEDICINE

97.59%

93.55%

100%

96.77%

98.62%

95.16%

97.37%

Capel Ward

430 - GERIATRIC MEDICINE

86.25%

91.4%

97.69%

95.16%

89.73%

92.9%

91.1%

Chaldon Ward

300 - GENERAL MEDICINE

90.16%

93.55%

95.7%

96.69%

92.63%

95.1%

93.54%

Charlwood Ward

301 - GASTROENTEROLOGY

84.16%

100%

81.19%

91.84%

83.1%

95.88%

87.44%

Copthorne Ward

301 - GASTROENTEROLOGY

96.21%

95.16%

97.88%

98.39%

96.77%

Coronary Care Unit

320 - CARDIOLOGY

93.41%

98.33%

200%

82.76%

95.7%

93.26%

94.51%

Delivery Suite

501 - OBSTETRICS

90.32%

91.94%

81.7%

88.71%

88.17%

91.13%

89.65%

Discharge Lounge

300 - GENERAL MEDICINE

91.52%

100%

93.31%

100%

92.39%

100%

95.07%

Godstone Ward (Haem)

303 - CLINICAL HAEMATOLOGY

100%

N/A

100%

Godstone Ward (Med)

300 - GENERAL MEDICINE

94.66%

100%

91.94%

98.39%

93.58%

99.19%

96.07%

Holmwood Ward

320 - CARDIOLOGY

95.32%

100%

93.33%

98.39%

94.76%

99.19%

96.38%

ITU/HDU

192 - CRITICAL CARE MEDICINE

98.1%

97.45%

92.95%

96.77%

97.37%

97.4%

97.39%

Leigh Ward

110 - TRAUMA & ORTHOPAEDICS

94.03%

90.32%

90.69%

90.32%

92.6%

90.32%

91.83%

Meadvale Ward

430 - GERIATRIC MEDICINE

92.2%

100%

98.39%

95.49%

99.19%

96.78%

Neonatal Unit

420 - PAEDIATRICS

94.65%

98.37%

91.79%

89.83%

93.79%

95.6%

94.68%

Newdigate Ward

110 - TRAUMA & ORTHOPAEDICS

91.8%

103.23%

96.55%

79.03%

93.81%

91.13%

92.91%

3 An Associated University Hospital of Brighton and Sussex Medical School

Nutfield Ward

430 - GERIATRIC MEDICINE

93.14%

100%

99.27%

100%

95.38%

100%

96.94%

Outwood Ward

420 - PAEDIATRICS

95.9%

94.54%

89.54%

74.29%

95.06%

91.28%

93.35%

Rusper Ward

501 - OBSTETRICS

92%

90%

100%

N/A

92.08%

90%

91.3%

Surgical Assessment Unit

100 - GENERAL SURGERY

95.16%

85.48%

96.77%

93.55%

95.48%

89.52%

92.83%

Tandridge Ward

300 - GENERAL SURGERY

92.15%

98.39%

88.97%

90.32%

90.78%

94.35%

92.08%

Tilgate Annex

100 - GENERAL MEDICINE

94.61%

91.3%

95.7%

96.77%

95.02%

93.51%

94.44%

Tilgate Ward

300 - GENERAL MEDICINE

95.48%

98.81%

94.2%

96.43%

95%

98.21%

96%

Woodland Ward

100 - GENERAL SURGERY

92.23%

96.67%

103.16%

95%

96.07%

95.83%

95.99%

93.28%

95.24%

94.26%

94.41%

93.61%

94.94%

94.14%

Total

Commentary The Trust has delivered planned versus actual staffing profile for July. The continued variance on Burstow Ward is due to staffing shortfalls in the maternity service and has been actively managed by the matrons with no adverse outcomes in relation to clinical care. The Delivery Suite has experienced staffing pressures this month in addition to increased activity in month. There has been a successful recruitment campaign and the division is over recruiting against base establishments to manage predicted shortfalls in t h e a u t u m n .

Nursing Agency Spend Rules Further to last monthâ&#x20AC;&#x2122;s report the TDA and Monitor circulated draft rules for nursing agency spend. Feedback to them was requested by 20 August which has been provided. Medical Directors Report 3.

Strengthening numbers and skills within Radiology

Since last Trust Board we have held our first Skype interviews for doctors working abroad and offered 4 candidates fixed term contracts, with a view to substantive appointment, of 12 months each. The candidates had been identified by a commercial partner and we were able to have discussions with doctors currently working in Canada, Egypt and the Middle East, and explore their specialist interest of Paediatrics, Breast imaging and general cross sectional imaging. We are still involved in the process and would like to build further strengths around leadership and interventional radiology skills through this round of appointments. 4.

External help with CDI.

Our infection control team has met with the TDA lead for infection control. Approximately two thirds of trusts in south of England are above trajectory for CDI numbers and no new insights were achieved that we as a trust are not already pursuing. Nonetheless we have refreashed our strategy for assessment and management of diarrhea with an emphasis on medical and nursing staff at ward level owning the pathway of care, with the site team helping with the challenge of isolation when deemed necessary. In addition we have worked with Groundvision to develop an electronic diarrhea EWS which prompts timely

4 An Associated University Hospital of Brighton and Sussex Medical School

action and can escalate lack of response. This will be trialed on up to 6 wards and if possible in the site team offices through September.

Review of 2015-16 CIPs deemed high risk (quality impact) at year start.

The Board will remember that unlike last financial year several of the proposed CIPs for 2015-16 had risk scores for adverse impact on quality of 6-9. These schemes were identified at the start of implementation as requiring early formal review (after three months rather than after the 6 months when all schemes would have routine follow up QIA). This review has occurred this month and in each case involved Chief Nurse, medical director, senior member of the finance team, and the owner of the relevant CIP. All schemes were held either in Pharmacy or in procurement. At the present time there has been no adverse impact where schemes have started, though by their nature it might be that some consequences would need time to develop. For some, national and international published evidence has allowed us to reduce the risk score attributed to the CIP. Some schemes have not started for instance because agreement is yet to be reached with external partners or commissioners. For these there has been no impact on quality as a consequence of the scheme.

Recommendation

To note the report

Fiona Allsop Chief Nurse August 2015

Des Holden Medical Director August 2015

5 An Associated University Hospital of Brighton and Sussex Medical School

Date: 27th August 2015

TRUST BOARD IN PUBLIC

Agenda Item: 2.3 REPORT TITLE:

SQC Richard Shaw, Chair Safety & Quality Committee Richard Shaw, Chair Safety & Quality Committee

EXECUTIVE SPONSOR: REPORT AUTHOR (s): REPORT DISCUSSED PREVIOUSLY: (name of sub-committee/group & date)

n/a

Action Required: Approval ()

Discussion ( )

Assurance (ď&#x192;ź)

Purpose of Report: To provide an update of the activities of the safety and quality committee. Summary of key issues The report provides a summary of the key agenda items which were discussed at the Safety and Quality Committee in August 2015. Recommendation: N/A Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring â&#x20AC;&#x201C; Ensure patients are cared for and feel cared about Corporate Impact Assessment: Legal and regulatory impact

Compliance with CQC, MHRA and Audit Commission

Financial impact

Serious incidents often become claims

Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication Attachment: N/A

Reporting, investigation and learning from serious incidents informs risk management

Trust Board Report Safety and Quality Committee Chair’s Report The Safety and Quality Committee met on 6th August 2015. It considered its standing agenda items; the reports from ECQRM and CQRM meetings and the SQC Dashboard and Quality Report. ECQRM and CQRM The Committee probed actions to reduce mortality rates in low risk conditions, an issue that had the potential to become an elevated risk in the CQC Intelligent Monitoring rating. It was pleased to note a reduction in the risk due to sustained focus, with the expectation that Intelligent Monitoring would reflect this trend. The Committee was also pleased to note that this year’s CQUINs had now been agreed and were shortly to be signed off with Surrey CCG and NHS England. Concern was expressed about delays and cancellations of achievement reviews. Noting that the Workforce Committee is has asked for a review of training compliance, it was suggested that a metric might be introduced to help manage compliance. No clinical quality concerns had been escalated from CQRM to the Single Performance Conversation. Some assurance was taken from recent discussions among Chief Operating Officers across the local health economy about capacity constraints and planning for winter pressures. Quality Report and SQC Dashboard In response to questions about the risk of Viral Gastroenteritis, it was reported that this is no longer predominantly a winter occurrence and will therefore remain on the Significant Risk Register. A written report will be provided at the next meeting. The Committee sought further assurance about risk emanating from re-admissions within 28 days following non-elective admission. A sample of cases will be considered, with the results being reported to the Committee. Annual Falls Report The Committee received a presentation and report on the impact of actions taken to address one of our top clinical priorities. There were clear signs of improvement in performance, with a slight increase in falls reported but a reduction in falls with harm measured against patient bed days. In discussion about the reasons for the reduction in harm, it was clear that this could not be attributed to a single action but that several actions were significant, including:  ward-based staff training;  pro-active ward leadership and joint-working with the Falls Team;  staff engagement;  ward design, informed by nurse consultation, that had impacted on bed-spacing and nurse visibility of patients;  non-slip flooring on Capel Annexe ward. The Trust is participating in a wider study about the effects of non-slip flooring, which can reduce harm but also manoeuvrability of beds and equipment.  It was also suggested patient moves between wards may lead to disorientation and an increased risk of falling. The Committee congratulated the Falls Team on this improving performance and in particular Tilgate and Capel Annexe wards, which have achieved significant reductions in falls with harm. It looked forward to a deepening understanding of what lessons can be drawn about best practice in falls management and how these can be disseminated across the Trust.

