Board papers January 2016 by Surrey and Sussex Healthcare NHS Trust

Surrey and Sussex Healthcare NHS Trust Board papers

January 2016

Trust Board Meeting – IN PUBLIC Thursday 28th January 2016 - 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 17th December 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

Clinical Presentation – Gastroenterology/IBD For assurance

D Holden/ Dr Ansari

Paper

2.2

Chief Nurse & Medical Director’s Report For assurance

D Holden/ F Allsop

Paper

OPERATIONAL PERFORMANCE 3.1

3.2

3.3

Integrated Performance Report (M09) For assurance

A Stevenson

3.1.1

Operational & Quality Key Performance Indicators

D Holden/ F Allsop

3.1.2

Workforce Key Performance Indicators

F Allsop

3.1.3

Finance Key Performance Indicators

P Simpson

Finance & Workforce Committee Update For assurance Audit & Assurance Committee Update For assurance

Paper

R Durban

Paper

P Biddle

Paper

13:05

13:25

RISK, REGULATORY AND STRATEGY ITEMS 4.1

Review of Quality Impact Assessments for 2015/16 For assurance

D Holden

Paper

4.2

Emergency Preparedness Resilience Plan For approval & assurance

A Stevenson

Paper

4.3

NHS Planning Guidance 2016/17 – 2020/21 For assurance

M Wilson

Paper

4.4

Annual Plan Update – Q3 For assurance

S Jenkins

Paper

OTHER ITEMS 5.1

Minutes from Board Committees to receive & note 5.1.1

Finance and Workforce Committee

5.1.2

Audit & Assurance Committee

5.2

ANY OTHER BUSINESS

5.3

QUESTIONS FROM THE PUBLIC Questions from members of the public may be submitted to the Chairman in advance of the meeting by emailing them to: gillian.francis-musanu@sash.nhs.uk

5.4

DATE OF NEXT MEETING 25th February 2016 at 11.00am

All

A McCarthy

Minutes of Trust Board meeting held in Public Thursday 17th December 2015 from 11:00 to 13:30 Room AD77, Trust Headquarters, East Surrey Hospital Present (AM) Alan McCarthy (MW) Michael Wilson (PS) Paul Simpson (DH) Des Holden (FA) Fiona Allsop (AS) Angela Stevenson (PB) Paul Biddle (RD) Richard Durban (PL) Pauline Lambert (RS) Richard Shaw

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

In Attendance (GFM) Gillian Francis-Musanu (SJ) Sue Jenkins (LB) Liz Butterfield (CP) Colin Pink 1.

Director of Corporate Affairs Director of Strategy Patient Story Head of Corporate Governance (Notes)

General Business 1.1

Welcome and Apologies for absence The Chairman opened the meeting by welcoming Trust Board members, members of the public, shadow governors and staff. Apologies for absence were noted from Alan Hall.

1.2

Declarations of Interest The Chairman asked whether any of the Board members had any new or additional declarations of interest. Pauline Lambert stated that she had started her new role as safeguarding named nurse at Queen Victoria Hospital NHS Foundation Trust. There were no other declarations.

1.3

Minutes of the last meeting – 26th November 2015 The minutes of the meeting held on 26th November were discussed. RD asked that for item 3.2 the minutes be amended to reflect the ‘extra benefits and opportunities made possible by the extra capital spend’ to explain the increased cost. PS highlighted the miss spelling of Filipino in section 2.2. With these amendments the minutes were approved as a true and accurate record. Page 1 of 9

1.4

Action Tracker

1.4.1

GFM updated the Board on the following actions: TBU-01 – is not due until 31.03.16 TBU-02 is not due until 31.01.16 TBU-03 is not due until 31.01.16 TBU-04 Board to received and review the Right Place, Right Time, Better Transfers of Care report is complete and the action closed. There were no other matters arising.

1.5

Chairman’s Report for Assurance The Chairman stated that there was nothing of interest to report since the last Board meeting which was not already covered within the body of the Chief Executives 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 highlighting the plans to develop a national whistleblowing policy as part of the “Freedom to Speak Up, open consultation from Monitor MW was also pleased to announce that the shared funding of the new Integrated Re-enablement Unit (IRU) was approved at Surrey County Council’s cabinet. The new unit will be an excellent addition to the growing health campus at SASH and will significantly improve pathways for patients who need assistance with the transfer from acute to primary care. The planned junior doctor strike had been cancelled at short notice which had impacted on circa 750 patients through canceled elective procedures and appointments. The Chairman reiterated the good news of development of the IRU, highlighting the benefits for patients and innovative development of joint working with the County Council. The Board duly noted and took assurance from the report.

1.7

Board Assurance Framework (BAF) and Significant Risk Register (SRR) for Approval and Assurance GFM introduced the board assurance framework and significant risk register. The BAF detailed 13 risks to the trusts strategic objectives which had been updated by the Executive team through December. The SRR has 11 operational significant risks following the downgrading of the cancer performance risk and merging of two financial risks. The Board discussed how the BAF financial risks did not reflect all of the detail of the finance papers. PS highlighted that due to the early December meeting that Page 2 of 9

the BAF had been updated before the finance papers had been prepared. This would be better reflected in the January 2016 updates. Action 1: PS RS asked for assurance as to why the cancer performance risk had been downgraded. AS stated that the associated pathways had been reviewed and improved to allow better management of individual patient pathways, which also increased accuracy of prediction of performance. There is also greater engagement with tertiary centres and the Trust was focusing on specific pathways. PB indicated that the BAF risk relating to delivery of income plan (5.1) could be amended to indicate the likelihood of delivery based on the Trust’s forecast. PS agreed stating that the risk was reviewed each month but that at present there was still opportunity to achieve the planned income. The Board duly approved and took assurance from the report. 2.

Safety, Quality and Patient Experience 2.1 Patient Story for Assurance DH introduced Liz Butterfield, a pharmacist by profession, who had been a recent emergency admission. DH reflected that Liz’s story was valuable as it describes how she perceived her care and re-assuring, as this was largely positive. LB thanked the Board for the opportunity to share her experience praising the efficiency of staff and the care she received. Liz explained that she had presented at the emergency department on a Saturday with breathing pain, triage and testing was quick and a working diagnosis of pneumonia was made. At this point she was told that she was being moved to ‘majors’ and despite knowing what this meant the terminology was still a cause of anxiety. In majors the multi-disciplinary team (MDT) worked well together and staff both cared and explained what was happening well. The decision was made to admit and the staff stated that she was being moved to the ‘Acute Medical Unit’ (AMU), and again the terminology caused anxiety. She had been reviewed quickly by a consultant on AMU and received good care and an explanation of the use of antibiotics. However, she noted that she received an anti-thrombosis drug in the middle of the night with no prior warning or explanation that it would be given or what it was for. On Monday she was transferred to Tillgate Ward where once again she received good care and stated that the nursing team was impressive. On the Wednesday her blood test indicated that the antibiotic treatment had been successful, which was followed by a sudden decision that she was fit for discharge. This had come as a surprise and LB went on to reflect that although this was not a problem for her, she imagined that it might be difficult for people with different circumstances. MW asked whether she had been given an estimated discharge date. LB confirmed that although she had been told that it would be a short admission she did not know an expected discharge date. RD asked if personal and case information had been passed between the various effectively. LB stated that she was asked background questions regularly but this was not annoying and was actually more reassuring. Page 3 of 9

FA asked what kind of discharge information had been given. LB stated that she could not recall but noted that she was given the discharge summary but was not concerned about details of the medication she was given on discharge. DH asked LB whether anything about the admission had left her feeling angry or upset. LB stated that nothing had caused her to feel angry or upset, reflecting that the staff had been caring pleasant and that she had been generally well informed. LB went on to state that during her admission she observed that all the patient’s around her appeared to be treated well and with compassion. The Chairman thanked Liz for sharing her story and welcomed her feedback and insight. PL agreed reflecting that LB’s reflection on our use of language, such as ‘Majors’ was an important reminder to all our staff. The Board noted and took assurance from the report. 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 Chief Nurse’s report stating that the drive to increase the number of midwifes had been successful and that all had now commenced bringing the ratio up to 1 to 32. FA went on to assure the Board that mitigation is in place to ensure safe provision in service for safer staffing metrics in the birthing centre. The Chairman asked for an update on recent international nursing recruitment drives in Europe. FA stated that the majority of the appointed nurses had arrived and work was underway to make them familiar with the hospital and differences in expected essentials of care. DH presented the Medical Directors report commenting on the recent engagement with the Trust’s Foundation Trust members to seek people willing to be involved in a survey of carers who support someone with dementia. The Board discussed diagnostic SIs, and associated capacity and staffing issues. PL commented on the SQC conversation and the Trust aim to achieve a zero error rate. DH reflected that issues in labs tend to relate to the misinterpretation of the sample where as in radiology incidents issues tend towards review of actions. DH went on to confirm that there was a capacity issue within radiology and that people were working extra hours to support the system. Extra Consultants are being recruited and there is an expectation that staffing will improve in Q4. The Board duly noted and took assurance from the report.

2.3

Safety & Quality Committee (SQC) Update for assurance The Board received and noted the report in advance of the meeting. RS introduced the report highlighting the Trust’s work to review ratios of female consultants and gender imbalance in surgical consultants. A focus group is meeting to consider ways of making the role more attractive for female consultants. Page 4 of 9

The SQC had received an overview of the implementation of the dementia strategy which was well received. There was agreement that there was work to do to ensure that the strategy reached all staff as it is not just a care of elderly responsibility and acknowledgment that some 1300 staff had received awareness training since the start of the strategy. RS went on to highlight ongoing issues with response rates to ‘Friends and Family’ tests and that the Executive Team would be considering the approach and use of ‘Your Care Matters’ systems. The Chairman asked for an update on CCG chaired ‘Single Performance Conversation’ which has been cancelled recently due to the lack of issues to discuss. MW confirmed that conversation’s had taken place and that it is expected that this important meeting would recommence. The Board noted the full report and gained assurance. 2.4

15 Steps Challenge – Update for Assurance & Approval The Board received and noted the report in advance of the meeting. FA introduced the report, giving a brief background of the scheme and some of the improvements that had been following direct observations such as the admission lounge refurbishment. FA went on to highlight plans to consider amending the scheme to include elements of transformational programme linked to the SASH + VMI work such as waste walks. The Board discussed this plan considering potential quality improvements, the cultural change and need to maximise impact. PL stated that she would like to see the 15 step programme remain in place. RD suggested that it would be more appropriate if teams requested a “15 Step” visit, perhaps after some VMI enabled change, rather than external teams independently looking at areas such as waste which risks the perception of inspection. Action: 2 FA The Board agreed that the guiding team would discuss and report back on the specifics of the proposal. The Board duly took assurance and approved the report.

Operational Performance 3. 3.1

2016/17 Cost Improvement Programme for Approval The Board received and noted the report in advance of the meeting which had been reviewed previously by the FWC. PS introduced the Trust’s indicative cost improvement plans for 2016/17 which will form the basis of the final plan to be agreed in March 2016. The plan explicitly does not include any SASH+ activity. PS stated that actions generated from the Carter report are not identified within this CIP noting that the methodology needs refinement. The Board discussed the potential make up of the CIP and the balance between pure cost reduction and greater contribution from increased income resulting from better productivity. The Board noted that the current financial years CIP was not going to plan and forecast was well below target. However plans such as the clinical supply reductions had been successful and there is expectation of further success in Page 5 of 9

2016/17. The Board noted how pressures from emergency activity and workforce issues had adversely affected delivery, notably against agency targets. The Board welcomed the early site of plans and noted the progress made to date. RD confirmed that the FWC would continue to review the CIP as it developed and start to review key projects. PS stated these included reduction in nurse agency costs. The Board asked FA for a report on nurse recruitment and agency use including the recruitment vs saving calculation went to the FWC. Action:3 FA The Chairman noted that delivery of CIPs had been a particular challenge for the Trust in 2015/16 and stated that we should be mindful of the implications of the Lord Carter report on efficiencies delivery of CIPs would require close monitoring in the future. The Board duly approved the indicative plan which would be signed off as final as part of the budget in March 2016. 3.2

Finance & Workforce Committee Chair Update – for Assurance The Board received and noted the report in advance of the meeting. RD reported that the FWC had met on the 15th December. The Committee had received the business case for refurbishment of ED’s resuscitation area and purchase of a CT scanner for ED which had been approved. It had also received updates on the radiology equipment replacement programme. It had agreed that the Managed Print Service full business case would now be approved by the Executive Committee as the contract value was below £1 million. The Committee had discussed the Trust’s 15/16 CIP and noted that £2.8 million pounds had been achieved to date with a forecast of £4.6 million, 56% of the target. The committee noticed that there had been some slippage since the month 7 position. The FWC had received the month 8 finance report. PS stated that the year to date deficit was £4.2m which is £2.2m adverse to the revised Trust plan submitted to the TDA. This position is also £0.6m adverse to the Q2 forecast. This continues to be driven by non-elective and emergency activity and the impact on ability to deliver elective activity. The Trust had kept the TDA appraised over its financial position and forecast end of year position. MW highlighted that a recent local decision to suspend elements of external end of life care until January would impact on these issues. PS went on to state that cash advances from CCG’s had been secured and cash flow in the short term was manageable. The backlog of creditors had been extended. Capital spend continues to remain on track and that capital to revenue transfer conversations have commenced. The Board discussed this position and noted that formal dispute processes had commenced with East Surrey CCG in relation to payment of income. The Private Board had reviewed the Trust full year forecast, noting continued adverse performance against the forecast at quarter 2. It had agreed that the Trust should revise its forecast to a deficit and inform the TDA. The deficit would Page 6 of 9

be approved through a delegated process, to the Chair and Chief Executive, next week. The Board duly noted and took assurance from the report. 3.3

Breaking the Cycle Update â&#x20AC;&#x201C; for Assurance and Approval The Board received and noted the report in advance of the meeting. AS introduced the report which provided a review of the November and December breaking the cycle weeks. The aim of each cycle is to improve patient care, patient flow and reduce the number of patients who are ready for discharge. The paper listed the key actions taken. One of the key elements was to manage the balance between admissions and discharges which impacts on getting patients into the right bed. The December cycle week had a challenged start with breaches and surges in ED activity. AS reminded the Board of issues relating to the ED targets, ambulance attendances and batching of GP patient attendances. However, the Trust had learned from the November cycle and achieved a good bed balance going into the weekend with high numbers of medically ready for discharge patients identified and prepared and significant drop in medical outliers. AS went to reflect that the focus must remain on clinical buy-- in, partnership working with the community, reducing escalation, reducing outliers and improving weekend care. The Board discussed how effective the cycle had been and asked when this would become the norm rather than an initiative. AS stated that there was a great deal to learn and adopt as business as usual but there remained a need to have the ability to do something different. PB asked whether there was any level of effect on line management in particular disempowerment caused by the level of management engagement. AS stated that the general commentary indicated that it was a constructive process and was not aware of any feelings of disempowerment. MW commented on the assurances and management of risk highlighting issues relating to ambulance attendance, awareness of pathways and poor predictive information relating to private ambulance arrivals. The Board noted this and agreed that there was strength in the real-time understanding of the situation that is developed during each cycle. The Chairman thanked AS for the report and all staff for their efforts during the period. The Board duly took assurance and approved the report.

Risk, Regulatory and Strategy Items 4.1

Serious Incidents Report - for Assurance The Board received and noted the report in advance of the meeting. FA introduced the paper highlighting the key information relating to the two new declared incidents a fall with harm and an MRSA blood stream infection. FA went Page 7 of 9

on to state that there are no overdue reports and similarly no related backlog. The Board duly took assurance from the report. 4.2

SaSH + (VMI Update) – for Assurance The Board received and noted the report in advance of the meeting. SJ introduced the paper which gave an overview of the 5 year programme and progress so far such as development of governance identification of the Trust’s 3 initial value streams and development of compacts between Trust’s and the TDA. SJ stated that the supporting team (Kaizen Promotion Office) had been established with taster sessions and management training sessions planned. The Board discussed both the benefits of the programme for the Trust and the NHS. Key to this conversation was the recognition that the Virginia Mason Hospital was 13 years into its journey and the NHS needed to learn quickly from the vast experience of the teams involved to identify issues and innovate rapidly to continue to meet the needs of patients and also the broader challenges facing the NHS. The Board went on to reflect that as a whole the Board needed to become more familiar with the programme, start to use the language and challenge key issues such as ‘passing on defects’ within a system. SJ confirmed that this would be included in future Board development seminars. DH reminded the Board that in this early stage of the journey the emphasis must remain on going and seeing the care provided at the front line in order to get a richer understanding of the reality of day to day practice. The Board agreed that they would like to have early sight of the Trust’s Clinical Compact with its staff. Action:4 SJ The Board duly took assurance from the report.

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 and Quality The minutes of the Committee were noted with no questions raised.

5.2

Any Other Business AS stated that the Trust had received a request to provide assurance of preparedness for involvement in the management of an emergency incident. Following the recent Paris terrorist attack the national threat level had been assessed as high. The NHS England return asks for assurance over issues relating to emergency preparedness such as management of telecoms and ability to receive casualties. AS confirmed that the response would be prepared and included in the January 2016 agenda item relating to the annual Emergency Page 8 of 9

Planning, Resilience and Response return. 5.3

Questions from the Public There were no questions raised.

5.4

Date of the next meeting Thursday 28th January 2016 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 9 of 9

TRUST BOARD ACTION TRACKER - PUBLIC BOARD MEETING Action Ref

Forum

Subject

Action

Date Open

Date Due

Date Closed

Status

ACTIONS FROM PUBLIC BOARD MEETINGs - December 2015

TBPU-01

TBPU-02

TB Public

Patient story

The Board requested that Dr J Webb update the Board on findings and actions of the sample group. Dr ZN/DH Zara Nadim will now be undertaking this work.

28/08/2015

31/03/2016

Not Due

Patient story

The Board asked for feedback on the outcome of the retrospective audit to ensure that patients have received the correct follow up. SI action to be considered by the Effectiveness Committee. FA

26/10/2015

31/03/2016

Not Due

SJ / Executive Team

26/10/2015

31/01/2016

On agenda

17/12/2015

31/01/2016

On agenda

17/12/2015

31/01/2016

Verbal update

17/12/2015

31/03/2016

Not Due

17/12/2015

28/02/2016

Not Due

TBPU-03

TB Public

Q2 Annual Plan Update

TBPU-04

TB Public

BAF & SRR

TBPU-05

TB Public

15 Step Challenege

TBPU-06

TB Public

Cost Improvement Programme

The Executive team is asked to consider the scoring of elements to ensure consistency across reports for the next quarterly update with particular focus on elements already RAG rated as red. To update BAF to take into account FWC and Board conversations throughout December. The Board agreed that the guiding team would discuss and report back on the specifics of the proposal to amend the 15 step programme to include elments of SASH+ work. Provide a report on nurse recruitment and agency use including the recruitment vs saving calculation went to the FWC.

TBPU-07

TB Public

SaSH + (VMI Update)

The Board agreed that they would like to have early sight of the Trustâ&#x20AC;&#x2122;s Clinical Compact with its staff.

TRUST BOARD IN PUBLIC

Date: 26th January 2016 Agenda Item: 1.6

REPORT TITLE:

CHIEF EXECUTIVE’S REPORT Michael Wilson Chief Executive Gillian Francis-Musanu Director of Corporate Affairs

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: • Joint Working by NHS Improvement/TDA and the Care Quality Commission Local: • Lord Prior Visit • Black Escalation Summit • Opening of Integrated Reablement Unit • Junior Doctors Industrial Action • Opening of Macmillan Cancer Information Centre 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 – 26th January 2016 CHIEF EXECUTIVE’S REPORT 1.

National Issues

1.1

Joint Working by NHS Improvement/TDA and the Care Quality Commission

The Trust received a joint national letter to Chief Executives, Finance and Medical Directors along with the Chief Nurse from Jim Mackey Chief Executive of NHS Improvement and Professor Sir Mike Richards, Chief Inspector of Hospitals at the Care Quality Commission (CQC) made clear that success is the delivery of the right quality outcomes within available resources. The letter also confirmed that quality and financial objectives cannot trump one another and that our responsibility as a Provider is to deliver the right quality outcomes; confirmation was also given that improving quality is more important than staying in financial surplus. There will be some changes in the regulatory framework from both NHS Improvement and CQC inspection regime going forward. A consultation will shortly be launched on the CQC’s future strategy and a single new NHS Improvement regulatory framework for providers. Both organisations have recognised the importance of a joint single clear and consistent message. The changes will include a jointly designed approach which the CQC will use to assess trusts’ use of resources. Consideration will be given as to how the CQC can use the financial data NHS Improvement holds and use the expertise of NHS Improvement staff in reaching its judgements on use of resources. Similarly, as NHS Improvement develops its view of the role of quality in the new, single, provider regulatory framework, this will be undertaken jointly by the CQC and NHS England. They will also be sharing revised National Quality Board staffing guidance and a new metric looking at care hours per patient day that will be used in looking at how trusts manage staffing resources. In practical terms, there is a desire for regulators and commissioners to rely on each other’s work, rather than duplicating effort, and create a single unified framework with a single way of measuring success that is used by all. This should bring greater clarity and consistency and reduce the regulatory burden. One of NHS Improvement’s early priorities will be to work with organisations with large deficits to help them return to surplus and ensure that even in trusts which face some of the biggest financial challenges support is provided to balance finance and quality.

Local Issues

2.1

Lord Prior Visit

The Trust was pleased to welcome Lord Prior, Minister for NHS Productivity on 20th January 2016. This was a welcomed and very positive opportunity for a range of clinical and senior leaders with the Trust to meet and discuss a diverse number of key issues affecting the NHS from a local and national perspective with Lord Prior who was very keen to hear from front line staff as well as tour the hospital.

2.2

Black Escalation Summit

As the system wide Black status has continued for longer than a period of 3 or 4 days a black summit should be held with all the executive directors from each organisation to understand the overarching clinical risk and patient safety issues across the health system. The TDA or Monitor representatives should also be invited to attend. The Black Escalation Summit has been convened and is due to take place on 28th January 2016 at 3.00pm and will be chaired by the NHS England (South â&#x20AC;&#x201C; Local Team) to provide leadership and support to issues identified as well as to agree actions to de-escalate the system.

2.3

Opening of Integrated Reablement Unit

We are pleased to confirm that the Integrated Reablement Unit opened on 21st January 2016. This is a unique collaborative partnership between SaSH, Surrey County Council and East Surrey CCG and will provide a dedicated unit for patients who no longer need to be in hospital and are medically ready for discharge.

2.4

Junior Doctors Industrial Action

On 12 January 2016 around 38,000 junior doctors went on strike for 24 hours â&#x20AC;&#x201C; the first industrial action of its kind for 40 years. This industrial action led to the cancellation at a national level of approximately 1,425 inpatient operations and procedures, while 2,535 outpatient appointments were also cancelled. Emergency only cover was provided on this day and significant. At SaSH we believe around 90% of junior doctors took industrial and there was significant impact on our services locally. The planned additional industrial action for 26th January has been recently suspended as negotiations continue at a national level. 2.5

Opening of Macmillan Cancer Information Centre

I am also pleased to confirm the official opening of the Macmillan Cancer Information Support Centre on 27th January 2016. This brand new facility brings specialist care and support closer to home for local people and builds on our strong partnership with Macmillan.

Recommendation

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

Michael Wilson Chief Executive 26th January 2016

Date: 28th January 2016

TRUST BOARD IN PUBLIC

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 Gillian Francis-Musanu Director of Corporate Affairs Colin Pink Head of Corporate Governance AAC 15th January 2016 Executive Team 20th January 2016

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, 6 of which are recorded as key strategic risks and red rated. It is proposed that BAF risk 5.2 be rescored from a 15 to a 12 to reflect ability to achieve forecast end of year budget. There are 10 significant risks recorded on the Trust risk register. One risk has been downgraded since the December Board relating to divisional overspend linked to the BAF risk above. Recommendation: The Board is asked to discuss and approve the report and consider the following: • Consider the proposed reduction in risk 5.2 • Does the Board agree with the recorded controls and assurances • Note the updated risks included in the Significant Risk Register 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: January 2016 BAF and the current SRR

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT – 28th January 2016 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

Following discussions at AAC and the Executive team it is proposed that the strategic risk relating to ‘Failure to stop divisional overspending against budget’ (5.2 BAF) is reduced to 12. This is based on the Trust’s current financial position and end of year focus. 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). There have been minor amendments throughout regarding controls, actions and assurances. The 15/16 BAF (attached) details a total of 13 risks to the 6 Trust strategic objectives which are scored as follows (not including proposed reduction):

An Associated University Hospital of Brighton and Sussex Medical School

Objective

Red (15-25)

Amber (8-12)

Green (1-6)

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 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). There have been minor amendments throughout regarding controls, actions and assurances. 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

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

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 Proposed S4 x L3 = 12

Target Risk Score

S5 x L3 = 15

Target Risk Score

S4 x L2 = 8 S3 x L2 = 6

5. 3 Unable to deliver realistic medium term financial plan

S5 x L3 = 15

S4 x L2 = 8

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

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

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 The Trust remains within the current FT pipeline and awaits national guidance on potential new organisational forms which could result in changes to the current timescale and associated requirements to the process. Due to the merger of the NHS TDA & Monitor and creation of NHS Improvement there is uncertainty over the longevity of the current FT model. 5.7. There is a risk that the Trust will not fully realise the benefits available from well embedded IT systems

An Associated University Hospital of Brighton and Sussex Medical School

2.3.