Under Reporting of Incidents The Committee considered a report on the reporting of incidents, including benchmarking data on incidents per thousand bed days. It concluded that the benchmarking did not obviously suggest a problem of under-reporting. On the other hand there was some evidence of a need for improvement in giving feedback to staff, ensuring that lessons were learned and information about actions taken shared effectively. It therefore endorsed an increased emphasis on lesson learning. Annual Adult Safeguarding Report: 2014/15 The Committee has received quarterly reports on Adult Safeguarding, and on this occasion considered the annual report for submission to the Trust Board. The number of alerts raised on Adult Safeguarding Alerts increased last year from 251 to 271. Of these, 34 were raised about the Trust, and one of these, regarding pressure damage and communication with the family, was substantiated. The Committee took some assurance from these figures. However, the large majority of alerts (237) were raised by the Trust with community partners. It was noted that the Trust received no feedback on the outcome of these community alerts and it was suggested that greater transparency would be helpful in providing assurance that alerts were looked into thoroughly and actions taken where appropriate. The Committee also questioned the adequacy of training. Assurance was given that while there are capacity issues for MAST safeguarding training, this is being reviewed. With these comments the Committee commended the report to the Trust Board. Annual Childrenâ&#x20AC;&#x2122;s Safeguarding Report The Committee has received quarterly reports on Childrenâ&#x20AC;&#x2122;s Safeguarding, and here considered the annual report for submission to the Trust Board. The Committee took assurance from the increase in Level 3 training compliance to 72%, and also from the attendance at weekly safeguarding meetings in the Trust of a Hospital Link Social Worker from Surrey Social Services. It also noted that the case number for the hospital remained constant despite a wider increase in referrals, and that there had been an increase of 8.5% in the information shared with members of the multi-agency teams Although there had been no deep dive reviews of Safeguarding, and this might be considered for the future, peer group meetings and reflection groups did occur and helped to raise awareness. The Committee commended the report to the Trust Board. The next meeting of the Committee is on 3rd September at 2pm.

Integrated Performance Report M04 â&#x20AC;&#x201C; July 2015

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

An University HospitalHospital of AnAssociated Associated University of Brighton andand Sussex Medical School School Brighton Sussex Medical

Performance – July 2015 Patient Safety • There was one SI related to delayed diagnosis declared in July 2015 and no Never Events declared. • Patient safety indicators continue to show expected levels of performance. • The Trust had no MRSA bloodstream infections and four Trust acquired C-Diff cases in July 2015.. Clinical Effectiveness • The Clinical Effectiveness Committee continues to monitor the latest HSMR data for the Trust and mortality is lower than expected for our patient group when benchmarked against national comparators. • Maternity indicators continue to show expected performance. Access and Responsiveness • July saw continuation of pressure on the emergency department with high levels of emergency admissions into the hospital. (94.3%) • All Cancer Access Standards were achieved except the 62 Day Referral to Treatment Standard. • The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end of each month. Patient Experience • In July 2015 the Inpatient FFT increased from 94.7% to 95.1%. The ED FFT reduced from 93.7% to 91.4%. Workforce • The Trust is actively reviewing initiatives to improve recruitment and retention, such as reducing time to recruit and ongoing local and overseas recruitment. • The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place and is reviewing recent Department of Health proposals for the management of temporary staffing spend, particularly for nursing.

An Associated University Hospital of Brighton and Sussex Medical School 2

Performance – July 2015 Finance • The Trust is adverse to plan by £0.25m at month 4 with a (£1.3)m deficit. Key Risks • The Significant Risk Register for the Trust includes five quality risks in relation to “Right bed first time”, ED Access standards, Outbreak of viral gastroenteritis, Increasing sickness absence levels and Cancelled and / or delayed elective operations.

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

What are the legal considerations & implications linked to this item? Please name relevant Act

Regulation:

What aspect of regulation applies and what are the outcome implications? This applies to any regulatory body.

Patient safety: Legal actions from unintentional harm to patients would normally be covered by negligence, an area of English tort (civil) law, providing the remedy of compensation. Case law is extensive. Criminal action could be pursued if investigation judged intentional harm and remedies will vary according to severity. Staff safety: The Health and Safety at Work Act etc 1974 may apply in respect of employee health and safety or non clinical risk to patients (usually reported under the Reporting of Injuries Diseases and Dangerous Occurrences Regulations (RIDDOR) 1995) The Care Quality Commission (CQC) regulates patient safety and quality of care and the CQC register and therefore license care services under the Health and Social Care Act 2009 and associated regulations. The health and safety executive regulates compliance with health and safety law. A raft of other regulators deal with safety of medicines, medical devices and other aspects.

An Associated University Hospital of Brighton and Sussex Medical School 3

Patient Safety Patient Safety Indicator Description

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

No of Never Events in month

No of medication errors causing Severe Harm or Death

Safety Thermometer - % of patients with harm free care (all harm)

90.8%

92.5%

92.0%

95.0%

93.0%

92.0%

91.3%

93.5%

92.0%

95.0%

Safety Thermometer - % of patients with harm free care (new harm)

95.3%

96.1%

94.5%

98.0%

96.0%

97.0%

96.0%

95.0%

96.0%

95.9%

97.3%

95.2%

97.7%

95%

100%

98%

100%

96%

100%

98%

100%

98%

96%

Serious Incidents - No per 1000 Bed Days

0.63

0.17

0.12

0.11

0.26

0.35

0.26

0.16

0.27

0.00

Percentage of Patient Safety Incidents causing Severe harm or Death

1.6%

0.6%

1.1%

0.7%

0.2%

0.6%

0.7%

0.6%

0.2%

0.6%

0.5%

0.0%

Percentage of patients who have a VTE risk assessment WHO Checklist Usage - % Compliance Number of Sis

Number of overdue CAS and NPSA alerts

Trend

• Patient safety indicators continue to show expected levels of performance. • There were no Never Events reported in July 2015. • Safety Thermometer – performance continued at expected levels in July 2015. • One SI was declared in July 2015 which is described below. . • A patient underwent a follow up CT scan for previous left seminoma testis in February 2014 , which was reported as normal. A subsequent routine scan in July 2014 identified a para-aortic lymph node recurrence which, on review, had been present on the February CT scan. The para-aortic lymph node had increased in size and was causing left sided kidney obstruction. The delay in diagnosis has necessitated more intensive treatment; chemotherapy rather than radiotherapy.

An Associated University Hospital of Brighton and Sussex Medical School 4

Patient Safety Infection Control Indicator Description

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

MRSA BSI (incidences in month)

CDiff Incidences (in month)

MSSA

E-Coli

Trend

• There were no cases of MRSA in July 2015, and four cases of trust acquired C.diff. • In light of the risk of outbreaks of viral gastroenteritis, the following risk is on the Trust's significant risk register: • Risk of outbreak of viral gastroenteritis - Risk of outbreak of viral gastroenteritis (outbreak of diarrhoea and vomiting). Impact on patient safety and experience – Risk score 15 (Likelihood of 5 and consequence of 3).

An Associated University Hospital of Brighton and Sussex Medical School 5

Clinical Effectiveness Mortality and Readmissions Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

HSMR (56 Monitored diagnoses - 12 Months)

93.7

93.2

92.7

91.6

93.0

94.4

93.5

93.0

93.5

93.2

93.9

Emergency readmissions within 30 days (PBR Rules)

6.6%

7.2%

6.8%

7.2%

7.1%

6.9%

6.7%

6.6%

6.4%

7.0%

Indicator Description

Jun-15

Jul-15

7.2%

7.3%

Trend

• The Clinical Effectiveness Committee continues to monitor the latest HSMR data for the Trust and mortality is lower than expected for our patient group when benchmarked against national comparators. • Readmissions within 30 days continues to remain at expected levels. Maternity Indicator Description

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

C Section Rate - Emergency

17%

14%

17%

12%

14%

17%

18%

16%

17%

13%

17%

18%

14%

C Section Rate - Elective

10%

13%

12%

13%

11%

10%

Admissions of full term babies to neo-natal care

8.5%

6.1%

8.0%

5.4%

3.8%

6.3%

6.0%

7.0%

6.2%

4.0%

5.0%

Trend

• As there have been no maternal deaths recorded in the last 13 months the indicator has been removed from the board template. Clinical Audit Programme • Programme will be reviewed at the next meeting of the Clinical Effectiveness Committee. To monitor progress and assurances from completed audit

An Associated University Hospital of Brighton and Sussex Medical School 6

Access and Responsiveness Emergency Department Indicator Description

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

97.6%

95.9%

95.4%

94.3%

95.7%

93.3%

92.0%

91.3%

95.0%

96.8%

96.0%

94.8%

94.3%

Ambulance Turnaround - Number Over 30 mins

151

183

344

163

259

247

227

192

251

242

Ambulance Turnaround - Number Over 60 mins

ED 95% in 4 hours Patients Waiting in ED for over 12 hours following DTA

Trend

• July saw continuation of pressure on the emergency department with high levels of emergency admissions into the hospital. • Considerable work has been carried out with SECAMB to improve ambulance handovers and reduce delays. • Validation now reinstated from August which will see 50% improvement. • Internal escalation process are being developed to support the emergency department when ambulance waits begin to increase. • In light of the on-going operational pressures in the Trust, the following three risks are on the significant risk register: • ED Access Standard - Failure to maintain the emergency department standard due to lack of capacity in the health system to manage winter pressures – Risk score 16 (Likelihood of 4 and consequence of 4) • Patient admitted to the right bed first time – If the trust does not maintain and improve the ability to allocate the right bed first time, there is an increased risk of reduced quality of care (effectiveness, experience and safety) – Risk score 15(Likelihood of 5 and consequence of 3) • Cancelled and / or delayed elective operations - Due to on-going operational pressures and increasing demand for emergency inpatient beds, elective inpatient surgery is being cancelled and / or postponed. Longer waiting times result in poor patient experience and increase the number of formal and informal complaints. (effectiveness, experience and safety) – Risk score 15(Likelihood of 5 and consequence of 3)

An Associated University Hospital of Brighton and Sussex Medical School 7

Access and Responsiveness Cancer Indicator Description

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Cancer - TWR

93.1%

93.0%

93.2%

93.8%

93.1%

93.3%

94.2%

93.1%

Cancer - TWR Breast Symptomatic

93.2%

94.4%

93.2%

93.3%

93.6%

93.5%

93.4%

96.3%

93.8%

90.6%

93.2%

Cancer - 31 Day Second or Subsequent Treatment (SURGERY)

100.0%

Cancer - 31 Day Second or Subsequent Treatment (DRUG)