Key risks Strategic risks Identified

The BAF highlights the following 6 key red risks to the Trust objectives that have been identified at time of updating the framework (not including the proposed reduction). 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 Trustâ&#x20AC;&#x2122;s ability to maximize financial and 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. 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

Current rating

Target risk score

S5 x L3 = 15

S5 x L2 =10

S3 x L5 = 15

S3 x L2 = 6

S4 x L4 = 16

S4 x L2 = 8

S5 x L3 = 15 S5 x L3 = 15

S4 x L2 = 8 S4 x L2 = 8

S5 x L3 = 15

S4 x L3 =12

3. Significant Risk Register The Executive Committee has reviewed and agreed the content of the significant risk register. There are 10 risks on the Trust significant risk register. Risk 1688, Risk of potential overspending from operational pressures, has been downgraded to reflect the reduction in risk. Each risk is in date and has mitigating actions to reduce the level of risk to an acceptable level. 3.1 SRR Breakdown ID

1401

Title Risk of outbreak of viral gastroenteritis

Initial Rating

Current Rating

Residual Rating

Next Review

31/03/2016

31/01/2016

31/03/2016

1501

Failure to maintain Emergency Department performance Patient admitted to the right bed first time

1603

Unable to provide realistic medium term financial plan

31/01/2016

1604

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

31/01/2016

1491

An Associated University Hospital of Brighton and Sussex Medical School

Title

1663

1672

Risk of not achieving Cost Improvement Plan Increasing Sickness Absence Levels with impact on day to day management and expenditure RTT Access Standards

1678

Initial Rating

Current Rating

Residual Rating

Next Review

31/01/2016

11/02/2016

1689

Risk of Contract income below plan

31/01/2016

1697

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

31/01/2016

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: • Consider the proposed reduction in risk 5.2 • Does the Board agree with the recorded controls and assurances • Note the updated risks included in the Significant Risk Register

Gillian Francis-Musanu Director of Corporate Affairs January 2016

Colin Pink Head of Corporate Governance

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

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

• 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

• 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

• 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)

Financial Management • Small loss <£1K

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

Governance Arrangements

• 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

Health & Safety

Quality of Service

• 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) 2) 3) 4)

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

14.

Clinical teams in place to implement patient safety plans in the Trust (falls, pressure ulcers and infection control) Regular review of patient safety data including the Safety Thermometer at divisional, executive and board level Groups/Committee established including SQC, ECQR and its subcommittees, N & M and Divisional Governance Policies, procedures and guidelines provide the framework by which risks and incidents are managed. Work undertaken to deliver â&#x20AC;&#x2DC;5 sign up to safety pledgesâ&#x20AC;&#x2122; (Monitoring patients for early signs of deterioration, Pain management for Dementia, Duty of Candor, COPD EQ pilot and improve shared learning from incidents) Matron on site 7 days a week to monitor nursing patient care and staffing Clinical Site Matron established 24/7 with enhanced team (2xB7 and 1x B8a) Nursing staffing levels monitored daily and issues managed Incident reporting policy in place and monitored Ward safety boards updated regularly and ward performance discussed at divisional level Serious incident review group established to monitor and evaluate investigation progress and progress against actions Training undertaken for clinical staff in the assessment and management of patients at risk of falls Patient falls strategic group meet monthly and report KPIs to the patient safety committee. System developed to split Trust and Community acquired VTE events which are reviewed at Clinical Effectiveness, Patient Safety and ECQR.

Developing ward safety dashboards Ward accreditation system under development as part of 15/16 CQUIN Updating and planning RCA analysis training for new managers/leaders Embedding DATIX incident review process within 14 day timeframe

Potential Sources of Assurance (documented evidence of controls effectiveness)

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

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 audit (+) QGAF assessment and action plan (+) New EWS trialed and audited (+) 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 including increase in reporting (+) Monthly trust wide reporting using national benchmarking (+) Falls Training data (+) Annual Falls Report 14/15

2) 3) 4)

External reports and visits to clinical areas both scheduled and unscheduled (e.g. 15 step challenge) Ward Dashboards Divisional and Trust Level Dashboards VMI/SASH Plus Program

Page 2

(+) Clinical Nurse Consultant for Falls and Patient Safety commenced 4 December 2014 (+) 15 Steps quality program (+) Annual Falls report 2013/14 reduction in falls with harm in year (+) Resource focus on patient safety and falls (+) Strong 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 (-) 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) VMI/SASH plus development program 2) 5 work streams identified in Trusts sign up to Safety Pledges (Monitoring patients for early signs of deterioration, Pain management for Dementia, Duty of Candor, COPD EQ pilot and improve shared learning from incidents)

Update by

Page 3

FA 08/01/16

Date discussed at board

1) 2)

Ongoing Ongoing action plan

To be discussed at January Board

Objective 1 - Safe –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). All cases C. diff joint review by CCGs and Trust. 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 – 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 (+)Antimicrobial prescribing audit compliance (+)Actions taken as part of annual program (updated July 2015) st (+)1 TDA visit inspecting controls and procedures nd (+)2 TDA visit comparison with other Trusts and brokered meeting with CCGs (+)PHE and NHSE walkthrough ED for VHF risk provides good assurance (+)Management of diarrhoea agreed as one of first ‘VMI Value Streams’ (+)Initiation of ‘Stop, Access, Send’ initiative for the management of Negative (-)Incidence of CDI 2015/16

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

Page 4

Assurance Level gained: RAG

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 (Fidaxomicin and Chloramphenicol IV) Update by Date discussed at Board DH 22/01/16

Page 5

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 January 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 116 Assurance Level gained: RAG

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

DH 22/01/16

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 January 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) Transformation Team in place 2) System Resilience Group 3) 3x3 meetings 4) CEO strategic meetings 5) Partnership boards 6) Trust part of national Virginia Mason transformation Programme 7) Integrated Reablment Unit build complete Potential Sources of Assurance (documented evidence of controls effectiveness)

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) Repatriation of tertiary services effected and influenced by external factors 3) Clear action plans linked to root causes of efficiency issues and using service improvement methodologies not yet fully embedded

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 (+) Extended theatre working days Crawley (20% increase capacity) (+) Second Cath Laboratory in place (+) VMI Guiding Team established, initial Value Streams agreed

1) Contracts 2) Plans 3) Referral activity 4) GP Support 5) Breaking the cycle 6) Divisional Performance Reviews 7) Productivity reporting

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 (10% vs 2% plan) Gaps in assurance Assurance Level gained: RAG Agreed activity modelling across SEC National policy decisions and effective of general election Mitigating actions underway 1) Full action plan development for transformation programme (theatres, outpatients, VMI Value streams) 2) Breaking the cycle and reducing LOS action plan

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) End of quarter 4 2) Ongoing

Update by

To be discussed at January Board

Page 7

AS 21/01/2016

Date discussed at 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 Nursing agency PMO, Workforce subcommittee, Exec Committee and the Board 2. Monitoring of Safety Thermometer, patient experience and staff turnover, sickness at ward level and at associated subcommittee, Exec and the Board 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 and project commenced b. Nursing recruitment plans developed by DCN and DCM in response to Right Staffing review and monitored by Agency PMO, Workforce subcommittee and divisional team meetings c. Recruitment process reviewed, KPIs in place 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. Weekly reporting in place to TDA/Monitor in place on all agency use above cap or outside framework g. Monthly reporting of total agency spend against TDA/monitor agreed trajectory 5. SNCT/Birthrate Plus tool/NICE guidelines utilized to monitor patient acuity and dependency presented to relevant committees including Board to determine future staffing demand 6. Work underway to develop SASH recruitment brand and retention strategy including the development of new nursing roles 7. SASH funded by HEKSS to develop and lead on physician associate training and recruitment for SEC 8. Foundation doctors workloads re-modelled such that 95% of time is spent with no more than 14 patients. 9. Strong relationship with HEKSS who place junior doctors in the organisation 10. Practice development nurses recruited to support ward nursing teams improve retention. 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 shifts both nursing/midwifery and medical 3. The Trust still carries a volume of vacancies specifically in clinical areas and turnover in some areas is above Trust target 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

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 and monitored in divisions 3. % of vacant shifts filled by Trust and agency staff 4. Revalidation (GMC) for locums 5. Monitoring agency utilisation and spend at PMO 6. Weekly & monthly reporting of agency use to TDA/Monitor

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 (+) European recruitment undertaken 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 08/01/2016 and DH 22/01/2016

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 January 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

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 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) 11) Increasing hospital at home capacity 12) Integrated Reablement Unit built 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.

Page 10

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

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 (New Consultant undertaking review) 4)Support of partners required to effectively reduce and sustain numbers of patients medically ready for discharge

Actual Assurances: Positive (+) or Negative (-) Positive (+) MRD Summit June agreed map capacity available across Surrey and Sussex (+) ED Standard delivered April, May, Aug, Sept, Oct and Dec 2015 (+) 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, July and Nov 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 (10% vs 2% plan)

Gaps in assurance Winter plans and local health economy position going into winter months Mitigating actions underway 1) 2) 3) 4) 5)

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 Planned breaking the cycle throughout weeks throughout winter

Update by

Page 11

AS 21/01/16

Date discussed at Board

Assurance Level gained: RAG

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1) Complete 2) Oct 2015 3) Complete 4) Complete 5) March 2016 To be discussed at January Board

Objective 5 – Well Led Priority ID and reference

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

5.A Live within our means to remain financially sustainable

Director responsible

Chief Finance Officer

Initial Risk

S5 x L3 = 15

5.1 Failure to deliver income plan

Current rating

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 Contracts 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)

Gaps in Control 1) There are issues with Sussex over the under commissioning of activity and contractual action has started to correct activity plans. 2) The Trust is also concerned over the robustness of plans for winter, noting delayed decision on investment in community schemes. A risk summit is being held to discuss winter pressures (focus isn’t income, but planning) 3) The strategic management of activity is not currently effective, but the Trust is doing all it can to support making it so. Note: other gaps in previous reports mitigated by actions currently in train with CCGs.

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

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 .

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 (+) resolution achieved on Endocrinology business case activity – part year shortfall, but underlying issues have now been corrected (+) Agreement now reached with Sussex over MRET and handover fines – surrey not expected to be far behind [but not yet agreed]

Gaps in assurance

Negative (-) Risk over income growth assumptions, now materialized – risk in last 3 months is from balance of emergency activity and capacity. . (-) Adverse income variance at M09 (-) 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. (-) disputes now received from Surrey – only one from Sussex – escalation status not confirmed by CCGs Assurance Level gained: RAG

Red because of level of risk, activity planning differences, issues with strategic health system management of urgent care activity and transactional processes with CCGs. Page 12

Mitigating actions underway 1) COO meetings have been held, COG updated - there is clear progress in Surrey, not in Sussex. 2) Complete all contractual commitments by revised long-stop dates (end date â&#x20AC;&#x201C; now Q2 reconciliation, which is now in process); 3) Revised forecast for elective activity completed, now being monitored 4) Specific action around dermatology, diabetes and cardiology where there is under delivery (and there is improvement in all these areas) 5) The integrated reablement unit opens on 21 January. 6) Robust contractual processes being operated. Update by Date discussed at Board PS 20/01/16

Page 13

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

To be discussed at January 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. 5) TDA agency reduction plan now submitted 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 S4 x L3 = 12

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) At M09 cost improvement plans are not fully delivering with adverse performance on agency and escalation in particular. Red rated savings have been partially mitigated. The forecast provides a £3.3m risk to savings delivery. 3) There is overspending in 2 areas against agreed forecast control totals at M09 The overspending risk has been reduced because overall we have been within the forecast for some months and the overspend is recorded in the forecast. Actual Assurances: Positive (+) or Negative (-) Positive (+) Budget changes made to match activity to Q1, and recovery plan actions largely complete in Medicine (although overspending against forecast in recent months); (+) All bar 2 areas meeting YTD forecast spend (+) Internal audit advises CIP process is sound Negative (-) Internal audit advises effectiveness of savings delivery rated red/amber. (-) Emergency activity pressures have continued to be greater than expected (-) Overall agency costs remain very high, with escalation still in use and significant costs (albeit within forecast) across Divisions. (-) Agency costs are high in Nursing still, with adverse increase in past months, but which is plateauing. (-) The forecast provides an adverse variance to 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, now, for all Divisions. Nursing agency PMO and fortnightly agency steering group. 2) Controls are being exercised in divisions and centrally – vacancy restriction and non-clinical procurement. 3) Decisions on business cases are now taken in light of affordability against forecast. Update by Date discussed at Board PS 20/01/16 To be discussed at January Board

Page 14

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. completed (submitted to Monitor in April 2015) 3) Reliance on centrally determined rules for PbR, Better Care Fund and the wider NHS finance regime. 3) TDA Plan submitted in April 2015 4) Board to Board held with the TDA in November 2014, Monitor 4) Risk over capacity from other operational pressures assessment now in train culminating in Monitor Board to Board in 5) Overall health system financial view (Chief Officer’s Finance Sub-Group) describes significant loss of resource to BCF funding – this reduces resource June 2015. available for health and social care overall. 5) Cost improvement plan process in place (including PMO structure) 6) Elective/outpatient activity growth and income plan in place – 6) Lack of clarity over tariff assumptions for 2016/17 – this is crucial to medium term capacity created planning [some information now available] 7) Contracts with CCGs allow for payment for “over performance” 7) Central actions over NHS overspend may have an adverse impact on Trust because of manner of application (e.g.: withholding capital). 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 [CCGs are paying over performance] (-) 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 actions to manage costs across the NHS are not yet clearly described and the tariff is not yet defined, plus cumulative impact of other finance risks here. Mitigating actions underway Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. Please see items above. Additional CIP contingency is identified, more is being sought. Progress is on timetable Monitor has agreed postponement of FT process. Board will review in November the suggested timetable. Tariff information is now emerging, but is nowhere near coherent or complete. The 2016/17 budget process will begin in September. Update by Date discussed at Board PS 20/01/16 To be discussed at January Board

Page 15

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

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) NOTE: This risk was reviewed at FWC 22 September and agreed to be maintained noting working capital facility. Additionally capital loan is now secure. An application for a £9.6m working capital loan has now been submitted 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)

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

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 – awaiting confirmation of agreement 2) Delay in receiving cash payments to match accrued income from CCGs, although main CCGs are providing cash advances 3) Threat of central cash controls in line with control totals (nb: which the Trust has not agreed) – need to hear more detail on operation. This point is important and the rigidity of application provides an increased level of risk Rating maintained after last discussion at Board (November) – position monitored 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, (+) Green internal audit report on cash management Negative (-) no 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. Assurance level “red” noting unresolved underlying cash issue. 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 20/01/16 To be discussed at January 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 values 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

S3 x L3 = 9

Current rating

S3 x L3 = 9

Target risk score

S3 x L2 = 6

Linked to Risk

1740

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 behavior (+) 64% compliance achieved following significant focused effort Negative (-) 2014 staff survey Q on appraisal in last 12 months is in bottom 20% (-) compliance rates for Achievement Review remains adverse to plan

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) 5)

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

Recovery plan for compliance in place 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

19/01/2016 JM

Date discussed at Board

1) 31 March 2016 2) 31 March 2016 3) Underway initial meetings positive 4) Complete and ongoing 5) February 2016

To be discussed at January 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 The Trust remains within the current FT pipeline and awaits national guidance on potential new organisational forms which could result in changes to the current timescale and associated requirements to the process. Due to the merger of the NHS TDA & Monitor and creation of NHS Improvement there is uncertainty over the longevity of the current FT model. 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 – “Good” 7) Elections to Shadow Council of Governors 8) HDD to be completed as part of Monitor phase 9) Submission of all current Monitor information requests

Gaps in assurance Completion of Historical Due Diligence Mitigating actions underway 1) Shadow Council of Governors in place 2) Monitor formal assessment currently paused Update by GFM 13/01/16 Page 18

Update by

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 (+) Election to the Council of Governors complete (+) 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 confirmed QGAF score as 3.5 – Further actions being implemented (+) Successful elections - Shadow Council of Governors in place (+) Discussion with Monitor on final timescales & remainder milestones to re-start the process (+/-) Awaiting national guidance on future FT model (NHS Improvement) 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 January Board

Objective 5 â&#x20AC;&#x201C; 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 â&#x20AC;&#x201C; greater clinical buy-in 9) Cerner Optimisation Group now in place 10) IT Road Map presented to FWC and Executive 11) EPR Roadmap signed-off by Executive November 2015 and Trust working on implementation plan and business case with EPR Provider 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 (+) Trust moved to latest version of EPR software (+) 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. 2. 3. 4. 5.

Procurement and implementation of replacement EPR - complete Establishment of Chief clinical Information Officer role - complete Clinical Cerner Optimisation Group now in place with strong leadership Greater focus on IT in Capital Plan for 2015/16 and future years EPR Roadmap now approved by Executive

Update by Page 19

IM 19/01/16

Date discussed at Board

Progress against mitigation (including dates, notes on slippage or controls/ assurance failing. 1. Completed 2. 724 Go-live November 2014. 3. PC Upgrade plan in-place, funded and business continuity almost complete 4. Network review first draft now complete and action plan being prepared. To be discussed at January 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

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

• 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

• 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

• 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)

Financial Management • Small loss <£1K

• Minor loss £2K to £100k

• Moderate loss, £100k - £1M

• Major loss, £1M-£10M

• Loss > £10M

Governance Arrangements

• 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

Health & Safety

Quality of Service

• 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

1)Items referred to in 5.A.1 and 5.A.2 above 2)V3.0 long term financial model and integrated business plan completed (submitted to TDA in February 2014) V4.0 now approaching completion 3)TDA Plan submitted January 2014 4) Timetable for refreshed IBP and LTFM going forward is part of national planning guidance (next iteration due 20 June)

Liquidity: Inability to pay creditors/staff Risk of not being able to pay suppliers from in resulting from insufficient cash due to sufficient cash due to poor liquidity problem poor liquid position

1) Bi weekly review of forward cash flow by finance team and CFO 2) Cash and working capital policy and strategy 3) Annual cash plan linked to business plan and capital plan

Risk of not achieving Cost Improvement Plan

Risk of not achieving financial plan as a result of non-delivery of Cost Improvement Plans

i) Delivery of savings managed through PMO (ongoing)

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

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.

Due to on-going operational pressures and increasing demand for elective services, the Trust cannot offer all services within the 18 weeks standards set out in the NHS Constitution. Longer waiting times result in poor patient experience and increase the number of formal and informal complaints

1. Access Policy revised 2014 2. Weekly PTL / performance meetings to monitor progress. 3. Service Level plans to increase capacity where required. 4. Operational plan for winter 2015/16 to support inpatient elective care

31/03/2016

15 5 3 15

As described on the BAF

31/03/2016

15 5 3 15

12 As described on the BAF

Next Review

31/03/2014 23/11/2015

9 3 5 15

As described on the BAF

31/03/2016

Current Rating

Current Likelihood

Residual Rating

31/01/2016

27/06/2014 31/08/2015 18/01/2016

30/09/2015

31/03/2016

As described on BAF Reviewing compliance to establish a key baseline target Build an integrated discharge unit to increase community capacity

31/03/2016

9 5 3 15

6 31/03/2015 31/08/2015

15 3 5 15

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)

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

15 3 5 15

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

31/01/2016

Unable to deliver realistic medium term As described on the BAF financial plan

1) Operational meeting three times a day chaired by AD Site Services with clinical involvement from Matrons, Nurse Specialists and therapists 2) Daily Board rounds by clinical site team. Focusing on #NOF, Stroke 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 review ward areas on a daily basis 5) Matron on site 7 days a week

31/03/2014 14/12/2015 30/09/2015 14/12/2015 31/01/2016 31/12/2015

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

31/01/2016

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)

As described on the board assurance framework Implementation of divisional escalation plan following key triggers. Escalation bed plan agreed implementation plans in place for each area. Ambulance handover escalation plan agreed and in place with new process for managing handovers agreed to maintain flow. Escalation to division with clear triggers in place. Weekly ED review meeting to review previous weeks performance and implement lessons learnt Plans in place to manage with reduced capacity during January through March 2016 whilst building works are underway.

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

########

Patient admitted to the right bed first time

Due 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

31/01/2016

Involvement of Service Users Involvement of Service Users Staffing - general

Financial Financial Manageme Management nt

Financial Management

Operations Finance Finance Fin. Fin. Manageme Management nt

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

20 4 4 16

RTT Access Standards

23/03/2015 CORP

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.

16 3 5 15

Treatment Plan 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 norovirus 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

11/02/2016

1678

01/02/2015 CORP

Service Access

1672

09/12/2014 CORP

HR - Workforce

1663

18/06/2014 CORP

Operations

1604

Patient Safety

Medical Director's Office

CORP

18/06/2014 CORP Finance - Fin. Management

1603

19/09/2013 CORP

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

29/08/2013 CORP

Operations

1501

23/01/2013

1401

1491

Existing controls

Current Consequence

Description (Policies)

Initial Rating

Risk Type

Risk Owner

Specialty

Open Date

Title (Policies)

Risk of outbreak of viral gastroenteritis 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.

09/02/2015 05/08/2015 18/09/2015

ii) Manage emergency activity within capacity through structural changes to ward configuration, improving length of stay (notably in cardiology to release beds) and other actions to improve efficiency.

As described on the BAF

31/03/2016

15 5 3 15

31/01/2016

Risk the Trust does not achieve its financial plan as i) Quarterly reconciliation with CCGs will inform variations to the a result of lower than planned contract income. monthly contract values (over performance at Q1 is likely to reduce the risk).

31/01/2016

11/06/2015 CORP

Financial Management

Finance - Fin. Management

Risk of Contract income below plan

Financial Management

1697

01/04/2015 CORP

Finance - Fin. Management

1689

Iii) Ring fence elective beds after new capacity has opened and monitor delivery.

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

Risk of failure to meet the financial plan as a result of a) increased costs to deliver staffing ratios, 7 day costs and expectations detailed in national guidance and plans, and b) failure to deliver adequate adjusted treatment index (Carter).

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.

15 3 5 15

30/09/2015

Presentation Title Clinical presentation 36pt Arial28Bold th January 2016 Sub heading 24pt Arial

Dr Ansari

The Patient Will See You Now Medicine's "Gutenberg moment." Digitised and Democratized

Obstacles and objectives Kings Fund co-ordinated care • patients engaged in decisions about their care • supported self-management • prevention, early diagnosis and intervention • emotional, psychological and practical support

Case 1 • 23 year old recurrent bouts of ulcerative colitis • X6 courses of steroids/ 2 years + x3 Hospitalisations • Weight gain/diabetes/bruised skin • Social isolation • Fear about loosing employment • X 2 Hospital OPD DNA’s • Moved to ESH area- picked up by IBD service

New Colitics: 90 year olds â&#x20AC;˘ Mr JD 91ys x3 hospitalisations with a steroid dependent flares of UC â&#x20AC;˘ Mr J: 89 severe diarrhoea- severe UC diagnosed

Patient Management System Patient Knows Best (PKB)

PKB

APatient knows best and iPhone apps

Automatic upload of data

Patient knows best

Scales (£70), thermometer (£11), blood pressure (£47-110) and glucose meter (£25£60)

Initiatives for success • • • • • • • • • • •

Personalised web site Secure and safe Instant symptomatic assessment Instant management advice is possible Direct alert system to the IBD Team Library of advice leaflets Direct portal of access to the hospital specialists Access - worldwide Integration with hospital results system iPhone and Android apps Patients are transferred to remote community care, with specialist overview - NOT discharged

Patient Benefits Improve • Patient satisfaction • Disease monitoring and instant notification • Empower patients • Confidence and knowledge to self manage • Access to specialist advice

Reduce • Negative impact on work and normal activity • Flare ups • Opportunistic infection rate • IBD complications rate • Demand on outpatients • Hospital attendance and admission

Clinical and service benefits Improve • Patient satisfaction surveys • Quality standards • Overview of community management • Access to specialist advice • Auditing and research • Develop a competitive IBD Service

Reduce • Demand on and waiting times for outpatient appointments and endoscopy • Reduce workload by automating testing • Reduce workload of immunity and vaccination screening • Overall morbidity and mortality

CCG and financial benefits Improve • GP vaccination targets • Specialist Led support

Reduce • Outpatient clinic visits • Unnecessary colonoscopies • Unnecessary X-ray procedures • GP clinic visits • Hospital admissions • Surgical interventions

Usual practice PATIENT Appropriate advice Or treatment

Steroids

Referral to GI Service IBD Service

Hospitalisation and complications

Transformation GP’s Practice Nurses Health Care workers

PATIENT IBD service Email Telephone Patient management Service

Early appropriate intervention

Better outcomes ↓ hospitalisations ↓ Less Surgeries

Hospitalisation

Improvements • Patient support structures: Email, telephone, patient management software • Improved and increased use of immunosuppressive combating severe disease

• Multidisciplinary service with good communication between clinicians • Shared care, rapid referral pathways • Patient Pathways

IBD Service: Examples of improvements Increased patient centred support: early detection • 3500-4,000 non face to face contacts: Patients satisfied • Reduced Costly Hospitalisations: UK wide Ulcerative colitis Audit: 2720 bed days saved • Reduced need for high cost drugs: £ 3 million/yr • Clinicians feel safer starting potentially toxic therapies • Patients perceive this confidence

Aza use and admission

Admissions ulcerative Colitis

Telephone and Email 4500

4000

3500

3000

2500

2000

1500

1000

500

0 2010

2011

2012

2013

2014

2015

Telephone and Email workflow 2500

Numberof apteints

2000

1500

1000

500

0 Monitoring

Advice

Flare

Prescriptions

Appoitments

Medications

Other

Conclusion • • • •

Benefits: patient and economic Stresses all conventional NHS structures Resourcing: Falls outside usual mechanisms Service redesign achieved for IBD: transferable to other specialities • SASH experience: Great interest to commissioners and clinicians nationally • Academic opportunities • Resource gap needs to be bridged if service is to continue

TRUST BOARD IN PUBLIC

Date: 28 January 2016 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 (December 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 current progress on nursing recruitment is outlined. An update is provided on nurse revalidation and on the ward accreditation CQUIN We have successfully recruited a consultant to take on clinical lead for radiology and for health informatics We will establish a novel way of working with patients and industry so that the benefits from drugs which matter most to patients are understood by the pharmaceutical industry having received the go ahead from NHS England

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 – 28 January 2016 Chief Nurse Report 1. Introduction To provide an update to the Board on nursing staffing in relation to planned versus actual staffing, an update regarding safer staffing monitoring, and a summary of the recent correspondence in relation to staffing and efficiency and on recruitment activity. 2.

Staffing Planned versus Actual – December 2016

Ward

Ward Specialty

Entries

RN Day

RN Night

NA Day

NA Night

Total Day

Total Night

Overall

Abinger Ward

430 - GERIATRIC MEDICINE

91.59%

100%

95.74%

100%

93.77%

100%

95.99%

Acute Medical Unit

300 - GENERAL MEDICINE

95%

98.62%

87.87%

93.55%

92.91%

96.77%

94.63%

Birthing Centre

501 - OBSTETRICS

95.58%

79.03%

N/A

95.58%

79.03%

87.31%

Bletchingley Ward

300 - GENERAL MEDICINE

97.11%

96.77%

94.87%

93.75%

96.03%

95.54%

95.84%

Brockham Ward

502 - GYNAECOLOGY

93.89%

97.8%

97.83%

103.03%

95.19%

99.19%

96.79%

Brook Ward

100 - GENERAL SURGERY

100%

98.36%

96.87%

N/A

98.94%

98.36%

98.71%

Buckland Ward

101 - UROLOGY

94.1%

98.39%

90.67%

95.16%

92.87%

96.77%

94.32%

Burstow Ward

501 - OBSTETRICS

98.11%

77.17%

86.89%

90.32%

94.37%

82.47%

88.98%

Capel Annex l Ward

100 - GENERAL MEDICINE

100%

97.85%

100%

99.08%

100%

99.41%

Capel Ward

430 - GERIATRIC MEDICINE

93.53%

100%

90.91%

100%

92.53%

100%

95.76%

Chaldon Ward

300 - GENERAL MEDICINE

94.52%

100%

98.91%

100%

96.37%

100%

97.63%

Charlwood Ward

301 - GASTROENTEROLOGY

91.05%

100%

110.36%

100%

98.5%

100%

99.07%

Copthorne Ward

301 - GASTROENTEROLOGY

96.49%

96.77%

101.62%

101.61%

98.2%

99.19%

98.6%

Coronary Care Unit

320 - CARDIOLOGY

93.57%

98.41%

N/A

100%

95.71%

98.95%

97.34%

Delivery Suite

501 - OBSTETRICS

93.34%

94.62%

89.76%

96.77%

92.44%

95.16%

93.8%

Discharge Lounge

300 - GENERAL MEDICINE

98.25%

100%

94.48%

100%

96.41%

100%

97.61%

Godstone Ward (Haem)

303 - CLINICAL HAEMATOLOGY

96.77%

100%

N/A

96.77%

100%

98.39%

Godstone Ward (Med)

300 - GENERAL MEDICINE

94.17%

100%

97.85%

95.55%

98.92%

96.99%

Hazelwood

300 - GENERAL MEDICINE

95.93%

98.36%

97.34%

100%

96.62%

99.18%

97.65%

Holmwood Ward

320 - CARDIOLOGY

91.71%

100%

93.95%

100%

96.08%

ITU/HDU

192 - CRITICAL CARE MEDICINE

98.59%

97.3%

86.16%

113.33%

96.81%

98.5%

97.62%

Leigh Ward

110 - TRAUMA & ORTHOPAEDICS

94.75%

100%

98.75%

96.77%

96.47%

98.36%

97.1%

Meadvale Ward

430 - GERIATRIC MEDICINE

88.61%

100%

97.83%

100%

93.41%

100%

95.63%

Neonatal Unit

420 - PAEDIATRICS

97.45%

100%

96.77%

100%

97.26%

100%

98.53%

Newdigate Ward

110 - TRAUMA & ORTHOPAEDICS

92.63%

95.16%

112%

101.56%

100.65%

98.41%

99.89%

3 An Associated University Hospital of Brighton and Sussex Medical School

Nutfield Ward

430 - GERIATRIC MEDICINE

96.09%

98.39%

101.6%

100%

98.03%

99.19%

98.43%

Outwood Ward

420 - PAEDIATRICS

91.28%

100.54%

88.96%

74.19%

91%

96.76%

93.41%

Rusper Ward

501 - OBSTETRICS

99.19%

100%

N/A

99.21%

100%

99.47%

Surgical Assessment Unit

100 - GENERAL SURGERY

95.16%

96.77%

100%

95.48%

98.39%

96.77%

Tandridge Ward

300 - GENERAL SURGERY

92.17%

96.77%

94.2%

96.77%

93.08%

96.77%

94.26%

Tilgate Annex

100 - GENERAL MEDICINE

94.16%

96.92%

95.71%

100%

94.74%

98.43%

95.99%

Tilgate Ward

300 - GENERAL MEDICINE

108.46%

119.23%

113.04%

119.23%

110.19%

119.23%

113.2%

Woodland Ward

100 - GENERAL SURGERY

91.28%

100%

94.31%

91.67%

92.43%

95.9%

93.58%

95.15%

97.89%

97.11%

98.27%

95.81%

98.03%

96.69%

Total

Commentary The Trust has delivered planned versus actual staffing profile for December. The variance in the Birthing Centre and Burstow ward was due to staffing shortfalls related to short notice sickness and active management by the matrons ensured no adverse outcomes in r e l a t i o n t o c l i n i c a l c a r e . T h e m a t e r n i t y s e r vi c e i s n o w f u l l y r e c r u i t e d . . Nursing Recruitment National and international nursing recruitment continues. The Filipino recruitment is continuing and the first cohort of staff of 10 staff have commenced in the Trust. In addition 6 trained nurses have also commenced from the EU bringing the total number of international nurses to commence in the organisation to approximately 60 since July 2015. Agency cap Weekly reporting is now established and demonstrates a reduction in overall nursing agency usage against the cap parameters. An exception has now been received for two non-framework providers until 31 March 2016. Nurse Revalidation Revalidation for registered nurses commences in April 2016. The Trust has identified that there are approximately 90 staff members due to revalidate in the first quarter of 2016/17. All of these nurses have been contacted with key information and advice on the actions that need to be undertaken. A dedicated revalidation page has been set up on the intranet with links to the relevant documentation on the NMC website and drop in clinics have been arranged for the 27th January and the 24th February. In addition, ward based training has been made available and a stand outside of the Three Arches restaurant will be held on February. Ward Accreditation Over recent months, the Trust has been developing a multi-disciplinary ward accreditation tool. The purpose of the tool is to develop a single method of measuring how each ward is performing against the CQC standards, for wards to analyse and learn from the outcomes of these measures and then for support to be provided to those areas that need it. Equally, its aim is to celebrate success by developing a system for recognising high performing wards which have the standard of an accredited ward. A pilot and three workshops have been held to date, with a work stream now in place to develop the electronic data entry system. Going forward, a long term aim and use of the tool will be for wards to demonstrate how they have incorporated the SASH+ principles into clinical

4 An Associated University Hospital of Brighton and Sussex Medical School

practice by demonstrating that quality improvements have been made through the implementation of the SASH+ methodology. Ward Accreditation is a local CQUIN for 2015/16 and the Trust is currently on track with the requirements of the quality improvement measure. Medical Director Report 3. Clinical Lead for Radiology and Clinical Chief of Informatics. We have recruited Dr Tony Newman â&#x20AC;&#x201C; Sanders to lead radiology (taking over from Dr Riaz Ahmed) and provide clinical leadership for the health informatics processes formerly led by Dr Ben Upton. Tony is an established consultant currently working at Croydon University hospitals. He has a lot of experience with Cerner and is also the medical director of the Health Innovation Network (The South London Academic Health Science Network) a role he will continue.

4. What medication outcomes mater to patients? Unlike in the USA where pharmaceutical companies can market direct to patients, it has become clear that industry has difficulty finding out what therapeutic outcomes matter to patients from the drugs they make available to clinicians. We have received permission (and encouragement) from Sir Bruce Keogh, medical director of NHS England, to explore how we as a hospital can work with the pharmaceutical industry to promote a dialogue between us, them and patients so that industry contribute in a more focussed and precise way on meeting the therapeutic needs of patients. Sir Bruceâ&#x20AC;&#x2122;s challenge to us is to make it happen in a way that benefits the wider NHS. 5. Recommendation To note the report

Fiona Allsop Chief Nurse 25th January 2016

Des Holden Medical Director

5 An Associated University Hospital of Brighton and Sussex Medical School

Integrated Performance Report M09 â&#x20AC;&#x201C; December 2015

Presented by: Angela Stevenson (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 – December 2015 Patient Safety • There were seven SIs declared in December 2015 and no Never Events. • Patient safety indicators continue to show expected levels of performance. • The Trust had no MRSA bloodstream infections and six Trust acquired C-Diff cases in December 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 • The 4hr ED standard was achieved with performance of 95.5% in December 2015. • The Two Week and 62 Day Cancer standards were achieved in December 2015. • The Trust continues to deliver against incomplete pathways which measures % of patients still waiting at the end of each month. Patient Experience • In December 2015 the Inpatient FFT remained at 95.1%. The ED FFT decreased to 97.5% 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 – December 2015 Finance • At the end of Month 9 the Trust has a YTD I&E deficit (after donated asset technical adjustments) of £(5.3)m which is £(4.0)m adverse to the revised TDA plan. Key Risks • The Significant Risk Register for the Trust includes six quality risks in relation to “Right bed first time”, ED Access standards, Outbreak of viral gastroenteritis, Increasing sickness absence levels and RTT Access Standards.

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

Legal:

All aspects of care provision is covered by the Health and Social care Act, this paper provides assurance on safe high quality care (Including mortality).

Regulation:

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.

Patient experience/ engagement:

This paper includes significant detail on both patient experience and access to services.

Risk & performance management

This is the main Board assurance report for performance against quality and financial measures and is linked to risk management through the SRR.

NHS constitution; equality & diversity; communication.

This report covers performance against access standards with the NHS Constitution.

An Associated University Hospital of Brighton and Sussex Medical School 3

Patient Safety Patient Safety Indicator Description

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-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)

93.0%

92.0%

91.3%

93.5%

92.0%

95.0%

92.2%

93.2%

95.4%

90.3%

92.6%

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

97.0%

96.0%

95.0%

96.0%

95.9%

97.3%

95.2%

97.7%

94.8%

96.7%

97.6%

95.0%

96.2%

Percentage of patients who have a VTE risk assessment

95%

TBC

WHO Checklist Usage - % Compliance

100%

96%

100%

98%

100%

98%

96%

100%

Serious Incidents - No per 1000 Bed Days

0.11

0.26

0.35

0.26

0.16

0.33

0.05

0.23

0.32

0.11

0.38

Percentage of Patient Safety Incidents causing Severe harm or Death

0.2%

0.6%

0.7%

0.6%

0.2%

0.6%

0.5%

0.0%

0.2%

0.8%

0.6%

0.4%

0.8%

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 December 2015. • VTE risk assessment performance for December 2015 is undergoing validation following changes in system usage within the Surgical Division. Performance of 95% is expected.

An Associated University Hospital of Brighton and Sussex Medical School 4

Patient Safety Seven SIs were declared in December 2015 (in all cases full investigations have been started): • 2015/37455 Fall. The patient, a 78 year old male, was admitted to ED following a fall at home on 27th August 2015 which resulted in a subdural haematoma. The patient was transferred to Copthorne ward where he was to be treated conservatively and was given a catheter due to urine retention. In the early hours of 28th August the patient fell over his catheter and a CT head scan showed that the subdural haematoma had increased. The patient died on 5th September 2015. • 2015/37463 Sub-optimal care of deteriorating patient. The patient, a 78 year old male, was admitted to CDU from ED following a fall downstairs on 13th June 2015. Although his imaging was clear he was having difficulty mobilising due to leg and knee pain. He was known to have bowel cancer with metastasis. He was referred to the physicians for further assessment and admitted to SAU on 14th June. The clinical documentation states that although he was slightly hypotensive he was considered to be well, with no evidence of shock or tachycardia. At approximately 01:00 on 15th June the patient suffered a sudden deterioration and died the following morning. • 2015/37802 Fall. The patient stood up from her chair and fell forward, landing on the floor on her left side. Imaging confirmed fractured neck of femur. • 2015/38654 Fall. Patient had an unwitnessed fall. No immediate action was taken at the time except for neuro observations which showed a GCS of 15/15. The patient reported to staff that she had not hit her head so the fall was not escalated to the doctors or the site team. The following day the patient's condition deteriorated and a CT scan showed a subdural haematoma and widespread malignancy. GCS deteriorated to 5/15, advice was obtained from St Georges. The patient has since died. • 2015/38769 Fall. Patient had an unwitnessed fall which resulted in a fractured neck of femur. • 2015/38771 Fall. Patient stood up from the bed and fell resulting in a fractured neck of femur. • 2015/37473 Sub-optimal care of deteriorating patient. The patient was admitted on 25th January 2014 with abdominal pain and urine retention. His past medical history of renal colic was noted and bloods taken. The blood results were abnormal, high creatinine and CRP were noted but no further action was taken until the patient arrested on the evening of 26th January 2014. The patient was transferred to ICU but died on 27th January, the post mortem result stated the cause of death as complications of sepsis.

An Associated University Hospital of Brighton and Sussex Medical School 5

Patient Safety Infection Control Indicator Description

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

MRSA BSI (incidences in month)

CDiff Incidences (in month)

MSSA

E-Coli

Trend

• There were no cases of MRSA in December 2015 and six 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 6

Clinical Effectiveness Mortality and Readmissions Indicator Description

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

HSMR (56 Monitored diagnoses - 12 Months)

93.3

92.8

92.6

93.4

93.0

95.0

93.5

94.0

95.2

Emergency readmissions within 30 days (PBR Rules)

7.1%

6.9%

6.7%

6.6%

6.4%

7.0%

7.2%

7.7%

7.4%

7.3%

Oct-15

Nov-15

6.3%

Dec-15

Trend

â&#x20AC;˘ Latest HSMR data for the Trust shows mortality remains lower than expected for our patient group when benchmarked against national comparators. Maternity Indicator Description

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

C Section Rate - Emergency

17%

18%

16%

17%

13%

17%

18%

14%

17%

14%

15%

16%

C Section Rate - Elective

11%

10%

11%

13%

10%

Admissions of full term babies to neo-natal care

6.3%

6.0%

7.0%

6.2%

4.0%

5.0%

5.1%

5.8%

7.1%

6.6%

5.9%

Trend

â&#x20AC;˘ Maternity indicators continue to show expected performance.

An Associated University Hospital of Brighton and Sussex Medical School 7

Access and Responsiveness Emergency Department Indicator Description

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

93.3%

92.0%

91.3%

95.0%

96.8%

96.0%

94.8%

94.3%

96.1%

97.1%

95.5%

92.9%

95.5%

Ambulance Turnaround - Number Over 30 mins

344

163

259

247

199

170

206

238

220

225

231

191

Ambulance Turnaround - Number Over 60 mins

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

Trend

• Despite continuation of pressure on the emergency department with high levels of emergency admissions, the ED 4hr standard was achieved in December 2015 with performance of 95.5% • Over the third quarter of the year, overnight non-elective admissions are up 7% (3% for East Surrey CCG and 16% for Crawley CCG) compared to last year. • Ambulance turnaround performance showed improvement in December and had the lowest number of delays over one hour since the previous December. The recent work on processes has been reviewed positively by CCGs and SECAmb have commended the Trust’s resilience over the recent period. • In light of the on-going operational pressures in the Trust, the following 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 – 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)

An Associated University Hospital of Brighton and Sussex Medical School 8

Access and Responsiveness Cancer Indicator Description

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Cancer - TWR

93.1%

93.3%

94.2%

93.1%

93.0%

89.6%

89.9%

93.2%

94.3%

Cancer - TWR Breast Symptomatic

93.5%

93.4%

96.3%

93.8%

90.6%

93.2%

93.3%

94.2%

93.8%

93.4%

96.2%

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

98.4%

97.1%

100.0%

98.2%

97.0%

96.2%

98.3%

99.2%

99.3%

98.2%

96.6%

92.4%

Cancer - 62 Day Referral to Treatment Standard

86.1%

85.4%

88.0%

83.7%

86.4%

83.9%

86.5%

80.7%

84.2%

86.2%

85.6%

88.3%

85.8%

Cancer - 62 Day Referral to Treatment Screening

100.0%

92.3%

100.0%

92.3%

84.6%

92.3%

100.0%

87.5%

88.9%

100.0%

87.5%

90.9%

100.0%

Trend

â&#x20AC;˘ In December 2015, all Cancer Access Standard except the 31 Day Diagnosis to Treatment standard were achieved. â&#x20AC;˘ On the 31 Day Diagnosis to Treatment pathway, 8 patients breached the standard as a result of capacity issues for Dermatology minor operations. Action has been taken to address this issue.

An Associated University Hospital of Brighton and Sussex Medical School 9

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

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

92.2%

92.1%

94.0%

93.7%

93.6%

93.5%

92.6%

92.2%

92.0%

92.1%

92.2%

92.5%

92.1%

RTT Admitted - 90% treated within 18 weeks

91.1%

90.2%

82.1%

88.4%

91.6%

90.1%

92.0%

84.0%

81.5%

77.9%

78.5%

80.7%

81.1%

RTT Non Admitted - 95% treated within 18 weeks

95.0%

91.7%

91.0%

93.5%

93.6%

95.3%

93.4%

89.4%

89.1%

88.7%

87.9%

85.2%

85.4%

Percentage of patients w aiting 6 weeks or more for diagnostic

0.1%

0.9%

0.7%

1.4%

1.0%

0.2%

0.8%

1.0%

0.1%

0.5%

0.2%

0.1%

133

0.0%

2.2%

0.0%

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

Last Minute Elective Cancellations for non clinical reasons % of operations cancelled on the day not treated within 28 days

Trend

• At aggregate level, the trust continues to deliver against the incomplete pathways standard which measures % of patients waiting less than 18 weeks at the end of each month. • Challenges remain in General Surgery, Trauma and Orthopaedics and Cardiology. A number of newly recruited consultants will increase capacity and support reduction in patients over 18 weeks. • The diagnostic standard continues to be achieved and capacity across all areas is subject to review in order to plan for expected growth over the coming 18 months as a result of the National Cancer Strategy. • 54 patients were cancelled at the “last minute” for non clinical reasons. • The following risk is on the significant risk register: • RTT Access Standards - Due to on-going operational pressures and increasing demand for elective services, the Trust cannot offer all services within the 18 weeks standards set out in the NHS Constitution. 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 10

Patient Experience Patient Voice Indicator Description

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Inpatient FFT - % positive responses

95.0%

95.7%

96.9%

94.2%

94.4%

95.1%

94.7%

95.1%

95.3%

96.1%

95.0%

95.1%

Emergency Department FFT - % positive responses

93.0%

95.8%

97.1%

94.7%

95.4%

95.3%

93.7%

91.4%

95.8%

96.9%

95.3%

97.3%

97.5%

Maternity FFT - Antenatal - % positive responses

90.0%

97.6%

97.1%

97.0%

96.3%

100.0%

83.3%

94.1%

98.8%

94.3%

96.5%

96.1%

96.0%

100.0%

95.5%

97.2%

100.0%

94.7%

97.0%

94.9%

93.8%

87.9%

95.4%

95.1%

97.6%

91.7%

96.0%

85.9%

91.0%

97.3%

86.7%

91.0%

86.5%

90.0%

87.7%

87.9%

88.9%

88.8%

88.9%

Mixed Sex Breaches

Complaints (rate per 10,000 occupied bed days)

Maternity FFT - Delivery - % positive responses Maternity FFT - Postnatal Ward - % positive responses

Trend

• Inpatients – The December Friends and Family Test (FFT) score for inpatient wards remains stable at 95.1%, based on a 30% response rate. The response rate dropped from the 40% that has been achieved over the last four months. • Emergency Department – The December FFT score has increased slightly to 97.5%, based on a response rate of 19%, a very slight drop from 20% in November. • Maternity – FFT scores for both the antenatal the postnatal delivery touchpoints have remained stable at 96.0% and 88.9% respectively. There has been a drop in the FFT score for delivery (91.7% compared to 97.6% in November). The response rate for touchpoints two and three remain at 22%, the response rate for touchpoint one has dropped to 13% (down from 17% in November). Following an improvement in the response rate for touchpoint four in November, it has dropped back to 1% in December. National comparisons for November • Inpatients/daycases – The Trust was ranked below average (94.9% against a national average of 95.4%). The combined response rate was also just below average (23% compared to 24%). • Emergency Department – the department was ranked 3rd best in the country, based on an above average response rate

An Associated University Hospital of Brighton and Sussex Medical School 11

Workforce Workforce Indicator Description

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

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

95.1%

94.8%

95.9%

96.5%

96.8%

95.7%

96.9%

93.3%

92.5%

95.0%

95.1%

95.4%

95.1%

Average fill rate – care staff (%) - Day

93.1%

92.6%

93.8%

94.5%

96.1%

93.8%

93.5%

94.3%

94.5%

95.1%

97.2%

98.7%

97.1%

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

97.3%

97.2%

97.7%

96.7%

96.5%

97.1%

94.1%

95.2%

94.3%

96.4%

96.9%

97.2%

97.9%

Average fill rate – care staff (%) - Night

93.7%

93.3%

94.9%

95.2%

95.9%

94.9%

94.4%

93.8%

96.4%

96.9%

97.8%

98.2%

Overall Sickness Rate

4.5%

4.3%

4.4%

4.2%

4.3%

4.1%

3.9%

3.7%

4.4%

4.0%

3.8%

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

72%

67%

68%

73%

71%

68%

58%

56%

57%

64%

72%

74%

15.6%

15.7%

15.2%

15.5%

15.9%

15.6%

15.2%

15.0%

14.4%

13.8%

Staff Turnover rate

Trend

• Compliance rate with the new Achievement Review (Appraisal) process is starting to improve as the organisation moves along its three year implementation plan. • Sickness absence reduced to 3.8% in December 2015, 0.7% less than the prior year.. • The increasing trend on sickness absence levels which impacts on day to day management and expenditure remains on the Trust’s significant risk register – Risk score 15 (Likelihood of 5 and consequence of 3) • Streamlined nursing recruitment with a new recruitment tracker with ward dashboard to highlight blockages is now in place and is discussed on a weekly basis. Activity around international recruitment continues. New staff are in post but do not all have their PINs which means there are short term double running costs. • Staff Turnover fell for the second month in a row to 13.8% in December 2015 as initiatives to improve retention and staff experience take effect. • The Trust continues to monitor ward nursing (numbers and skill mix) on a daily basis and is assured that adequate staffing is in place.