100.0%

Cancer - 31 Day Diagnosis to Treatment

99.2%

97.1%

99.2%

100.0%

99.1%

98.4%

97.1%

100.0%

98.2%

97.0%

96.2%

98.3%

Cancer - 62 Day Referral to Treatment Standard

90.8%

87.9%

78.8%

87.1%

86.3%

86.1%

85.4%

88.0%

83.7%

86.4%

83.9%

86.5%

TBC

Cancer - 62 Day Referral to Treatment Screening

50.0%

100.0%

83.3%

100.0%

92.3%

100.0%

92.3%

84.6%

92.3%

100.0%

Trend

• All Cancer Access Standards were achieved in July 2015 except for the 62 day standard. • The Trust is still validating the July 62 day referral to treatment standard (final position will be reported in September) • The Trust will not have achieved the 85% target but is likely to be circa 82% • Work is ongoing to review cancer pathways focussing on known issues in tracking and pathway reporting • Q1 data presented at Executive Committee indicates that the Trust’s cancer performance is the 3rd best for the South of England (circa 40 Trusts)

An Associated University Hospital of Brighton and Sussex Medical School 8

Access and Responsiveness Referral to Treatment (RTT) and Diagnostics Indicator Description

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

94.9%

93.9%

93.8%

93.5%

93.3%

92.2%

92.1%

94.0%

93.7%

93.6%

93.5%

92.6%

92.2%

RTT Admitted - 90% treated within 18 weeks

92.8%

90.4%

90.7%

88.1%

81.4%

91.1%

90.2%

82.1%

88.4%

91.6%

90.1%

92.0%

84.0%

RTT Non Admitted - 95% treated within 18 weeks

95.2%

95.8%

93.2%

93.9%

92.8%

95.0%

91.7%

91.0%

93.5%

93.6%

95.3%

93.4%

89.4%

Percentage of patients w aiting 6 weeks or more for diagnostic

0.3%

0.1%

0.0%

0.4%

0.1%

0.9%

0.7%

1.4%

1.0%

0.2%

0.8%

1.0%

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

0.0%

1.0%

1.6%

0.0%

2.2%

0.0%

RTT Incomplete Pathways - % waithing less than 18 weeks RTT Patients over 52 weeks on incomplete pathways

Trend

• The Trust continues to deliver against incomplete pathways standard which measures % of patients waiting less than 18 weeks at the end of each month. • Although previous admitted and non admitted standards were not achieved against the old standard of ‘patients actually treated’. This is due to prioritisation of focus on patients who are long waiters.

An Associated University Hospital of Brighton and Sussex Medical School 9

Patient Experience Patient Voice Indicator Description

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Inpatient FFT - % positive responses

98.0%

96.0%

97.0%

95.0%

95.7%

96.9%

94.2%

94.4%

95.1%

94.7%

95.1%

Emergency Department FFT - % positive responses

99.0%

98.0%

95.0%

96.0%

93.0%

95.8%

97.1%

94.7%

95.4%

95.3%

93.7%

91.4%

Maternity FFT - Antenatal - % positive responses

97.0%

99.0%

96.0%

97.0%

95.0%

90.0%

97.6%

97.1%

97.0%

96.3%

100.0%

83.3%

94.1%

100.0%

98.0%

95.0%

93.0%

100.0%

95.5%

97.2%

100.0%

94.7%

97.0%

94.9%

93.8%

Maternity FFT - Postnatal Ward - % positive responses

92.0%

93.0%

90.0%

92.0%

96.0%

85.9%

91.0%

97.3%

86.7%

91.0%

86.5%

90.0%

Maternity FFT - Postnatal Community Care - % positive responses

93.0%

100.0%

94.0%

100.0%

85.0%

100.0%

77.8%

100.0%

Maternity FFT - Delivery - % positive responses

Mixed Sex Breaches Complaints (rate per 10,000 occupied bed days)

Trend

• Inpatients - The July Friends and Family Test (FFT) score for inpatients increased slightly to 95.1%, maintaining the steady continuum of recent months. The inpatient response rate for July reduced to 34% having been 38% in June. • ED - There has been a drop in the July ED FFT score, down to 91.4% from 93.7% in June. The ED response rate for FFT has also fallen to 10.2%, well below the 20% target. The decline in ED response rate has been steady since the February high of 24%. • Maternity - FFT scores improved in July for touchpoints one and three. Touchpoint one increased from 83.3% to 94% and touchpoint three increased from 86.5% to 90%. Touchpoint two dropped very slightly to 93.8% from 94.9%. • National FFT comparisons July – Inpatients – The national average FFT score for inpatients in June 2015 was 95.54%. SASH scored slightly below this at 94.95%. National results ranged from 77.06% to 100% positive. The drop in response rate to 21% is because the national figures now include day case patients as well as inpatients. ED - Our combined adult and paediatric ED Friends and Family Test score for June was 93.68%, well above the national average of 88.6%. National ED results ranged from 59.52% to 99.31% positive.

An Associated University Hospital of Brighton and Sussex Medical School 10

Workforce Workforce Indicator Description

Jul-14

Aug-14

Sep-14

Oct-14

Nov-14

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Average fill rate – registered nurses/midwives (%) - Day

97.5%

95.7%

95.4%

96.4%

97.1%

95.1%

94.8%

95.9%

96.5%

96.8%

95.7%

96.9%

93.3%

Average fill rate – care staff (%) - Day

95.1%

97.5%

96.4%

95.3%

95.0%

93.1%

92.6%

93.8%

94.5%

96.1%

93.8%

93.5%

94.3%

Average fill rate – registered nurses/midwives (%) - Night

98.2%

97.2%

98.1%

99.2%

99.4%

97.3%

97.2%

97.7%

96.7%

96.5%

97.1%

94.1%

95.2%

Average fill rate – care staff (%) - Night

97.2%

97.5%

96.7%

97.4%

95.3%

93.7%

93.3%

94.9%

95.2%

95.9%

94.9%

94.4%

Overall Sickness Rate

3.8%

3.2%

4.0%

4.4%

4.0%

4.5%

4.3%

4.4%

4.2%

4.3%

4.1%

3.9%

%age of staff who have had appraisal in last 12 months

80%

75%

74%

72%

69%

72%

67%

68%

73%

71%

68%

58%

56%

15.0%

15.8%

15.6%

15.3%

15.6%

15.7%

15.2%

15.5%

15.9%

15.6%

Staff Turnover rate

Trend

• Sickness absence decreased to 3.9% in July 2015. The Trust is currently auditing sickness absence and recommendations for actions to improve management are being undertaken. • The following workforce related risks remains on the Trust’s significant risk register: Increasing Sickness Absence Levels with impact on day to day management and expenditure – Risk score 15 (Likelihood of 5 and consequence of 3) • The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place. • There remains a significant focus on nursing recruitment with a new recruitment tracker to improve efficiency at the recruitment process. • Staff Turnover remains at 15.6% in July 2015 and the Trust is developing initiatives to improve retention.

An Associated University Hospital of Brighton and Sussex Medical School 11

Key Financial Indicators: M04 2015/16 Indicator Description

Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 M01 M02 M03 M09 M10 M11 M12 M06 M07 M08 M05

Jul-15 M04

Trigger Basis

Overall Financial Position - Outturn £m Surplus / (Deficit) - Plan - Outturn £m Surplus / (Deficit) - Forecast - YTD £m Surplus / (Deficit) - Plan - YTD £m Surplus / (Deficit) - Actual - Outturn UNDERLYING £m Surplus / (Deficit) - Plan - Outturn UNDERLYING £m Surplus / (Deficit) - Actual - YTD Savings £m - Actual - OT Risk £m Surplus / (Deficit) - Assessment - Outturn Cash position £m Fav / (Adv) - Forecast - YTD Cash position £m Fav / (Adv) - Actual - YTD Liquid ratio - days - YTD BPPC (overall) volume £m - YTD BPPC (overall) value £m - Outturn Capital spend Fav / (Adv) - forecast

2.3 2.3 (1.5) (1.5) 3.4 3.4 2.8 (8.5) 2.6 3.1 (17.0) 94% 88% 19.4

2.3 2.3 (1.3) (1.3) 3.4 1.0 3.8 (8.5) 2.6 3.0 (10.0) 94% 87% 19.4

2.3 2.3 0.1 0.1 3.4 1.0 5.0 (8.5) 2.6 3.8 (8.0) 90% 92% 19.4

2.3 2.3 0.4 0.5 3.4 (0.7) 6.2 (6.3) 2.6 2.8 (9.0) 92% 86% 19.4

2.3 2.3 1.0 1.0 3.4 (5.2) 7.4 (6.3) 2.6 4.8 (8.0) 88% 84% 19.3

2.3 2.3 1.9 1.9 3.4 (5.2) 8.6 (5.5) 2.6 3.8 (8.0) 87% 83% 19.3

2.3 (2.5) 1.4 (2.9) 3.4 (5.2) 9.8 (0.7) 2.6 3.8 (18.0) 86% 83% 19.3

2.3 (2.4) 2.3 (2.4) 3.4 (5.2) 11.0 0.0 2.6 2.6 (21.0) 82% 81% 19.3

1.6 1.6 (0.8) (0.8) 3.8 3.8 0.3 0.0 7.6 3.2 (20.0) 62% 65% 17.1

1.6 1.6 (1.2) (1.1) 3.8 3.3 0.5 (1.0) 7.6 2.9 (21.0) 75% 73% 17.1

1.6 1.6 (2.0) (2.0) 3.8 3.3 0.8 0.0 7.6 2.6 (23.0) 78% 75% 17.1

1.6 1.6 (1.1) (1.3) 3.8 3.3 1.3 0.0 2.6 2.5 (22.0) 78% 75% 17.1

Red is a deficit < (0.1)% income Red is a variance < (0.1)% Red is a variance <£(0.,5m) Red is adverse <(1.0)% Red is a deficit <£(0.5m) Red is <£(0.6)m adv to plan and <£0.6m) Red is <£(0.6)m adv to plan and <£0.6m) Red is <(15) days Green is >15 days Red is <85% Green is >95% Red is <85% Green is >95% Red is <£(0.5m) adv to plan



The Trust is adverse to plan by £0.25m at month 4 with a (£1.3)m deficit.



Emergency activity levels remain high and are driving additional cost. Budget changes have been implemented to reflect this as part of quarterly action to match activity and spend. Recovery plan actions in the Medical Division are now ¾ complete with agreement over necessary staffing changes in ED to support activity and other steps to reduce overspending.