An Associated University Hospital of Brighton and Sussex Medical School 12

Finance Indicator Description

Dec-14

Jan-15

Feb-15

Mar-15

Apr-15

May-15

Jun-15

Jul-15

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Outturn £m Surplus / (Deficit) - Plan

2.3

1.6

Outturn £m Surplus / (Deficit) - Forecast

2.3

(2.5)

(2.4)

1.6

(3.0)

YTD £m Surplus / (Deficit) - Plan

1.0

1.9

1.4

2.3

(0.8)

(1.2)

(2.0)

(1.1)

(0.7)

(0.6)

(2.0)

(1.3)

YTD £m Surplus / (Deficit) - Actual

1.0

1.9

(2.9)

(2.4)

(0.8)

(1.1)

(2.0)

(1.3)

(2.6)

(3.3)

(3.6)

(4.2)

(5.3)

Outturn UNDERLYING £m Surplus / (Deficit) - Plan

3.4

3.8

Outturn UNDERLYING £m Surplus / (Deficit) - Actual

(5.2)

3.8

3.3

(6.3)

YTD Savings £m - Actual

7.4

8.6

9.8

11.0

0.3

0.5

0.8

1.3

1.9

2.1

2.5

2.8

3.2

OT Risk £m Surplus / (Deficit) - Assessment

(6.3)

(5.5)

(0.7)

0.0

(1.0)

0.0

Outturn Cash position £m Fav / (Adv) - Forecast

2.6

7.6

2.6

1.2

2.4

2.5

YTD Cash position £m Fav / (Adv) - Actual

4.8

3.8

2.6

3.2

2.9

2.6

2.5

3.0

3.9

4.8

5.0

5.7

YTD Liquid ratio - days

(8.0)

(18.0)

(21.0)

(20.0)

(21.0)

(23.0)

(22.0)

(25.0)

(19.0)

(13.0)

(16.0)

YTD BPPC (overall) volume £m

88%

87%

86%

82%

62%

75%

78%

76%

69%

59%

60%

YTD BPPC (overall) value £m

84%

83%

81%

65%

73%

75%

74%

68%

61%

63%

Outturn Capital spend Fav / (Adv) - forecast

19.3

17.1

14.1

Trend

• The Trust is reporting against the revised plan submitted to the TDA in September 2015. • At the end of Month 9 the Trust has a YTD I&E deficit (after donated asset technical adjustments) of £(5.3)m which is £(4.0)m adverse to the revised TDA plan. • Month 9 includes a £0.4m income accrual in respect of anticipated reimbursement from the TDA in respect of lost income resulting from the Junior Doctors industrial action in December. • The underlying position at the end of December is a £(5.9)m deficit, reflecting the non recurrent use of the Trust’s balance sheet provisions. The Trust forecast is now a £(3.0)m deficit (after donated asset technical adjustments). This position includes £3.0m nonrecurrent income from the TDA. • The Trust has achieved £3.2m of savings to date (a £2.1m shortfall measured against the TDA plan). The forecast CIP position is £3.5m adverse to the full year plan and this has been factored into the overall Trust forecast.

An Associated University Hospital of Brighton and Sussex Medical School 13

Finance • The Trust’s cash balance at the end of December was £5.7m, with a forecast year end cash balance of £2.5m. Backlog creditors increased by a further £2.2m in month. • The capital spend forecast this year has reduced by £3.0m, from £17.1m to £14.1m following an application to TDA for Capital to Revenue transfer which has been provisionally approved.

An Associated University Hospital of Brighton and Sussex Medical School 14

TRUST BOARD IN PUBLIC

Date: 28 January 2016 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 January 2016 and was quorate. •

The UKPN Addendum was approved.

•

M09 reports were received for Finance & the 15/16 CIP, Workforce and Organisational Development, Capital and IT.

•

The Trust has year to date I&E deficit of £(5.3m) which is £(4.0m) adverse to the revised TDA plan.

•

The Trust’s cash balance at the end of December was £5.7m, with a forecast year end cash balance of £2.5m

•

The Trust has delivered £3.2m of savings and is behind both the TDA plan and also the internal plan

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:

Legal and regulatory impact

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. 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 – 28 January 2016

Finance & Workforce Committee Chair Update The Finance and Workforce Committee met on 25th January 2016 and it was quorate. The key points from Part 1 were as follows: -

An update was received on the current legal and financial situation between the Trust and UK Power Networks (UKPN) and following negotiations the extra claim has been reduced to £61K plus VAT. Assurance was received that no further costs should now arise. The Committee approved the addendum on a “full and final” basis.

The Communication Plan was welcomed by the Committee. The plan provides a set of actions for 16/17 across all platforms. The Committee noted the progress made to date. It asked for an update on outcomes and a view on achievement against the strategic objectives at an appropriate time. Month 9 CIP report

The savings target YTD in the submitted TDA plan for 2015/16 is £5.3m and at month 9 the Trust has delivered £3.2m of savings and is behind both the TDA plan and also the internal plan. Contingency savings of £0.6m have been used to achieve this position. The Committee noted that achieving the year end forecast of £4.8m would require delivery of £1.6m in Q4 against a quarterly average of £1.1m. Draft 16/17 Revenue Budget The draft budget shows a deficit of £(4.1m). This position is predicated on achieving the 15/16 forecast of £(6.0m) set off by the capital to revenue transfer of £3m ie a net position of a deficit of £(3.0m) . There are four main actions required to firm up the budget: -

Complete a demand & capacity plan for emergency activity Surgical Division to provide a capacity plan for elective activity describing cost and income Complete a demand and capacity plan for outpatients Directors to complete actions on the CIP

The Committee noted that the CIP is set at £9.2m v a forecast outturn of £4.8m for 15/16 although it recognised the contingency in the budget of £3.5m of which £1.5m is specific to nurse costs. The Committee asked that a percentage of the saving be applied depending on which gateway had been achieved; that the CIP is phased to show the rate required by quarter and that a total in excess of £9.2m be scoped to allow for underachievement; the Carter analysis may be helpful. -

The Month 9 Workforce and Organisational Development paper was presented. The Committee noted plans against each of the 6 strategic objectives would be refreshed, that a new set of KPIs would be in place for the new financial year, that work to deliver the Achievement review target would continue and that the definition and approach to delivering mandatory training was being reviewed. An Associated University Hospital of Brighton and Sussex Medical School

The Month 9 Capital report was presented. The Committee noted the openings of the IRU and the Macmillan Information Centre.

The IT report was noted and the Committee extended their congratulations to the IT team in the successful upgrade to the new Cerner version.

[END]

An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD IN PUBLIC

Date: 28th January 2016 Agenda Item: 3.3

REPORT TITLE:

Audit & Assurance Committee Chair Update

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

Paul Biddle (Non-Executive Director and AAC Chair) Colin Pink Head of Corporate Governance Audit & Assurance Committee – 15/01/16

Action Required: Approval (√)

Discussion ()

Assurance (√)

Purpose of Report: This report provides the Board with an executive summary of the January Audit and Assurance Committee. Summary of key issues • Review of BAF and linkages to SRR focussing on financial risk management and assurance. • Tender results for Internal Audit and Counter Fraud provision. • Internal audit findings; i. Significant improvement in NICE compliance monitoring ii. Cash flow forecasting (Green) iii. Backlog maintenance (Green Amber) • Focussed review of Internal Audit findings into CIP systems and delivery Recommendation: To note the report. 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: The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all statutes applied to an NHS Trust. Legal and regulatory impact Financial performance is subject to Schedule 5 of the NHS Act 2006 which provides the “breakeven duty”.

The AAC reviews assurance in respect of all Trust systems of control which includes reporting and compliance with all regulation applied to an NHS Trust. The main regulators, however are as follows: - External audit (the Audit Commission for this Trust) give an opinion on the Trustâ&#x20AC;&#x2122;s compliance with International Financial Reporting Standards and with NHS accounting conventions â&#x20AC;&#x201C; this is not purely financial and deals with procurement, fraud, transparency and legal duties. It also gives a Value for Money Conclusion on the Trustâ&#x20AC;&#x2122;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. Financial impact

Committee review of Trust financial position

Patient Experience/Engagement

No relevant aspects

Risk & Performance Management

The committee provides assurance about internal control and risk management. This report discusses BAF reporting

NHS Constitution/Equality & Diversity/Communication

No relevant aspects

Attachment: N/A

2 An Associated University Hospital of Brighton and Sussex Medical School

TRUST BOARD REPORT â&#x20AC;&#x201C; 28/01/2016 Audit & Assurance Committee Chair Update The Audit and Assurance committee met on the 15/01/2016; it was quorate. 1) Board Assurance Framework & SRR The Committee discussed the board assurance framework prior to the January public board. It focussed on the long-term strategic and operational risks relating to the management of patient flow through the ED and into the hospital. The committee noted the transition to business continuity and the effect this had had on local health economy. The Chief Finance officer indicated that the strategic risk relating to divisional overspend would reduce as the Divisions are on track to meet the forecast. The committee were assured that plans to apply for a ÂŁ9.6 million working capital loan would stabilise the liquidity risk. 2) Standards of Business Conduct Policy review The Director of Corporate Affairs presented the review, highlighting that the policy had been amended to further strengthen controls relating to declarations of interest and referral to commercial representatives. Our Counter Fraud service agreed to review the revised policy and once this had been completed the policy was approved and would be presented to the Board for ratification in February 3) Internal Audit and Counter Fraud Management confirmed that RSM had successfully been appointed following tendering to provide internal audit and counter fraud services. This is welcomed as there are potential benefits for the Trust from a direct linkage between audit and counter fraud expertise. Internal Audit presented their update report, which detailed improvements in internal controls to support oversight of NICE compliance this represents, a significant improvement since the last audit. The Committee discussed the CIP audit which highlighted good processes but significant under achievement of delivery in year. The Committee noted that the main emphasis for improvement in processes is the ability to provide greater testing and assurance of delivery of plans before they are approved. Internal audit went on to highlight that the review of the Trusts systems to support cash flow forecasting had been particularly positive (Green no recommendations). Backlog maintenance review had been scored as amber green with no significant concerns. The Committee noted that there were no overdue actions developed from internal Audit recommendations. 4) AAC Annual Report The Committee reviewed the AAC annual report to Board which was accepted with some minor amendments. In particularly the committee noted the need to review the work of both the Charitable Funds and Remuneration Committee during 2016 as theses had not been considered recently.

3 An Associated University Hospital of Brighton and Sussex Medical School

The Committee agreed that the three lines of defence model of assurance is recognised as best practice and will seek to identify assurance at all level through 2016. The ‘First line’ of defence relates to risk and control systems at local level, the ‘Second line’ of defence relates to oversight and scrutiny by Executive Team and the Board and the third level refers to external assurances. -End-

4 An Associated University Hospital of Brighton and Sussex Medical School

Date: 28TH January 2016 TRUST BOARD IN PUBLIC Agenda Item: 4.1 REPORT TITLE:

2015/16 CIP & QIA In year review

EXECUTIVE SPONSOR:

Dr Des Holden

Fiona Allsop

Medical Director

Chief Nurse

Maria Gubala – Finance Manager

REPORT AUTHOR (s): 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 impact on quality and patient care of the 2015/16 Cost Improvement schemes on quality. Summary of key issues This paper evaluates whether the delivery of 15/16 CIP plan have had any adverse effect on quality and patient care. It considers both schemes that did not deliver and those that did deliver a financial return and whether in either case there was an impact on quality (positive or negative). By analysing the 2015/16 CIP delivery in this way we hope to 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.

TRUST BOARD REPORT – 28th January 2016 2015/16 Quality Impact Assessment of CIPs 1. Introduction The Trusts financial plan for 2015/16 includes a CIP target of £8.168m. The M09 (Dec 15) summary of the CIP have been delivered to date is tabled below: 2015/16 £’000s CIP plan for year

8,168

Position @M09: YTD target

5,287

YTD actual

3,200

YTD variance

(2,087)

1. Quality and patient experience review of delivered CIP plans To date £3,200k of savings have been delivered with £1,902k (59%) of this related to Central schemes and £1,298k (41%) to Divisional schemes. Before being signed off, all schemes have their quality indicators reviewed by both the Medical Director and the Chief Nurse for any adverse impact on quality, safety or patient experience. The schemes are then reviewed in year as they have progressed.

2. Findings from reviews and lessons learnt Division of Surgery As at M09 the Division has achieved £311k saving. Of this total, clinical supplies account for 71% and medical agency 22%. The Chief of Surgery has stated that:



“Clinical Supplies - this has been largely successful and is expected to deliver most of the projected savings. The items do not have a clinical impact but are about reducing waste with standard work and using cheaper alternatives. E.g. Hip prostheses, anaesthetic disposables Medical Agency- we have reduced our use of agency locums in most specialties and have only a consultant agency locum in ophthalmology. We still require agency

 

locums in General Surgery to cover gaps in the Core Trainee rota but the new rota will come into force in February will reduce that Non-clinical agency - this has been achieved without impact on quality. Private Patients - we have been unable to use the beds on Brook for private patients or amenity beds due to bed capacity problems. This has impacted marginally on patient experience.”

Division of Medicine As at M09 the Division has delivered £122k worth of savings, of which 50% relates to clinical supplies, 30% to junior medical agency and 15% to Pharmacy agency. As per the ADO for Medicine, there has “been no reported unintended consequences” arising from the savings that have been delivered. The schemes with the highest scores for the quality impact assessments prior to schemes starting related to changes in the supply of drugs, particularly related to cancer care, to Boots the chemist. The risk was assessed as an 8 as the impact of supply going wrong on our reputation and on patient care was considered significant. These schemes were impact assessed after three and six months and we found no adverse effect, and a well evaluated service change by patients.

WaCH As at M09 the Division has delivered £57k worth of savings, with 79% of this arising from Medical agency. Some comments from the WaCH ADO:    

There are no concerns arising from the savings on quality. Due to the large level of Corporate schemes the process this year feels very different. Approximately half of planned schemes have been delivered. An issue relating to the use of Masimo probes has come to light. The probes appear to fall off children more easily than the previous product leading to a second probe being attached. In order to confirm the validity of the claim, a review of the spend is being undertaken to see whether an increased total number of probes has offset the cheaper unit price. No clinical impact of this has been seen.

Cancer As at M09 the Division has delivered £56k worth of savings, with 80% of this attributable to agency. No feedback received.

Estates and Facilities As at M09 the Division has delivered £484k with 44% due to cark park income and 22% from catering income. No feedback received

Other schemes As at M09 the Central schemes have achieved £1,902k saving with 51% relating to reserves, 11% on CNST improved rate due to CQC rating, 9% on contracts and 6% on improved income.

Lessons learnt include: 

Where clinical staff were unhappy with taking forward a CIP scheme, the CIP was not actioned. Issues included insufficient capacity and the inability to recruit.



The reviews have been time consuming with difficulties in being able to find sufficient diary time.



Successful implementation and outcomes were greatly facilitated by medical agreement.



The review meetings have given the opportunity to have specific feedback on product changes. For example: o

QIA 1.21 Tissue Adhesion a detailed evaluation paper was presented on the use of Derma+flex. The results of which proved that this product could be used safely and effectively for the closure of appropriate wounds with 100% patient satisfaction and no reports of pain, burning or adverse effects.



The review meeting has also given the opportunity for project leads to ask for assistance when they have issues in implementation. For example DH 1.15 – Banning the use of couriers delivering discharge medicines



The under estimation of lead in times for projects is still an issue, with some schemes now commencing in 2016/17.



It is suggested that a financial review is undertaken at the end of 15/16 in order to identify those scheme types that have proved successful and those that have failed to deliver. This will help identify pitfalls and help in future planning.

Dr Des Holden

Medical Director

Fiona Allsop

Chief Nurse

Maria Gubala

Finance Manager, Division of Medicine

28 January 2016

TRUST BOARD PUBLIC

Date: 26TH January 2016 Agenda Item: 4.2 Emergency Planning Resilience and Response Core Standards Assurance Angela Stevenson Chief Operating Officer Jamie Hogg Emergency Planning Manager

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

Executive Committee

Action Required: Approval (√)

Discussion

Assurance (√)

Purpose of Report: NHS England has issued revised core standards for Emergency Planning, Resilience and Response (EPRR). As a Trust we are required to benchmark ourselves against these standards and put in place an action plan to meet them. The key desired outcomes in this area are: • Ability to respond to a business continuity incident (e.g. flooding) • Ability to respond to a major incident (e.g. mass casualty, pandemic flu, terrorist incident) • Ability to maintain services during peak stresses (e.g. winter, heatwave) The supporting requirements are: • Adequate plans (over-arching and local) – e.g. Incident Response Plan, Pandemic Influenza Plan, business continuity plans • Systems and infrastructure – e.g. resilient IT, telecoms and internal communications • Competent staff – based on training, exercising, live and simulated incidents Summary of key issues Executive Summary: The attached document gives our benchmarked position now and over the next six to twelve months, by which time we aim to be fully compliant. This document was submitted to NHS England on 24th September 2015, and presented at an assurance meeting on 9th October. A similar formal assurance process took place last year. In overall terms based on RAG ratings, current standing is as follows: 2015 Red

Amber

17%

Green

83%

Some specific areas of improvement already addressed include: • The trust undertook and completed the three yearly mandated a major incident exercise in September 2015. With some lessons to learn from the exercise. The feedback from Public Health England reflected that, overall it successfully achieved the aim and the objectives set for this exercise. • Further mandated training took place for senior staff who attended a bespoke

training session on ‘surviving public enquiries’. The amber areas in the RAG rating relate to: • Key areas developing their business continuity plans to support • • •

Delivery of training and development of a BCM/Evacuation exercise which is in progress. Continue with the development of additional telecoms resilience Provision of improved storage for chemical protection suits

Recommendation: Agree the core standards report and actions to achieve full compliance. 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

This is a legal requirement

Financial impact

Non compliance could have potential implications

Patient Experience/Engagement

Compliant

Risk & Performance Management

Compliant

NHS Constitution/Equality & Diversity/Communication

Compliant

Attachment: Surrey & Sussex NHS Healthcare Trust, EPRR Core Standards, Self-Assessment 2015

2 An Associated University Hospital of Brighton and Sussex Medical School

NHS England Core Standards for Emergency preparedness, resilience and response v3.0 The attached EPRR Core Standards spreadsheet has 6 tabs: EPRR Core Standards tab - with core standards nos 1 - 37 (green tab) Pandemic Influenza :- with deep dive questions to support the pandemic influenza 'deep dive' for EPRR Assurance 2015-16 (blue) tab) HAZMAT/ CBRN core standards tab: with core standards nos 38- 51. Please note this is designed as a stand alone tab (purple tab) HAZMAT/ CBRN equipment checklist: designed to support acute and ambulance service providers in core standard 43 (lilac tab) MTFA Core Standard: designed to gain assurance against the MTFA service specification for ambulance service providers only (orange tab) HART Core Standards: designed to gain assurance against the HART service specification for ambulance service providers only (yellow tab).

This document is V3.0. The following changes have been made : • Inclusion of Pandemic Influenza questions to support the pandemic influenza 'deep dive' for EPRR Assurance 2015-16 • Inclusion of the HART service specification for ambulance service providers and the reference to this in the EPRR Core Standards • Inclusion of the MTFA service specification for ambulance service providers and the reference to this in the EPRR Core Standards • Updated the requirements for primary care to more accurately reflect where they sit in the health economy • update the requirement for acute service providers to have Chemical Exposure Assessment Kits (ChEAKs) (via PHE) to reflect that not all acute service providers have been issued these by PHE and to clarify the expectations for acute service providers in relation to supporting PHE in the collection of

Organisations have an overarching framework or policy which sets out expectations of emergency preparedness, Arrangements are put in place for emergency preparedness, resilience and response which: resilience and response. • Have a change control process and version control • Take account of changing business objectives and processes • Take account of any changes in the organisations functions and/ or organisational and structural and staff changes • Take account of change in key suppliers and contractual arrangements • Take account of any updates to risk assessment(s) • Have a review schedule • Use consistent unambiguous terminology, • Identify who is responsible for making sure the policies and arrangements are updated, distributed and regularly tested; • Key staff must know where to find policies and plans on the intranet or shared drive. • Have an expectation that a lessons identified report should be produced following exercises, emergencies and /or business continuity incidents and share for each exercise or incident and a corrective action plan put in place. • Include references to other sources of information and supporting documentation The accountable emergency officer will ensure that the Board and/or Governing Body will receive as appropriate After every significant incident a report should go to the Board/ Governing Body (or appropriate delegated governing group) . reports, no less frequently than annually, regarding EPRR, including reports on exercises undertaken by the Must include information about the organisation's position in relation to the NHS England EPRR core standards self assessment. organisation, significant incidents, and that adequate resources are made available to enable the organisation to meet the requirements of these core standards. Duty to assess risk Assess the risk, no less frequently than annually, of emergencies or business continuity incidents occurring Risk assessments should take into account community risk registers and at the very least include reasonable worst-case scenarios for: which affect or may affect the ability of the organisation to deliver it's functions. • severe weather (including snow, heatwave, prolonged periods of cold weather and flooding); • staff absence (including industrial action); • the working environment, buildings and equipment (including denial of access); • fuel shortages; • surges and escalation of activity; • IT and communications; • utilities failure; There is a process to ensure that the risk assessment(s) is in line with the organisational, Local Health • response a major incident / mass casualty event Resilience Partnership, other relevant parties, community (Local Resilience Forum/ Borough Resilience Forum), • supply chain failure; and and national risk registers. • associated risks in the surrounding area (e.g. COMAH and iconic sites) There is a process to consider if there are any internal risks that could threaten the performance of the organisation’s functions in an emergency as well as external risks eg. Flooding, COMAH sites etc.

There is a process to ensure that the risk assessment(s) is informed by, and consulted and shared with your Other relevant parties could include COMAH site partners, PHE etc. organisation and relevant partners. Duty to maintain plans – emergency plans and business continuity plans Effective arrangements are in place to respond to the risks the organisation is exposed to, appropriate to the role, size and scope of the organisation, and there is a process to ensure the likely extent to which particular types of emergencies will place demands on your resources and capacity.

Incidents and emergencies (Incident Response Plan (IRP) (Major Incident Plan))

NHS England local teams

NHS England Regional & national

CCGs

Other NHS funded organisations

Mental healthcare providers

Primary care (GP, community pharmacy)

Community services providers

CSUs (business continuity only)

Ambulance service providers

Governance Organisations have a director level accountable emergency officer who is responsible for EPRR (including business continuity management) Organisations have an annual work programme to mitigate against identified risks and incorporate the lessons Lessons identified from your organisation and other partner organisations. identified relating to EPRR (including details of training and exercises and past incidents) and improve response. NHS organisations and providers of NHS funded care treat EPRR (including business continuity) as a systematic and continuous process and have procedures and processes in place for updating and maintaining plans to ensure that they reflect: - the undertaking of risk assessments and any changes in that risk assessment(s) - lessons identified from exercises, emergencies and business continuity incidents - restructuring and changes in the organisations - changes in key personnel - changes in guidance and policy

Specialist providers

Clarifying information

Acute healthcare providers

Core standard

Self assessment RAG

Severe Weather (heatwave, flooding, snow and cold weather)

Mass Countermeasures (eg mass prophylaxis, or mass vaccination) Mass Casualties

Fuel Disruption

Surge and Escalation Management (inc. links to appropriate clinical networks e.g. Burns, Trauma and Critical Care) Infectious Disease Outbreak

Evacuation Lockdown

Utilities, IT and Telecommunications Failure Y

Excess Deaths/ Mass Fatalities

having a Hazardous Area Response Team (HART) (in line with the current national service specification, including a vehicles and equipment replacement programme) - see HART core standard tab firearms incidents in line with National Joint Operating Procedures; - see MTFA core standard tab Ensure that plans are prepared in line with current guidance and good practice which includes: • Aim of the plan, including links with plans of other responders • Information about the specific hazard or contingency or site for which the plan has been prepared and realistic assumptions • Trigger for activation of the plan, including alert and standby procedures • Activation procedures • Identification, roles and actions (including action cards) of incident response team • Identification, roles and actions (including action cards) of support staff including communications • Location of incident co-ordination centre (ICC) from which emergency or business continuity incident will be managed • Generic roles of all parts of the organisation in relation to responding to emergencies or business continuity incidents • Complementary generic arrangements of other responders (including acknowledgement of multi-agency working) • Stand-down procedures, including debriefing and the process of recovery and returning to (new) normal processes • Contact details of key personnel and relevant partner agencies • Plan maintenance procedures (Based on Cabinet Office publication Emergency Preparedness, Emergency Planning, Annexes 5B and 5C (2006)) Arrangements include a procedure for determining whether an emergency or business continuity incident has Enable an identified person to determine whether an emergency has occurred occurred. And if an emergency or business continuity incident has occurred, whether this requires changing the - Specify the procedure that person should adopt in making the decision deployment of resources or acquiring additional resources. - Specify who should be consulted before making the decision - Specify who should be informed once the decision has been made (including clinical staff) Arrangements include how to continue your organisation’s prioritised activities (critical activities) in the event of an emergency or business continuity incident insofar as is practical.

Arrangements explain how VIP and/or high profile patients will be managed.

Arrangements include a debrief process so as to identify learning and inform future arrangements

Those on-call must meet identified competencies and key knowledge and skills for staff.

Documents identify where and how the emergency or business continuity incident will be managed from, ie the Incident Co-ordination Centre (ICC), how the ICC will operate (including information management) and the key roles required within it, including the role of the loggist . Arrangements ensure that decisions are recorded and meetings are minuted during an emergency or business continuity incident. Arrangements detail the process for completing, authorising and submitting situation reports (SITREPs) and/or commonly recognised information pictures (CRIP) / common operating picture (COP) during the emergency or business continuity incident response.

COO has the lead as the accountable emergency officer for the Trust.

COO

Business continuity plans are in a cycle to be reviewed and updated on a yearly basis or more frequently if highlighted through an evetn, debrief and lessons learned. The LHRP risk assessments inform the planning for the Trust in combination with the National and LRF Risk register. The Trust has copies of the NHS supplies BCM plan and this has been distributed to support departments BCM planning.

The work to imbed the Trust and Resilience service levelt BCM planning is Manager ongoing with a proprtion of departments seen and others still to be consulted and supported in producing their plans.

Trust level business continuity plan is in draft and awaits presentation to board for sign off.

Plan to be ratified by board

There is a chmical incident plan in place and in date. The required level of equipment is in place in line with NHS England and PHE guidnace. There is a rolling programme of training for staff to fulfil the role during the response to a chemical incident. There are plans in place for Heatwave, Cold Weather both of which are in date. The snow plan to be published later this year. The Trust has invested in a add on snow plough to aid site clearance.

Detailed at 5

Key plans support sevre weather response and strong connections with partners to ensure timely notifications and response if needed. Influenza & pandemic Flu plan reviewed yearly and in response to any significant new guidnace or unseasonal outbreak. Mass propalaxis plan in place LRF Mass Casualty plan is in place as gudiance and local major incident plan supports a no notice escalation. LRF fuel plan puts the onus on organisations to have BCM planning developed and Trust has a series of mitigations to ensure electircal supply is maintained and a regieme of generator testing. Distribution of fuel through filling stations to support staff working off site would need LRF support. Details of supply chain for fuel for on site generator need to be included in Estates BCM plan.

Estates & facilites BCM plan under review

There is currently an escalation policy, which is about to be reviewed and recorded therefore as work in progress. There is an infectious disease woubreak plan the the Trust supported the development of the Ebola planning The existing fire plan supports a progressive invacuation and shelter in situ process. Work has commenced on developing a specific evacuation plan. This will require exercising. There is a lockdown policy in place. It is planned to test / exercise an abduction from maternity in the curent year. Key site services have an established down time plan for loss of IT. A series of telecomms exercises has taken place and the switchboard are developing a more robust fallback capability. DR for IT systems needs to be incorporated into the IT BCM plan. LRF plan for managing excess deaths plan is in place if needed. Local planning to manage mortuary capacity is well established and was highlighted as good practice during peak demand in 2014 to 15

Resilience Manager Resilience Manager

Dec-15

Oct-15 Dec-15

Estates Manager

Nov-15

Escalation policy to be reviewed A/D Site Services

Nov-15

Fire evacuation forms the inerim Fire Safety position ahead of a review of a Advisor specific non fire evacuation

Dec-15

Switchboard Manager and IT Manager

Dec-15

Resilience Manager

Dec-15

N/A

Y Y

N/A Plans and policies are version controlled and dated for review period. The programme of work recognises this cycle and is directed to keep all of the relevant documents in date. PHE, NHS England and the LHRP supports identifying key risks areas as well as good practice and guidance. These are included as references in plans as they are updated. Palns are reviewe in keeping with Trust policy through Board sign off.

Decide: - Which activities and functions are critical - What is an acceptable level of service in the event of different types of emergency for all your services - Identifying in your risk assessments in what way emergencies and business continuity incidents threaten the performance of your organisation’s functions, especially critical activities

This refers to both clinical (including HAZMAT incidents) management and media / communications management of VIPs and / or high profile management

Internally planning is supported through the Trust Resilience Group and with key stakeholders as the need arises. Externally there are stong links to the LHRP, CCG Providers and Communities. This is the same with other key partners through the LRF, including Police, Fire , SEACamb and Gatwick; this is through formal meetings and established networking.

The full range of debriefing approach is avaliable and used dependent on the circumstances and level of incident.

The site team provide 24/7, 365 day cover formanaging no notice emergency and business continuity incidents in the first instance. They are supported by a team of general Managers and Directors who are on call, this is managed through a rota system. The cascade is supported where needed by the trust switchboard staff.

Explain the de-briefing process (hot, local and multi-agency, cold)at the end of an incident.

Timescale

There is a rolling programme of work, covering equipment, training exercising and planning. Audit and assurance is provided through a review process and held on a database, this records all planned and unplanned events that could impact on service delivery. Where appropriate these are debriefed and feed into future planning through lessons learned.

Command and Control (C2) Organisation to have a 24/7 on call rota in place with access to strategic and/or executive level personnel Arrangements demonstrate that there is a resilient single point of contact within the organisation, capable of receiving notification at all times of an emergency or business continuity incident; and with an ability to respond or escalate this notification to strategic and/or executive level, as necessary.

Lead

Green = fully compliant with core standard.

Preparedness is undertaken with the full engagement and co-operation of interested parties and key stakeholders (internal and external) who have a role in the plan and securing agreement to its content

Amber = Not compliant but evidence of progress and in the Action to be taken EPRR work plan for the next 12 months.

There is an agreed reporting process.

HAZMAT/ CBRN - see separate checklist on tab overleaf

Pandemic Influenza (see pandemic influenza tab for deep dive 2015-16 questions)

Evidence of assurance

The Trust has a Resilience policy which is in date and provides the foundation for the emergency planning and business continuity arrangements.

corporate and service level Business Continuity (aligned to current nationally recognised BC standards)

Have arrangements for (but not necessarily have a separate plan for) some or all of the following (organisation dependent) (NB, this list is not exhaustive):

Red = Not compliant with core standard and not in the EPRR work plan within the next 12 months.

• Oncall Standards and expectations are set out. • Include 24-hour arrangements for alerting managers and other key staff.

New Trust BCM plan provides an algotithm and action cards to support decision making

Plan linked to police Operation Carbon Steeple which is at hand for ED staff.

NHS England publised competencies are based upon National Occupation Standards .

There is a rolling programme of walkthroughs, briefings, exercises and training sessions.

This should be proportionate to the size and scope of the organisation.

The establishment of the ICC is detailed in the major incident plan and would be used as the current basis for a BCM response. As detailed above the Trust level business continuity plan is in draft and awaits presentation to board for sign off. This will provide addditonal guidnace to establsih command and control to respond to a BCM event. A number of staff are trained as loggists to support activations either of a major incident or business continuity incident. Training and plans reflect the importance of accurate record keeping in both decision logs and meetings. There is an established reporting process during escalation and the mechanisms for providing key updates were extensively used during the mortuary capacity meetings in 2014 / 2015.

Arrangements to have access to 24-hour specialist adviser available for incidents involving firearms or chemical, Both acute and ambulance providers are expected to have in place arrangements for accessing specialist advice in the event of incidents biological, radiological, nuclear, explosive or hazardous materials, and support strategic/gold and tactical/silver chemical, biological, radiological, nuclear, explosive or hazardous materials command in managing these events. Arrangements to have access to 24-hour radiation protection supervisor available in line with local and national Both acute and ambulance providers are expected to have arrangements in place for accessing specialist advice in the event of a radiation mutual aid arrangements; incident Duty to communicate with the public Arrangements demonstrate warning and informing processes for emergencies and business continuity incidents. Arrangements include a process to inform and advise the public by providing relevant timely information about the nature of the unfolding event and about: - Any immediate actions to be taken by responders - Actions the public can take - How further information can be obtained - The end of an emergency and the return to normal arrangements Communications arrangements/ protocols:

Other NHS funded organisations

Primary care (GP, community pharmacy)

CSUs (business continuity only)

CCGs

NHS England Regional & national

NHS England local teams

Mental healthcare providers

Community services providers

Ambulance service providers

Specialist providers

Clarifying information

Acute healthcare providers

Core standard

Self assessment RAG Red = Not compliant with core standard and not in the EPRR work plan within the next 12 months. Evidence of assurance

Green = fully compliant with core standard.

Support and specialist advice is available from Police, SEACamb and PHE (ECOSA). Y

Support and specialist advice is available from SEACamb and PHE (ECOSA).

Amber = Not compliant but evidence of progress and in the Action to be taken EPRR work plan for the next 12 months.

The communcations team provides the ability to distibute key messaging both internally and externally. It is supported by an internal communcations plan as well as information sharing protocols established by the LRF partnership.

Lead

Timescale

Arrangements ensure the ability to communicate internally and externally during communication equipment failures Information Sharing – mandatory requirements Arrangements contain information sharing protocols to ensure appropriate communication with partners.

Arrangements are in place to ensure attendance at all Local Health Resilience Partnership meetings at a director level

Preparedness ensures all incident commanders (oncall directors and managers) maintain a continuous personal development portfolio demonstrating training and/or incident /exercise participation.

Other NHS funded organisations

Primary care (GP, community pharmacy)

CSUs (business continuity only)

CCGs

NHS England Regional & national

NHS England local teams

Mental healthcare providers

Ambulance service providers

Community services providers Y

• Staff are clear about their roles in a plan • Training is linked to the National Occupational Standards and is relevant and proportionate to the organisation type. • Training is linked to Joint Emergency Response Interoperability Programme (JESIP) where appropriate • Arrangements demonstrate the provision to train an appropriate number of staff and anyone else for whom training would be appropriate for the purpose of ensuring that the plan(s) is effective • Arrangements include providing training to an appropriate number of staff to ensure that warning and informing arrangements are effective

Red = Not compliant with core standard and not in the EPRR work plan within the next 12 months. Evidence of assurance

Amber = Not compliant but evidence of progress and in the Action to be taken EPRR work plan for the next 12 months.

Lead

Timescale

Green = fully compliant with core standard.

Regular checks are made to ensure that both day to day communication systems are functional as well as emergency systems. There is an established information sharing protocol with the LRF in place and consulatation continues with the Vulnerable people workstream.

Y Y

The Resilience Manager attends LRF, LHRP, Gatwick meetings. Also represents on identified task and finish groups as needed. The Resilience Manager represents the other Acute EP's at the LRF DG, Climate Change, Telecommunciations, Reslience Direct workstreams and meetings. Also attends Gatwick Resilience meetings. Supports training delivery with the LRF at Intro to Emergency Planning and Resilince Direct, Additinally ad hoc as needed. Contribute to the mutual aid arrangements within the health economy. This occurred during the mortuary capacity peak deand in 2014 /1 2015. Support he LRF and other partners in line with planning locally. N/A N/A Requested updates are collated and infrmation returned in a timely manner. This is supported by use of the nhs.net e-mail.

N/A

Y Y Y

Arrangements include an ongoing exercising programme that includes an exercising needs analysis and informs • Exercises consider the need to validate plans and capabilities future work. • Arrangements must identify exercises which are relevant to local risks and meet the needs of the organisation type and of other interested parties. • Arrangements are in line with NHS England requirements which include a six-monthly communications test, annual table-top exercise and live exercise at least once every three years. • If possible, these exercises should involve relevant interested parties. • Lessons identified must be acted on as part of continuous improvement. • Arrangements include provision for carrying out exercises for the purpose of ensuring warning and informing arrangements are effective Demonstrate organisation wide (including oncall personnel) appropriate participation in multi-agency exercises

NB: mutual aid agreements are wider than staff and should include equipment, services and supplies.

Arrangements outline the procedure for responding to incidents which affect two or more Local Health Resilience Partnership (LHRP) areas or Local Resilience Forum (LRF) areas. Arrangements outline the procedure for responding to incidents which affect two or more regions. Arrangements demonstrate how organisations support NHS England locally in discharging its EPRR functions Examples include completing of SITREPs, cascading of information, supporting mutual aid discussions, prioritising activities and/or services and duties etc. Plans define how links will be made between NHS England, the Department of Health and PHE. Including how information relating to national emergencies will be co-ordinated and shared Arrangements are in place to ensure an Local Health Resilience Partnership (LHRP) (and/or Patch LHRP for the London region) meets at least once every 6 months

Training And Exercising Arrangements include a training plan with a training needs analysis and ongoing training of staff required to deliver the response to emergencies and business continuity incidents

These must take into account and inclue DH (2007) Data Protection and Sharing – Guidance for Emergency Planners and Responders or any guidance which supercedes this, the FOI Act 2000, the Data Protection Act 1998 and the CCA 2004 ‘duty to communicate with the public’, or subsequent / additional legislation and/or guidance.

Co-operation Organisations actively participate in or are represented at the Local Resilience Forum (or Borough Resilience Forum in London if appropriate) Demonstrate active engagement and co-operation with other category 1 and 2 responders in accordance with the CCA

Arrangements include how mutual aid agreements will be requested, co-ordinated and maintained.

Specialist providers

Clarifying information

Acute healthcare providers

Core standard

Self assessment RAG

N/A

Meeting dates and papers circualted in advance of meetings, COO will normally attend or seek a deputy when unable to. Current training programme identifies key training needs which cover Major Incidents, BCM and CBRNe. Additional training is developed, sought and delivered as needed.An example of this is a specific input to redress a gap around 'surviving public enquiries' required for executives and directors.

Key workstreams and guidnace from NHS England support the identification and dvelopment of exercising needs. These are in turn incorporated into exisiting exercisies or bespoke exercises developed as needed.

Y Y

Major incident exercise to be delivered in September 2015. Further walkthroughs to support on call staff to be delivered. Internal and external training is provided by the LRF and other providers. This needs aligning and recording, so indivuduals can demonstrate competence as needed.

Resilience Manager Resilience Manager

Apr-16 Apr-16

Other NHS funded organisations

CCGs

Primary care (GP, community pharmacy)

NHS England Regional & national

CSUs (business continuity only)

NHS England local teams

Organisations have taken their plans to Boards / Governing bodies for sign off

Mental healthcare providers

DD4

• local organisations have held an internal exercise or participated in a multi-organisation exercise since updating their local arrangements to reflect changes and learning described in DD1 • if this has not taken place, there is a clear plan to deliver an exercise in the next six months • updated arrangements that reflect changes and learning described in DD1 have been taken to Boards or Governing Bodies, and even if they have not yet have been signed off by such bodies, the process towards this has been started

Community services providers

Organisations have undertaken a pandemic influenza exercise or have one planned in the next six months DD3

• relevant local partners (particularly other NHS providers/ commissioners, PHE and local authority public health and social care teams where appropriate) have been engaged in the development of local plans - at a minimum through an opportunity to comment on draft versions

Ambulance service providers

Organisations have developed and reviewed their plans with LHRP and LRF partners DD2

• changes since April 2013 are reflected in local plans including formation of NHS England, CCGs and PHE; as well as the move of the previous PCT public health function into local authorities • key changes to the national pandemic infleunza strategy (such as de-coupling from WHO, development of DATER phases, and removal of UK alert levels) as well as relevant local learning is reflected

Specialist providers

2015 Deep Dive Organisation have updated their pandemic influenza arrangements to reflect changes to the NHS and partner organisations, as well as lessons identified from the 2009/10 pandemic including through local debriefing DD1

Clarifying information

Acute healthcare providers

Core standard

Self assessment RAG

Red = Not compliant with core standard and not in the EPRR work plan within the next 12 months. Evidence of assurance

Green = fully compliant with core standard.

Plan was published post April 2013

Plan developed utilising PHE guidance and establishing key links Y

Amber = Not compliant but evidence of progress and in the Action to be taken EPRR work plan for the next 12 months.

it is understood that a regional exercise is planned in this work area to take place during the last quarter of 2015.

Broad consulataion took place when the plan was reviewed and updated and will follow again with any new guidance this year. Evidence of 'deep dive being researched'.

Lead

Timescale

Core standard

Preparedness There is an organisation specific HAZMAT/ CBRN plan (or dedicated annex)

Mental Health care providers

Community services providers

Ambulance service providers

Specialist providers

Acute healthcare providers

Hazardous materials (HAZMAT) and chemical, biological, radiolgocial and nuclear (CBRN) response core standards (NB this is designed as a stand alone sheet)

Clarifying information

Action to be taken Self assessment RAG Red = Not compliant with core standard and not in the EPRR work plan within the next 12 months. Amber = Not compliant but evidence of progress and in the EPRR work plan for the next 12 months. Green = fully compliant with core standard. Evidence of assurance

Arrangements include: • command and control interfaces • tried and tested process for activating the staff and equipment (inc. Step 1-2-3 Plus) • pre-determined decontamination locations and access to facilities • management and decontamination processes for contaminated patients and fatalities in line with the latest guidance • communications planning for public and other agencies • interoperability with other relevant agencies • access to national reserves / Pods • plan to maintain a cordon / access control • emergency / contingency arrangements for staff contamination • plans for the management of hazardous waste • stand-down procedures, including debriefing and the process of recovery and returning to (new) normal processes • contact details of key personnel and relevant partner agencies

There is a version controlled Chemical incident Plan in place. Aid memoire's placed in strategic locations and provided as part of the training to staff during training sessions. Steps 1-2-3 process is at the core of the CBRNe training for staff. Locations are pre-determined and trained staff aware of these. Warning and informing is central to the response to ensure patients and public are informed as appropriate. The acredited training covers joint working, the use and process of cordon control, decontamnination of staff, the plans for managing hazardous waste, stand down and debriefing, as well as key contacts; PHE, SUrrey Fire and Rescue Service as well as HART.

Staff are able to access the organisation HAZMAT/ CBRN management plans.

Decontamination trained staff can access the plan

Plans and aid memoir's are available to staff.

HAZMAT/ CBRN decontamination risk assessments are in place which are appropriate to the organisation.

• Documented systems of work • List of required competencies • Impact assessment of CBRN decontamination on other key facilities • Arrangements for the management of hazardous waste

Central to the training and response.

Rotas are planned to ensure that there is adequate and appropriate decontamination capability available 24/7.

Staff on-duty know who to contact to obtain specialist advice in relation to a HAZMAT/ • For example PHE, emergency services. CBRN incident and this specialist advice is available 24/7.

ED staff planning aijms to ensure sufficient staff with the appropriate level of training are on duty. Training regieme aims to ensure that refresher and new courses are run regulkalrly to maintain staffing levels. Central to the training and response.

There is an accurate inventory of equipment required for decontaminating patients in • Acute and Ambulance service providers - see Equipment checklist overleaf on separate Y place and the organisation holds appropriate equipment to ensure safe tab decontamination of patients and protection of staff. • Community, Mental Health and Specialist service providers - see Response Box in 'Preparation for Incidents Involving Hazardous Materials - Guidance for Primary and Community Care Facilities' (NHS London, 2011) (found at: http://www.londonccn.nhs.uk/_store/documents/hazardous-material-incident-guidance-forprimary-and-community-care.pdf) • Initial Operating Response (IOR) DVD and other material: http://www.jesip.org.uk/what-willjesip-do/training/

The organisation has the expected number of PRPS suits (sealed and in date) There is a plan and finance in place to revalidate (extend) or replace suits that are reaching Y available for immediate deployment should they be required (NHS England published the end of shelf life until full capability of the current model is reached in 2017 guidance (May 2014) or subsequent later guidance when applicable)

Trust has more suits than required to support the diversity of staff.

There are routine checks carried out on the decontamination equipment including: A) Suits B) Tents C) Pump D) RAM GENE (radiation monitor) E) Other decontamination equipment

Equipment is checked on a regualr basis and all checks recirded.

There is a preventative programme of maintenance (PPM) in place for the maintenance, repair, calibration and replacement of out of date Decontamination equipment for: A) Suits B) Tents C) Pump D) RAM GENE (radiation monitor) E) Other equipment There are effective disposal arrangements in place for PPE no longer required.

As above, equipment is replaced as required.

All suits are in date to 2017, disposal arrangements for cleaning replacement are well establsihed.

Decontamination Equipment

48 49

50 51

There is a named role responsible for ensuring these checks take place

(NHS England published guidance (May 2014) or subsequent later guidance when applicable)

Training The current HAZMAT/ CBRN Decontamination training lead is appropirately trained to Y deliver HAZMAT/ CBRN training Y Internal training is based upon current good practice and uses material that has been • Documented training programme supplied as appropriate. • Primary Care HAZMAT/ CBRN guidance • Lead identified for training • Established system for refresher training so that staff that are HAZMAT/ CBRN decontamination trained receive refresher training within a reasonable time frame (annually). • A range of staff roles are trained in decontamination techniques • Include HAZMAT/ CBRN command and control training • Include ongoing fit testing programme in place for FFP3 masks to provide a 24/7 capacity and capability when caring for patients with a suspected or confirmed infectious respiratory virus • Including, where appropriate, Initial Operating Response (IOR) and other material: http://www.jesip.org.uk/what-will-jesip-do/training/ The organisation has sufficient number of trained decontamination trainers to fully support it's staff HAZMAT/ CBRN training programme. Staff that are most likely to come into first contact with a patient requiring • Including, where appropriate, Initial Operating Response (IOR) and other material: decontamination understand the requirement to isolate the patient to stop the spread http://www.jesip.org.uk/what-will-jesip-do/training/ of the contaminant. • Community, Mental Health and Specialist service providers - see Response Box in 'Preparation for Incidents Involving Hazardous Materials - Guidance for Primary and Community Care Facilities' (NHS London, 2011) (found at: http://www.londonccn.nhs.uk/_store/documents/hazardous-material-incident-guidance-forprimary-and-community-care.pdf)

Y Y

Trust has equipment in excess of PHE guidnace. ED has an established process for tracking patients.

Training is delivered by an accredited trainer from another Trust. Y

All records are kept of risk assessments and training attended. Staff are issued permit to work cards and can only be used in a deployment if they produce a current and valid pernit to work card.

Provided by another Trust currently. Established as part of the Step 1-2-3 training.

Lead

Timescale

HAZMAT CBRN equipment list - for use by Acute and Ambulance service providers in relation to Core Standard 43. No

Equipment

Equipment model/ generation/ details etc.

EITHER: Inflatable mobile structure E1 Inflatable frame E1.1 Liner E1.2 Air inflator pump E1.3 Repair kit

N/A N/A N/A N/A

E1.2 Tethering equipment OR: Rigid/ cantilever structure E2 Tent shell OR: Built structure E3 Decontamination unit or room E4 E5 E6 E7 E8 E9

The organisation (acute and ambulance providers only) has the expected number of PRPS suits (sealed and in date) available for immediate deployment should they be required. (NHS England published guidance (May 2014) or subsequent later guidance when applicable).

E11

E12 E13

Providers to ensure that they hold enough training suits in order to facilitate their local training programme Ancillary A facility to provide privacy and dignity to patients Buckets, sponges, cloths and blue roll

E14

Decontamination liquid (COSHH compliant)

E15

Entry control board (including clock) A means to prevent contamination of the water supply Poly boom (if required by local Fire and Rescue Service)

E18

Minimum of 20 x Disrobe packs or suitable equivalent (combination of sizes)

E19

Minimum of 20 x re-robe packs or suitable alternative (combination of sizes - to match disrobe packs) Waste bins Disposable gloves Scissors - for removing patient clothes but of sufficient calibre to execute an emergency PRPS suit disrobe FFP3 masks Cordon tape Loud Hailer Signage Tabbards identifying members of the decontamination team Chemical Exposure Assessment Kits (ChEAKs) (via PHE): should an acute service provider be required to support PHE in the collection of samples for assisting in the public health risk assessment and response phase of an incident, PHE will contact the acute service provider to agree appropriate arrangements. A Standard Operating Procedure will be issued at the time to explain what is expected from the acute service provider staff. Acute service providers need to be in a position to provide this support.

E20 E21 E22 E23 E24 E25 E26 E27

E28 E29 E30 E31 E32

N/A

AND: Lights (or way of illuminating decontamination area if dark) Shower heads Hose connectors and shower heads Flooring appropriate to tent in use (with decontamination basin if needed) Waste water pump and pipe Waste water bladder PPE for chemical, and biological incidents

E10

E16 E17

Self assessment RAG Red = Not in place and not in the EPRR work plan to be in place within the next 12 months. Amber = Not in place and in the EPRR work plan to be in place within the next 12 months. Green = In place.

Radiation RAM GENE monitors (x 2 per Emergency Department and/or HART team) Hooded paper suits Goggles FFP3 Masks - for HART personnel only Overshoes & Gloves

Partner Agency

Yes- checking and tesing regieme on a monthly basis is in place. Ebola PPE Ebola PPE N/A

Governance

Organisations have an MTFA capability at all times within their operational service area.

Organisations have a local policy or procedure to ensure the effective prioritisation and deployment (or redeployment) of MTFA staff to an incident requiring the MTFA capability.

Organisations maintain a local policy or procedure to ensure the effective identification of incidents or patients that may benefit from deployment of the MTFA capability.

Organisations have an appropriate revenue depreciation scheme on a 5-year cycle which is maintained locally to replace nationally specified MTFA equipment.

Organisations use the NARU coordinated national change request process before reconfiguring (or changing) any MTFA procedures, equipment or training that has been specified as nationally interoperable.

Organisations maintain an appropriate register of all MTFA safety critical assets.

Organisations ensure their operational commanders are competent in the deployment and management of NHS MTFA resources at any live incident.

12 13

• Deployment to the Home Office Model Response sites must be within 45 minutes.