Contract income remains adverse to plan as described in past reports.



The cost improvement schemes are slightly behind the TDA plan at month 4 with £1.35m delivered, including contingency from new schemes of £0.4m.



The underlying position at the end of June is £(1.8)m deficit, reflecting the non recurrent contingency savings.



The outturn forecast remains a £1.6m. The Board reviewed the forecast at its last meetings and recovery actions are in place with Divisions.



Risks to the 2015/16 financial plan remain at £5.8m and are all mitigated.



The cash balance at the end of July 2015 was £2.5m. This is adverse to the TDA plan which assumed the £18m liquidity loan would have been received. Cash is very tight (with delays in the receipt of the £4.4m capital loan and from over-performance monies from CCG’s). The plan is to draw down £4.0m of the temporary working capital facility in September.



The capital spend forecast this year is £17.1m.

An Associated University Hospital of Brighton and Sussex Medical School 12

TRUST BOARD IN PUBLIC

Date: 27 August 2015 Agenda Item: 3.2

REPORT TITLE:

Finance & Workforce Committee Chair Update – Part 1

EXECUTIVE SPONSOR:

Paul Simpson (Chief Financial Officer)

REPORT AUTHOR (s):

Richard Durban (Non-Executive Director and FWC Chair)

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

No – Board Update

Action Required: Approval ( )

Discussion ( )

Assurance (√)

Purpose of Report: To update the Board on the discussions and actions from the Finance and Workforce Committee. Summary of key issues

The Finance and Workforce Committee met on the 25th August 2015. The key points from the meeting were as follows: • •

The ED CT and Recus OBC was received and approved The Committee received the Hospital at Home PIR

Financial, Workforce, Capital and IT M04 performance reports •

M04 reports were received for Finance, Workforce and Organisational Development, Capital and IT.

•

The Trust is £0.25m adverse to plan at month 4 with a £1.3m deficit.

•

Updates were received by the Committee on the progress of 2015/16 and 2016/17 Cost Improvement Plans.

•

The Committee received the Workforce & Organisational Development monthly report, feedback on vacancy reporting and the Workforce Internal Control framework.

Recommendation:

Relationship to Trust Strategic Objectives & Assurance Framework: SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment:

The FWC reviews assurance in respect of workforce, capital and investment projects, business planning (which includes financial planning) and cash aspects. Employment law: laws governing the rights of individuals and terms and conditions terms include: National Minimum Wage Act 1998; the Working Time Regulations 1998; Employment Rights Act 1996; Equality Act 2010; Employment Rights Act 1996, and; the Transfer of Undertakings (Protection of Employment) Regulations 2006. Other key laws affecting employees include the Pensions Act 2004 and the Trade Union and Labour Relations (Consolidation) Act 1992.

Legal and regulatory impact

Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the “breakeven duty”. Legal aspects related to capital works will depend on the nature of the works. The main regulators, are as follows: -

Financial impact

External audit (the Grant Thornton for this Trust) gives an opinion on the Trust’s compliance with International Financial Reporting Standards and with NHS accounting conventions – this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trust’s ability to put in place arrangements to deliver economy, efficiency and effectiveness in its use of resources.

The Care Quality Commission registers the Trust according to its compliance with regulations concerning the safety and quality of services The report provides assurance about savings, capital spend and the structure of the business planning process.

Patient Experience/Engagement

Indirect impact through Trust planning and workforce.

Risk & Performance Management

The committee, and this report, provides assurance about workforce and capital management.

NHS Constitution/Equality & Diversity/Communication Attachment: Report Paper

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 25 August 2015

Finance & Workforce Committee Chair Update The Finance and Workforce Committee met on 25 August 2015 and it was quorate. points from Part 1 were as follows:

The key

Business Cases The Committee was presented with the Emergency Department (ED) CT and Resus Outline Business Case (OBC) for approval. The business case proposed a refurbishment of the Resus area and the installation of a CT scanner in ED at a capital cost of £1.9m. It was noted that the preferred option gives the Trust future flexibility on possible expansion of services offered whilst improving current patient pathways. The recruitment requirement for the project is small; it was noted that the contribution would be reduced if agency staff needed to be used. It was noted that the CT scanner is not currently included in the Medical Equipment Services contract. The Committee will receive a full business case in due course which will include more tangible benefits. The OBC was approved by the Committee.

The Committee welcomed the Hospital at Home Post Implementation Review (PIR) noting that the project had delivered on its quality, patient satisfaction and financial objectives. The Committee noted that the contract allowed for up to 50 patients asked whether the current level of 29 could be increased. It was agreed that this was desirable and would be targeted but to do so would require the service to be developed to include patients with more complex needs. The service continues to work with Community Services on the hand over process. The Committee will be kept updated on any future expansion plans.

Financial, Workforce, Capital and IT M04 performance reports The month 4 Finance, Capital and IT reports were presented to the Committee: -

The Trust is £0.25m adverse to plan at month 4 with a £1.3m deficit. As in previous months contract income is adverse to plan. Emergency activity levels remain high (c8% above the budgeted increase of 2%) and are driving additional costs. Budget changes have been implemented to reflect this. Recovery plan actions in the Medical Division are now ¾ complete with agreement over necessary steps to reduce overspending.

Delays in the receipt of the £4.4m capital loan and over performance monies from the CCG’s have resulted in the Trust planning to draw down a £4.0m working capital facility in September.

The cost improvement schemes are slightly behind plan at month 4 with £1.35m delivered, including contingency from new schemes of £0.4m.

The 2016/17 cost improvement plan has been analysed by the agreed “gateways”. No schemes have been quality impact assessed at this point, and no scheme has been categorised above Gateway 2 (scoped and costed). The Committee noted the increased assumption for nurse agency savings, which is subject to review.

An Associated University Hospital of Brighton and Sussex Medical School

The Committee welcomed the Nursing Recruitment paper noting the 18% vacancy rate (291 vacancies v an establishment of 1595) against a target of 12% . The paper provided a comprehensive view to the Committee on the many initiatives in place to reduce turnover and fill vacancies. These included international recruitment (Philippines and the EU), local recruitment, improvements in the recruitment process, and actions to improve retention such as a trainee post with the Open University (OU). In total c 220 nurses had accepted positions â&#x20AC;&#x201C; they would be allocated to the areas of greatest need. The 2016/17 nurse agency CIP was based on the recruitment

The Workforce and Organisational Development paper was presented to the Committee and it was highlighted that the achievement review process is not yet completed (currently at 55%) but the target is for all staff to have had their achievement review by the end of October. There was an oral update on the work on understanding and reducing sickness levels. The audit suggested some changes to the policy to encourage a less formal approach for anticipated long term sickness and the application of consistent timelines within the process.

The Workforce Internal Control Framework was presented to the Committee. It was noted that this had been signed off by the Executive and was the final version. It showed 7 areas rated green, 5 rated amber (Recruitment, Staff Training, Appraisal, Nurses & Midwives Revalidation, Payroll) and 1 rated red (Temporary Staffing). Whilst each section showed â&#x20AC;&#x153;areas for actionâ&#x20AC;? the Committee suggested that they be expanded for amber and red section before the paper was taken to the Audit and Assurance Committee. (AAC) on 1st September.

The Capital and IT reports were presented and noted by the Committee. Early data analysis showed that EPR response time is faster since the move to Cerner and that there is an opportunity to move to best practice workflows at an individual level. This will be reported in more detail at a later date. [END]

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date:27 April 2015 Agenda Item: 3.3

REPORT TITLE:

Charitable Funds Committee Chair Update

EXECUTIVE SPONSOR:

Paul Simpson (Chief Finance Officer)

REPORT AUTHOR:

Pauline Lambert (Non-Executive Director and Committee Chair)

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

No – Board Update

Action Required: Approval ()

Discussion ()

Assurance (√)

Summary of Key Issues This report briefs the Board on the key issues discussed at the meeting of the committee on 4 August 2015. Key points were: •

Fund raising update;

•

Finance review including spending plans;

•

Expenditure guidance

•

Review of Terms of Reference.

•

Savile Action Plan - Refresh

Relationship to Trust Strategic Objectives & Assurance Framework: SO3: Caring – Ensure patients are cared for and feel cared about

Corporate Impact Assessment: The Charity is registered with the Charity Commission in accordance with the Charities Act 1993, registered number 1054072.

Legal and regulatory implications

Financial implications Patient Experience/Engagement Risk & Performance Management

Charitable funds received by the Charity are accepted, held and administered as funds and property held on trust for purposes relating to the health service in accordance with the National Health Service Act 1977, the National Health Service and Community Care Act 1990, the National Health Service Act 2009. These funds are held on trust by the corporate body. The fund is audited by the Trustâ&#x20AC;&#x2122;s External Auditor (Grant Thornton UK LLP) The report provides assurance about the financial management of the charitable fund. A deliberate positive impact from the use of the fund to support patient experience. The committee, and this report, provides assurance about risk management relevant to the fund.