• Organisations maintain a minimum of ten competent MTFA staff on duty at all times. Competence is denoted by the mandatory minimum training requirements identified in the MTFA capability matrix. • Organisations ensure that, as part of the selection process, any successful MTFA application must have undergone a Physical Competence Assessment (PCA) to the nationally agreed standard. • Organisations maintain the minimum level of training competence among all operational MTFA staff as defined by the national training Organisations have the ability to ensure that ten MTFA staff are released and available to respond to scene within standards. 10 minutes of that confirmation (with a corresponding safe system of work). • Organisations ensure that each operational MTFA operative is competent to deliver the MTFA capability. • Organisations ensure that comprehensive training records are maintained for each member of MTFA staff. These records must include; a record of mandated training completed, when it was completed, any outstanding training or training due and an indication of the individual’s level of competence across the MTFA skill sets.

Organisations ensure that appropriate personal equipment is available and maintained in accordance with the detailed specification in MTFA SOPs (Reference C).

• Organisations have MTFA capability to the nationally agreed safe system of work standards defined within this service specification. • Organisations have MTFA capability to the nationally agreed interoperability standard defined within this service specification. • Organisations have taken sufficient steps to ensure their MTFA capability remains complaint with the National MTFA Standard Operating Procedures during local and national deployments.

• To procure interoperable safety critical equipment (as referenced in the National Standard Operating Procedures), organisations should use the national buying frameworks coordinated by NARU unless they can provide assurance through the change management process that the local procurement is interoperable. • All MTFA equipment is maintained to nationally specified standards and must be made available in line with the national MFTA ‘notice to move’ standard. • All MTFA equipment is maintained according to applicable British or EN standards and in line with manufacturers’ recommendations. • Organisations ensure that Control rooms are compliant with JOPs (Reference B). • With Trusts using Pathways or AMPDS, ensure that any potential MTFA incident is recognised by Trust specific arrangements.

Organisations have a proces to acknowledge and respond appropriately to any national safety notifications issued for MTFA by NARU within 7 days.

FRS organisations that have an MTFA capability the ambulance service provider must provide training to this FRS

Organisations ensure that staff view the appropriate DVDs

Y Y Y

• Assets are defined by their reference or inclusion within the National MTFA Standard Operating Procedures. • This register must include; individual asset identification, any applicable servicing or maintenance activity, any identified defects or faults, the expected replacement date and any applicable statutory or regulatory requirements (including any other records which must be maintained for that item of equipment).

Organisations maintain accurate records of their compliance with the national MTFA response time standards and make them available to their local lead commissioner, external regulators (including both NHS and the Health & Safety Executive) and NHS England (including NARU operating under an NHS England contract). In any event that the organisations is unable to maintain the MTFA capability to the interoperability standards, that provider has robust and timely mechanisms to make a notification to the National Ambulance Resilience Unit (NARU) on-call system. The provider must then also provide notification of the specification default in writing to their lead commissioners. Organisations support the nationally specified system of recording MTFA activity which will include a local procedure to ensure MTFA staff update the national system with the required information following each live deployment. Organisations ensure that the availability of MTFA capabilities within their operational service area is notified nationally every 12 hours via a nominated national monitoring system coordinated by NARU. Organisations maintain a set of local MTFA risk assessments which are compliment with the national MTFA risk assessments covering specific training venues or activity and pre-identified high risk sites. The provider must also ensure there is a local process / procedure to regulate how MTFA staff conduct a joint dynamic hazards assessment (JDHA) at any live deployment. Organisations have a robust and timely process to report any lessons identified following an MTFA deployment or training activity that may be relevant to the interoperable service to NARU within 12 weeks using a nationally approved lessons database. Organisations have a robust and timely process to report, to NARU and their commissioners, any safety risks related to equipment, training or operational practice which may have an impact on the national interoperability of the MTFA service as soon as is practicable and no later than 7 days of the risk being identified.

Y Y

Y Training to include: • Introduction and understanding of NASMed triage • Haemorrhage control • Use of dressings and tourniquets • Patient positioning • Casualty Collection Point procedures. • National Strategic Guidance - KPI 100% Gold commanders. • Specialist Ambulance Service Response to MTFA - KPI 100% MTFA commanders and teams. • Non-Specialist Ambulance Service Response to MTFA - KPI 80% of operational staff.

Other NHS funded organisations

Primary care (GP, community pharmacy)

CSUs (business continuity only)

CCGs

NHS England Regional & national

NHS England local teams

Mental healthcare providers

Community services providers

Ambulance service providers

Specialist providers

Clarifying information

Acute healthcare providers

Core standard

Self assessment RAG Red = Not compliant with core standard and not in the EPRR work plan within the next 12 months.

Evidence of assurance

Amber = Not compliant but evidence of progress and in the EPRR work plan for the next 12 months. Action to be taken Green = fully compliant with core standard.

Lead

Timescale

Governance 1

Organisations maintain a HART Incident Response Unit (IRU) capability at all times within their operational service area.

Organisaions maintain a HART Urban Search & Rescue (USAR) capability at all times within their operational service area.

Organisations maintain a HART Inland Water Operations (IWO) capability at all times within their operational service area.

Organisations maintain a HART Tactical Medicine Operations (TMO) capability at all times within their operational service area.

Organisations maintain a local policy or procedure to ensure the effective prioritisation and deployment (or redeployment) of HART staff to an incident requiring the HART capabilities.

Organisations maintain a criteria or process to ensure the effective identification of incidents or patients at the point of receiving an emergency call that may benefit from the deployment of a HART capability.

• Organiations maintain the four core HART capabilities to the nationally agreed safe system of work standards defined within this service specification. • Organiations maintain the four core HART capabilities to the nationally agreed interoperability standard defined within this service specification. • Organiations take sufficient steps to ensure their HART unit(s) remains complaint with the National HART Standard Operating Procedures during local and national deployments. • Organiations maintain the minimum level of training competence among all operational HART staff as defined by the national training standards for HART. • Organiations ensure that each operational HART operative is provided with no less than 37.5 hours protected training time every seven weeks. If designated training staff are used to augment the live HART team, they must receive the equivalent protected training hours within the seven week period (in other words, training hours can be converted to live hours providing they are re-scheduled as protected training hours within the seven week period). • Organiations ensure that all HART operational personnel are Paramedics with appropriate corresponding professional registration (note s.3.4.6 of the specification). • As part of the selection process, any successful HART applicant must have passed a Physical Competence Assessment (PCA) to the nationally agreed standard and the provider must ensure that standard is maintained through an ongoing PCA process which assesses operational staff every 6 months and any staff returning to duty after a period of absence exceeding 1 month. • Organiations ensure that comprehensive training records are maintained for each member of HART staff. These records must include; a record of mandated training completed, when it was completed, any outstanding training or training due and an indication of the individual’s level of competence across the HART skill sets. • Four HART staff must be released and available to respond locally to any incident identified as potentially requiring HART capabilities within 15 minutes of the call being accepted by the provider. Note: This standard does not apply to pre-planned operations or occasions where HART is used to support wider operations. It only applies to calls where the information received by the provider indicates the potential for one of the four HART core capabilities to be required at the scene. See also standard 13. • Organisations maintain a minimum of six competent HART staff on duty for live deployments at all times. • Once HART capability is confirmed as being required at the scene (with a corresponding safe system of work) organisations can ensure that six HART staff are released and available to respond to scene within 10 minutes of that confirmation. The six includes the four already mobilised. • Organisations maintain a HART service capable of placing six competent HART staff on-scene at strategic sites of interest within 45 minutes. These sites are currently defined within the Home Office Model Response Plan (by region). Competence is denoted by the mandatory minimum training requirements identified in the HART capability matrix. • Organisations maintain any live (on-duty) HART teams under their control maintain a 30 minute ‘notice to move’ to respond to a mutual aid request outside of the host providers operational service area. An exception to this standard may be claimed if the live (on duty) HART team is already providing HART capabilities at an incident in region.

Y • To procure interoperable safety critical equipment (as referenced in the National Standard Operating Procedures), organisations should have processes in place to use the national buying frameworks coordinated by NARU unless they can provide assurance through the change management process that the local procurement is interoperable.

Organisations ensure an appropriate capital and revenue depreciation scheme is maintained locally to replace nationally specified HART equipment.

Organisations use the NARU coordinated national change request process before reconfiguring (or changing) any HART procedures, equipment or training that has been specified as nationally interoperable.

Organisations ensure that the HART fleet and associated incident technology are maintained to nationally specified standards and must be made available in line with the national HART ‘notice to move’ standard.

Organisations ensure that all HART equipment is maintained according to applicable British or EN standards and in line with manufacturers recommendations.

Organisations maintain an appropriate register of all HART safety critical assets. Such assets are defined by their reference or inclusion within the National HART Standard Operating Procedures. This register must include; individual asset identification, any applicable servicing or maintenance activity, any identified defects or faults, the expected replacement date and any applicable statutory or regulatory requirements (including any other records which must be maintained for that item of equipment).

12 13

Organisations ensure that a capital estate is provided for HART that meets the standards set out in the HART estate specification. Organisations ensure their incident commanders are competent in the deployment and management of NHS HART resources at any live incident. In any event that the provider is unable to maintain the four core HART capabilities to the interoperability standards,that provider has robust and timely mechanisms to make a notification to the National Ambulance Resilience Unit (NARU) on-call system. The provider must then also provide notification of the specification default in writing to their lead commissioners. Organisations support the nationally specified system of recording HART activity which will include a local procedure to ensure HART staff update the national system with the required information following each live deployment. Organisations maintain accurate records of their compliance with the national HART response time standards and make them available to their local lead commissioner, external regulators (including both NHS and the Health & Safety Executive) and NHS England (including NARU operating under an NHS England contract). Organisations ensure that the availability of HART capabilities within their operational service area is notified nationally every 12 hours via a nominated national monitoring system coordinated by NARU. Organisations maintain a set of local HART risk assessments which compliment the national HART risk assessments covering specific training venues or activity and pre-identified high risk sites. The provider must also ensure there is a local process / procedure to regulate how HART staff conduct a joint dynamic hazards assessment (JDHA) at any live deployment. Organisations have a robust and timely process to reportany lessons identified following a HART deployment or training activity that may be relevant to the interoperable service to NARU within 12 weeks using a nationally approved lessons database.

Y Y

Organisations have a robust and timely process to report, to NARU and their commissioners, any safety risks related to equipment, training or operational practice which may have an impact on the national interoperability of the HART service as soon as is practicable and no later than 7 days of the risk being identified.

Organisations have a proces to acknowledge and respond appropriately to any national safety notifications issued for HART by NARU within 7 days.

Other NHS funded organisations

Primary care (GP, community pharmacy)

CSUs (business continuity only)

CCGs

NHS England Regional & national

NHS England local teams

Mental healthcare providers

Community services providers

Ambulance service providers

Specialist providers

Clarifying information

Acute healthcare providers

Core standard

Self assessment RAG Red = Not compliant with core standard and not in the EPRR work plan within the next 12 months.

Evidence of assurance

Amber = Not compliant but evidence of progress and in the EPRR work plan for the next 12 months. Action to be taken Green = fully compliant with core standard.

Lead

Timescale

TRUST BOARD IN PUBLIC

Date: 26th January 2016 Agenda Item: 4.3 NHS PLANNING GUIDANCE 2016/17 – 2020/21 Michael Wilson Chief Executive Gillian Francis-Musanu Director of Corporate Affairs

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

N/A

Action Required: Approval ( )

Discussion (√)

Assurance (√)

Purpose of Report: Provide an overview of the new NHS planning requirements for 2016/17 – 2020/21 Summary of key issues As part of the planning process, all NHS organisations are asked to produce two separate but interconnected plans: • A local health and care system ‘Sustainability and Transformation Plan’, which will cover the period October 2016 to March 2021; and • A plan by organisation for 2016/17 which will need to reflect the emerging Sustainability and Transformation Plan. Recommendation: The Board is asked to note the report and the Trusts plans to work in partnership with the health system to deliver the requirements. 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

TRUST BOARD REPORT – 26th January 2016 NHS PLANNING GUIDANCE 2016/17 – 2020/21 1.

Introduction

The leading national health and care bodies in England recently jointly published ‘Delivering the Forward View: NHS Shared Planning Guidance 2016/17 – 2020/21’ which sets out steps to help local organisations deliver a sustainable, transformed health service and improve the quality of care, wellbeing and NHS finances. Backed up by £560 billion of NHS funding, including a new Sustainability and Transformation Fund to support financial balance, the delivery of the Five Year Forward View, and enable new investment in key priorities. As part of the planning process, all NHS organisations are asked to produce two separate but interconnected plans: • A local health and care system ‘Sustainability and Transformation Plan’, which will cover the period October 2016 to March 2021; and • A plan by organisation for 2016/17 which will need to reflect the emerging Sustainability and Transformation Plan.

Local health system Sustainability and Transformation Plans (STPs)

Every health and care system must come together, to create an ambitious local blueprint for accelerating its implementation of the Forward View. STPs will cover the period between October 2016 and March 2021 and will be subject to formal assessment in July 2016 following submission in June 2016. Organisations have the next six months to develop and deliver core access, quality and financial standards while planning properly for the next five years. Planning by individual institutions will increasingly be supplemented with planning by place for local populations. For many years now, the NHS has emphasised organisational separation and autonomy that does not make sense to staff or the patients and communities they serve. Producing a STP is not just about writing a document, nor is it a job that can be outsourced or delegated. Instead it involves five things: • local leaders coming together as a team; • developing a shared vision with the local community, which also involves local government as appropriate; • programming a coherent set of activities to make it happen; • execution against plan; and • learning and adapting. Where collaborative and capable leadership cannot be found, NHS England and NHS Improvement will help secure remedies through more joined-up and effective system oversight. Success in developing the plans will also depend on having an open, engaging, and iterative process that harnesses the energies of clinicians, patients, carers, citizens, and local community partners including the independent and voluntary sectors, and local government through health and wellbeing boards.

As a truly place-based plan, the STPs must cover all areas of CCG and NHS England commissioned activity including: • specialised services, where the planning will be led from the 10 collaborative commissioning hubs; and • primary medical care, from a local CCG perspective, irrespective of delegation arrangements. The STP must also cover better integration with local authority services, including, but not limited to, prevention and social care, reflecting local agreed health and wellbeing strategies. For the first time, the local NHS planning process will have significant central money attached. The STPs will become the single application and approval process for being accepted onto programmes with transformational funding for 2017/18 onwards. This step is intended to reduce bureaucracy and help with the local join-up of multiple national initiatives. The most compelling and credible STPs will secure the earliest additional funding from April 2017 onwards.

Agreeing ‘transformation footprints’

The STP will be the umbrella plan, holding underneath it a number of different specific delivery plans, some of which will necessarily be on different geographical footprints. For example, planning for urgent and emergency care will range across multiple levels: a locality focus for enhanced primary care right through to major trauma centres. The first critical task is for local health and care systems to consider their transformation footprint – the geographic scope of their STP. They must make proposals to regulatory bodies by Friday 29 January 2016, for national agreement. Local authorities should be engaged with these proposals. Taken together, all the transformation footprints must form a complete national map. The scale of the planning task may point to larger rather than smaller footprints. Transformation footprints should be locally defined, based on natural communities, existing working relationships, patient flows and take account of the scale needed to deliver the services, transformation and public health programmes required, and how it best fits with other footprints such as local digital roadmaps and learning disability units of planning. In future years regulatory bodies will be open to simplifying some of these arrangements. Where geographies are already involved in the Success Regime, or devolution bids, the expectation is that these determine the transformation footprint. Although it is important to get this right, there is no single right answer. The footprints may well adapt over time. The focus of energies should be on the content of plans rather than have lengthy debates about boundaries.

National ‘must dos’ for 2016/17

Whilst developing long-term plans for 2020/21, the NHS also has a clear set of plans and priorities for 2016/17 that reflect the Mandate to the NHS and the next steps on Forward View implementation. Some of the most important requirements for 2016/17 involve partial roll-out rather than full national coverage.

The ambition is that by March 2017, 25 percent of the population will have access to acute hospital services that comply with four priority clinical standards on every day of the week, and 20 percent of the population will have enhanced access to primary care. There are three distinct challenges under the banner of seven day services: â&#x20AC;˘ reducing excess deaths by increasing the level of consultant cover and diagnostic services available in hospitals at weekends. During 16/17, a quarter of the country must be offering four of the ten standards, rising to half of the country by 2018 and complete coverage by 2020; â&#x20AC;˘ improving access to out of hours care by achieving better integration and redesign of 111, minor injuries units, urgent care centres and GP out of hours services to enhance the patient offer and flows into hospital; and â&#x20AC;˘ improving access to primary care at weekends and evenings where patients need it by increasing the capacity and resilience of primary care over the next few years. Where relevant, local systems need to reflect this in their 2016/17 Operational Plans, and all areas will need to set out their ambitions for seven day services as part of their STPs.

The Nine must dos for 2016/17 for every local system

5.1 Develop a high quality and agreed STP, and subsequently achieve what we determine are our most locally critical milestones for accelerating progress in 2016/17 towards achieving the triple aim as set out in the Forward View. 5.2 Return the system to aggregate financial balance. This includes secondary care providers delivering efficiency savings through actively engaging with the Lord Carter provider productivity work programme and complying with the maximum total agency spend and hourly rates set out by NHS Improvement. CCGs will additionally be expected to deliver savings by tackling unwarranted variation in demand through implementing the RightCare programme in every locality. 5.3 Develop and implement a local plan to address the sustainability and quality of general practice, including workforce and workload issues. 5.4 Get back on track with access standards for A&E and ambulance waits, ensuring more than 95 percent of patients wait no more than four hours in A&E, and that all ambulance trusts respond to 75 percent of Category A calls within eight minutes; including through making progress in implementing the urgent and emergency care review and associated ambulance standard pilots. 5.5 Improvement against and maintenance of the NHS Constitution standards that more than 92 percent of patients on non-emergency pathways wait no more than 18 weeks from referral to treatment, including offering patient choice. 5.6 Deliver the NHS Constitution 62 day cancer waiting standard, including by securing adequate diagnostic capacity; continue to deliver the constitutional two week and 31 day cancer standards and make progress in improving one-year survival rates by delivering a year-on-year improvement in the proportion of cancers diagnosed at stage one and stage two; and reducing the proportion of cancers diagnosed following an emergency admission. 5.7 Achieve and maintain the two new mental health access standards: more than 50 percent of people experiencing a first episode of psychosis will commence treatment with a NICE approved care package within two weeks of referral; 75 percent of people with common mental health conditions referred to the Improved Access to Psychological Therapies (IAPT) programme will be treated within six weeks of referral, with 95 percent

treated within 18 weeks. Continue to meet a dementia diagnosis rate of at least two-thirds of the estimated number of people with dementia. 5.8 Deliver actions set out in local plans to transform care for people with learning disabilities, including implementing enhanced community provision, reducing inpatient capacity, and rolling out care and treatment reviews in line with published policy. 5.9 Develop and implement an affordable plan to make improvements in quality particularly for organisations in special measures. In addition, providers are required to participate in the annual publication of avoidable mortality rates by individual trusts.

Operational Plans for 2016/17

An early task for local system leaders is to run a shared and open-book operational planning process for 2016/17. This will cover activity, capacity, finance and 2016/17 deliverables from the emerging STP. By April 2016, commissioner and provider plans for 2016/17 will need to be agreed by NHS England and NHS Improvement, based on local contracts that must be signed by March 2016. The detailed requirements for commissioner and provider plans are set out in the technical guidance. All plans will need to demonstrate: • how they intend to reconcile finance with activity (and where a deficit exists, set out clear plans to return to balance); • their planned contribution to the efficiency savings; • their plans to deliver the key must-dos; • how quality and safety will be maintained and improved for patients; • how risks across the local health economy plans have been jointly identified and mitigated through an agreed contingency plan; and • how they link with and support with local emerging STPs. The 2016/17 Operational Plan should be regarded as year one of the five year STP, and we expect significant progress on transformation through the 2016/17 Operational Plan. Building credible plans for 2016/17 will rely on a clear understanding of demand and capacity, alignment between commissioners and providers, and the skills to plan effectively. A support programme is being developed jointly by national partners to help local health economies in preparing robust activity plans for 2016/17 and beyond.

Our approach to the requirements in the planning guidance

The Trust has already begun working with our partners across the health system and plans are being put in place for organisations to come together to input, develop and agree a clear process for development and agreement of the STP. CCGs and NHS England are providing guidance on the geographical footprint which will be based on the commissioning intentions and landscape and SaSH will have an important role in agreeing this footprint.

Timetable

A full copy of the planning guidance can be found at https://www.england.nhs.uk/wp-content/uploads/2015/12/planning-guid-16-17-20-21.pdf

Recommendation

The Board is asked to note the requirements for the NHS Planning Guidance for 2016/17 and beyond and the plans in place to deliver these requirements.

Michael Wilson Chief Executive 26th January 2016

TRUST BOARD IN PUBLIC

Date: 26TH January 2016 Agenda Item: 4.4

REPORT TITLE:

NHS England Major Incident Assurance Return Angela Stevenson Chief Operating Officer Jamie Hogg Emergency Resilience Planning Manager

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

Executive Committee

Action Required: Approval (√)

Discussion

Assurance (√)

Purpose of Report: NHS England is seeking assurance of Trusts preparedness in relation to a specific set of questions concerning preparedness for a major incident. Summary of key issues Executive Summary: The attached document addresses the questions raised with the overall position being that the Trust has adequately prepared to respond and recover to a major incident. Recommendation: Agree the assurance provided against the criteria set in the NHS England assurance return. 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

Legal and regulatory requirements

Financial impact

Non-compliance could incur financial penalties

Patient Experience/Engagement

Compliant

Risk & Performance Management

Compliant

NHS Constitution/Equality & Diversity/Communication

Compliant

Attachment: NHS England MI Assurance Return

2 An Associated University Hospital of Brighton and Sussex Medical School

NHS England Assurance Return Trust Name: Surrey & Sussex NHS Healthcare Trust EPRR Accountable Executive officer: COO Angela Stevenson EPRR Lead: Hazel Gleed Date: 23.12.2015 Part 1: Assurance

Statement of assurance

You have reviewed and tested your internal cascade systems to ensure that you can activate support from all staff groups, including doctors in training posts, in a timely manner including in the event of a loss the primary communications system;

•

A test of the emergency cascade was conducted by switchboard on Friday the th 11 December 2015, it is reported that an adequate number of consultants and doctors responding. New equipment is in place to enable a relocation of the switchboard in the event of a loss of premises. If primary communications are lost, radios are available to the enable co-ordination across the Trust. Clinical areas have reviewed their staff contact lists to ensure these are both complete and current.

You have arrangements in place to ensure that staff can still gain access to sites in circumstances where there may be disruption to the transport infrastructure, including public transport where appropriate, in an emergency;

•

The Trust has arrangements within the Adverse Weather which could be used in part to support transport of staff.

•

The trust is a prioritised user of a local taxi company with agreement to release taxis for any identified need ahead of other customers.

•

A large number of staff do utilise public transport to travel to the site any disruption would have an impact on normal travel arrangements. Plans to help manage this eventuality are being developed.

Plans are in place to significantly increase critical care capacity and capability over a protracted period of time in response to an incident, including where patients may need to be supported for a period of time prior to transfer for definitive care;

â&#x20AC;˘

The MI plan allows for us to upgrade some of our beds temporarily whilst waiting to transfer out. However in the event of the system being overwhelmed, our Pandemic flu plan has a graded response from using all our Level 2 & 3 beds for Level 3 patients to expanding into the theatre suite using Recovery and theatres if we are unable to transfer out.

The Trust has given due consideration as to how specialist advice can be gained in relation to the management of a significant number of patients with traumatic blast and ballistic injuries.

â&#x20AC;˘

There is a network of experienced clinical staff that has this specialist advice and can be contacted if needed. Arrangements for a seminar are being made to deliver training/briefing to key staff. The target to deliver this is by the end of April 2016.

Date of public Board meeting to present statement of readiness:

28th January 2016

TRUST BOARD IN PUBLIC

Date: 28 January 2016 Agenda Item: 4.5

REPORT TITLE:

Annual plan 2015/16 update Sue Jenkins Director of Strategy Sue Jenkins Director of Strategy

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

Executive Committee

Action Required: Approval

Discussion

Assurance (√)

Purpose of Report: The purpose of this report is to provide assurance to the Board that the annual operating plan for 2015/16 has been delivered Summary of key issues The annual plan for 2015/16 was approved by the Board in April 2015. The original annual plan included progress against 107 actions. For quarter 3 this has now reduced to 106 actions. The one that has been deleted is 2.17 which relates to enhanced recovery pathways for breast and C-sections. This work was being led by the AHSN who have decided not to progress this work during 15/16. This will be reviewed for inclusion in the 16/17 plan. Of the 106 actions the status for the quarter is reported as follows:Status Q1 – April Q2 – July to Q3 – October to June September to December 2015 2015 2015 Red 1 <1% 4 4% 2 <2% Amber 27 25% 29 27% 26 25% Green 75 70% 70 65% 66 62% Blue 4 4% 4 4% 12 11%

This quarter’s performance has generally improved and moved in a positive direction. 11% of the actions have already been completed and 73% are being delivered according to plan or have been completed which is on track for a Q3 position. There are two actions with a red status. These are;  1.15 – Healthcare acquired infection. 31 cases have now been reported against a target of 15. This target reduced from 24 cases last year. The target of 15 relates to those cases which are deemed a lapse of care by both the Trust and CCG. So far 2 cases have been deemed a lapse of care but there are a number of cases which are still to be reviewed in partnership to agree their final status. The

management of diarrhoea has been identified as a value stream for VMI work to better understand the detail and areas for improvement around this.  2.2 – Manage non elective demand. An AMU consultant has started and is developing plans to increase ambulatory capability. Escalation processes to respond to increases in demand include and elective winter plan, plans for the opening of an integrated reablement unit and a length of stay group

Recommendation: The Board are asked to confirm that this report provides assurance that the annual plan 2015/16 is being delivered 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 Financial impact Patient Experience/Engagement

Risk & Performance Management NHS Constitution/Equality & Diversity/Communication

The annual plan demonstrates delivery of key actions to support the strategic objectives Business cases will be developed for any significant resource developments. The annual plan includes a number of objectives linking to patient experience and engagement Delivery of the annual plan is monitored by the executive Committee and reported to the Trust Board The annual plan demonstrates delivery of the organisations strategic objectives

Attachment: Annual plan 2015/16 Q3 update

2 An Associated University Hospital of Brighton and Sussex Medical School

Annual plan 2015/16 v1.4 - Q3 update Work stream off track and unlikely to deliver as described

Work stream off-track but plans in place to recover

SO1 - Safe - Deliver safe services and be in the top 20% against peers New Action Ref Source or bf

Lead director

Lead manager/clinician

1.1 NEW Strategic objectives delivery plan

Complete deep dive process for all relevant specialties

Sue Jenkins

1.2 NEW Strategic objectives delivery plan

Maintain a CQC inspection rating of good or outstanding

Fiona Allsop

1.3 NEW Strategic objectives delivery plan

Demonstrate improved learning from incidents across the Trust

Fiona Allsop/ Des Holden

Katharine Horner

1.4 NEW Strategic objectives delivery plan

Actively participate in national Patient Safety Collaborative in Kent, Surrey and Sussex area

Des Holden

1.5 NEW Strategic objectives delivery plan

Implement achievement review and include safety goals for all staff Mark Preston

Janet Miller

1.6 NEW Quality account

Evidence compliance with Sign up to Safety

Kim Rayment

1.7

Clinical strategy Divisional plans

1.8

Clinical strategy Divisional plans

Fiona Allsop

Maintain the low incidence of surgical site infections

Meet all access targets including ED, 2 weeks referral, 31 days and Angela Stevenson 62 days

Des Holden

Work stream on track and to plan

Barbara Bray

Ben Emly

Q3 Update Series of deep dives planned for all specialties from January to April 2016 Good rating still in place Included on divisional board agendas Medicine, Cancer and WaCH are now producing regular newsletters that highlight learning from incidents and complaints. Reporters of incidents now have the facility to request automatic feedback from incidents. An e-mail is generated from Datixweb outlining the action taken by the reviewing manager. This went live 21/9/15 and will be monitored over the coming months. In medicine division, comms folders, safety briefings and lessons learned are shared across teams Fully signed up. Leads for emergency laporotomy and sepsis identified. Attended all relevant events Achievement Review compliance is at 74%. New risk 1740 added to the Trust risk register recognising the impact of embedding the Trust values and behaviours and the ability to pilot the '9 blocker' for 8As and above. Communication on 2nd year to commence January 2016 The strategic project meetings have taken place as scheduled. Q3 report submitted to Patient Safety Committee and Executive Committee for Quality and Risk meetings in January 2016 as planned. SSIs are discussed monthly at Divisional Board. Every orthopaedic infection has an RCA that is reported to Divisional Board. Woodland elective beds are not consistently ring-fenced. ED Oct 95.5% Nov 92.9% Dec 95.5% Q3 94.6% 2 week rule Oct 90% Nov 93.3% Dec 94.3% 31 days Oct 98.2% Nov 96.6% Dec 92.4% 62 days Oct 85.6% Nov 88.3% Dec 85.8%

Complete

RAG status G G

1.9 NEW Quality account

1.10

Clinical strategy Divisional plans

1.11 NEW Quality Account

1.12

1.13

Quality Account Quality strategy

Deliver CQUIN plans for 2015/16:Local - Discharge to Assess (Sue Jenkins) Local - Improving Discharge (Angela Stevenson) Local - Enhanced Quality (Jonathan Parr) Local - Ward accreditation (Fiona Allsop) National - Acute Kidney Injury (Phil Williams) National - Sepsis (Julian Webb) National - Dementia and delirium (Steve Adams) National - Avoid emergency admissions Angela Stevenson) National - Improving diagnosis of mental health patients in ED (Julian Webb)

Des Holden

Jonathan Parr

Monitor compliance with national midwifery staffing guidance

Fiona Allsop

Michelle Cudjoe

Explore opportunities of improving the safety journey by learning from international best practice i.e. Virginia Mason

Des Holden

Sue Jenkins

Avoidable falls/ falls resulting in Demonstrate further improvement harm in number of falls

Pressure damage

Maintain achievement of no hospital acquired major pressure damage and aim to reduce hospital acquired minor damage

Fiona Allsop

Francis Fernando

Louise Evans

ERP performance much improved and meeting targets for 2/3 pathways. COPD pathway having data collection issues, but data completeness now rising. Plans have had to be put in pace to cover Demetia Specialist Nurse who is leaving the Trust in Janaury to ensure delivery of programme whilst post vacant. Some risks around Sepsis which is not yet reaching the required 90% target for screening and antibiotic administration.

Staffing requirements to achieve Maternity Ratios added to WACH Business Plan Currently recruiting to senior midwife post and expected to have in post by April 2016 Part 2 of Advanced Lean Training completed in November and both candidates were succesful Trust Guiding team completed trip to Seattle in October 2015 Executive sponsors agreed for 3 value streams Cardiology inpatient flow, outpatients and management of diarrhoea Value stream sponsorship team recruited for Cardiology Improvement workshop agreeing current state value stream map and future state value stream map completed for Cardiology in December 2015 The number of falls in Q3 fell by 8% compared to Q2. Although the percentage of falls with harm increased in Q3, from 28% to 31%. But this only equates to an increase of 2 falls with harm compared with Q2. Low harms constituted 92% of all the falls with harm in Q3. The remaining 8% of all the harms in Q3 were severe and one death. This death is being investigated at present. Falls care bundle being reviewed at present to reflect the results of the 1st National In-patient Falls Audit and to comply with the NICE CG 161 (2015). Annual falls data (JanuaryDecember 2015) showed a 50% reduction in moderate harms, 35% reduction in severe harms and a 22% reduction in Serious Incidents compared to the same period in 2014. Year to date we have had 35 minor pressure damage incidents against a target of 40. Despite some of these being unavoidable incidents we are unlikely to meet our target this year. We still are on track to have no avoidable major pressure damage.

1.14

1.15

NEW 1.16

Quality Account Quality Strategy

Dementia

Healthcare acquired infection

Venous thromboembolism (VTE)

1.17

1.18

1.19

Quality Account Quality strategy

Quality Account Quality strategy Clinical strategy Divisional plans

Quality Account Quality strategy

World Health Organisation (WHO) safer surgery checklist

Fractured neck of femur (hip)

Patients admitted with stroke

Develop community facing approach to dementia care

Meet the DH central infection control targets of <15 Cdiff cases and no preventable MRSA blood stream infections Continue to screen patients for MRSA and administer MRSA suppression treatment in a timely way

Fiona Allsop

Steve Adams

31 cases against a target of 15 which the CCG jusge as a lapse of care. Currently only 2 have been confirmed as a lapse of care by CCG and most are awaiting review Des Holden

Ashley Flores

Continue risk assessment on > 95% of patients on admission

Des Holden

Maintain and further improve timely admission and operative Des Holden intervention Improve length of stay for #NOF Improve follow up data collection To improve SSNAP audit Des Holden performance to at least a B rating Further improve scanning time

Des Holden

Barbara Bray

Ben Mearns Ben Mearns

Improve use of safety information at divisional meetings 1.20

Quality Account Quality Strategy

Incident reporting

Increase number of audits that impact on patient safety

Fiona Allsop

Katharine Horner Jonathan Parr DCNs

Make patient safety data more transparent for staff and patients

1.21

CQC improvement plan

Deliver outpatients improvement plan

1 MRSA has been reported in a baby A

Improve completion of assessment Des Holden on discharge

Continue to audit quality of safer surgery processes

Work is progressing as described previously. The "comfort blankets pilot scheme is being managed by Pamela Trangmar Physicians Associate, `who has been instrumental in trying to establish the project and seeking engagement with community services. Dementia lead nurse is leaving the Trust at the end of January. Successor has been appointed who will commence in April. Handover plans are in place in the interim.

Angela Stevenson

Natasha Hare Linda Judge

VTE group established. VTE nurse appointment increased from temporary part time to substantive full time Q2 was met and Q3 is currently being validated Theatre continuously audit the performance of the WHO checklist and review the results at the Theatre Management Group. Performance remains good. The WHO checklist is one of the National Safety Standards for Invasive Procedure(NatSSIPs) and the Division of Surgery has a working group to review and update all their safety processes to ensure they are consistent with the national standards. The progress of this is monitored through the Division and reported to the NatSSIP steering group. Progressing well against time to theatre. 4 hour standard to ward is not as good although sometimes this is because patients go directly to theatre from ED Currently a band C and action plan being progressed CT in ED being progressed which will seek to improve position Dashboard used live in the Patient Safety subcommittee in September. Dashboard is still being developed and refined. Progress made in registration of audit projects and assessing impact of audit on patient safety. Update presented to SQC in November. Patient safety dashboard show compliance with metrics at service level for staff. New Governance agreed and implemented, including a weekly operational meeting (Delivery Group)and a monthly strategic group (OP Board); ToR approved December 2015. Medical Director confirmed as VMI executive sponsor.

G G

A A A A G

G G

1.22

CQC improvement plan

Deliver medical records improvement plan

Ian Mackenzie

1.23

CQC improvement plan

Deliver Dictate IT improvement plan

Jim Davey

1.24

Quality Account

1.25 NEW Quality Account

1.26 NEW Quality Account

Improve communications and information around medication on discharge

Safety thermometer

Maintain compliance of 95% and increase average compliance to 97% from January to March 2016

Continue to maintain high standards of cleanliness and to ensure patients are not disturbed unnecessarily

SO2 - Effective: Deliver effective and sustainable clinical services within the local health economy New Action Ref Source or bf IBP service development Develop second cardiac angiography suite 2.1 BF Estate strategy

Angela Stevenson

Fiona Allsop

Phil Stone

Completed Q1 - Plan delivered and savings realised

David Heller

Vicky Daley

Fiona Allsop

Vicky Daley

Lead Director

Lead Manager/clinician

Angela Stevenson

2.2

IBP service development Strategic objectives delivery plan

Manage non elective care

2.3

Strategic objectives delivery plan

Continue participation in wider health system transformation forums Sue Jenkins to influence development of new models of care

Develop plans to support re-procurement of EPR and EPMA

Ian Mackenzie

2.4 NEW Strategic objectives delivery plan

Angela Stevenson

2.5

Clinical strategy Divisional plans

Redesign the stroke pathway to create a seamless in and out of hospital patient centred pathway across all providers

Des Holden

Ben Mearns

2.6

Clinical strategy Divisional plans

Redesign the pathways in elderly medicine to create seamless Des Holden patient care across all providers including early supported discharge

Ben Mearns

2.7

Clinical strategy Divisional plans

Redesign service to create HDU respiratory beds

Des Holden

Virach Phongsathorn

Clinical strategy Divisional plans

Redesign of service to ensure that the birthing unit provides intrapartum and postnatal care for 20% of women booked for maternity services at East Surrey hospital

Des Holden

Debbie Pullen Michelle Cudjoe

2.8

Work starts on site in January 2016

Cerner e-discharge letter pilot now to commence in Feb 2016 EpMA project business case to be included in roll out of acceleration of EPR work MaPPs leaflets still in use and continued reinforcment of their importance is maintained with staff The Safety Thermometer continues to be monitored and discussed at the Patient Safety and Clinical Risk sub-committee. 95% compliance for harm free care (new harm) for November 2015. Medicines Safety Thermometer piloted in 6 wards in November 2015. As per the previous quarter, infection control remains as a standing item at the PSCRC and the NMPC. In addition, the Infection Control Tasforce meeting continues on a weekly basis to discuss operational and strategic issues pertinant to improving and maintaining standards of cleanliness. Formal CCG cdi review meetings continue. Since the last update, a CCG Clostridium Difficile Lapse in Care Assessment tool has been agreed, inclusive of a RAG rating criteria to determine the application of sanctions. Noise at night remains on the inpatient survery action plan, which is monitored via the Patient Experience sub-committee.

Q3 Update Build complete and unit fully operational AMU consultant started and developing plans to increase ambulatory capability Escalation process includes elective winter plan, plans for integrated reablement unit, LOS group AMU consultant to support ED in key times Summit planned with CCGs Completed Q1 - Procurement was completed in October 2014 Continuing to work with Surrey and Stroke networks to develop whole system pathway for stroke

G B

RAG status B

G B G

Further developing the frailty pathway A Completed Q1 - High dependency respiratory bay developed on Tilgate Annexe and now operational

Utilisation of BU continues to be in excess of 20% per month

2.9

Clinical strategy Divisional plans

To consider recommendations from the strategic review of radiology services undertaken in autumn 2013 and agree and implement Des Holden action plan

Ed Cetti Mo Luqman

Actions being followed up in Radiology at the 'Seniors team meeting' as standard agenda item. Group meets every 2 weeks to progress action plan.

2.10

Clinical strategy Divisional plans Estate strategy

Redesign of service to support the installation of a digital mammography machine on the ESH site

Angela Stevenson

Ed Cetti Mo Luqman

FBC Approved in Dec. Build started with completion expected Mid Feb 16

Clinical strategy Divisional plans

Implement a managed equipment service which is supported by a rolling equipment replacement schedule

Des Holden

Ed Cetti Mo Luqman

OBC approved by TDA late Dec 15. Progressing works to FBC following feedback from TDA on OBC. Still working to implementation date of April 16

2.11

2.12

Quality Account Quality strategy

Mortality

Focus on categories of death rather than individual and make recommendations via clinical effectiveness committee to make improvements Roll out enhanced review of all patient deaths

Mortality Group continue to meet and reports being received by specialties on learning. Group has also recommended specific work to be done around NIV and impact of winter pressures Des Holden

Quality Account Quality strategy

2.14

Quality Account Quality strategy

Readmissions

(NICE) technology appraisals

Undertake review of one month’s clinical readmission data and implement any lessons learned Increase statement compliance. Audit against NICE technology appraisals and post on audit intranet

Latest report reports Trust no longer 'better than expected' in latest 12 month rolling report (Oct 2014 Sep 2015) Completed in Q3 Jim Davey

Quality Account Quality strategy

Reducing need for admission

Maintain core hospital at home beds all year

Des Holden

7 day working SDIP

2.17 NEW Quality account

2.18 NEW Quality account

Implement 7 day working for all relevant specialties Enhanced recovery

Enhanced quality

Commence enhanced recovery pathways for breast and Csections

Angela Stevenson

3.1

Strategic objectives delivery plan

Demonstrate that audit plans include issues raised by YCM, FFT and inpatient survey

Jonathan Parr

Paula Tooms Jim Davey

Sue Jenkins

Des Holden

Jonathan Parr

A LOS action plans being developed as part of business planning process

Capacity increased in line with plan

Black escalation summit to take place in New Year Growth being considered as part of SRG plans

Audit results received

The AHSN has decided to no longer lead a project for both pathways for 15/16 N/A

Commence new enhanced quality pathways for COPD, fractured Des Holden neck of femur and emergency laparotomy

SO3 - Caring - Ensure patients feel cared for and cared about New Action Ref Source or bf

Chiefs

Review pathways to develop alternatives to admission 2.16

No further progress with other audits identified.

Reduce LOS 2.15

Jonathan Parr

Maintain “better than expected” rating for mortality by Dr Foster 2.13

Jonathan Parr

Lead Director

Lead Manager/clinician

Des Holden

Jonathan Parr

Trust represented at #NoF meetings and data collectionnow underway. Emergency Laparotomy regional meetieng attended by Trust leads. COPD reporting slightly behind schedule due to coding issues, but plan in place to get data back up to date and achieve minimum data completeness Q3 Update Progress made in registration of audit projects and assessing impact of audit on patient safety. Update presented to SQC in November.

RAG status G

3.2

Strategic objectives delivery plan Nursing & Midwifery strategy

3.3 NEW Strategic objectives delivery plan

3.4 NEW

Strategic objectives delivery plan Nursing & Midwifery strategy

3.5

Clinical strategy Divisional plans

3.6

Quality Account Quality strategy

Demonstrate delivery of â&#x20AC;&#x153;Provide safe and effective care in all that we doâ&#x20AC;? objective from nursing and midwifery strategy at safety and quality committee

Establish and undertake a programme of patient listening events

Fiona Allsop

Demonstrate that nursing review and assessment reflects individual Fiona Allsop needs of patients Work with Olive Tree, Friends of east Surrey and Macmillan Cancer Support to develop and implement a Cancer Information and Angela Stevenson Support Centre at East Surrey Hospital Continue to ensure there are no Angela Stevenson mixed sex breaches Right bed, right time

Share and implement learning from Breaking the Cycle

Angela Stevenson

Vicky Daley DCNs

Cathy White

DCNs

Jane Penny -

Participate in 5th National Audit of Care of the Dying patient 3.7 NEW

Quality Account Quality strategy

End of life care

Complete internal audit of end of life care documentation

Fiona Allsop

Jane Penny

Develop and introduce second version of SaSH end of life care plan 3.8 NEW Estates strategy

Review and develop scheme to modernise East Entrance environment and facilities including additional retail outlets.

Maintaining safe levels of nursing care is an ongoing key focus. Safe and effective care is of a better standard when provided by permanent members of staff that are experienced in the speciality of the ward/department and familiar with the Trust's policies and procedures. In line with the the TDA/Monitor requirements to reduce agency spend and keep hourly rates below a cap, the organisation continues on a significant programme or recruitment both locally and overseas. Their induction and development is supported by the PD team and 2 Clinical Support Nurses appointed in Q3 2015/16. In addition, the Trust has been awarded funding by HEKSS to recruit a Band 7 Practice Development Nurse for Career Development and a Band 6 Clinical Support Nurse for Elderly Care with a view to developing and retaining our existing experienced nursing workforce. The band 7 post holder commences on the 22nd February, with the band 6 post still to be filled. Focus groups have been undertaken among endoscopy patients. Carers discussions took place in October 2015 and a maternity listening event was completed in November Nursing documentation review still to be progressed Centre opened and launch to take place in January 2016 No mixed sex breaches for Q3 Monthly breaking the cycles have been in place throughout winter. Last ones planned the first week of January and February The Trust participated in the audit, we have submitted organisational data and reviewed 80 sets of notes and still awaiting the results. Audit completed and submitted to the audit department , presented to cancer division October 15 Second version of Care Plan developed and in use on the wards. To be reviewed later in 2016.

Ian Mackenzie

Shaun Cunningham

Completed in Q3

B G

3.9 NEW Quality Account

3.10

Quality Account

3.11 NEW Quality Account

Implement oral healthcare initiative and demonstrate improvement of patient and clinical care

Nutrition

Patient feedback

Des Holden

Mili Doshi

Continue to make improvements to Fiona Allsop protected meal times

Vicky Daley

Seek ways to broaden how we get Fiona Allsop feedback from wider community

Vicky Daley Cathy White

Continue to promote FFT and YCM and make changes on basis of Fiona Allsop feedback

SO4 - Responsive - Become the secondary care provider of choice for our catchment population New Action Ref Source or bf Develop programme of engagement activities with patients and 4.1 NEW Strategic objectives delivery plan members

Vicky Daley Cathy White

Lead director

Lead manager/clinician

Gillian FrancisMusanu

Laura Warren

4.2

IBP service development

Chemotherapy service development

Anglea Stevenson

Jane Penny

4.3

Strategic objectives delivery plan Membership strategy

Establish CoG and demonstrate meaningful engagement which shapes our services

Gillian FrancisMusanu

Laura Warren Colin Pink

4.4

Clinical strategy Divisional plans Estate strategy

Complete refurbishment of and open theatres

Angela Stevenson

Bill Kilvington Barbara Bray

Market Development strategy

To maintain market share through excellent service provision and securing AQP contracts where CCGs have given notice on the service that was previously part of the acute contract

4.5

Paul Simpson

Larisa Wallis

MCM team have completed phase 1 ( training all wards in ES) . There have been improvement in the mouth care of patients but only 31% have a fully completed mouth care form. The team are developing new incentives to engage staff but there is a need for senior nursing support. We will be managing the roll out of MCM initially across 11 sites in KSS. A work shop is being held on 27.1.16 and we have a representative form each trust. Protected mealtimes remains as a regular item at the Oral Nutrition and Hydration Group. Spot checks continue to be taken on ward areas to determine levels of compliance.Results are variable in some areas.Discussion around improving protected mealtimes. Revised Oral Nutrion and Hydration Policy ratified and uploaded in January 2016. Policy includes a section on protected mealtimes and the new MUST tool which has been widely communicated to clinical staff. The Patient Experience Sub-Committee meets on a monthly basis, and there are standing items on the agenda on FFT and YCM. A series of hot topic events provide an opportunity for attendees to give feedback and seek clarification on relevant service areeas. An option also exists for patients and the public to feedback direct on our website. Q3 Update Plan greed and in place. Currently paused awaiting discussion with Macmillan as their structure has changed and there is increased pressure on their finances. Macmillan Head of Service Development for South and Eastern England visit planned for April 17. The first meeting of theShadow Council of Governors has been held and terms of reference agreed. Membership enegagement group plans developed to meet early q4 The completion of the final stage which is the theatre reception area is due to commence on 18 January 2016 and be finished by 8 February 2016 Trust applied for AQP for Non-Invasive Ventilation and AQP for Non-Obstetric Ultrasound Service (NOUS) and currently awaits the outcome of the qualification process on both AQPs.

RAG status G

4.6

4.7

4.8

Market Development strategy

To expand market share for elective activity targeted market that have traditionally referred patients to other providers

Paul Simpson

Market Development strategy

To expand market share for elective activity by working with CCGs and other providers to repatriate elective activity from distant tertiary Paul Simpson providers where this is clinically appropriate

Market Development strategy

To explore opportunities for further joint ventures/partnership arrangements to continue to develop the East Surrey Hospital campus so that local patients can receive an increasing range of specialist services at ESH whether provided by SASH or a partner organisation

Paul Simpson

Larisa Wallis

4.9

Market Development strategy

To move to new markets, such as private practice, where this is clinically and financially viable and supports the long term strategic intentions of the Trust

Paul Simpson

Larisa Wallis

4.10

QGAF

Deliver QGAF action plan

Des Holden/ Fiona Allsop

Colin Pink

SO5 â&#x20AC;&#x201C; Well led â&#x20AC;&#x201C; Become an employer of choice and deliver financial and clinical sustainability around a clinical leadership model New Action Ref Source Lead director or bf

5.1

Strategic objectives delivery plan

Demonstrate increase in market share due to repatriation of services

Paul Simpson

Lead manager/clinician

Larisa Wallis

Plans for additional elective activity have been compromised by high levels of non elective activity and 18 weeks backlog. The numbers of elective patients seen this year are higher than last year. Integrated Reablement Unit (IRU) has been built and opened on 21st Jan-16 as a result of tripartite partnership of Surrey County Council, East Surrey CCG and SASH. The aim of the unit is to provide step-down / rehab beds for those patients who no longer need acute care but who cannot be discharged due to the delays in social care packages. Second Cardiology Angio Suite will be opening in February which will enable the Trust to repartriate some NHS activity and to expand Cardiology private patient activity which are currently send away to other NHS and private providers. The project plan is being worked up for the start in April 2016. BSUH/SaSH joint venture for pathology services progressing. New name agreed as Frontier. Final business case to be considered by both Boards later this year New Cardiology Angio lab went live on 28th Sept-15 but income from additional activity was compromised by waiting list activity which was the first priority to clear. Second Cardiology Angio Suite will be opening in February which will enable the Trust to repartriate some NHS activity and to expand Cardiology private patient activity which are currently send away to other NHS and private providers. The project plan is being worked up for the start in April 2016. Delivery of specific elements of QGAF proceeding as planned, outstanding elments focus on delivery of data quality stratgey Q3 Update Market Share Report for 6 months of 2015-16 is being prepared and shared with Divisions and Finance & Workforce Committee to show the trends and shifts in Trust's market share for elective, emergency and outpatient activity.