NHS Constitution/Equality & Diversity/Communication Attachments: Report paper

2 An Associated University Hospital of Brighton and Sussex Medical School

Charitable Funds Committee Chair Update The Charitable Funds Committee met on 4 August 2015. Fund Raising The Committee was advised that a successful candidate for Fund Raiser post had been found in the last round of interviews, but unfortunately they had accepted an alternative offer. The post will be re-advertised through NHS Jobs and social media. As an interim measure Katrina Swanston has continued to assist with the role. The SASH Charity continues with promotional activities including quiz night and sponsored runs; the comfort blankets/mitts has received a good response, and this has been picked up by the local media and interviews conducted with the BBC. In order to increase awareness, Michael Wilson (MW) has met with Stewart Wingate, the CEO of Gatwick Airport, to explore how Gatwick Airport may incorporate SASH Charity within the airport. MW has also met with Lord Aster of Hever, who is a past patient of East Surrey Hospital and the committee acknowledged exploring potential to develop a liaison with Hever Castle in promotional activities. It was also agreed that the SASH Charity would continue to focus on Elderly care for 2015. Finance, Policy & Savile Action Plan The current fund balance totalled ÂŁ0.654m, the Divisions are aware the available funds, d the majority have submitted spending plans and some have agreed to transfer unspent monies to the general fund. The annual accounts and report for 2014-15 are ready for independent examination in October 2015 before statutory filing. It was agreed that where significant staff training costs are involved, in the event that the staff leave the Trust employment within 1 year costs are to be reimbursed to CFC, a policy will be included in the expenditure guidance. The Committee were content with the Terms of Reference and asked review date to be amended to 2015. The Committee members were asked to review the Savile Action Plan Refresh report and raise any queries with the Chief Nurse. Pauline Lambert Chair of Charitable Funds Committee 27 August 2015 [END]

3 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 27 August 2015 Agenda Item: 4.1

REPORT TITLE:

CQC Improvement Action Plan

EXECUTIVE SPONSOR:

Sue Jenkins

REPORT AUTHOR (s):

Sue Jenkins

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

Executive Committee

Action Required: Approval ()

Discussion ()

Assurance (√)

Purpose of Report: This report provides the Board with assurance that the recommendations made following the CQC visit in May 2014 are being addressed Summary of key issues The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as “good” for all domains. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. Since the CQC inspection work has been ongoing to address the concerns raised in the report. However the main concern around patient waiting times and the large number of ad-hoc clinics remains a challenge. This report details the actions being taken over the summer of 2015 to address this challenging area and demonstrates progress against existing and revised KPIs that have been previously shared with the Board Recommendation: The Board is asked to consider this report and ensure that it provides assurance around delivery of the CQC improvement plan. Relationship to Trust Strategic Objectives & Assurance Framework: SO1: Safe -Deliver safe services and be in the top 20% against our peers SO2: Effective - Deliver effective and sustainable clinical services within the local health economy SO3: Caring – Ensure patients are cared for and feel cared about SO4: Responsive – Become the secondary care provider and employer of choice our catchment population SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment:

Legal and regulatory implications Financial implications Patient Experience/Engagement Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

Compliance with CQC recommendations and delivery of action plan to address areas highlighted is essential Capital and revenue implications will be addressed through separate business cases Feedback from patients regarding their experience in outpatients is a key part of this action plan A monthly steering group is in place to ensure delivery of the plan N/A

Attachment: CQC Improvement action plan â&#x20AC;&#x201C; August 2015

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT –27 August 2015 CQC Improvement Plan Update - Outpatients 1. Introduction The Chief Inspector of Hospitals visited the Trust in May 2014. The Trust was rated as “good” for all domains. In terms of the 8 core services that were reviewed the Trust received a “good” rating for all services apart from Outpatients services which were rated as “requires improvement”. A revised action plan is now presented which demonstrates progress against key recommendations. Revised and new KPIs are also reported. 2. Outpatient review update There are four key work streams that the outpatient action plan covers. They are • Environment • Workforce and leadership skills • Communications • Systems and processes The table below details the key actions that are being undertaken for each of the four areas and a RAG status is included:RAG B G A R

Definition Action complete Action being delivered to plan Action delayed or outside of budget but plans in place to bring back on track Action unlikely to be delivered to plan

Ref 1.0 1.1

Details Environment Identify and implement IT solution to support more efficient room allocation – Go live due late July 2015

1.2

Accommodation for additional clinics and re-provision of priority areas including ophthalmology, clinical haematology and gynae

Progress “Bookwise” identified as preferred solution Business case approved by CHIG. Implementation continues with main OPD sites (East Surrey, Crawley, Horsham) currently being uploaded to system by “Bookwise”. Training for the system administrators is scheduled for late August with full go live by end of September 2015. Further development at Earlswood not progressed further but still an option that is being explored. Timescale will be subject to planning permission and agreement with landlord and anticipated at 12 – 18 months Plans to develop East Entrance as

RAG G A

3 An Associated University Hospital of Brighton and Sussex Medical School

1.3

2.0 2.1

2.2

2.4

3.0

4.0 4.1

4.2

additional outpatient space are being drawn up. Timescale ties in with medical records annexe re-provision. Clinical haematology plans paused whilst clinical team reviews space options within budget. Timescale for completion before 31.03.16 Consider development of Included in capital plan for 16/17 and business case for re-provision of 17/18. outpatients’ facilities Plans to be developed and OBC due by end of 15/16 Workforce Review skill mix of nursing staff - Skill mix is being reviewed as part of registered to un-registered an overall strategy to address the CQC concern of a ‘flat structure’ being in place. This will be incorporated in the consultation mentioned in point 2.2. Develop consultation to support A consultation is planned for late extended day and 6 day service summer/early autumn to extending provision clinic hours to a 12 hour day. Evening and weekend clinics are already taking place on an ad-hoc basis. Develop outpatient staff focus Staff focus groups were undertaken groups to ensure views and during June 2015. Feedback to staff feedback from staff are is being given through staff meetings considered and actioned – June and email updates. Action plan is 2015 being developed and implemented. Communications Ensure on-going and effective Meetings and improved communications with:communications in place with all stakeholders on both formal and • CCGs informal basis. Led by lead clinician • GPs for outpatients and supported by • SaSH clinicians management team. Systems and processes Set up e-referral email address – An NHS.net email address is in June 2015 place. Internal processes for handling are being developed. Once in place CCGs will be offered the ability to submit referrals by email. East Surrey CCG have appointed a project manager to work with GPs and providers to deliver a higher percentage of referrals via e-referrals (formerly Choose and Book). Initial meeting has taken place. Instability of the e-referral system since migration to a new IT platform in June has delayed progress. The Trust is exploring other external systems to support the move to a fully electronic system. Develop standard template for e- This work has commenced and is onreferrals – June 2015 going. Detailed input and support

G G

A A

4 An Associated University Hospital of Brighton and Sussex Medical School

4.3

4.4

Discuss proposed e-referral system to all GPs via CCGs – June 2015 Offer amnesty to return all referrals to OBO – June 2015

4.5

Share details of revised process with consultants – June 2015

4.6

Share and discuss details of revised process with service managers and ADs – June 2015 Share and discuss details of revised process with lead clinicians – June 2015 Complete validation of waiting lists – June 2015

4.7

4.8

4.9

Agree new realistic consistent milestones across all specialties – June 2015

4.10 Agree KPIs to measure success and compliance – June 2015

4.11 Develop reports to share compliance with KPIs – June 2015 4.12 Agree demand and capacity plans for all specialties – June 2015

from each of the specialties is required and completion will take approximately 3 months and will link with work undertaken at 4.1 Linked to update at 4.1

Planned as part of summer workstream. Working is on-going with key specialties where first appointment waits are beyond 6 – 8 weeks to reduce wait times through planned additional clinics 95% of referrals are now entered on the patient administration system within 24 hours. Meetings have taken place with lead clinicians, some clinician groups, divisional boards and medical secretary leads to share details of revised booking processes to support better management of changes to clinics and appointments. Further meetings with targeted groups will take place over the summer. Ongoing discussion at weekly Elective Care Board.

Presentation given to lead clinician meeting on 22 June 2015.

This is an on-going process which started in June and will take an estimated three months to complete. Part of the work detailed in 4.4 Review of milestones currently underway. Working is continuing to have all new first appointments <18 weeks by end of Q2 and all new first appointments between 8 and 13 weeks by end of Q4 (specialty dependent). New KPIs being discussed and actioned to provide realistic reporting. Will be in place by end of August 2015 Will be in place by end of August 2015.

Working with service managers and Information team to identify demand trends and forward plan requirements for additional resources. Also standing item at weekly Elective Care Board.

5 An Associated University Hospital of Brighton and Sussex Medical School

4.13 Recruit temporary team to support OBO for 10 weeks to facilitate change in practice and training of team – June 2015 4.14 Ensure rooms are available to support revised clinic templates – July 2015

Recruitment complete and temporary team in place supporting referral processing and clinic appointment bookings. Linked to 4.4 On-going and part of the “Bookwise” work now planned for September. Better use of satellite locations being encouraged through job planning of new clinicians.

5.0 Measuring success A new suite of KPIs has been developed to monitor the successful delivery of the action plan and the following demonstrate progress so far. Total ad hoc clinics per month

Medicine division ad hoc clinics

6 An Associated University Hospital of Brighton and Sussex Medical School

Surgery division ad hoc clinics

WACH division ad hoc clinics

7 An Associated University Hospital of Brighton and Sussex Medical School

Total number of clinics cancelled per month

Total number of clinics cancelled <6 weeks

8 An Associated University Hospital of Brighton and Sussex Medical School

Calls in and out of central booking office

Referrals received electronically â&#x20AC;&#x201C; target 50% by December 2015 Month April 2015 May 2015 June 2015 July 2015

% referrals received electronically 8% 8% 6%* 6%

* Reduction in June percentage due to issues encountered with HSCIC migration from Choose and Book platform to e-Referrals. System was only intermittently available for two weeks. Referrals logged on Cerner < 24 hours Month April 2015 May 2015 June 2015 July 2015

Referrals logged on Cerner <24 hours 25% 30% 20% ** 95%

** Challenges encountered due to staff sickness and annual leave. Referrals graded by clinician and returned to OBO <48 hours (2 working days) Month April 2015 May 2015 June 2015 July 2015

% referrals graded < 48 hours 25% 25% 25% 25%

9 An Associated University Hospital of Brighton and Sussex Medical School

Total number of patients waiting >18 weeks for first outpatient appointment â&#x20AC;&#x201C; target nil by end of Q2

Total number of patients waiting >13 weeks for first outpatient appointment â&#x20AC;&#x201C; target nil by end of Q4

6.0 Recommendation The Board is asked to consider this report and ensure that it provides assurance around delivery of the CQC improvement plan. Sue Jenkins Director of Strategy August 2015

An Associated University Hospital10 of Brighton and Sussex Medical School

Date: 27th August 2015 Public Trust Board Agenda Item: 4.2 REPORT TITLE:

2014/15 CIP Post Implementation Review Des Holden, Medical Director

EXECUTIVE SPONSOR:

Fiona Allsop, Chief Nurse REPORT AUTHOR (s):

Maria Gubala – Finance Manager

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

Discussion (√)

Assurance (√)

Purpose of Report: To update the Board on the assessment of the 2014/15 Cost Improvement Plan – impact on Quality. Summary of key issues

This paper evaluates whether the delivery of 14/15 CIP plan had any adverse effect on quality and patient care. Specifically it considers schemes that did not deliver and schemes which did deliver a financial return and whether in either case there was an impact on quality (positive or negative). Through analysing the 2014-15 CIP delivery in this way we draw conclusions which may help in subsequent CIP design and delivery. Recommendation: For discussion and assurance.