RAG status

5.2

Strategic objectives delivery plan

5.3 NEW Strategic objectives delivery plan

5.4 NEW

Strategic objectives delivery plan IBP service development

5.5 NEW Strategic objectives delivery plan

Develop nurse recruitment plan, monitor delivery and report to workforce committee

Fiona Allsop

Sue Carr DCNs

Develop and implement SLM model with clinical leads

Paul Simpson

Catriona Tait

Develop plans for new outpatient facilities

Sue Jenkins

Natasha Hare

Establish multisource feedback system for all staff

Mark Preston

Sarah Wood

5.6

Strategic objectives delivery plan

Complete delivery of SaSH plus GE clinical leadership programme

Des Holden

Colin Pink

5.7

Strategic objectives delivery plan

Complete delivery of Foresight board development programme

Gillian FrancisMusanu

5.8 NEW Strategic objectives delivery plan

Governance processes adapted to support clinical leadership model Gillian Francis and remain effective Musanu

Colin Pink

5.9 NEW Membership strategy

Establish and deliver engagement and communications strategy for Gillian Francis members following FT authorisation Musanu

Laura Warren

Membership strategy IBP

Hold election for Council of Governors

Gillian Francis Musanu

Laura Warren

Complete induction for CoG

Gillian Francis Musanu

Establish CoG meetings and effective engagement and communications strategy

Gillian Francis Musanu

Laura Warren

31 European nurses arrived between October and December 2015. 26 now have their NMC PIN number 18 nurses on the overseas nursing programme have received their NMC PIN number European recruitment continuing with Skype interviews booked for January 2016. Trust has engaged a second recruitment partner in order to improve fulfilment. First of Phillipino nurses arriving on 15 January. Succesful Bank recruitment for nursing assistants continues with a proportion of applicants who are student nurses from across the region and students on the access to nursing course from East Surrey College. The final handover meeting with GE took place and the Chief Operating Officer is developing a proposal for taking SLM forward within the organisation. Business case due in Q4 following completion of demand and capacity exercise Agreed additional questions added to SF&FT in Q 4. These are: How strongly do you agree or disagree with the following statements: 1. There are clear expectations of how staff should behave whilst working in the Trust 2. I've observed staff quickly answering a ringing telephone and pro-actively helping the caller Five point scale: Strongly agree to strongly disagree, plus ‘don’t know’ option Review of effectiveness to be undertaken with a view to tailoring questions each quarter to develop a multi source feedback system for staff. Culture champion network maturing, Trust wide 'Standards of Behaviour' developed and agreed during Q3. Complete Stable governance system in place including strengthened divisional and speciality level reporting. Engagemnt plan agreed at initial Shadow Council of Governors meeting, initial steps taken to implement Election to the shadow Council of Governors complete with all seats filled, Selection of nominated governors 98% complete.

5.11

IT strategy

Upgrade of end-of-life Trust operating systems

Ian Mackenzie

Peter Hodgetts

CoG Induction currently in progress due for completion by end of Q4 Engagement plan agreed at initial Shadow Council of Governors meeting, initial steps taken to implement Completed in Q3

5.12

IT strategy

Provide upgraded email solution

Ian Mackenzie

Peter Hodgetts

Plan being developed for implementation in 2016

5.10 NEW

Council of Governors (CoG)

G B G G G G G B G

5.13

IT strategy

Complete Network Upgrade

Ian Mackenzie

Peter Hodgetts

permission to proceed to business case developed and to be approved in Q4. Aim will be to accelerate the implementation of EPR

5.14

Estate strategy

Deliver estates capital programme

Ian Mackenzie

Shaun Cunningham

Ongoing and on track

Continue to embed the setting of personal goals that effect the quality of service for all staff in annual achievement reviews

Des Holden Mark Preston

Adam Stacey-Clear Janet Miller

Focus in Q3 has been on compliance against targets and audit and analysis will be undertaken in Q4.

5.15 NEW Quality Account

5.16

5.17

Workforce and OD strategy

Launch the Leadership Framework and an effective assurance process for the organisation to assess how each line manager is performing against the key people performance requirements

Mark Preston

Nathaniel Johnston

Workforce and OD strategy

Develop integrated workforce plans (demand and supply) at divisional/ business unit level - identifying workforce changes required for 24/7 working in appropriate areas

Angela Stevenson

Mark Preston

Nathaniel Johnston

5.18

Workforce and OD strategy

Focus on increasing workforce productivity â&#x20AC;˘ realise the benefits of technological business processes across the Trust â&#x20AC;˘ harness productivity gains identified in service developments advances in medical/surgical innovations e.g. telemedicine,

5.19

Workforce and OD strategy

Refocus of induction to support OD intervention around behaviours and values.

Mark Preston

Janet Miller

Work has been on-going to develop a multidisciplinary education strategy which will include embedding the Healthcare Leadership Model (HLM). As part of this work, we will explore how we utilise the HLM into all professional leadership development, and we will look to phase out the medical L.E.A.D.E.R tool that is being used currently by our medical workforce. Next steps in this process include a meeting between Dr Sarah Rafferty, Chief of Education and Nathaniel Johnston, Head of Workforce Development at the end of January 2016, to develop this further and agree an action plan for delivery. Business Planning Guidance includes reference to Workforce Plans. ESR project commenced to validate Establishment for each service area prioritising medical and nursing staff as a starting point. SOPs for agreeing changes with Service/Finance/HRBP. Divisional Workforce Plans to be generated following Business planning seminar in Q4 27/1/16. Divisional Workforce Plans to be generated following Business Planning seminar 27/1/16 Project manager for eroster recruited and implementation has commenced Permission to proceed to business case being developed to support acceleration of EPR programme The Induction Programme has been revised and is being re-launched in April 2016. Changes to the programme include hosting a marketplace in the atrium for staff to meet different departments, (for example Occupational Health and Libraries). The 'Exec Welcome' has been brought forward in the Induction Programme to open the day rather than being held after lunch. Capacity has been created in the Induction Programme for a Values Workshop, which will be an interactive session where new staff will be asked to consider the SaSH values and how they will role model them in their work. The staffs stories will then be collected to help understand what our staff think about our Values.

5.20

5.21

Workforce and OD strategy

5.22 NEW Workforce and OD strategy

5.23 NEW Workforce and OD strategy

Have in place a range of interventions to reduce the top reasons for absence such as workplace stress musculoskeletal disorders Mark Preston (MSD), flu.

Create the SaSH identity and brand so that we are recognised as the â&#x20AC;&#x2DC;Employer of Choiceâ&#x20AC;&#x2122;

Ensure access to a range of leadership programmes, to cover the range of levels and focused on leading our values and behaviours.

Mark Preston

Develop a Talent Management framework and succession planning tool to help identify potential leaders to fill key positions within the Mark Preston organisation.

Janet Miller

Nathaniel Johnston

Stress related absence reduced although it is still consistent in the top 5 reasons for absence through Q3. Continue with actions introduced. Wellbeing Strategy revision behind schedule but completion by end Q2 (16/17) achievable. Well being Group to focus on arranging Wellbeing Day in Q2 of 16/17. Significant Flu immunisation undertaken during Q3. Following a focus on our brand at recruitment stage, work begins on developing our "brand" as an employer that is passionate about developing and training our workforce. We are currently developing an infographic to showcase our work in education and training to use as part of our marketing and communications materials. Further to this we are working on a multi-professional plan to increase our community engagement by visiting schools and colleges as well as increasing our profile with universities. In addition, we are building the Trusts profile on multi-media sites (eg Facebook / Linked In), in order to help share information with local online networking/community groups In February 2016 we will launch the HEKSS suite of leadership e-learning modules, the Edward Jenner online programme and we continue to promote the regional/national leadership programmes to staff via our communications channels. We have a multidisciplinary leadership Expo planned for March 2016, facilitated by Dr Jean Arokiasamy, Medical Leadership Tutor, that will showcase paired working between professional groups. Future leadership development will be explored through the development of the education strategy.

We are working with the HEKSS leadership collaborative to align our local talent tools and resources with those that are being developed at a national level. The purpose of this is to ensure we are utilising recognised tools, endorsed by regulators/national organisations, making us 'Champions for Talent' within our region. The 9blocker, or its equivalent, will be piloted at band 8a and above following the completion of band 8a Achievement Reviews in line with the achievement review cascade.

5.24 NEW Workforce and OD strategy

Develop knowledge and skills vital for innovative thinking and service improvement

Mark Preston

Nathaniel Johnston

5.25 NEW Workforce and OD strategy

Ensure effective processes are in place for the prevention and management of violence and aggression against staff.

Mark Preston

Nathaniel Johnston

5.26 NEW Workforce and OD strategy

5.27 NEW Workforce and OD strategy

Promoting schemes to recruit local people into the NHS careers and Mark Preston posts.

Positively engaging parents, young people, careers advisors, university advisors, through individual contact and Trust initiatives.

Mark Preston

Nathaniel Johnston

The Workforce Development Team is actively working with the Kaizen Promotion Office (Sash+ Programme) who will deliver service improvement training in line with the Virginia Mason value streams/ methodology. The KPO team will deliver our service improvement module on the 'Essentials of Management' Programme to ensure all staff understand /utilise the same methodologies. In addition we are designing a programme to embed Human Factors at SaSH, supported by the AHSN/ HEKSS. The Trust's new Conflict Management programme was developed and will be launched in January 2016. The programme will be delivered in house by Alexandria Dyer, Workforce Development Advisor. Conflict resolution will be included on the MaST programme, and delivered to teams on a bespoke basis. Topics include emotional intelligence and resilience, which have been identified as learning needs in the wider "conflict resolution" sphere. Programme content has been aligned to the Core Skills Training Framework.

The Workforce Development Team continue to engage with our local FEI/HEIs to create opportunities for students to learn about and/or work at the Trust. For example we have a cohort of health and care students at East Surrey College coming to the Trust on placement and we have opened up opportunities for hospitality (non-health) students to support with ward hostessing/ meal times. The Recruitment Team are developing our profiles on social media to engage local communities. We now have a "work for us" banner outside the main entrance and another in reception which can be seen by the public when they visit our campus. We have developed, for a January 2016 launch, an Apprenticeship/Work Experience page on the external internet site and our Apprenticeship Advisor is working with the Trust's HR Business Partners to engage Managers in the organisation to support apprentices and work experience. Members of the Workforce Development Team continue to work with our universities, schools and colleges to promote placements/work experience opportunities in the Trust.

5.28 NEW

IBP service development IT strategy

Joint venture for pathology - As part of the proposed pathology development with BSUH procure laboratory system that meets long- Paul Simpson term Trust requirements.

Bruce Stewart

New LIMS procurement is included with the procurement for a new laboratory build, the OBC for which is currently under preparation and is subject to the Trust Boards agreeing (in Q4 2015/16) to proceed on the basis of a Pathology JV FBC addendum laying out the re-worked 10-year finances. Planned go-live has been put back by at least 6 months from March 2017 due to the time it has taken in 2015/16 to re-work and agree the JV finanical plan.

Minutes of the Finance and Workforce Committee Held on 15 December 2015 at 8.30am In AD77, East Surrey Hospital, Redhill PUBLIC Present Richard Durban Paul Biddle Paul Simpson Angela Stevenson Ian Mackenzie Gillian Francis-Musanu

Non-Executive Director (Chair) Non-Executive Director Chief Finance Officer Chief Operating Officer Director of Information & Facilities Director of Corporate Affairs

Alan McCarthy Sue Jenkins Janet Miller Ben Emly Peter Burnett Alison James (part meeting) Julian Webb (part meeting) Charminia Fletcher (part meeting) Mohammad Luqman (part meeting) Catriona Tait

Chairman Director of Strategy Deputy Director of Human Resources Head of Performance Deputy Chief Finance Officer Associate Director, Medicine Division Clinical Lead for Emergency Medicine Service Manager, Medical Specialties Radiology Services Manager Head of Costing and SLR (Committee Secretary)

In attendance

MINUTES AND ACTIONS OF THE PREVIOUS MEETING The minutes of the 27th October 2015 were approved. The Committee sought an answer to the change in the non-pay in relation to a reduction in nonpay variance on page 8 of the Financial Performance M06 report. This has subsequently been confirmed to have been caused by the rephrasing of the TDA Plan. Review of Actions The action tracker was presented. Janet Miller confirmed that the current rate of completion for Achievement Reviews is 72%. A hierarchical view of compliance will be presented to the next meeting. Angela Stevenson confirmed that the risk and benefit sections for the Integrated Discharge Unit FBC would be updated for next monthâ&#x20AC;&#x2122;s meeting. All other items due for November are included on the agenda.

BUSINESS CASE INVESTMENT

ED CT and Resus Full Business Case (FBC) Alison James presented the CT and Resus in the Emergency Department Full Business case. The Committee was advised that the cost of the project had reduced by £80k from the OBC and that it would deliver patient safety and quality improvements to Emergency patient by providing 24 hour access to a CT within the Emergency Department. Richard Durban asked about the recruitment of staff and the costs in the business case for staffing. Mohammad Luqman replied that the department had had issues recruiting Radiographers but this is now improving. Alison James added that the Trust would have 8 months from the approval of the business case to recruit the staff. Richard Durban asked about the quantifiable benefits of the investment. Alison James responded that these could be added to the business case and circulated. Action: Benefits of the business case to be updated are circulated to the Committee

Sue Jenkins asked if the 9-5 option of additional hours is reflective of when the activity increase will be. Julian Webb confirmed that the out of hours scanning will now all the done in ED and the resource change is to have both the current CT in Radiology and the ED CT running between 9-5. The Committee approved the business case MES Update Paul Simpson provided a verbal update on the Radiology Managed Equipment Service and the Managed Print Service. Paul Simpson advised that the Radiology Managed Equipment Service OBC is with the TDA Capital Committee for approval. Issues with the scheme due to VAT rule changes have been shared with the preferred provider and will be reviewed as part of the FBC process. Paul Simpson confirmed that the Managed Printer Service full business case is being finalised following a review of the Trust print requirements. The OBC had a value of £1.3m but the FBC is expected to be less than £1m over the 5 year contract. It was agreed therefore that if the cost is less than £1m the FBC can be approved by the Trust Executive Committee rather than the FWC. 3

FINANCE Financial Performance M08 The finance performance paper was presented by Paul Simpson and noted that the Trust had an adverse variance of £0.6m against the M6 forecast. The other highlights included:  

At Month 8 the Trust had YTD I&E deficit (after donated asset technical adjustment) of £4.8m which is £2.2m adverse to revised TDA plan The reasons for the financial performance remain the same, an increase in Emergency

  

activity that is impacting on Elective activity and driving up costs, notably agency costs. The Trust forecast position remains a £1.6m surplus but this will be discussed at the December Trust Board meeting. The Trust’s cash position at the end of November 2015 was £5.0m. The capital spend forecast this year remains £17.1m

Paul Simpson stated that the Trust is now significantly adverse to the TDA resubmitted plan and the reasons for the performance remain the same. Paul Simpson advised that the position has not improved as forecasted and the elective activity is now going against plan tracking The Committee noted the worsening position and the impact on the M8 Forecast due to be discussed at the Private Board. The Trust is having conversations with the TDA over a capital to revenue transfer for 2015/16, this may total some £3m. Paul Simpson will provide a brief on the impact on the capital programme and advised that the conversion of working capital facilities to loans is also being discussed. Paul Simpson advised that the Trust was still experiencing delays with CCGs on cash receipts but that advances had been agreed. Paul Simpson stated that the TDA and the DH are requiring Trusts to convert their working capital facilities to loans and that the Trust is planning to make an application to the ITFF Board at the beginning of 2016. Paul Biddle asked if that cash request would be to fix the cash shortfall for the year or just in the short term as the Board, as responsible for ensuring the Trusts going concern, needs to ensure cash resources until March 2017. Paul Simpson replied that the application would be for £18m as this is the recognised gap in the Trusts balance sheet position. 2015/16 CIP Update Paul Simpson presented the 2015/16 CIP Update to the Committee and highlighted that the CIPs are not delivering and there had been an adverse movement due to operational pressures. Year to date £2.8m of CIPs have been achieved aided by £0.6K of non-recurrent contingency savings. The forecast is to deliver £4.6m (including the £0.6m contingency) against a target of £8.2m, a worsening of £0.35m since Month 7. 2016/17 Budget Update Paul Simpson presented the 2016/17 budget update. For the tariff deflator prudence has been applied to the modelling with 3% efficiency requirement being used. There was full discussion around the risks to delivering a largely cost reduction based CIP and the benefits of the inclusion of Productivity related CIPs. The Committee noted the indicative CIP for 2016/17 as presented. 4

WORKFORCE AND ORGANISATIONAL DEVELOPMENT Workforce and Organisational Development Report M08 The report was noted by the Committee.

CAPITAL AND ESTATES

Capital & Estates Report M08 The report was noted by the Committee.

IT IT Report M08 The report was noted by the Committee.

GENERAL Date of next meeting Monday 25th January 2016 3.30pm â&#x20AC;&#x201C; AD65

AUDIT & ASSURANCE COMMITTEE Meeting held on Tuesday 10th November 2015, 10:00am â&#x20AC;&#x201C; 13:00pm Venue: Room AD77, Trust HQ, East Surrey Hospital Present: Paul Biddle Richard Durban Richard Shaw

PB RD RS

Committee Chair / Non Executive Director Non Executive Director Non Executive Director

In attendance: Paul Simpson Fiona Allsop Jamie Bewick Nick Atkinson Sarah Pratley Djafer Erdogan Colin Pink

PS FA JB DM SP DE CP

Chief Finance Officer Chief Nurse (Item 3.1) External Audit Internal Audit Local Counter Fraud Specialist Head of Financial Accounts Head of Corporate Governance Action by

1.1

Welcome and Apologies for absence The Chair welcomed members and attendees to the meeting. Apologies for absence had been received from GFM.

1.2

Minutes of last meeting The Committee reviewed and agreed the minutes of previous meeting were as a true record.

1.3

Actions from previous meetings: The action tracker was reviewed and the Committee noted that actions 2.1 and 3.2 had been closed prior to the meeting. Action 3.1, relating to workforce controls, is not due until May 2016.

Audit & Assurance Committee Minutes November 2015

An Associated University Hospital of Brighton and Sussex Medical School

Page 1 of 6

2.1

Review of Board Assurance Framework PS introduced the BAF for review prior to the November Public Board meeting, highlighting that no changes had been made since the October Public Board meeting. The Committee discussed the IT related strategic risk. PS highlighted that an updated IT road map would be presented at the IT Strategy meeting on the 13th November. PS went on to provide reassurance that actions to meet the first phases of the road map are occurring. The Committee asked that the relevant BAF risk be updated to reflect output of the strategy meeting. Action CP and IM CP and IM The Committee discussed the Trust’s main financial risks in detail, noting that both the Trust’s forecast and gross risk is expressed in Board papers. The Committee requested that PS reconsider the risk score agreeing that the plan to meet the forecast had been well PS described in board papers. Action PS The Committee asked for assurances that efforts to improve quality and productivity within the Trust’s Outpatient’s services are on track. The Committee was assured that the issue was not a safety risk and that appropriate management focus is in place, including VMI work stream focus and productivity reviews. The Committee noted the overall improvements in risk management which facilitates conversations at Executive level and has strengthened Trust governance overall. Noting that the BAF included assurances from third parties and had recently received a further green Internal Audit. The Committee focussed on the Trust’s liquidity position challenging management on the detail that supports its description of risk and noting that restrictions to access to extra cash had started to be enacted, making the process of application harder. PS highlighted that the TDA and DOH are both aware of the Trust’s financial position, that the issue was not materially worsening and was dependant on the income the Trust received. PS went on to state that the Chief Executive had formally written to Sussex CCG to request a rebase of indicative plans. As such

Audit & Assurance Committee Minutes November 2015

An Associated University Hospital of Brighton and Sussex Medical School

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contractual activity is due to start shortly. There have also been meetings to start to resolve issues of non-payment. The Chair brought the discussion to a close stating that the issue of the Trust’s liquidity would be raised at the Public Board meeting. The Committee noted the report. 2.2

Review of Significant Risk Register PS introduced the SRR for review prior to the November Public Board. The Committee raised no issues for discussion that had not been included in early Board Assurance Framework conversations. The Committee noted the report.

3.1

Internal Controls RS presented management’s review of internal controls relating to patient systems, highlighting that the paper had been discussed at SQC, which had provided good assurance. RS went on to highlight that the main issue of action related to training for safeguarding, but there was evidence of good improvements in overall compliance. FA described how actions to improve training compliance for children’s safeguarding are being monitored both internally and externally and is on track. The Committee noted that the Trust had chosen to provide the highest level of training to all relevant staff (Level 3). The Committee noted that the patient property policy was due for review and took assurance that this was in hand. PS highlighted the factual error relating to the named management lead for ‘private and Overseas patients’, this should read Ruth Blanc. The Committee took assurance from the report.

Audit & Assurance Committee Minutes November 2015

An Associated University Hospital of Brighton and Sussex Medical School

Page 3 of 6

3.2

Losses and Comps DE presented the Trust’s midyear position for losses and comps, highlighting the error in the coversheet that should read a total of 19 special payments rather than a total of 16. DE went on to highlight that year to date there had been 93 cases where a loss or special payment had been made, totalling £178k. This compares to 140 cases totalling £375k for the full 2014-15 financial year. The main payments so far relate to write off of overseas debt (£77k) and payments made under legal obligation (£65k). DE stated that the large waiver recorded in the paper related to the development of the new Re-enablement Unit. The Committee challenged the detail of the paper and took assurance from both the detail of the controls in place and the forecasted reduction in number of losses, based on the cases in the pipeline. DE highlighted that the overseas debts position was similar to previous years, however he went on to highlight that recovering overseas debt was becoming more administratively challenging. The Committee took assurance from the paper and noted that the overall value of losses was high.

4.1

Internal Audit Progress Report NA introduced the report, highlighting the amount of activity that was underway towards completing audits detailed in the annual plan. Noting in particular the pharmacy stock review, mortality systems audit and right bed first time audit. The review of the Board Assurance Framework had been completed which had included one low level recommendation and action relating to the recording of healthcare acquired infections controls on the BAF. NA went on to highlight the actions still outstanding on the action tracker which relate to procedural issues and temporary staffing controls.

Audit & Assurance Committee Minutes November 2015

An Associated University Hospital of Brighton and Sussex Medical School

Page 4 of 6

4.2

External Audit Report JB introduced the paper which highlighted the need to set an ‘Auditor Panel’ to facilitate appointment of External Audit from 2017, changes in format of annual report and changes to assessment of ‘value for money’ opinion. The Committee discussed the need for the Trust to appoint an ‘audit panel’ and responsibility to recommend to the Shadow Council of Governors the appointment of the Trust’s External Auditor. The Committee agreed to request that the Board approve the AAC committee membership as the Trust's Audit Panel Action PB. JB highlighted that the National Audit Office code of practice had been amended to include a new definition of ‘value for money’. The Committee noted that the assessment will be based on proper practice and arrangements, including independent decision making, sustainability and working in partnership. The Committee discussed the proposed agency price caps noting that temporary staffing agencies willingness and capability to join national frameworks would be the key issue in determining the success of the national imperative. The Chair thanked JB for the valuable emerging issues report.

4.3

LCFS Report SP introduced the report highlighting specific investigations and their issues and outcomes (successful dismissal and the striking off of a biomedical scientist). These cases included potential time sheet fraud and allegations of staff working whilst on sick leave. The Committee asked for details of the value that the Trust had successfully reclaimed in recent years. SP indicated that this detail was in the annual report. The Committee asked for an update on what actions the team are taking to raise awareness of the success of the team. SP highlighted that all campaigns are based on an assessment of likelihood of fraud and potential effectiveness of awareness campaign. Highlighting ebulletin stories, staff magazine articles and training events.

Audit & Assurance Committee Minutes November 2015

An Associated University Hospital of Brighton and Sussex Medical School

Page 5 of 6

The Committee went on to discuss issues relating to overpayments and plans to strengthen controls supporting leavers and starters that do not commence work but are paid in error. PS commented on the work carried out in radiology which had highlighted some good practice and was no longer a counter fraud issue. The Committee discussed SBS’s involvement in these matters and the Trust’s effort to resolve issues. RS queried the case relating to an illegal worker and asked for assurance that appropriate DBS checks had been carried out. SP assured the Committee that this was an issue over eligibility to work and there was no suggestion that the background check had failed. The Chair thanked SP for the report. 5

5.1

Draft Annual Report to Board CP introduced the first draft of the annual report to Board. This was based on the previous year’s report and include key updates on internal controls and the possibility of including a self-assessment based on the ‘Good Governance Institutes’ maturity matrix for Audit Committees. The Committee discussed the draft report and asked for amendments to be made prior to review at the January meeting. Action CP to amend draft report as detailed.

5.2

AOB PS announced that the Trust had been selected to be involved in the national reference cost audit carried out by PricewaterhouseCoopers. The expectation is that the report will be ready in January 2016 and will be reviewed by the Finance and Workforce Committee. No further AOB was raised.

6.1

Date of Next Meeting: 15th January 2016, 09:30 pre-meet, 10:00 meeting start.

Audit & Assurance Committee Minutes November 2015

An Associated University Hospital of Brighton and Sussex Medical School

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