Relationship to Trust Strategic Objectives & Assurance Framework: SO5: Well led: Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model Corporate Impact Assessment:

Legal and regulatory impact

No legal breach is reported, or forecast.

Financial impact

Savings delivery impacts on the overall financial position of the Trust. No adverse impact reported or expected.

Patient Experience/Engagement

Risk & Performance Management NHS Constitution/Equality & Diversity/Communication Attachment: None

All savings plans are subject to Quality Impact Assessments (QIAs). No compliance issues. Risks are stated in the report. No compliance issues.

1. Introduction The Trusts financial plan for 2014/15 included a CIP target of £11m. At the beginning of the financial year £4.3m of that plan was red rated and by month 3 it was evident that certain schemes were not going to deliver to plan. Mitigations and contingency from both corporate and central underspends and from contract income (in the form of reduced fines and penalties) were used throughout the year to achieve the £11m target. The final summary of how the CIP was delivered is tabled below – only 28% of the original plan was delivered. 2014/15 £000 CIP plan % of plan achieved Total CIPs achieved Less: new schemes Less: Mitigation & reserves Total of original schemes achieved % of original plan achieved

11,000 100% 11,000 (5,865) (2,047) 3,088 28%

1. Quality and patient experience review of delivered CIP plans The £3,088m delivered by the Divisions comprised of many small schemes. The schemes have been reviewed by the Medical Director and the Chief Nurse for any adverse impact on quality, safety or patient experience and to ensure lessons are learnt for the future.

2. Findings from review and lessons learnt Division of Surgery The Division did not achieve the level of non-pay savings originally put forward.

“…last year’s CIPs …weren’t well thought through at the end of the previous year. Diane Lester only arrived half way through the year and so wasn’t involved in these.”

Schemes that didn’t deliver: 1) The theatre drapes chosen to replace existing stock were didn’t work and therefore were not used, so saving was not realised. This year the division have chosen a better alternative, the change has already been achieved and this is set to save £30K on drapes and gowns. 2) Warming devices CIP was based on a capital bid for underwarming mattresses thus eliminating the need for disposables. This was rejected on cost and practicality grounds so CIP not achieved. Savings at best would take several years to achieve. 3) Theatres non-pay savings was not achieved as schemes were insufficiently worked through by the then theatre team. 4) T&O outsourcing reduction didn’t achieve not because it was too ambitious in theory, but because it was not possible to protect enough bed capacity to do the work. The Chief of surgery reports that the system for CIPS is now much more robust under Diane’s control. They have weekly divisional meetings and fortnightly progress meetings with the CFO. They have £1.2M identified for this year and feel confident over £1.0M.”

Division of Medicine Within the division of medicine the review process identified an undelivered saving in relation to syringe procurement and use that was not recognized by the clinical lead for the area. WaCH CIP scheme: The saving relating to the Clinical Psychologist 0.27 in O&G (delivered): “the loss of service has been quite significant. It was difficult to recruit to the post, which was very part time in any case.” Bill Kilvington ADO. It is likely that there has been an adverse quality impact in relation to this saving, though the saving has resulted from inability to recruit or mitigate through enhancing the service level agreement with psychiatric service suppliers. The clinical consequence may in part be seen by Sash but is more likely to be seen in primary care where it reasonable to presume patients will present. CIP scheme: The saving arising from a band 7 midwife being converted to band 6 (delivered): The savings associated from this scheme were realised through an internal re-organisation. While the division do not believe delivery of the scheme resulted in an adverse effect directly, they are in the process of writing a business case to further strengthen their senior midwifery tier.

CSS CIP scheme: A review of Crawley Microbiology Manager saving (delivered) showed that: “We took the view that this was an opportunity to streamline the top-level management of Microbiology in line with the workforce plan for a unified service, albeit that it was slightly premature in that Crawley’s and BSUH’s laboratories were not yet co-located in the planned new build.

The risks were managed by our senior Quality and Management Team, and included recruiting an existing 8B at BSUH to come to Crawley for one day a week and to be directly available by phone to the team of senior biomedical scientists (band 7s), who, as part of the overall plan, were supported in taking on a greater leadership role in the department in certain areas. The only adverse outcome potentially associated with this was the eyes off the ball of the annual check and servicing of the autoclaves, which resulted in an HSE Improvement Notice. We now have a senior BMS designated as H&S Lead. In terms of indicators to demonstrate that quality standards have been met and upheld: -

We have addressed the non-conformities identified in the UKAS inspection visit in the summer; overseen by QMT to completion; We have continued to perform as well as we have always done in our KPIs, internal quality assurance (IQA) and national external QA (NEQAS); The Microbiology QMT has continued to meet monthly to review performance as business as usual (attached is a monthly report for information); now Chaired by Mike Rayment.

If anything, there have been improvements: -

Developmental improvements in some aspects of the service through BSUH’s input (e.g. validation of a NAAT for enteric pathogens, moving away from conventional culture); - Improved service resilience (e.g. back-up for processing of TB samples while we address problems with the category 3 room at Crawley); - Bringing Crawley’s quality management system (QMS) under the supervision of the JV’s designated full-time Quality Lead (John McBride); - Professional development of the band 7s (senior BMSs), who have stepped up to the plate leadership-wise” Dr Bruce Stewart Clinical Director Pathology JV

Estates and Facilities CIP scheme: One of the E & F CIPs was the removal of a B3 maintenance staff post (delivered). “It would be incorrect to state categorically that there is no impact when numbers of staff are reduced, but in this case the work load for this vacant post had already been re-allocated around existing staff and so there was no noticeable impact on service delivery. As for positive outcomes, the trust was able to maintain its present level of service but at a reduced cost, and as far as negative go I’m sure if you asked the staff if they thought the additional workload was a positive or negative thing they would suggest a negative, but other than limiting the ability to take on additional work not previously undertaken then removal of this post did not impact on the existing level of service Estates where able to offer at that time”. Ian MacKenzie Director

Other schemes There was a lack of savings on large schemes such as the 65% conversion of agency to bank and agency, the closure of 28 beds and flatter organization structure. These are now considered to have been too optimistic.

Lessons learnt include: •

Granularity was not necessarily available in order to understand the impact on Quality (with regard to answering the question of quality impact) or to enable scheme delivery.

•

Where the CIP has involved the loss of staff or a change in skill mix, it has given Divisions the opportunity to review structures, improve service resilience and allow development of other staff. There are examples where this has probably improved quality, but where such mitigation or opportunity has not been realized there are examples of negative impact on quality.

•

Changes in clinical care are not always easy to implement, even if the change is small, however some simple product changes (e.g. size) could lead to large savings. The probable key to delivery, unsurprisingly is to ensure there is a will from the impacted teams to take the change forward.

•

Some Divisional savings were impacted by issues out of their control, such as the ring-fencing of beds, or general increases in unscheduled demand

•

Clearer ownership by Project Leads - this now being addressed in 2015/16 by in year meetings with Medical Director and Nursing Director

•

The lead in time for some projects underestimated. Some of these are however starting in 2015/16

•

Some projects were overly ambitious in the light of issues such as staff recruitment

•

The increase in bed base, patient acuity and external issues had an impact on the larger value schemes

The QIA team did not review quality impact during the 2014-15 year. This was partly because the whole QIA process was new and more focused on description to the Board than on governance, and partly because all schemes were risk assessed as low risk. This is not the case this year and the assessment team has benefitted from talking about CIPs and QIAs with Monitor’s assessment function. Ongoing review of QIA is in place this year (see CN MD report) as is ongoing delivery review. Dr Des Holden

Medical Director

Fiona Allsop

Chief Nurse

Maria Gubala

Finance Manager, Division of Medicine

Minutes of the Finance and Workforce Committee Held on 28 July 2015 at 8.30am In AD77, East Surrey Hospital, Redhill PART 1 Present Richard Durban Alan Hall Paul Biddle Paul Simpson

Non-Executive Director (Chair) Non-Executive Director Non-Executive Director Chief Finance Officer

Lorraine Clegg Sue Jenkins Janet Miller Natasha Hare Peter Burnett Shaun Cunningham (part meeting) Catriona Tait

Deputy Chief Finance Officer Director of Strategy Deputy Director of Human Resources Assistant Director of Operations â&#x20AC;&#x201C; Surgery Assistant Director of Finance Head of Capital Projects Head of Costing & SLR (Minute Taker)

In attendance

WELCOME AND APOLOGIES FOR ABSENCE Apologies: Apologies were received from Gillian Francis-Musanu (Director of Corporate Affairs), Fiona Allsop (Chief Nurse), Ian Mackenzie (Director of Information and Facilities) and Paul Bostock (Chief Operating Officer). Declarations of Interest: There were no declarations of interest.

MINUTES AND ACTIONS OF THE PREVIOUS MEETING The minutes of the 23rd June 2015 were approved. Review of Actions The action tracker was presented and noted that the items due would be discussed within the presented papers.

FINANCE Financial Performance M03

Paul Simpson presented the M03 finance report and noted that NEL 2 day admissions had increased by 8.7% against a plan of 2% and this was driving costs, notably in the use of agency staff. This additional activity also impacted on our ability to carry out planned elective work. He highlighted the following:

The adverse variance on income is partly due to phasing but will result in under delivery over the year.

The Trust is continuing to report delivery of the plan – a £1.6m surplus - subject to discussion of the Q1 Forecast at the Private Board. The main overspends are in the Divisions and action is ongoing to manage the position.

Alan Hall asked what has caused the income phasing and Lorraine Clegg replied it was the opening of the 10th Theatre where associated income would not start until later in the financial year. Paul Simpson added that there would be a £4m adverse variance against the £14m planned additional income for 2015/16 which is offset by a reduction in costs. It is estimated that the loss of contribution would be £600k this financial year. Paul Biddle asked if this was due to either capacity restraints or receiving the referrals. Natasha Hare replied that it was mainly due to recruitment. The physical capacity will be ready in August and the additional activity will start in October. Paul Simpson added that as part of the £14m plan work had been done on activity issues in Endocrinology and Cardiology to get the income back on track and that the key challenge is to ensure that the emergency activity does not impact on this. Richard Durban asked if there was any sense in the organisation that we were over admitting from ED and there was therefore an opportunity to reduce the level. Natasha Hare replied that senior clinicians do regular audits and have not found that the Trust is admitting inappropriately. Richard Durban commented that therefore the Trust needed to address issues of capacity and productivity. Paul Biddle asked if medically ready for discharge (MRD) patients were an issue. Sue Jenkins stated that the Trust currently had MRD 100 patients. Paul Simpson said that this continued to be an issue that the Trust discusses with local authorities and CCGs. Alan Hall asked about the difference between the income values and the activity volumes. Lorraine Clegg advised that the income is reporting the plans that the divisions have signed up to where the activity is reporting the Trust total. Paul Biddle expressed concern that it is difficult to catch up activity that is not delivered in the first quarter. Richard Durban asked whether the Non Elective activity that is now paid at 70% tariff is covering its costs. Paul Simpson said it was not, agency costs are higher and all new income is only paid at 70%. Richard Durban noted that bank staff numbers were down and outsourcing elective activity and drug and non-pay costs were up. Paul Simpson confirmed that these were consequences of the increase in emergency activity, Paul Biddle asked if the Trust can get a permanent loan of £18m as an NHS Trust rather than this being dependant on being a Foundation Trust. Paul Simpson advised that we had submitted a loan application to the TDA for the £18m cash and it had not been taken forward. 2015/16 CIP update Paul Simpson presented the CIP report. Paul Biddle noted that the CIP plans were back end phased. Paul Simpson confirmed that they were and that the forecast described a £3.4m adverse delivery. This is mainly due to nursing and other agency costs not being reduced, escalation and Pathology. Peter Burnett added that for the nursing agency replacement scheme the costs of the recruitment were spread across the 3 years of the project. Alan Hall said he would like 2

transparency around the total costs and forecast for the life of the project. Lorraine Clegg advised that the CIP paper would be updated to show this for future months. 2016/17 CIP update Paul Simpson told the Committee that the CIP projects would be managed by a gateway process. Richard Durban noted that the Trust needed both individual schemes and the CIP total to be targeted above what is needed in order to hit the plan. He asked if there is anything else we can include other than cost reductions and income contributions. Paul Simpson replied that the NHS will take any scheme that they can but we need to focus on schemes that are cash releasing and have productivity gains and what aspects of the transformation schemes will then produce savings. 4

WORKFORCE AND ORGANISATIONAL DEVELOPMENT Workforce and Organisational Development Report M03 Janet Miller presented the workforce papers. She advised the Committee that the new achievement review is only at 50% against a target of all having been done by the end of July. Managers are reporting difficulty achieving the target and the expectation is that it will take 3 years to reach a position where all reviews being done in the first 4 months of the financial year. Richard Durban asked if 3 years was too slow given their importance and what is the revised target for this year. Janet Miller replied the target was to have them all done before the winter. Janet Miller then told the Committee that the achievement review process is only for agenda for change staff and that HR is working with Medical Staff to get the values and behaviours process into their appraisal and revalidation. Janet Miller advised the Committee that the level of MAST training had improved and that the Executive committee would decide by October on how the MAST reporting will be calculated in the future. Janet Miller highlighted to the Committee changes in the establishment and recruitment processes. Work has been done with ward managers on a revised tracker and an agreed a time to recruit metric of 42 days from close of the advert to a formal offer being made. Workforce has revised the staff leaving process and included an online questionnaire. Paul Biddle asked that, given how critical it is to address the vacancy issues, what feedback are we getting. Janet Miller replied that we needed to collate the information but an early learning was that as an organisation we had always thought we were losing staff to London Trusts but the questionnaires suggest we are losing staff to other local NHS organisations. Executive Team feedback on Vacancy reporting Janet Miller presented the paper from Sally Spencer which was to help the Committee understand the funded establishment and vacancy level for nurses. She noted that within the funded establishment nursing posts there is uplift for sickness and absence. For clarity Richard Durban asked whether therefore the 625 funded positions in Medicine included the 22% uplift. Janet Miller said that Medicine has made the decision to include 18% of the uplift and Surgery includes a lower percentage and it is at the discretion of the Divisional Chief Nurse (DCN) to agree the position for the division. Richard Durban asked what happens to the uplift that 3

is not included. Janet Miller replied that this is what is left for the agency spend and if a high percentage is included in funded establishment then there is a high risk of overspends against budgets. Workforce Internal Control Framework Janet Miller advised that since the last time the framework was presented nurse validation have been added into the metrics. All the metrics had been discussed at the Workforce Sub Committee and it was happy with the framework. Richard Durban repeated a point made at the last FWC – given the amount of change to core processes that are not yet bedded down and the many red rated KPIs, were some of the ratings not overly optimistic? He asked that the Executive Committee review the ICF before the final version comes back to the August FWC. It will be presented to the AAC on 1st September. Paul Simpson added that there were gaps in reporting of metrics that allowed assurance to be taken and suggested that a new section on “Reporting” be added to the Workforce ICF. Action: Add a section on Reporting to the Workforce ICF. The Executive to review and agree the Workforce ICF before it is presented to the August FWC. Janet Miller 5

CAPITAL AND ESTATES Capital & Estates Report M03 Shaun Cunningham presented the M03 Capital Report. Alan Hall asked why the reduction in pathology spend and its reallocation to the Medical Records project was not included within the narrative of the report. Paul Simpson replied that it was in the Partnership report in Part 2 and it was the timing of the process that means it will fall into next year’s capital spend. This will be clear in next month’s capital report.

IT IT Report M03 The month 3 IT report was presented. Alan Hall expressed concern that the Trust is not seeing the full benefits of the EPR project and would like more detailed information around planned benefits and their timing. Richard Durban agreed that the Trust needed to strengthen benefits management and asked that this be included in the next iteration of the IT Roadmap. Action: The IT Roadmap to provide an outline of planned benefits for each project; individual projects to provide detailed benefit plans. Ian Mackenzie

GENERAL Date of next meeting Tuesday 25th August 2015 8.30am – 11.00am – AD77

Safety & Quality Committee Thursday 2nd July 2015 14.00 - 15.00 AD77 Trust Headquarters, East Surrey Hospital Minutes of Meeting

Present: Richard Shaw Pauline Lambert Alan McCarthy Paul Simpson Debbie Pullen Victoria Daley Barbara Bray Katharine Horner Ben Emly Jonathan Parr Stephanie Biden Presenting: Shalini Srivastava Sumit Kar Zara Nadim

RS PL AM PS DP VD BB KH BE JP SB

Non-Executive Director (Chair) Non-Executive Director Chairman Chief Financial Officer Chief of WACH Deputy Chief Nurse Chief of Surgery Patient Safety & Risk Lead Head of Information Clinical Governance Compliance Manager Risk Manager for Medicine

SS SK ZN

Consultant, WaCH Consultant, WaCH Consultant, WaCH

Apologies Des Holden, Fiona Allsop, Virach Phongsathorn, Paul Bostock, Colin Pink, Julian Webb, Ed Cetti Action 1

GENERAL BUSINESS 1.1. Chair welcomed everyone to the meeting and apologies were noted. RS explained that this would be a one-hour long meeting, closing 15:00. 1.2.

Minutes of the previous meeting

The June meeting minutes where agreed as an accurate record. 1.3.

Actions from previous meeting were discussed as follows All actions are on the agenda. The Annual Falls and Safeguarding reports together with the report on incidents have been deferred to the August meeting.

COMMITTEE BUSINESS 1.4. Highlights from Executive Committee for Quality & Risk PL asked what progress had been made on reducing noise at night, nd

SQC Minutes 2 July 2015 Page 1 of 5

VD VD agreed to get an update. PL asked whether it would be appropriate to replace “clinically led, managerially enabled” with “patient focused, clinically led, managerially enabled”. The committee agreed. RS asked whether the “easily achievable quality improvements” had been articulated and captured, and what they are. BE replied that the Divisions would be presenting these at ECQR w/c 6/7/15. RS asked that that progress on this be monitored through the ECQR reports to SQC. RS asked about the elevated risk on CQC monitoring report for stroke. JP confirmed that this related to access to the stroke ward and is being monitored through the Medical Division. BB added that the site team have put greater emphasis on ringfencing the beds. It is expected that both pieces of work will be soon reflected in the indicators. RS asked about coding in low risk mortality groups and the potential to become an elevated risk. JP reported that there is a daily report going to the coding manager, which enables an immediate investigation. There have been no episodes coded in this category for the past 2 months. This data will eventually feed through from Dr Foster and positively impact the CQC Intelligent Monitoring report. RS asked where the Q4 Benchmarking Report goes. PS explained that it was agreed that it would go to one meeting, FWC, he agreed that it is relevant to SQC. RS asked that any “stand out” points from the Benchmarking report be included in the Quality Report. 1.5.

Highlights from CQRM

PS reported that the report sums up the position, the Single Performance Conversation scheduled for w/c 6/7/15 has been cancelled because there are no items escalated. PS explained that it has been agreed that there will be an offline nurse to nurse agreement about the funding for nurse staffing ratios. The Trust needs to confirm the CCG position formally with regard to the quality (not financial) aspects of this decision. PS confirmed that the CCG action plan to reduce bed days within the Trust is progressing. 2

QUALITY PERFORMANCE 2.1 Quality Report PL requested that the issues relating to the urology pathway be explained. BE confirmed that there were internally there is a demand and capacity mismatch and externally there are issues with the Royal Surrey which is receiving focused attention being led by Ed Cetti and Angela Stevenson. PL asked about the situation with hoists. VD reported that seven nd

SQC Minutes 2 July 2015 Page 2 of 5

hoists had recently failed their LOLER tests, she has asked the manual handling lead to undertaking a scoping exercise to assess the available alternatives for moving patients. This will be managed through the Patient Safety Committee. PL asked about the safeguarding police investigation, VD reported that it is still under investigation an updated can be provided when this is complete. AM stated that he would like to understand more about the new RTT targets and whether there is any danger of unintended consequences and how the Trust will manage that. It was agreed that there would be BE a short written report to the next meeting. RS asked about the failure to record compliance with the Duty of Candour regulation. VD responded that the process is still embedding but that progress is positive. RS asked about the readmission audit and clarification on the issues. JP reported that the audit was triggered by the red flags on the scorecard and is to pin point the clinical reasons to see if there are any trends. JP is currently sourcing the notes and the results will go back to clinical effectiveness. RS asked that the outcome be reflected in the Quality Report. 2.2 SQC Dashboard AM noted that the dashboard had already been discussed at the Board. 3

QUALITY Sumit Kar and Shalini Srivastava presented the work being done by the Obstetric team to manage and provide assurance that the Caesarean section rate is appropriate for the Trustâ&#x20AC;&#x2122;s patients taking into account their clinical condition. RS asked for clarification on â&#x20AC;&#x153;complexityâ&#x20AC;?, this was explained as maternal co-morbidities, increasing maternal age etc. AM asked how mothers respond to a caesarean section (CS) and what the long term implications are. SK replied that a normal birth has a quicker recovery time, the mother and baby can be discharged within a few hours and there is no wound (less chance of infection, bleeding, clots). PS clarified that there was a target in place regarding CS rates but that this was withdrawn following a WHO report which said that CS were just as safe as a vaginal birth. SK explained that pregnancies following a CS have to be carefully managed. In addition it can add complexity to any future abdominal surgery. nd

SQC Minutes 2 July 2015 Page 3 of 5

MC explained that some women can be very disappointed if they have a CS and need to be debriefed. Equally there are some women who request a CS and are disappointed when it is not clinically supported. DP referenced the Morecambe Bay report which found that there were midwives who were promoting a vaginal birth at any cost which had adverse consequences for a number of babies. ZN reiterated the extensive work that the department and the Birth Choice Clinic have been doing to ensure that the clinical pathways for pregnant women are clinically appropriate and effective. It is important that normality is promoted in the best interests of the patient. PL was sorry to hear that the clinical skill of turning breach babies has been lost, but was pleased that the department is currently addressing this. RS remarked that the committee can take assurance from the work of the team; that the team takes a balance approach, looks at the needs of the individual, agrees plans with the mother, and appears to adopt a sensitive and thought-through approach. RS asked whether there was any outstanding issue of concern which might affect the quality of the service. MC reported that there are number of women who will request a birth option that has a high level of risk and needs to be managed very carefully. ZN replied that at a general level the team has no concerns about their CS rates. DP agreed and that the surveillance would continue. ZN stated that there were still small areas to be improved but that this would make only a marginal difference to the overall CS rate. RS thanked the team for presenting. 4

PATIENT EXPERIENCE PL asked about the Baby friendly initiative. MC explained that it had been extended to include paediatricians and neonatologists. It has not been possible to train all staff in the time available but the team remains committed to taking the initiative forward. Update to FFT: MC explained that there are three touch points for pregnant women giving feedback to the Trust; 36 weeks, post-natal discharge and the point of transfer from community midwife to health visitor. By the time they reach the last touch point they have given feedback three times in six weeks, this is a national issue. The figure has increased from 1% to 3% the national average is 5%. The general feeling is that the comments have been positive. The team had had two focus groups before Christmas to gather more in-depth feedback and plan to repeat the exercise in August. nd

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VD asked how the Trust compares with neighbouring Trusts; MC replied that they are about the same. RS sought and received confirmation that MC, as head of the service, is getting the feedback necessary to manage improvements to the service. ANY OTHER BUSINESS JP informed the committee that the National Childrenâ&#x20AC;&#x2122;s and Young People Survey has been published and that the Trust is one of the best performing Trusts. This was well received. DATE OF NEXT MEETING 6th August 2015 14.00 â&#x20AC;&#x201C; 16.00 AD77

SQC Minutes 2 July 2015 Page 5 of 5

CHARITABLE FUNDS COMMITTEE 05 March 2015 1.00pm – 2.00pm AD77

Attendees:

Yvette Robbins

In attendance:

Pauline Lambert Paul Simpson Fiona Allsop Gillian Francis-Musanu Ian Mackenzie Laura Warren Katrina Swanston Djafer Erdogan Helena Usman Janita Gardner

YR PL PS FA GFM IM LW KS DE HU JG

Chair of Charitable Funds Deputy Chairman / Non Executive Director Non Executive Director Chief Finance Officer Chief Nurse Director of Corporate Affairs Director of Information and Facilities Head of Communications Charitable Funds Fundraiser Head of Financial Accounts Charitable Funds Accountant Note taking

Apologies for absence Yvette welcomed members to the meeting. Apologies received from Paul Biddle.

Minutes of last meetings The minutes of the last meeting held on 04 November 2014 and the extraordinary meeting on 24 November 2014 were both recorded as a true and accurate record.

Outstanding Issues from previous meetings

3.1

Charitable Funds Committee meeting on 04 November 2014 Review following receipt of spending plans PS will review forecasts for Trust once plans received. Review need for charitable funds pending outcome of business case submission.

Action 1

Action closed

League of Funds to fund “Your Care Matters” Review source of charitable funds. Trust/Charitable Funds to cover

Action closed

Spending plans for charitable funds Report on planned expenditure. PS/DE to request and review expenditure plans from fundholders

Action 2

Action 3

Organ Donation Committee PL to discuss ideas and funding options with PS.

Charitable Funds Committee – notes of 5 March 2015 meeting

Page 1

Expenditure Guidance A further review of the guidelines to take place to include relevant information sought from other trusts. To also include clearer statement around financing of staffing costs

Action 4

DE/PS

Managing Charitable Funds Costs Review decision to apportion fundraisers costs. CF to cover with allocation to all funds.

Action closed

Fund Raising Prepare communications paper for extraordinary CFC meeting.

Action closed

Schedule extraordinary CFC meeting.

Action closed

KS to distribute suggested logos by email for approval and also agreed branding.

Action closed

Fund Raising YR confirmed that following BG leaving the Trust in December there had not been a Fund Raising Co-ordinator in place. As an interim measure, the committee acknowledged the contribution from KS, who was now supporting this work. CFC Fund raising update presentation was tabled by KS for discussion, and attached herewith for ease of reference. 

Achievement and Current Status SASH Charity launched on 12 December 2014. New website received over 2,000 hits to date, with a presence on social media. Charity boxes in place throughout the hospital. Numerous partnerships formed. YR agreed this was a good performance (and the committee agreed).



Ward and Special Purpose Fundraising KS explained how other hospital charities raise funds, and not always for a particular cause or a general fund. SASH individual wards were currently raising specific funds under their own banner. YR challenged the committee to consider the legitimacy of general fundraising when there was £630k held in relatively small accounts which was not being spent. She proposed pooling funds for general and specific funds. Queried whether the general fund should be supporting other funds. DE to check the legalities and the practicalities of pooling monies from all these various accounts into the general fund (noting the need to affirm spending plans). Action : DE to report on legal position.

Charitable Funds Committee – notes of 5 March 2015 meeting

Action 5

Page 2

LW advised the need to raise our profile by spending out of the general fund. PL suggested staff were not always aware that there was funding available to them and how to apply. Action LW to review how to make staff aware of existence of funds in their areas.

Action 6

Action 7

LW/PS/DE

Action 8

KS/FA

Action 9

HU/DE

IM raised concern that we need to be clear on what we’re raising funds for, and who decides on how it is spent and the difficulties over funding of posts from the perception of the public. It was agreed that this is a CFC decision and was open to review and addition of themes/causes. Following discussion, it was agreed that going forward, all subsequent fund raising takes place under the SASH Charity banner - to ensure a single identity. Action : A communication will be issued, directing staff to the intranet for information and guidelines. Secondly, that all new funds raised goes into one fund. Future single donations made to specific wards or causes, would remain unchanged and this would not contravene rules around restricted and unrestricted funds where donors were specific about use of donations. It was also agreed the SaSH Charity would continue to focus on Elderly Care for 2015. Action: FA to email her team stories to support. 5.

Finance YR queried a mathematical error on the Divisional Fund Activity spreadsheet with the balance in the General Fund. HU confirmed that this error had already been picked up and the figures amended. Actions: Confirm balance in GF of existing commitments going forward. Current balance in all accounts is £632k. 

Spending Plans Divisions are aware of their fund balances, but funds were not being expended. There was a need to increase the spending appropriately. PS suggested a “spend it or lose it” approach to those fundholders with significant monies. It was agreed that unspent monies would be transferred into the general fund. Charities Commission does not advocate hoarding of charitable monies for rainy days or investment purposes. Committee needs to encourage fundholders to increase spend out of their specific funds. Otherwise, balances would be transferred to the general fund. Committee recommend balanced approach and caution over the wording of the directive as it was not proposing expenditure of £630k in one year but was encouraging a

Charitable Funds Committee – notes of 5 March 2015 meeting

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step change in expenditure on appropriate items, in keeping with the purpose of the funds. Action Agree wording of directive and advise Divisions of their spending plan deadlines.

Action 10

PS/DE/LW

DE advised there were significant costs involved in staff training and that in the event members of staff leaving Trust employment within 1 year, the costs should be reimbursed to CF and that this should be included in ToR. Committee agreed Action: Amend CF expenditure guidance and appropriate Policy to be drafted for implementation and ToR

Action 11

Savile Action Plan - Refresh Due to time constraints, this item was not covered during the meeting. FA recommended CFC members read the report for discussion at the next meeting. Action: members to read report and raise any queries by email with FA

Action 12

ALL

LW asked if there was a system in place regarding spending limits. YR confirmed that spends up to ÂŁ2k were jointly authorised by herself and PS. Larger amounts were put to the CFC for approval. FA questioned whether any irregularities were picked up in spending trends, ie differing equipment across wards. DE/HU confirmed there were appropriate checks made against the purposes of the individual funds and such instances flagged to PS. 6.

Terms of Reference

Proposed date of next meeting To be confirmed

Charitable Funds Committee â&#x20AC;&#x201C; notes of 5 March 2015 meeting

YR/DE

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